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ABSTRACT: INTRODUCTION: Although many studies have suggested that the presence of autoantibodies, such as rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP) in rheumatoid arthritis (RA) are predictors of joint damage, the association with disability and quality of life questionnaires are not known. OBJECTIVES: To evaluate the correlation between the Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) scores with serological markers, such as RF, anti-CCP, and anti-citrullinated vimentin (anti-Sa). PATIENTS AND METHODS: Sixty five patients with early RA (ERA) from the Brasília Cohort of ERA were evaluated. Serology tests (ELISA) for RF (IgM, IgG, and IgA), anti-CCP (CCP2, CCP3, and CCP3.1), and anti-Sa were performed, with the application of the HAQ and SF-36 questionnaires in the initial evaluation. RESULTS: The mean age was 45 years, with a female predominance (86%). At the initial evaluation, RF was positive in 32 individuals (49.23%), anti-CCP in 34 (52.3%), and anti-Sa in nine (13.8%). The initial HAQ score was 1.8. The SF-36 scores were as follow: role-emotional, 19.3; social functioning, 43.1; bodily pain, 25.43; general health, 57.6; mental health, 48.1; vitality, 49.5; role-physical, 4.6; and physical functioning, 24.7. The HAQ and SF-36 scores did not vary with autoantibody levels. CONCLUSION: In many patients, ERA has a major impact on physical ability and health-related quality of life. Although RF and anti-CCP tests have been related with joint destruction and worse clinical prognosis, there is no correlation with the results of questionnaires of quality of life and disability.
Revista Brasileira de Reumatologia 12/2012; 52(6):824-829.
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ABSTRACT: Early diagnosis of rheumatoid arthritis is essential for its proper management. Currently, the initial phase of rheumatoid arthritis is known to provide a window of therapeutic opportunity. Although the diagnosis is primarily clinical, the development and improvement of laboratory and imaging methods have contributed to earlier diagnosis and determination of procedures in early rheumatoid arthritis. In this article, the authors review the role of the major imaging methods used for assessing early rheumatoid arthritis, especially conventional radiography, ultrasonography, and magnetic resonance imaging.
Revista Brasileira de Reumatologia 10/2012; 52(5):761-766.
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ABSTRACT: This study evaluates prospectively whether baseline scores [Health Assessment Questionnaire (HAQ) and SF-36] can predict clinical and radiographic evolution in a cohort of early rheumatoid arthritis (RA) during a 3-year follow-up. Forty consecutive early RA patients were followed for 3 years, while receiving standardized treatment according to a pre-established protocol. HAQ and SF-36 were administered at the initial evaluation and at 3, 6, 12, 18, 24 and 36 months. Hands and feet radiographs were obtained at the initial evaluation and at 12, 24 and 36 months. Preselected outcomes were the occurrence of radiographic erosions, the achievement of an EULAR remission, low disease activity status and the need for biological therapy. The mean age at onset was 45 years with a 90% female predominance. Erosions were found in 42% of patients at T0 and in 70% after 3 years (P < 0.001). At T0, the proportion of patients in remission, low, moderate or high disease activity was 0, 0, 7.5 and 92.5% and 22.5, 7.5, 32.5 and 37.5%, respectively, at 3 years. The mean baseline HAQ score was 1.89 and 0.77 by the third year (P < 0.0001). Most SF-36 domains showed significant improvement except for general state and vitality. Biological therapy was deemed necessary in 22.5% of patients. The initial HAQ and SF-36 scores were not associated with clinical remission, bone erosions or the need for biological therapy at 36 months. The HAQ and SF-36 scores measured at baseline could not predict at 3 years, the preselected outcomes in a Brazilian cohort.
