Risk of osteoporotic fracture in women using the FRAX tool with and without bone mineral density score in patients followed at a tertiary outpatient clinic ‒ An observational study

Objectives: Fragility fractures increase morbidity and mortality. Adding assessment of clinical risk factors independently or as a previous step to Bone Densitometry (BD) should provide better accuracy in fracture risk prediction. FRAX tool might be used to stratify patients in order to rationalize the need for BD and risk classification. The primary objective of this study is to describe and perform comparisons between the estimated risk of fractures in 10 years using the FRAX calculator based on clinical factors with and without BD results for women aged 40 or more with clinical diseases monitored in tertiary care service in internal medicine. Methods: Cross-sectional. Women over 40 years with BD in the previous year. After medical chart review, identification of risk factors and risk estimations using FRAX-BRAZIL with (FRAX BDI) and without (FRAX BDNI) the inclusion of T-score. Results: 239 women. Age 65 ± 10.35 years. BMI 29.68 ± 6.27kg/m2. Risk factors: 32(13.4%) previous fractures; 23 (9.6%) current smoking; 78 (32.6%) corticosteroids use; 44 (18.4%) rheumatoid arthritis; 38 (15.9%) secondary causes; FRAX scores were higher when BD was not included. Spearman correlation coefficients between FRAX BDNI and FRAX BDI for major fractures r = 0.793 (95% CI 0.7388‒0.836). For hip fractures r = 0.6922 (95% CI 0.6174‒0.75446) Conclusion: Using FRAX to estimate 10-year fracture risk without BD data might be a reliable tool for screening, even for patients with a high prevalence of risk factors, improving accessibility and equity in health systems. The present study's data suggest an overestimation of fracture risk with FRAX BDNI, suggesting that it is safe to be widely used as a screening tool

Being sick or ill? Impact of pain, multimorbidity and medication regimen complexity on quality of life and illness perception at an outpatient clinic of Internal Medicine

