342º Reunião Ordinária do Conselho Nacional de Saúde - 10 maio 2023

Targeting Environmental Risks to Prevent Rheumatic Disease.

Targeting environmental factors can be an important way to reduce the incidence of rheumatic diseases (RDs). Such approaches may be at population levels; furthermore, an emerging ability to identify an individual who is at very high risk for the development of a future RD can allow for personalized approaches to environmental modification for prevention. In this article, we will discuss challenges and opportunities to targeting environmental factors for the prevention of RDs.

Estado actual y retos futuros en el tratamiento de las enfermedades reumáticas / Current status and future challenges in the treatment of rheumatic diseases

Las nuevas estrategias, que incluyen el diagnóstico y el tratamiento tempranos, el enfoque de tratamiento dirigido a un objetivo, la remisión como ese objetivo principal del tratamiento, la participación de los pacientes en las decisiones terapéuticas, junto con el desarrollo de nuevos tratamientos efectivos, han cambiado las expectativas de los reumatólogos y de los pacientes con enfermedades reumáticas. Todavía existen, sin embargo, importantes desafíos tales como la seguridad a largo plazo de los tratamientos actuales y poder escoger tratamientos más individualizados y eficaces, de forma tal de elegir el mejor tratamiento para cada paciente. El futuro, como en el resto de la medicina, probablemente sea la prevención del desarrollo de enfermedades reumáticas. Discutiremos estos temas en esta revisión. (AU)

New strategies, including early diagnosis and treatment, targeted therapy, remission as the main objective of treatment, patient involvement in therapeutic decision-making, and the development of new effective therapies, have changed the expectations of rheumatologists and patients with rheumatic diseases.There are still serious challenges, such as the long-term safety of current treatments and the ability to make more individualized and effective treatments to choose the best treatment for each patient. The future, as that of the whole of medical science, will probably lie in preventing the development of rheumatic diseases. We will discuss these issues in this review. (AU)

Prevention and adherence in Rheumatic and Musculoskeletal disease.

Rheumatic and Musculoskeletal Diseases (RMDs) are chronic conditions that affect a substantial number of people. RMDs are significantly related to co-morbidity. Therefore, focusing on prevention in RMDs is of importance to promote and maintain health. Prevention includes primary-, secondary-, tertiary-, and clinical prevention. Primary prevention aims to prevent the onset of disease before the disease process begins, secondary prevention includes detecting and reducing disease and risk factors at the earliest possible point, and tertiary prevention aims to limit the influence of a recognized or verified disease and to address or reduce further development or worsening of the disease, including physical and psychosocial disability. Clinical prevention attempts to integrate prevention into the disease management to limit disease progression and prevent complications and relapse. This chapter will focus on the evidence for prevention and highlight how innovations and trends can contribute by using digital technologies as an example.

Application of the 2019 European League Against Rheumatism/American College of Rheumatology systemic lupus erythematosus classification criteria in clinical practice: a single center experience.

Originally developed as research tools, different classification criteria sets for systemic lupus erythematosus (SLE) are also used to diagnose SLE in routine clinical care. The recently developed European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) 2019 criteria set is noted to perform better than previous SLE classification criteria. This study applied the new criteria schema to a tertiary center SLE cohort, ascertained its performance, and identified the clinical characteristics of patients who did not fulfill these criteria. From the 217 patients who were included, 11 (5%) did not meet the new criteria, mainly because of the antinuclear antibody entry criterion, resulting in a diagnostic sensitivity of 94%. Within this group, we found that constitutional and renal manifestations were unusual. Additionally, specific SLE antibodies as well as hypocomplementemia were less likely to be present. We did not observe a statistically significant difference in outcomes between the two groups of patients (fulfilling vs. unfulfilling the new criteria). We conclude that the EULAR/ACR criteria may misclassify a small subset of SLE patients with milder disease. It is important to be cognizant of key clinical and serologic features of these patients and treat them accordingly to prevent further irreversible damage.

Efficacy, immunogenicity and safety of vaccination in adult patients with autoimmune inflammatory rheumatic diseases: a systematic literature review for the 2019 update of EULAR recommendations.

Aim: To present a systematic literature review (SLR) on efficacy, immunogenicity and safety of vaccination in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD), aiming to provide a basis for updating the EULAR evidence-based recommendations. Methods: An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Outcome was determined by efficacy, immunogenicity and safety of vaccination in adult patients with AIIRD, including those receiving immunomodulating therapy. Furthermore, a search was performed on the effect of vaccinating household members of patients with AIIRD on the occurrence of vaccine-preventable infections in patients and their household members (including newborns). The literature search was performed using Medline, Embase and the Cochrane Library (October 2009 to August 2018). Results: While most investigated vaccines were efficacious and/or immunogenic in patients with AIIRD, some were less efficacious than in healthy control subjects, and/or in patients receiving immunosuppressive agents. Adverse events of vaccination were generally mild and the rates were comparable to those in healthy persons. Vaccination did not seem to lead to an increase in activity of the underlying AIIRD, but insufficient power of most studies precluded arriving at definite conclusions. The number of studies investigating clinical efficacy of vaccination is still limited. No studies on the effect of vaccinating household members of patients with AIIRD were retrieved. Conclusion: Evidence on efficacy, immunogenicity and safety of vaccination in patients with AIIRD was systematically reviewed to provide a basis for updated recommendations.

