Efeito do ácido zoledrônico nas múltiplas fraturas vertebrais induzidas por glicocorticóide no lúpus eritematoso juvenil

Glucocorticoids are widely used in the treatment of lupus patients, and adverse effects, which include osteoporosis and associated fractures, are frequent. Treatment of osteoporosis of young patients should be effective and not harmful to bone growth and remodeling. Bisphosphonates are drugs that decrease the incidence of bone fractures, but their use in juvenile patients is still controversial because of their possible side effects on the growing skeleton. However, recently published studies showed that linear growth continued normally after treatment with these drugs, and there was no excessive suppression of bone remodeling or mineralization defects. Zoledronic acid is a new intravenous bisphosphonate that has been approved by the US FDA for use with hypercalcemia of malignancies and might be an effective treatment for postmenopausal osteoporosis. The authors report a case of a young girl with systemic lupus who developed multiple vertebral collapses due to glucocorticoid therapy, and zoledronic acid was used producing significant clinical and densitometric improvement.Glicocorticóides são fármacos comumente usados no tratamento de pacientes lúpicos, porém apresentam efeitos adversos importantes, principalmente a osteoporose e fraturas. O tratamento da osteoporose em pacientes jovens deve ser eficaz e não prejudicial ao crescimento e remodelamento ósseo. Os bisfosfonatos são drogas que reduzem a incidência de fraturas, mas seu uso em crianças e adolescentes ainda é controverso, devido a seus possíveis efeitos adversos no esqueleto em crescimento. Estudos recentemente publicados demonstraram que o crescimento linear se manteve normal com o uso de bisfosfonatos, não havendo supressão excessiva do remodelamento ósseo ou defeitos de mineralização. O ácido zoledrônico é um novo bisfosfonato endovenoso aprovado pelo FDA para o uso na hipercalcemia das neoplasias e parece ser um tratamento eficaz para a osteoporose pós-menopáusica. Os autores descrevem um caso de uma adolescente lúpica que desenvolveu múltiplas fraturas vertebrais induzidas pelo glicocorticóide e obteve importante melhora clínica e densitométrica após o tratamento com o ácido zoledrônico

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Disease activity as a major risk factor for osteonecrosis in early systemic lupus erythematosus

OBJETIVO. Identificar fatores preditivos para o desenvolvimento da osteonecrose (ONA) em pacientes com Lúpus Eritematoso Sistêmico (LES) de diagnóstico recente. METODOLOGIA. Quarenta e seis pacientes consecutivos, de uma coorte informatizada no ambulatório de LES do serviço de Reumatologia do Hospital das Clínicas de São Paulo, participaram deste protocolo que ocorreu entre julho de 2004 e julho de 2005. Os critérios de inclusão foram: pacientes do sexo feminino; menos de cinco anos de diagnóstico de LES; e idade maior que 18 anos. Todas as pacientes foram submetidas à ressonância nuclear magnética (RNM) dos quadris para o diagnóstico de ONA, independente da sintomatologia. Variáveis clínicas foram obtidas através de prontuários médicos, entrevista e exame clínico. Variáveis laboratoriais incluíram: lipoproteínas séricas, auto-anticorpos, fatores trombofílicos e de hipofibrinólise. Densidade mineral óssea foi medida através da densitometria de dupla emissão de raios-X. Fraturas vertebrais foram investigadas através da realização de radiografias da coluna. RESULTADOS. A ONA foi encontrada em 10 das 46 pacientes. Idade, duração de doença e raça não diferiram entre pacientes lúpicas com e sem ONA. Comparações envolvendo as várias manifestações clínicas do LES, perfil lipoprotéico e de auto-anticorpos, freqüência de trombofilia e hipofibrinólise também não foram estatisticamente diferentes entre os grupos. A freqüência de pacientes com SLEDAI ?8 no ano anterior ao diagnóstico clínico de ONA foi significativamente maior (60%) do que no grupo sem ONA considerando-se o ano anterior à entrada no estudo (19,4%), p=0,011. Corroborando com esse achado, a dose cumulativa de glicocorticóide (GC) utilizada no anterior ao diagnóstico de ONA foi maior quando comparada ao ano anterior à entrada no estudo(p=0,045). Não foram observadas diferenças com relação aos dados densitométricos e radiográficos da coluna. Na análise multivariada somente o SLEDAI permaneceu como fator de risco independente para ONA (OR=6,6, IC=1,07-41,29, p=0,042). CONCLUSÃO. Este estudo revela que a atividade de doença no ano anterior ao diagnóstico clínico de ONA é fator de risco preponderante para o desenvolvimento desta complicação no LES recente.OBJECTIVE. To evaluate predictive factors for osteonecrosis (ON) development in patients with early Systemic Lupus Erythematosus (SLE). METHODS. Forty-six consecutive SLE patients from an electronic cohort in a Lupus Clinic from the Rheumatology Division in the University of São Paulo were enrolled on this study that occurred between July 2004 and July 2005. Inclusion criteria were female gender, age > 18 years-old and less than 5 years of disease duration. All patients underwent magnetic resonance imaging (MRI) of the hips for ON diagnosis irrespective of symptoms. Clinical variables were obtained through medical records, interview and physical examination. Laboratory variables were: serum lipoproteins, autoantibodies profile, trombophilia and hypofibrinolysis factors. Bone mineral density was acquired through dual energy x-ray absorptiometry. Vertebral fractures were investigated by spine X-rays. RESULTS. ON was found in 10 of 46 patients. Age, disease duration and race did not differ between patients with and without ON. The frequency of clinical features, lipoprotein and auto-antibodies profile and frequency of trombophilia and hypofibrinolysis were also alike in the two groups. Importantly, disease activity (frequency of patients with SLEDAI ?8) in the previous year of ON clinical diagnosis was significantly higher when compared to patients without ON in the previous year of study entrance (60.0% vs. 19.4%, p=0.011). Reinforcing this finding, glucocorticoid cumulative dose used in the previous year of ON diagnosis was also higher compared to SLE without ON in the previous year of study entrance (p=0.045). Differences concerning the densitometric and radiographic data were not observed. Remarkably, in the multivariate analysis only SLEDAI remained as an independent risk factor for ON (OR=6.6, CI=1.07-41.29, p= 0.042). CONCLUSION. This study has clearly revealed that disease activity in the previous year of ON clinical diagnosis is the main predictor factor for the development of this complication in early SLE