INTRODUÇÃO: Ao lidarem com sintomas e rótulos associados a doenças, as pessoas geram representações das doenças em níveis cognitivos e afetivos, que interagem para gerar uma resposta representada pelos comportamentos de saúde. Essa percepção é multifatorial, dinâmica e tem impacto sobre desfechos clínicos. Não há clareza na literatura acerca da percepção de doença em pacientes ambulatoriais com multimorbidade e quais seus determinantes. Assim, o objetivo deste estudo foi compreender a percepção de doença dos pacientes acompanhados em ambulatório de Clínica Médica a partir da descrição de determinantes quantitativos relacionados a dor; complexidade da farmacoterapia; qualidade de vida em suas dimensões física e mental; presença de sintomas depressivos e da análise qualitativa de suas narrativas. MÉTODOS: Metodologia mista sequencial explanatória, buscando identificar o perfil dos pacientes em termos de multimorbidade, presença de dor, sua intensidade e interferência nas atividades, complexidade farmacoterápica, qualidade de vida em suas dimensões física e mental e investigar associações dessas variáveis à percepção da doença na fase quantitativa do estudo. Para a análise qualitativa, a proposição foi aprofundar, sob a perspectiva construtivista, a avaliação das narrativas de doenças a fim de nos aproximarmos por essa via da percepção e seus determinantes. Foram incluídos para a fase quantitativa 100 pacientes com idade entre 18 e 80 anos acompanhados no ambulatório de Clínica Médica do HC-FMUSP. Para a etapa qualitativa, foram incluídos aqueles com Escore de comorbidades de Elixhauser >= 3 e presença de dor. RESULTADOS: Foram incluídos 58 mulheres e 42 homens, com média de idade de 55 ± 13,5 anos. A mediana do total do B-IPQ foi 41 (IQR 30,7-49). A percepção avaliada pelo B-IPQ correlacionou-se com a intensidade e com a interferência da dor. Não houve associação do B-IPQ com os índices de multimorbidade Elixhauser, Charlson e Índice de complexidade funcional. A prevalência de dor foi 65%, com escore de severidade médio de 5,4 ± 1,9 e escore médio de interferência de 5,5 ± 1,9. Para o escore de comorbidades de Elixhauser a mediana foi 3 (IQR 2-4,2), sendo as mais frequentes hipertensão, diabetes e obesidade. Para o índice de complexidade da farmacoterapia, a mediana para todos os pacientes foi 18 (IQR 12-28,2), sendo maior nos pacientes com dor e tendo correlação com os índices de multimorbidade incluídos. Qualidade de vida avaliada pelo SF-12 teve média do escore físico PCS-12 36,9 ± 12,2 e do escore mental MCS-12 46,4 ± 13,5. A mediana de pontuação no inventário de Beck foi 9,5 (IQR 5,2-16,7). Na fase qualitativa, aprofundaram-se os determinantes da percepção e foram observados os padrões mais comuns de experiência da doença: resiliência; vulnerabilidade; disrupção. CONCLUSÕES: A percepção de doença dentre os pacientes acompanhados em ambulatório de Clínica Médica em hospital terciário incluídos no estudo foi negativa, com altos valores no B-IPQ e relacionada à presença de dor. A percepção não se associou nem aos índices de multimorbidade nem à complexidade da farmacoterapia. A percepção observada - tanto na fase quantitativa quanto na qualitativa do estudo - da maior parte dos pacientes foi de ameaça e vulnerabilidade, com grande repercussão emocional. A presença de muitos sintomas somáticos, dentre os quais a dor, interfere na funcionalidade e na qualidade de vida. A vulnerabilidade e a sensação de desamparo frente ao curso da doença foram frequentes. Dor e multimorbidade foram frequentes nesta população e associadas com a complexidade da farmacoterapiaINTRODUCTION: Faced with symptoms and labels associated with diseases, people generate representations of diseases at cognitive and affective levels, which interact to generate a response represented by health behaviors. This perception is multifactorial, dynamic and has an impact on clinical outcomes. It\'s not fully clarified in the literature how the perception is manifested and and what are its determinants. Thus, the aim of this study was to understand illness perception of patients followed up in an outpatient clinic of Internal Medicine guided by the description of quantitative determinants related to pain; complexity of pharmacotherapy; quality of life in its physical and mental dimensions; presence of depressive symptoms and qualitative analysis of their narratives. METHODS: Sequential explanatory mixed methodology, seeking to identify the profile of patients in terms of multimorbidity, presence of pain, its intensity and interference in activities, medication regimen complexity, quality of life in its physical and mental dimensions and to investigate associations of these variables with the perception of the disease in the quantitative phase of the study. For qualitative analysis, the proposition was to deepen, under the constructivist perspective, the evaluation of disease narratives in order to approach this path of perception and its determinants. For the quantitative phase, 100 patients aged between 18 and 80 years followed up at the HC-FMUSP internal medicine outpatient clinic were included. For the qualitative stage, those with an Elixhauser comorbidity score >= 3 and the presence of pain were included. RESULTS: 58 women and 42 men were included, with a mean age of 55 ± 13.5 years. The median of the total B-IPQ was 41 (IQR 30.7-49). The perception assessed by the B-IPQ correlated with the intensity and the interference of pain. There was no association between B-IPQ and the Elixhauser, Charlson and functional complexity index multimorbidity indexes. The prevalence of pain was 65%, with a mean severity score of 5.4 ± 1.9 and a mean interference score of 5.5 ± 1.9. For the Elixhauser comorbidity score, the median was 3 (IQR 2-4.2), with the most frequent being hypertension, diabetes and obesity. For the pharmacotherapy complexity index, the median for all patients was 18 (IQR 12-28.2), being higher in patients with pain and correlating with the included multimorbidity indexes. Quality of life assessed by SF-12 had an average of the physical score PCS-12 36.9 ± 12.2 and the mental score MCS-12 46.4 ± 13.5. The median score on Beck\'s inventory was 9.5 (IQR 5.2-16.7). In the qualitative phase, the determinants of perception were deepened and the most common patterns of disease experience observed were as follow: resilience; vulnerability; disruption CONCLUSIONS: Illness perception among patients followed at an internal medicine outpatient clinic in a tertiary hospital included in the study was negative, with high values in the B-IPQ and related to the presence of pain. The perception was not associated with either multimorbidity rates or the complexity of pharmacotherapy; Perception - both in the quantitative and qualitative phase of the study - of most patients was of threat and vulnerability, with great emotional repercussion. The presence of many somatic symptoms, including pain, interferes with functionality and quality of life. The vulnerability and the feeling of helplessness in the face of the disease course were frequent; Pain and multimorbidity were frequent in this population and associated with the complexity of pharmacotherap

Current and relevant concepts in psoriatic arthritis

A artrite psoriásica (APs) é uma doença articular sistêmica e polimórfica de apresentação e curso clínico variáveis, associada a comorbidades importantes como diabetes mellitus, hipertensão arterial e dislipidemia. Para o diagnóstico precoce da doença é necessário alto grau de suspeita clínica, sobretudo quando as manifestações cutâneas são sutis e pouco definidas. Doença erosiva progressiva pode ocorrer em até metade dos pacientes, associada a alterações anatômicas e funcionais em cerca de 20%, de modo que o prognóstico da APs permanece obscuro, especialmente se diagnóstico e tratamento forem tardios. Fundamentados em ampla revisão da literatura (PubMed e Lilacs) e experiência dos nossos serviços, novos conceitos de imunogenética, fisiopatologia, aspectos clínicos e terapêuticos serão discutidos. Fatores que reduzem a qualidade e a expectativa de vida dos pacientes e novas diretrizes que norteiam um tratamento mais precoce e efetivo serão enfatizados. O controle do processo inflamatório, especialmente nas formas axiais e entesíticas da APs, tornou-se possível graças à introdução dos medicamentos biológicos anti-TNF. Finalmente, o papel do GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) deve ser ressaltado, já que promove reuniões e estudos conjuntos entre reumatologistas e dermatologistas no sentido de fornecer evidências científicas para as amplas mudanças no manejo clínico e terapêutico de pacientes com AP