[Infective endocarditis in Morocco through the experience of a hospital department]. / L'endocardite infectieuse au Maroc à travers l'expérience d'un service hospitalier.

Infective endocarditis is a grave disease because of a high level of morbidity and mortality. We conducted a retrospective analysis of 100 patients hospitalized for infective endocarditis from January 2009 until December 2015. The mean age was 41 years with a male predominance. Infective endocarditis occurs on a native valve (77 patients), prosthetic valves (12 patients), Pacemaker (7 patients) and congenital heart disease (4 patients). The diagnostic delay was 77 days on average. The fever was present in 85 patients. Blood cultures were negative in 54 patients. Echocardiography allowed visualizing the vegetations in 95 patients. In patients with prosthetics valves, a paraprosthetic regurgitation was diagnosed in 54 % of these patients and vegetation in 18 %. The main complications are heart failure (42), neurological (19), spleen (10) and renal (23) complications. The evolution under medical treatment was marked by the clinical-laboratory improvement in 57 patients, the lack of improvement with persistent fever in 21 patients. The mortality rate of our series is 23 %. Only seven patients underwent urgent surgery for hemodynamic and infectious indications. At the end of this work, it is emphasized that the epidemiological profile of infective endocarditis does not follow the changes of Wold. Its management is difficult in our context (significant diagnostic delay, often negative blood cultures, high level of morbidity, lack of recourse to early surgery). The improvement of this disease consistes of the prevention of acute articular rhumatism and the establishment of an heart team endocarditis to adapt international recommendations to our context.

Avances en la atención de salud a los pacientes con enfermedades reumáticas / Advances in health care in rheumatoid diseases

Introducción: Las enfermedades reumáticas, debido a su evolución natural, provocan afectaciones a la calidad de vida de las personas afectadas por eso es de vital importancia el diagnóstico temprano, el tratamiento oportuno y la prevención. El conocimiento de los adelantos contemporáneos en la atención de salud es una herramienta que ayuda a tomar decisiones clínicas en la práctica diaria, aunque la decisión final sobre el diagnóstico y el tratamiento de un paciente determinado dependerá de las características particulares de cada uno. Objetivo: Discutir algunos avances en la atención de salud a los pacientes con en enfermedades reumáticas. Desarrollo: Debido a que en la práctica clínica se encuentran con frecuencia resultados discordantes, la actualización de temas como este permite socializar los resultados obtenidos con profesionales del gremio, mostrar las estrategias más efectivas o los mejores métodos para el diagnóstico precoz, tratamiento y cuidado de estas enfermedades sobre la base de experiencias asistenciales e investigativas en varias regiones del mundo o en contextos diferentes. Conclusiones: Para controlar mejor las enfermedades reumáticas se necesita una estrategia organizativa en el marco de la cual se aprovechen las fortalezas de la prevención primaria, secundaria y terciaria y que los profesionales, de acuerdo con sus conocimientos y competencias, lleven a cabo acciones que prevengan las graves complicaciones de estas enfermedades. En varios estudios clínicos y ensayos terapéuticos se trabaja con novedosos fármacos biológicos, donde se evalúa su efectividad, se identifican los efectos adversos y se valora la relación riesgo-beneficio(AU)

Rheumatic diseases, due to their natural evolution, bring with them effects on the quality of life of the people carrying this conditions, which is why their early diagnosis, timely treatment and prevention are of vital importance. The knowledge of contemporary advances in health care is a tool to help when making clinical decisions in daily practice, although the final decision on the diagnostic or therapeutic approach of a specific patient will depend on the characteristics of the same. Objective: to discuss some advances in health care in rheumatoid diseases. Development: due to the fact that in clinical practice discordant results are frequently found, the updating of topics such as these allows to socialize the results obtained with professionals of the guild, to show the most effective strategies or the best methods for the early diagnosis, treatment and management of these diseases, on the basis of assistance and research experiences in various regions of the world or in different contexts. Conclusions: for a better control of rheumatic diseases requires a strategy of articulation where the strengths of primary, secondary and tertiary prevention are exploited, where the professionals in accordance with their competence execute actions that prevent the serious complications of these diseases and where properly treat infectious processes in particular, those produced by Streptococcus A, among others. Results of several clinical trials and therapeutic trials work with novel biological drugs, assessing their effectiveness, identifying adverse effects, assessing the risk-benefit ratio and the convenience of these forming part of the treatment scheme against various targets(AU)

Rheumatology science and practice in India.