Rheumatology International 12/2011; · 1.88 Impact Factor
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ABSTRACT: Autoantibodies in early rheumatoid arthritis (RA) have important diagnostic value. The association between the presence of autoantibodies against cyclic citrullinated peptide and the response to treatment is controversial. To prospectively evaluate a cohort of patients with early rheumatoid arthritis (<12 months of symptoms) in order to determine the association between serological markers (rheumatoid factor (RF), anti-citrullinated protein antibodies) such as anti-cyclic citrullinated peptide antibodies (anti-CCP) and citrullinated anti-vimentin (anti-Sa) with the occurrence of clinical remission, forty patients diagnosed with early RA at the time of diagnosis were evaluated and followed for 3 years, in use of standardized therapeutic treatment. Demographic and clinical data were recorded, disease activity score 28 (DAS 28), as well as serology tests (ELISA) for RF (IgM, IgG, and IgA), anti-CCP (CCP2, CCP3, and CCP3.1) and anti-Sa in the initial evaluation and at 3, 6, 12, 18, 24, and 36 months of follow-up. The outcome evaluated was the percentage of patients with clinical remission, which was defined by DAS 28 lower than 2.6. Comparisons were made through the Student t test, mixed-effects regression analysis, and analysis of variance (significance level of 5%). The mean age was 45 years, and a female predominance was observed (90%). At the time of diagnosis, RF was observed in 50% of cases (RF IgA-42%, RF IgG-30%, and RF IgM-50%), anti-CCP in 50% (no difference between CCP2, CCP3, and CCP3.1) and anti-Sa in 10%. After 3 years, no change in the RF prevalence and anti-CCP was observed, but the anti-Sa increased to 17.5% (P = 0.001). The percentage of patients in remission, low, moderate, and intense disease activity, according to the DAS 28, was of 0, 0, 7.5, and 92.5% (initial evaluation) and 22.5, 7.5, 32.5, and 37.5% (after 3 years). There were no associations of the presence of autoantibodies in baseline evaluation and in serial analysis with the percentage of clinical remission during follow-up of 3 years The presence of autoantibodies in early RA has no predictive value for clinical remission in early RA.
Rheumatology International 12/2011; · 1.88 Impact Factor
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ABSTRACT: The diagnostic and prognostic value of the serial measurement of antibodies, such as rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), and anti-citrullinated vimentin (anti-Sa) antibodies, has not been defined in early rheumatoid arthritis (ERA).
To prospectively assess the presence of RF, anti-CCP, and anti-Sa in ERA patients.
Forty ERA (less than 12 months) patients of the Brasília cohort were evaluated and followed up for three years. Both clinical and demographic data were recorded, in addition to the results (ELISA) of RF (IgM, IgG, and IgA), anti-CCP (CCP2, CCP3, and CCP3.1), and anti-Sa at the baseline assessment and after 3, 6, 12, 18, 24 and 36 months of follow-up. The results were compared by use of Student t test and paired t test.
The patients' mean age was 45 years, and 90% of them were female. At the time of diagnosis, RF was identified in 50% of the patients (RF IgA, 42%; RF IgG, 30%; and RF IgM, 50%), anti-CCP in 52.5% (no difference between CCP2, CCP3, and CCP3.1), and anti-Sa in 10%. After three years, no difference was observed in RF and anti-CCP prevalence, but anti-Sa increased to 17.5% (P = 0.001).
Repeated RF and anti-CCP measurement, including different isotypes, during three years of follow-up showed no significant changes. The third generation of anti-CCP assays did not increase the diagnostic value of the second-generation assays.
Revista Brasileira de Reumatologia 12/2011; 51(6):564-71.
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ABSTRACT: To describe clinical and ultrasound findings in a patient with infantile systemic hyalinosis (ISH). A 5-month-old boy was evaluated of joint contractures. In addition to clinical and laboratory investigations, an ultrasound of his joints was done and compared to a child with similar age. On examination, a short neck, gingival hyperplasia and papular rash were noted. Joint examination showed painful passive movement, reduced range of motion, and joint contractures in knees, elbows, and small joints of the hands, without any evidence of synovial thickness. Ultrasound of the affected joints showed irregular cortical surface of MCPs and PIP, the presence of osteophytes and bone erosions, increased synovial fluid without evidence of synovial hyperplasia. This is the first report to show evidence of US findings in ISH. Ultrasound findings may help to distinguish ISH from JIA in early stages.
Rheumatology International 12/2010; 31(10):1393-5. · 1.88 Impact Factor
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ABSTRACT: To characterize a population of patients with early rheumatoid arthritis (RA) according to laboratory aspects, comparing it with other similar cohorts.
