Doenças reumáticas pediátricas e a educação física escolar : uma revisão narrativa

Introdução: As doenças reumáticas pediátricas (DRP), principalmente a artrite idiopática juvenil (AIJ) e o lúpus eritematoso sistêmico juvenil (LESJ), são doenças autoimunes, inflamatórias e crônicas. Ambas apresentam manifestações sistêmicas (como dor,fadiga e perda de peso) que podem levar ao ciclo vicioso de agravamento dos sintomas, inatividade física, incapacidade física, estilo de vida sedentário, diminuição da qualidade de vida e má prognóstico. A atividade física como tratamento não-farmacológico, no ambiente escolar, pode estabilizar este ciclo vicioso. Objetivo: Descrever, a partir de uma revisão narrativa, as alterações na aptidão física de pacientes com AIJ e LESJ e apresentar a importância da atividade física no ambiente escolar para esta população. Métodos: A presente pesquisa narrativa baseou-se ensaios clínicos randomizados- não randomizados, artigos de revisão sistemática, artigos de revisão narrativa e estudos observacionais, publicados nos últimos 10 anos, usando MEDLINE (via PubMed) e outras fontes relevantes. As estratégias de pesquisa foram baseadas em palavras-chave pré-definidas. Resultados: Pacientes com DRP apresentam níveis de atividade física mais baixos quando comparado com indivíduos saudáveis. Além disto, baixa aptidão física foi encontrada em pacientes com DRP quando comparada com crianças saudáveis. Por fim, apenas dois estudos foram encontrados com o objetivo de estimar a participação em esportes escolares entre pacientes com doenças reumáticas pediátricas e não observou-se nenhuma programa/intervenção específico para esta população no ambiente escolar. Conclusão: A partir da presente revisão narrativa pode-se concluir que pacientes com DRP apresentam manifestações extra-articulares que levam a incapacidade física. O ciclo vicioso de agravamento dos sintomas, inatividade física e incapacidade física resultam em piora da aptidão física destes pacientes. A diminuição da participação de pacientes com DRP na educação física está associada a atividade da doença, limitações funcionais e qualquer uso de DMARDs, injeções intra-articulares de glicocorticóides ou fisioterapia. Sabendo que os benefícios da atividade física compensam os efeitos da inatividade física e que não se tem na literatura programa/intervenção específico para esta população no ambiente escolar, estudos com programa/intervenção de atividade física no ambiente escolar para crianças com DRP são necessários a fim de avaliar os efeitos benéficos sobre a aptidão física. Portanto, nós propusemos um programa/intervenção específico para esta população no ambiente escolar baseado em outros programas/intervenção descritos na literatura com outras populações.Introduction: Pediatric rheumatic diseases (PRD), especially juvenile idiopathic arthritis (JIA) and juvenile systemic lupus erythematosus (JSLE), are autoimmune, inflammatory and chronic diseases. Both have systemic manifestations (such as pain, fatigue and weight loss) that can lead to a vicious cycle of worsening symptoms, physical inactivity, physical disability, sedentary lifestyle, decreased quality of life and poor prognosis. Physical activity as a non-pharmacological treatment in the school environment can stabilize this vicious cycle. Objective: To describe, from a narrative review, the changes in physical fitness of patients with JIA and JSLE and to present the importance of physical activity in the school environment for this population. Methods: This narrative research was based on randomized non-randomized controlled trials, systematic review articles, narrative review articles, and observational studies published over the past 10 years using MEDLINE (via PubMed) and other relevant sources. Search strategies were based on predefined keywords. Results: Patients with PRD have lower levels of physical activity when compared to healthy individuals. In addition, poor physical fitness was found in patients with PRD compared with healthy children. Finally, only two studies were found to estimate participation in school sports among patients with pediatric rheumatic diseases and no specific program/intervention was observed for this population in the school setting. Conclusion: Based on the present narrative review, we concluded that patients with PRD have extra-articular manifestations that lead to physical disability. The vicious cycle of worsening symptoms, physical inactivity and physical disability result in worsening physical fitness of these patients. Decreased participation of patients with PRD in physical education is associated with disease activity, functional limitations and any use of DMARDs, intra-articular glucocorticoid injections, or physical therapy. Knowing that the benefits of physical activity outweigh the effects of physical inactivity and that there is no specific program/intervention literature for this population in the school environment, studies with the program/intervention of physical activity in the school environment for children with PRD are necessary in order to evaluate the beneficial effects on physical fitness. Therefore, we proposed a specific program/intervention for this population in the school environment based on other programs/intervention described in the literature with other populations