The practice of rheumatology in a country like India presents its own unique challenges, including the need to manage patients in a cost-constrained setting, where the lack of uniform government funding for healthcare merits the need to optimize the use of cheaper medicines, as well as devise innovative strategies to minimize the use of costlier drugs such as biologic disease-modifying agents. Use of immunosuppressive agents is also associated with increased risks of infectious complications, such as the reactivation of tuberculosis. In this narrative review, we provide a flavor of such challenges unique to Rheumatology practice in India, and review the published literature on the management of common rheumatic diseases from India. In addition, we critically review existing guidelines for the management of rheumatic diseases from this part of the world. We also discuss infectious etiologies of rheumatic complaints, such as leprosy, tuberculosis, and Chikungunya arthritis, which are often encountered here, and pose a diagnostic as well as therapeutic challenge for clinicians. There remains a need to identify and test more cost-effective strategies for Indian patients with rheumatic diseases, as well as the requirement for more government participation to enhance scant facilities for the treatment of such diseases as well as foster the development of healthcare services such as specialist nurses, occupational therapists and physiotherapists to enable better management of these conditions.

Predictors for influenza vaccine acceptance among patients with inflammatory rheumatic diseases.

BACKGROUND: Patients with inflammatory rheumatic diseases are at higher risk for influenza and current guidelines recommend vaccination for this group of patients. The aim of this study was to evaluate the vaccination coverage and predictors for influenza vaccination among patients with inflammatory rheumatic diseases. METHODS: This survey was conducted at the outpatient rheumatology clinic at the Medical University of Vienna between July and October 2017. All patients diagnosed with an inflammatory rheumatic disease and receiving immunosuppressive therapy were asked to complete a questionnaire about their influenza vaccination status for 2016/17. RESULTS: 490 patients with rheumatic diseases completed a questionnaire (33% male, mean age 55.3 years). The influenza vaccination rate for the previous season was 25.3% (n = 124/490). Predictors for a positive influenza vaccination status were higher age (Adjusted Odds Ratio 5.0, 95% Confidence Interval 2.4-10.4) and treatment with biological disease-modifying antirheumatic drugs (AOR 2.0, 95% CI 1.3-3.1). Patients who received a recommendation for influenza vaccination by their general practitioner were significantly more likely to be vaccinated than those who did not (57% vs. 15%, AOR 6.6, 95% CI 4.1-10.8); even more so if they received a recommendation by their rheumatologist (62% vs. 19%, AOR 9.0, 95% CI 4.9-16.5). The main reasons for patients to decline influenza vaccination were fear of side effects (36%), concerns that vaccination might not be effective due to their immunosuppressed condition (38%) or that it might worsen the rheumatic disease (20%). CONCLUSIONS: A moderate influenza vaccination rate of 25.3% was detected among patients with inflammatory rheumatic diseases. Recommendation of the influenza vaccine by a physician exerts the most effective impact on a positive vaccination status.

Fibromialgia

Site dedicado a informar sobre essa doença reumatológica crônica. Sintomas, causas e tratamentos.

Rheumatic manifestations of hepatitis C virus chronic infection: Indications for a correct diagnosis.

Hepatitis C virus (HCV) is a hepato- and lymphotropic agent that is able to induce several autoimmune rheumatic disorders: vasculitis, sicca syndrome, arthralgias/arthritis and fibromyalgia. The severity of clinical manifestations is variable and sometimes life-threatening. HCV infection can mimic many primitive rheumatic diseases, therefore, it is mandatory to distinguish HCV-related manifestations from primitive ones because the prognosis and therapeutic strategies can be fairly dissimilar. The new direct-acting antivirals drugs can help to avoid the well-known risks of worsening or new onset of autoimmune diseases during the traditional interferon-based therapies.

[Scurvy. A rare differential diagnosis of rheumatic diseases]. / Skorbut. Eine seltene Differenzialdiagnose rheumatischer Erkrankungen.

BACKGROUND: In December 2014 a patient presented to our clinic with the clinical symptoms of vasculitis. However, treatment with glucocorticoids did not lead to any improvement; therefore, the differential diagnostics were extended to other indications and ultimately led to the diagnosis of scurvy. OBJECTIVE: This article describes the clinical picture of scurvy and its relationship to rheumatic diseases based on a clinical case and additional information from the literature. Differences and similarities with important rheumatological disease symptoms are presented. RESULTS: Scurvy is a rare hypovitaminosis disease which can be manifested in different forms. In addition to vasculitis the symptoms can also resemble arthritis and hemarthrosis is a typical finding. These symptoms can be accompanied by unspecific manifestations, such as muscle pain and due to impaired collagen synthesis characteristic features, such as corkscrew hair can be observed. The causal therapy of scurvy is substitution of ascorbic acid. CONCLUSION: Scurvy is a rare differential diagnosis in the context of rheumatic diseases. The indications for scurvy can be a lack of response to immunosuppressive and immunomodulatory drugs as well as individual symptoms, such as corkscrew hair.

Prevention of rheumatic diseases: strategies, caveats, and future directions.

Rheumatic diseases affect a significant portion of the population and lead to increased health care costs, disability, and premature mortality; effective preventive measures for these diseases could lead to substantial improvements in public health. Natural history studies show that for most rheumatic diseases there is a period of preclinical disease development during which abnormal biomarkers or other processes can be detected. These changes are useful to understand mechanisms of disease pathogenesis; in addition, they may be applied to estimate a personal risk of future disease while individuals are still relatively asymptomatic and ultimately be used to identify individuals who may be targeted for preventive interventions.