Data presented are part of a prospective incident cohort study that evaluated 65 patients with early RA, followed for 36 months from the diagnosis at Early Rheumatoid Arthritis Clinic of Hospital Universitário de Brasília (HUB). We recorded demographics, clinical, and laboratory data relevant to the cohort initial assessment, including red blood cells, evidence of inflammatory activity, and presence of autoantibodies (rheumatoid factor (RF)), cyclic citrullinated peptide antibodies (anti-CCP), and antivimentin citrullinated (anti-Sa).
There was a preponderance of female (86%) with mean age of 45.6 years. Twelve patients (18.46%) had laboratory diagnosis of anemia (hemoglobin < 12 g / dL). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were above the reference value for 51 (78.46%) and 46 (70.76%) patients, respectively. Thirty-two patients (49.23%) were positive for at least one of the RF isotypes, and 28 patients (43.07%) were positive for IgA RF, 19 (29.23%) for IgG, and 32 ( 49.23%) for IgM RF, respectively; 34 patients (52.30%) were positive for at least one of the techniques used in investigation of anti-CCP (CCP2, or CCP3, or CCP3.1), while 9 (13,85%) were positive for anti-Sa.
The laboratory characteristics of patients enrolled in this Brazilian cohort are similar in many respects to those of North-American, European, and Latin-American cohorts previously published.
Revista Brasileira de Reumatologia 08/2010; 50(4):375-88.
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ABSTRACT: Very few studies carried out with Latin American populations on the demographic and clinical characteristics of patients diagnosed with early rheumatoid arthritis (RA) can be found in the literature.
To characterize a population of patients with early RA, prospectively followed, concerning demographic and clinical aspects and compare them with other similar cohorts.
The data presented are part of an incident cohort prospective study, in which 65 patients with early RA were evaluated and followed regularly for 36 months at the Early Rheumatoid Arthritis Outpatient Clinic of the University Hospital of Brasília (HUB, from the Portuguese). The demographic and clinical data of the initial evaluation, including general characteristics, clinical history, and physical examination were recorded. Descriptive statistics of the variables was applied.
Women (86%) with a mean age of 45.6 years, Caucasian or Black (47.6%), belonging to intermediate-low social classes (53.85%), with 8.3 years of schooling, predominated. The presenting symptoms of the majority of patients were acute (76.9%), with polyarticular onset (69.2%), persistent synovitis of the hands (90.7%), and prolonged morning stiffness (157 minutes on average). Patients had a high average score of painful (18.6) and swollen (13.9) joints and high prevalence of rheumatoid nodules (15.3%), which suggests disease with aggressive presentation in its initial phases.
The demographic and clinical characteristics of patients enrolled in this Brazilian cohort differed, on several aspects, from previously published North American, European, and Latin American cohorts.
Revista Brasileira de Reumatologia 06/2010; 50(3):235-48.
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ABSTRACT: Few studies have prospectively assessed the tools used to measure quality of life, both generic and specific, in patients with early rheumatoid arthritis (RA).
The objective of this study was to characterize a population of patients with early RA (less than 12 months after symptom onset at the time of the diagnosis) prospectively followed for the pattern of responses to questionnaires addressing quality of life, the Health Assessment Questionnaire (HAQ) and Medical Outcomes Study SF-36 Health Survey (SF-36).
Forty patients with early RA at the time of diagnosis, treated with a standard treatment regimen, were prospectively followed for 3 years. Demographic and clinical data were recorded, and HAQ and SF-36 questionnaires were applied at baseline and after 3, 6, 12, 18, 24, and 36 months. Paired Student t test and Wilcoxon test were used for comparisons (significance level of 5%).
The mean age was 45 years, with a prevalence of the female gender (90%). The average score of the initial HAQ was 1.89, with a progressive decline to 0.77 in the third year (P < 0.0001). Most domains of the SF-36 questionnaire presented significant improvement during the three years of follow-up, except for general health and vitality.
In this population of patients with early RA at the time of diagnosis, the results showed significant impact on quality of life at the time of diagnosis, as measured by HAQ and SF-36 questionnaires. The early treatment of RA seems to be associated with improved health-related quality of life reported by patients.
Revista Brasileira de Reumatologia 06/2010; 50(3):249-61.