O efeito da atividade da doença sobre a caquexia em pacientes com artrite reumatoide : um estudo de coorte prospectivo

Base teórica: A artrite reumatoide (AR) é uma doença autoimune, que envolve inflamação crônica, comprometimento articular e extra-articular. Entre as manifestações extra-articulares estão às alterações de composição corporal. A diminuição da massa livre de gordura e o aumento da massa gorda em pacientes com AR são denominados caquexia reumatoide (CR), enquanto caquexia clássica é determinada pela perda de peso corporal de 5% ou mais em 12 meses, além de outras características. Na AR, há poucos dados avaliando a prevalência e progressão da caquexia ao longo do tempo, bem como seus fatores associados. Objetivos: Avaliar a prevalência de caquexia reumatoide e fatores associados a esta condição em uma coorte de pacientes com artrite reumatoide. Métodos: Pacientes com AR, segundo os critérios de classificação do ACR/EULAR 2010, foram recrutados de forma consecutiva em uma clínica de AR de um hospital universitária e acompanhada inicialmente por doze meses. As seguintes avaliações foram realizadas no início e após um ano: estado da doença (atividade da doença pelo DAS28 e drogas), composição corporal por densitometria por dupla emissão de raios-X, função física (HAQ-DI, força de preensão palmar pelo dinamômetro Jamar, velocidade da marcha pelo teste Timed Up and Go (TUG) e a força dos membros inferiores pelo teste sentar e levantar da cadeira por 30 segundos), fadiga pela escala The Functional Assessment of Chronic Illness Therapy fatigue, anorexia pela escala The Functional Assessment of Anorexia/Cachexia Therapy, marcadores inflamatórios e bioquímicos séricos. Para diagnosticar caquexia foram utilizados três critérios de diagnóstico, sendo os dois primeiros específicos para a caquexia reumatoide e o terceiro para caquexia clássica. Engvall e colaboradores propuseram caquexia reumatoide quando pacientes com AR apresentassem: índice de massa livre de gordura (IMLG) abaixo do percentil 10 e índice de massa gorda (IMG) acima do percentil 25. Elkan e colaboradores propuseram caquexia reumatoide quando pacientes com AR apresentassem: IMLG abaixo do percentil 25 e IMG acima do percentil 50. Evans e colaboradores propuseram caquexia clássica quando pacientes apresentassem: perda de peso de 5% ou mais dentro de 12 meses (ou índice de massa corpórea (IMC)≤20 kg/m2) e pelo menos três dos seguintes fatores: 7 diminuição da força muscular; fadiga; anorexia; baixo IMLG; bioquímica anormal (aumento dos marcadores inflamatórios [Proteína C Reativa(PCR),interleucina (IL)-6], anemia [Hemoglobina(Hb)<12g/dL], albumina baixa no soro [<3,2g/dL]. A análise de frequência, teste t-Student pareado, o teste de McNemar e as análises por Modelo de Equações de Estimações Generalizadas (GEE) foram utilizados e a significância estatística foi considerada como p<0,05. A análise dos dados foi realizada no software SPSS 21.0. Resultados: Dos 90 pacientes incluídos, 81 pacientes com AR completaram o estudo. A maioria dos pacientes eram do sexo feminino (88,9%), com idade de 56,5±7,3 anos, com atividade moderada da doença (média do DAS28 (Disease Activity Score 28) 4,0±1,3). Caquexia reumatoide foi encontrada em 13,3% dos pacientes com AR utilizando os critérios de Engvall e colaboradores e 30% usando os critérios de Elkan e colaboradores no início do estudo. Usando critério diagnóstico para caquexia clássica proposta por Evans e colaboradores, não encontramos caquexia em nossos pacientes. Quanto à função física, a força de preensão manual foi o parâmetro que apresentou diminuição estatisticamente significativa após 12 meses (p<0,05). Remissão de doença foi significativamente associada com as alterações no IMLG, IMG, HAQ, força de preensão manual e força dos membros inferiores (p<0,05) em relação a pacientes com doença em atividade ao longo dos 12 meses. O tratamento com DMCDs biológicos associou-se significativamente com alterações no IMLG, velocidade da marcha e força muscular de membros inferiores ao longo dos 12 meses (p<0,05). Conclusão: Caquexia reumatoide foi frequente quando utilizados os critérios específicos, mas nenhum paciente apresentou os critérios de caquexia clássica. Além disto, a função física é um parâmetro que merece destaque, pois ela apresentou-se prejudicada desde o início do estudo e se manteve após um ano de acompanhamento. As observações de que o estado de remissão está associado às alterações da função física e da composição