Lesões destrutivas da linha média induzidas por cocaína com ANCA positivo mimetizando a granulomatose de Wegener Cocaine-induced midline destruction lesions with positive ANCA test mimicking Wegener's granulomatosis

O uso crônico de cocaína por inalação pode causar lesões destrutivas de linha média (LDLMIC), que podem ser difíceis de distinguir das lesões da granulomatose de Wegener (GW) nos ouvidos, nariz e garganta. Descrevemos o caso de uma paciente de 43 anos admitida com história de dois anos de obstrução nasal e rinorreia. Ela havia recebido o diagnóstico de GW há cinco meses e estava em tratamento com prednisona e ciclofosfamida. Ao exame físico apresentava perfuração de septo nasal e palato. Exames de laboratório mostraram elevação das proteínas de fase aguda e teste p-ANCA positivo. Ensaios ELISA antiproteinase 3 e mieloperoxidase foram negativos. Tomografia computadorizada (TC) dos seios paranasais mostrou destruição de septo nasal e palato, bem como sinusite maxilar bilateral. TC de tórax resultou normal. Biópsia da mucosa nasal revelou infiltrado inflamatório sem granuloma ou vasculite. Quando questionada, admitiu ser usuária de cocaína há cinco anos. Os imunossupressores foram suspensos e a paciente não mais fez uso da droga. Ela está sendo monitorada há seis meses e não desenvolveu novas lesões ou sintomas de outros órgãos. O diagnóstico diferencial em pacientes com LDLMIC pode ser desafiador. A avaliação deve incluir pesquisa de uso intranasal de cocaína. Embora o teste de ANCA não diferencie claramente o ANCA encontrado em alguns pacientes com LDLMIC daqueles em pacientes com GW, o envolvimento localizado e os achados de biópsia não típicos de vasculite granulomatosa de pequenos vasos devem ser reconhecidos como características das lesões induzidas por cocaína.<br>Chronic use of cocaine by inhalation may induce midline destructive lesions (CIMDL), which can sometimes be difficult to distinguish from the ear, nose and throat lesions of Wegener's Granulomatosis (WG). We describe the case of a 43-year-old female patient admitted with a two-year history of nasal obstruction and rhinorrhea. She had been diagnosed with WG for five months, being on prednisone and cyclophosphamide. On her physical examination, perforation of her nasal septum and palate was observed. Laboratory tests showed elevated acute phase proteins and a positive p-ANCA test. ELISA assays anti-proteinase 3 and myeloperoxidase were negative. The paranasal sinus computed tomography (CT) showed destruction of the nasal septum and palate, in addition to bilateral maxillary sinusitis. Chest CT was normal. Nasal mucosal biopsy revealed an inflammatory infiltrate, with neither granuloma nor vasculitis. When questioned, she admitted being a cocaine user for five years. Medical therapy and cocaine use were withdrawn. She has been followed up for six months and no other lesion or other organ symptoms occurred. Differential diagnosis in patients with midline destructive lesions can be very challenging. Evaluation should include enquiry about intranasal use of cocaine. Although ANCA testing does not clearly differentiate the ANCA found in some patients with CIMDL from those found in WG patients, the localized involvement and the biopsy findings non-characteristic of small vessel granulomatous vasculitis should be recognized as features for cocaine-induced lesions