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ABSTRACT: The progression of rheumatoid arthritis (RA) is quite variable, ranging from very mild or subclinical forms (approx. 10%) to rapidly progressing and debilitating forms (10-15%). The majority of patients present with an intermediate stage with episodes of exacerbation separated by periods of relative inactivity, which evolves to progressive functional losses. To optimise the therapeutic management of early RA it is necessary to perform periodic evaluations of the clinical and laboratory test responses to the treatment instituted, as well as the parameters indicating disease prognosis. Composite measures are frequently used to evaluate the disease activity score (DAS), including the response criteria of the American College of Rheumatology (ACR), the response criteria and the DAS according to the European League Against Rheumatism (EULAR) and the composite indices of disease activity (CIDsA): DAS, the index of disease activity based on 28 joints (DAS 28), the simplified disease activity index (SDAI) and the clinical disease activity index (CDAI). The evaluation of prognosis includes investigation of the absence or occurrence of disease and joint damage remission. Due to the multifaceted nature of RA, no single clinical or laboratory parameter is able to describe satisfactorily the level of inflammatory activity or the disease prognosis at any given time.
Schweizerische medizinische Wochenschrift 01/2010; 140:w13100. · 1.68 Impact Factor
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ABSTRACT: 8 p. : il. Introdução: O fator reumatoide (FR), apesar de suas limitações, ainda é o marcador sorológico mais utilizado para diagnóstico da artrite reumatoide (AR) inicial. Há controvérsias sobre sensibilidade, especificidade, correlação com prognóstico radiológico e variação ao longo do tempo dos títulos dos sorotipos IgG, IgM e IgA. Objetivo: Avaliar o comportamento dos diferentes sorotipos de FR (IgG, IgM e IgA), em avaliações seriadas, e sua correlaçãocom a ocorrência de erosões radiográficas. Pacientes e métodos: Foram avaliados 40 pacientes com o diagnóstico de AR inicial (menos de 12 meses de sintomas) durante três anos de acompanhamento. A titulação dos sorotipos de FR foi feita por ELISA, na avaliação inicial, e seriadamente ao longo de 36 meses. Aplicou-se um modelo de regressão de efeitos mistos, considerando-se como desfecho a ocorrência de erosões radiográficas (radiografia de mãos e punhos, pés e tornozelos anuais). Resultados: Na avaliação inicial, 30%, 42,5% e 50% dos pacientes foram positivos para FR IgG, IgA e IgM, respectivamente. Os títulos de FR IgA e FR IgM foram maiores nos pacientes que apresentaram erosões radiográficas durante o acompanhamento (10-220 UI/dL contra 0 a 10 UI/dL nos pacientes sem erosões, P < 0,05). Os títulos de FR IgM e IgG não variaram ao longo dos três anos de acompanhamento. Por outro lado, em relação aos títulos de FR IgA houve uma tendência linear positiva ascendente significativa (P = 0,0013) apenas no grupo que apresentou erosões radiográficas. Conclusão: 1) Pesquisa dos sorotipos FR IgA e FR IgG não aumenta a frequência de positividade do FR e, portanto, não contribui para o diagnóstico de AR; 2) a estabilidade observada do FR IgM ao longo do tempo não justifica solicitações repetidas do FR durante a evolução da AR; 3) títulos mais altos de FR IgA e FR IgM são observados nos pacientes mais graves, com erosões radiográficas; 4) FR IgA apresenta um comportamento claramente distinto nos pacientes que apresentam ou não erosões radiográficas, o que pode ter implicações na fisiopatogenia e na avaliação prognóstica da doença.
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ABSTRACT: The main goals of the treatment of a patient with RA are: to reduce pain, joint swelling and constitutional symptoms such as fatigue, to improve joint function, stop progression of bone-cartilage damage , prevent disabilities and reduce morbidity and mortality. In recent years, the therapeutic concept of early RA (first 12 months of symptoms) has undergone major changes. Three aspects in particular have become the basis of the new treatment paradigm: early diagnosis, immediate beginning of Disease Modifying Antirheumatic Drugs therapy (DMARD) and strict control of the inflammatory activity. In this article, the authors review the general principles of management of patients with early RA.