corporal ao longo do tempo enfatizam a importância do controle adequado da atividade da doença. As observações sobre o efeito do tratamento biológico na caquexia foram controversas, demonstrando a necessidade de mais estudos avaliando estes parâmetros.Background: Rheumatoid arthritis (RA) is an autoimmune disease, which involves chronic inflammation, joint and extra-articular involvement. Among the extra-articular manifestations are the changes in body composition. The decrease in fat-free mass and the increase in fat mass in RA patients are termed rheumatoid cachexia (CR), while classic cachexia is determined by 5% or more body weight loss over 12 months, as well as other characteristics. In RA, there is little data evaluating the prevalence and progression of cachexia over time, as well as its associated factors. Objectives: To evaluate the prevalence of rheumatic cachexia and factors associated with this condition in a cohort of patients with rheumatoid arthritis. Methods: RA patiens, according to the classification criteria of ACR/EULAR 2010, were recruited consecutively in a RA clinic of a university hospital and initially followed up for twelve months. The following evaluations were performed at baseline and after one year: disease status (disease activity by DAS28 and drugs), body composition by X-ray dualdensity densitometry, physical function (HAQ-DI, palmar grip strength by dynamometer Jamar, gait velocity by the Timed Up and Go (TUG) test and the strength of the lower limbs by the sit and stand test for 30 seconds), fatigue by the scale The Functional Assessment of Chronic Illness Therapy fatigue, anorexia by The Functional Assessment of Anorexia/Cachexia Therapy, inflammatory markers and serum biochemists. Three diagnostic criteria were used to diagnose cachexia, the first two being specific for rheumatoid cachexia and the third for classical cachexia. Engvall et al proposed rheumatoid cachexia when patients with RA presented: fat free mass index (FFMI) below the 10th percentile and fat mass index (FMI) above the 25th percentile. Elkan et al proposed rheumatoid cachexia when RA patients presented: FFMI below the 25th percentile and FMI above the 50th percentile. Evans et al proposed classic cachexia when patients presented: weight loss of 5% or more within 12 months (or body mass index (BMI)≤20 kg/m2) and at least three of the following factors: decreased muscle strength; fatigue; anorexia; low FFMI; (C-reactive protein (CRP), interleukin (IL)-6], anemia [hemoglobin (Hb)<12g/dL], serum albumin [<3,2g/dL]. (Student's t-test, McNemar's test, and Generalized Estimating Equation (GEE) model analyzes were used and the statistical significance was considered as p<0.05. Data analysis was performed in SPSS 21.0 software. 9 Results: Of the 90 patients included, 81 RA patients completed the study. The majority of the patients were female (88.9%), aged 56.5±7.3 years, with moderate disease activity (DAS28 (Disease Activity Score 28) 4.0±1.3). Rheumatoid cachexia was found in 13.3% of RA patients using the criteria of Engvall et al. and 30% using the criteria of Elkan et al. at baseline. Using diagnostic criteria for classical cachexia proposed by Evans et al. We did not find cachexia in our patients. Regarding physical function, manual grip strength was the parameter that showed a statistically significant decrease after 12 months (p<0.05). Disease remission was significantly associated with changes in FFMI, FMI, HAQ, manual grip strength and lower limb strength (p<0.05) relative to patients with active disease over 12 months. Treatment with biological DMARDs was significantly associated with changes in FFMI, gait velocity, and lower limb muscle strength over the 12 months (p<0.05). Conclusion: Rheumatoid cachexia was frequent when specific criteria were used, but no patient presented classic cachexia criteria. In addition, physical function is a parameter that deserves to be highlighted, since it has been impaired since the beginning of the study and was maintained after one year of follow-up. Observations that remission status is associated with changes in physical function and body composition over time emphasize the importance of adequate control of disease activity. Observations on the effect of biological treatment on cachexia were controversial, demonstrating the need for further studies evaluating these parameters

Prevalence of rheumatoid cachexia in rheumatoid arthritis : a systematic review and meta-analysis