Alterações eletrocardiográficas em dermatomiosite e polimiosite

ResumoIntroduçãoAcometimento cardíaco nas miopatias inflamatórias é frequente. Eletrocardiograma (ECG) pode mostrar indícios desse acometimento e suas alterações devem ser bem conhecidas e descritas.ObjetivosDevido à escassez de trabalhos na literatura, analisamos as alterações de ECG em pacientes com dermatomiosite (DM) e polimiosite (PM) e as comparamos com um grupo controle.MétodosEste estudo transversal comparou ECGs de 86 indivíduos sem doenças reumatológicas (controles) com 112 pacientes (78 DM e 34 PM), de 2010 a 2013. Também comparamos os ECGs entre DM e PM.ResultadosCaracterísticas demográficas, comorbidades e alterações de ECG foram semelhantes entre controles e pacientes (p>0,05), exceto pela maior frequência de sobrecarga de ventrículo esquerdo (SVE) nos pacientes (10,7% vs. 1,2%; p=0,008). Características demográficas, comorbidades, manifestações clínicas e laboratoriais também foram semelhantes entre os grupos PM e DM, exceto por lesões cutâneas apenas em pacientes com DM. Um terço dos pacientes apresentou alterações de ECG, que foram mais prevalentes em PM do que em DM (50% vs. 24,4%, p=0,008). Sobrecarga de câmaras esquerdas (SCE), distúrbios do ritmo e da condução foram mais encontrados em PM do que em DM (p<0,05 para todos), sobretudo o bloqueio divisional do ramo anterossuperior.ConclusõesEncontramos alterações distintas de ECG entre PM e DM e frequência aumentada de SVE em pacientes quando comparados com controles. Investigação do acometimento cardíaco nessas doenças deve ser considerada mesmo em pacientes assintomáticos, especialmente em se tratando de PM. Mais estudos são necessários para correlacionar os achados de ECG com outros exames complementares, manifestações clínicas, atividade das miopatias e evolução para outras doenças cardíacas.AbstractIntroductionCardiac involvement is frequent in inflammatory myopathies. Electrocardiogram (ECG) may show evidence of this involvement and its changes should be well‐known and described.ObjectivesDue to the lack of studies in the literature, we conducted an analysis of the ECG findings in patients with dermatomyositis (DM) and polymyositis (PM), comparing them with a control group.MethodsThis cross‐sectional study compared the ECG of 86 individuals with no rheumatic disorders (controls) with 112 patients (78 DM and 34 PM), during 2010 to 2013. The ECG findings between DM and PM were also compared.ResultsDemographic characteristics, comorbidities and ECG abnormalities were similar between controls and patients (p>0.05), except for a higher frequency of left ventricular hypertrophy (LVH) in patients (10.7% vs. 1.2%, p=0.008). Demographic characteristics, comorbidities, clinical and laboratory manifestations, were also similar between the groups PM and DM, except for the presence of cutaneous lesions only in DM. One third of the patients had ECG abnormalities, which were more prevalent in PM than DM (50% vs. 24.4%, p=0.008). LVH, left atrial enlargement, rhythm and conduction abnormalities were more frequent in PM than DM (p<0.05 for all), especially the left anterior fascicular block.ConclusionsWe showed distinct ECG changes between DM and PM and a higher frequency of LVH in patients compared to controls. Investigation of cardiac involvement should be considered even in asymptomatic patients, especially PM. Further studies are necessary in order to determine the correlation of ECG findings with other complementary tests, clinical manifestations, disease activity and progression to other cardiac diseases

Electrocardiographic changes in dermatomyositis and polymyositis

ABSTRACT Introduction: Cardiac involvement is frequent in inflammatory myopathies. Electrocardiogram (ECG) may show evidence of this involvement and its changes should be well-known and described. Objectives: Due to the lack of studies in the literature, we conducted an analysis of the ECG findings in patients with dermatomyositis (DM) and polymyositis (PM), comparing them with a control group. Methods: This cross-sectional study compared the ECG of 86 individuals with no rheumatic disorders (controls) with 112 patients (78 DM and 34 PM), during 2010 to 2013. The ECG findings between DM and PM were also compared. Results: Demographic characteristics, comorbidities and ECG abnormalities were similar between controls and patients (p > 0.05), except for a higher frequency of left ventricular hypertrophy (LVH) in patients (10.7% vs. 1.2%, p = 0.008). Demographic characteristics, comorbidities, clinical and laboratory manifestations, were also similar between the groups PM and DM, except for the presence of cutaneous lesions only in DM. One third of the patients had ECG abnormalities, which were more prevalent in PM than DM (50% vs. 24.4%, p = 0.008). LVH, left atrial enlargement, rhythm and conduction abnormalities were more frequent in PM than DM (p < 0.05 for all), especially the left anterior fascicular block. Conclusions: We showed distinct ECG changes between DM and PM and a higher frequency of LVH in patients compared to controls. Investigation of cardiac involvement should be considered even in asymptomatic patients, especially PM. Further studies are necessary in order to determine the correlation of ECG findings with other complementary tests, clinical manifestations, disease activity and progression to other cardiac diseases

Update on the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline of the Brazilian Society of Cardiology-2019

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