Revista da Associação Médica Brasileira 56(3):360-2. · 0.77 Impact Factor
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ABSTRACT: Tuberculosis, a polymorphic disease, is a diagnostic challenge, particularly when arises concomitantly to an autoimmune disease such as rheumatoid arthritis (RA). Herein, the authors describe a 33-year-old woman with nodular RA who was being treated with methotrexate, sulfasalazine and corticosteroids and presented with subcutaneous nodules simultaneously with aseptic meningitis. Mycobacterium tuberculosis was identified in cultures from a biopsy of an axillary nodule. The patient also developed polyuria and polydipsia with normal glycemia; antidiuretic hormone (ADH) treatment before and after a 3% saline infusion test was performed and diabetes insipidus was diagnosed. An encephalic MRI showed sellar and suprasellar masses, suggesting central diabetes insipidus (CDI). The patient received standard tuberculosis (TB) treatment for 6 months and also DDAVP (desmopressin acetate) during this period. Control of CDI was observed. A pre-surgical magnetic resonance imaging (MRI) showed no pituitary mass. It is known that intrasellar tuberculoma occurs in only 1% of TB patients. TB should be considered in the differential diagnosis of CDI, especially in immunosupressed patients and in countries where this infection is a serious public health problem.
Acta reumatologica portuguesa 35(2):232-5. · 0.55 Impact Factor
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ABSTRACT: Generalization of the concept of early rheumatoid arthritis -RA and existence of a window of therapeutic opportunity, the period when appropriate therapy for this disease would determine clinical improvement, led to the concept that early diagnosis and treatment can change the disease's course. Currently, the goal is to evaluate patients with joint symptoms at the earliest opportunity. Definition of the initial phase of RA includes the first few weeks or months of symptoms (usually less than 12 months), and the first 12 weeks of symptoms of very early or initial RA are considered to be the critical period. Although all patients require early assessment and treatment, there are specific reasons for the involvement of a specialist soon in the evaluation of patients with early RA, since the inflammation that characterizes the disease should be treated as soon as possible. Failure to diagnose or treat a patient with RA at the very early stage of the disease increases the risk of progression to persistent joint inflammation and damage. On the other hand, aggressively treating patients with mild arthritis, which probably will not evolve to erosive forms is equally damaging. It exposes patients to risk without proven benefits and represents the opposite of effective early treatment. Therefore, within the current concept of a window of opportunity, early diagnosis of RA is essential and to establish, as soon as possible those patients who will progress to more severe forms, and therefore require more aggressive therapy.
Revista da Associação Médica Brasileira 56(2):227-9. · 0.77 Impact Factor
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ABSTRACT: The association between serological markers with the need of biological therapy for early rheumatoid arthritis (ERA) is not known, with few available data addressing this question.
To prospectively evaluate a cohort of patients with ERA (less than 12 months of symptoms) in order to determine the possible association between serological markers (rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP), and citrullinated anti-vimentin (anti-Sa) with parameters of therapeutic outcome (this later defined by the need of introducing biological therapy).
Forty patients with early RA were evaluated at the time of diagnosis and have been followed for 3 years, in use of standardized therapeutic treatment. Demographic and clinical data were recorded, as well as serology tests (ELISA) for RF (IgM, IgG and IgA), anti-CCP (CCP2, CCP3 and CCP3.1) and anti-Sa in the initial evaluation and at 3, 6, 12, 18, 24 and 36 months of follow-up. As outcomes of the RA development, the need or not for biological therapy during the follow-up period were considered. Comparisons were made through the Student t test, mixed-effects regression analysis and analysis of variance (significance level of 5%).
The mean age was 45 (+/- 12) years; a female predominance was observed (90%). At the time of diagnosis, RF was observed in 50% of cases (RF IgA - 42%, RF IgG - 30% and RF IgM - 50%), anti-CCP in 50% (no difference between CCP2, CCP3 and CCP3. 1) and anti-Sa in 10%. After 3 years, no change in the RF prevalence neither in the anti-CCP was observed, but the anti-Sa increased to 17.5% (p = 0.001). Biological therapy was necessary in 22.5% of patients. The mean RF IgA and anti-CCP 2 levels during the 3 years were higher among patients who needed biological therapy (p <0.05 for both).
Higher titles of RF and anti-CCP over time were associated with the need for biological therapy.
Acta reumatologica portuguesa 35(2):156-66. · 0.55 Impact Factor