Análise do impacto do uso concomitante de corticoide nos desfechos clínicos de pacientes com artrite reumatoide de longa duração em diferentes tratamentos

Background and objective: To analyze the impact of the concomitant use of corticosteroids on the treatment of patients with long-term rheumatoid arthritis in different clinical outcomes. Methods: A cross-sectional study was carried out in a sample of 100 patients with rheumatoid arthritis attended at specialized centers in rheumatology in Florianópolis. Validated instruments were used to evaluate the disease activity (DAS-28 VHS, DAS-28 PCR, SDAI and CDAI), functional hability (HAQ-DI) and quality of life (SF-12 and SF-6D). Statistical analysis was performed using qui-square test (Pearson), Fisher's exact test, Student's t-test, seeking to study the association between the independent variables and the use of corticosteroids. Results: The mean disease duration of the patients was 15.1 ± 8.7 years, which of, 25% used corticosteroids, with an average dose of 6.7 ± 3.9 mg/day. The mean of the physical component summary (PCS) of SF-12 increased significantly by 1.87 points (47.72 ± 3.23 vs 45.85 ± 2.52 p=0.013) in patients who used corticosteroids; on the other hand, in the mental component summary (MCS) we observed a reduction of the mean by 1.5 points (57.91 ± 3.68 vs 56.41 ± 2.98 p=0.046) in these patients. In the association between the use of corticosteroids with DAS-28 VHS and PCR, SDAI, CDAI, HAQ and SF-6D no differences were found independent of the synthetic and/or biological DMARD used. Conclusions: Use of corticosteroids in different treatment strategies is not associated with an increase in the frequency of clinical remission in patients with rheumatoid arthritis. In patients using corticosteroids there was a better quality of life evaluated by the PCS, but not by the MCS.Justificativa e Objetivos: Analisar o impacto da utilização concomitante de corticoide no tratamento de pacientes com artrite reumatoide de longa duração em diferentes desfechos clínicos. Métodos: Realizou-se um estudo transversal em uma amostra de 100 pacientes com artrite reumatoide atendidos em centros especializados em reumatologia da grande Florianópolis. Utilizou-se instrumentos validados para avaliar a atividade da doença (DAS-28 VHS, DAS-28 PCR, SDAI e CDAI), capacidade funcional (HAQ-DI) e qualidade de vida (SF-12 e SF-6D). A análise estatística foi feita empregando teste qui-quadrado de Pearson, exato de Fisher, teste T de Student, buscando estudar a associação entre as variáveis independentes e o uso de corticoides. Resultados: O tempo médio de doença dos pacientes foi de 15,1±8,7 anos. Destes, 25% faziam o uso de corticoides, com uma dose média de 6,7±3,9 mg/dia. A média do componente físico do SF-12 aumentou significativamente em 1,87 pontos (47,72±3,23 vs 45,85±2,52 p=0,013) nos pacientes que utilizavam corticoides, já no componente mental observou-se redução da média em 1,5 pontos (57,91±3,68 vs 56,41±2,98 p=0,046) nestes pacientes. Ao associar o uso de corticoides com o DAS-28 VHS e PCR, SDAI, CDAI, HAQ e SF-6D não foram encontradas diferenças independente do DMCD sintético e/ou biológico utilizado. Conclusões: A utilização de corticoide em diferentes estratégias de tratamento, não se associa ao aumento da frequência de remissão clínica em pacientes com artrite reumatoide. Nos pacientes em uso de corticoides houve melhor qualidade de vida avaliada pelo componente físico, mas não pelo componente mental