Background: Low muscle mass occurs in patients with rheumatoid arthritis without weight loss; this condition is referred asrheumatoid cachexia. The aim of the current study was to perform a systematic review with meta-analysis to determine therheumatoid cachexia prevalence. Methods: A systematic review with meta-analysis of observational studies published in English, between 1994 and 2016, wasconducted using MEDLINE (via PubMed) and other relevant sources. Search strategies were based on pre-defined keywordsand medical subject headings. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale.Meta-analysis was used to estimate the prevalence, and because studies reported different methods and criteria to estimatebody composition and prevalence of rheumatoid cachexia, subgroup analyses were performed. Meta-regression adjusted forthe 28-joint disease activity score and disease duration (years) was performed (significance level atP≤0.05). Results: Of 136 full articles (one duplicate publication) screened for inclusion in the study, eight were included. The esti-mated overall prevalence of rheumatoid cachexia was 19% [95% confidence interval (CI) 07–33%]. This prevalence was 29%(95% CI 15–46%) when body composition was measured by dual-energy X-ray absorptiometry. When the diagnostic criteriawere fat-free mass index below the 10th percentile and fat mass index above the 25th percentile, rheumatoid cachexia prev-alence was 32% (95% CI 14–52%). The 28-joint disease activity score and disease duration had no influence on the estimatedprevalence of rheumatoid cachexia (P>0.05). Most studies were rated as having moderate methodological quality. Conclusions: Meta-analysis showed a prevalence of rheumatoid cachexia of 15-32%, according to different criteria, demon-strating that this condition is a frequent comorbidity of rheumatoid arthritis. To better understand its clinical impact, more studies using standardized definitions and prospective evaluations are urgently needed

Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Background There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann–Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren’s syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03–2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19–6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31–3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46–0.98). Conclusion Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection

A review of metabolomic profiling in rheumatoid arthritis : bringing new insights in disease pathogenesis, treatment and comorbidities

Metabolomic analysis provides a wealth of information that can be predictive of distinctive phenotypes of pathogenic processes and has been applied to better understand disease development. Rheumatoid arthritis (RA) is an autoimmune disease with the establishment of chronic synovial inflammation that affects joints and peripheral tissues such as skeletal muscle and bone. There is a lack of useful disease biomarkers to track disease activity, drug response and follow-up in RA. In this review, we describe potential metabolic biomarkers that might be helpful in the study of RA pathogenesis, drug response and risk of comorbidities. TMAO (choline and trimethylamine oxide) and TCA (tricarboxylic acid) cycle products have been suggested to modulate metabolic profiles during the early stages of RA and are present systemically, which is a relevant characteristic for biomarkers. Moreover, the analysis of lipids such as cholesterol, FFAs and PUFAs may provide important information before disease onset to predict disease activity and treatment response. Regarding therapeutics, TNF inhibitors may increase the levels of tryptophan, valine, lysine, creatinine and alanine, whereas JAK/STAT inhibitors may modulate exclusively fatty acids. These observations indicate that different disease modifying antirheumatic drugs have specific metabolic profiles and can reveal differences between responders and non-responders. In terms of comorbidities, physical impairment represented by higher fatigue scores and muscle wasting has been associated with an increase in urea cycle, FFAs, tocopherols and BCAAs. In conclusion, synovial fluid, blood and urine samples from RA patients seem to provide critical information about the metabolic profile related to drug response, disease activity and comorbidities

Anthropometric nutritional status and association with blood pressure in children and adolescents : a population-based study

Objetivos: Avaliar o estado nutricional de crianças e de adolescentes por meio de indicadores antropométricos e avaliar a associação desses resultados com a pressão arterial. Métodos: Foram incluídos neste estudo crianças e adolescentes entre quatro e 19 anos de idade, oriundos de escolas rurais e urbanas de um município do Rio Grande do Sul. Foram excluídos aqueles que recusaram (ou cujos pais recusaram) participar ou não assinaram o termo de consentimento livre e esclarecido, ou nos quais não foi possível realizar as medidas antropométricas ou da pressão arterial. Foram mensurados peso, estatura, circunferência da cintura, pregas cutâneas e pressão arterial, e foi calculado o índice de massa corporal. Os dados foram descritos por média, desvio padrão, amplitude de variação, frequências absolutas e relativas. Foi realizada estratificação por sexo, índice de massa corporal e obesidade central, para analisar a influência destas variáveis sobre as demais. O Qui-quadrado de Pearson foi utilizado para avaliar as associações. O nível de significância foi de p<0,05 Resultados: No período da coleta de dados estavam matriculados nas escolas do município 7.082 crianças e adolescentes dentro da faixa etária determinada, os quais foram convidados a participar. Após aplicação dos critérios de exclusão, 5.936 crianças/adolescentes foram incluídos no estudo. A amostra apresentou prevalência de excesso de peso de 30,3%, obesidade central 31,1% e excesso de gordura corporal 8,7%. O excesso de peso foi maior em crianças de escolas particulares (44,1%) quando comparadas com escolas estaduais (29,5%) e municipais (29,9%) (p<0,001). Foram encontradas associações estatisticamente significativas de hipertensão arterial com sobrepeso, obesidade e obesidade central (p<0,001). Conclusões: A prevalência de excesso de peso foi elevada e a hipertensão arterial associou-se com sobrepeso, obesidade e obesidade central nas crianças e adolescentes da população estudada.Aims: To evaluate the nutritional status of children and adolescents by anthropometric indicators and to evaluate the association of these results with blood pressure. Methods: Children and adolescents between four and 19 years of age from rural and urban schools of a municipality of Rio Grande do Sul were included in this study. Those who refused (or whose parents refused) to participate or did not sign the consent form, or in whom it was not possible to carry out the anthropometric or blood pressure measurements, were excluded. Weight, height, waist circumference, skin folds and blood pressure were measured, and the body mass index was calculated. Data were described by mean, standard deviation, amplitude of variation, absolute and relative frequencies. Stratification by gender, body mass index and central obesity was performed to analyze the influence of these on the other variables. Pearson's Chi-square was used to evaluate the associations. The level of significance was p<0.05. Results: At the time of data collection, 7,082 children and adolescents within the age group were enrolled in the municipal schools, and they were invited to participate. After applying the exclusion criteria, 5,936 children/adolescents were included in the study. The sample presented prevalence of overweight of 30.3%, central obesity 31.1% and excess body fat 8.7%. Overweight was higher in children from private schools (44.1%) than in state schools (29.5%) and municipal schools (29.9%) (p<0.001). There were statistically significant associations of high blood pressure with overweight, obesity, and central obesity (p<0.001). Conclusions: Prevalence of overweight was high and hypertension was associated with overweight, obesity and central obesity in children and adolescents of the studied population

The effects of resistance training with blood flow restriction on muscle strength, muscle hypertrophy and functionality in patients with osteoarthritis and rheumatoid arthritis : a systematic review with meta-analysis

Introduction Rheumatoid arthritis(RA) and osteoarthritis(OA) patients showed systemic manifestations that may lead to a reduction in muscle strength, muscle mass and, consequently, to a reduction in functionality. On the other hand, moderate intensity resistance training(MIRT) and high intensity resistance training(HIRT) are able to improve muscle strength and muscle mass in RA and OA without affecting the disease course. However, due to the articular manifestations caused by these diseases, these patients may present intolerance to MIRT or HIRT. Thus, the low intensity resistance training combined with blood flow restriction (LIRTBFR) may be a new training strategy for these populations. Objective To perform a systematic review with meta-analysis to verify the effects of LIRTBFR on muscle strength, muscle mass and functionality in RA and OA patients. Materials and methods A systematic review with meta-analysis of randomized clinical trials(RCTs), published in English, between 1957–2021, was conducted using MEDLINE(PubMed), Embase and Cochrane Library. The methodological quality was assessed using Physiotherapy Evidence Database scale. The risk of bias was assessed using RoB2.0. Mean difference(MD) or standardized mean difference(SMD) and 95% confidence intervals(CI) were pooled using a random- effects model. A P<0.05 was considered statistically significant. Results Five RCTs were included. We found no significant differences in the effects between LIRTBFR, MIRT and HIRT on muscle strength, which was assessed by tests of quadriceps strength(SMD = -0.01[-0.57, 0.54], P = 0.96; I2 = 58%) and functionality measured by tests with patterns similar to walking(SMD = -0.04[-0.39, 0.31], P = 0.82; I2 = 0%). Compared to HIRT, muscle mass gain after LIRTBFR was reported to be similar. When comparing LIRTBFR with low intensity resistance training without blood flow restriction(LIRT), the effect LIRTBFR was reported to be higher on muscle strength, which was evaluated by the knee extension test. Conclusion LIRTBFR appears to be a promising strategy for gains in muscle strength, muscle mass and functionality in a predominant sample of RA and OA women