Trapeziometacarpal Dislocations in Pediatric Age, Is There a Better Treatment? Series of Cases and a Systematic Review.

(1) Background: Dislocations of the trapeziometacarpal joint (TMC) are uncommon in children and adolescents. Only a few isolated cases are reported in the literature. Therapeutic guidance is minimal and inconclusive. (2) Methods: The authors present four patients treated for this unusual lesion. We evaluated the evolution according to treatment, age, patient activity, and quickDASH. Despite the clear limitation of the small number of patients, it is relevant to try to better understand this lesion and its evolution. A systematic review of the literature was also conducted. (3) Results: This is the largest published series of TMC dislocations in children and adolescents. Patients included a 12-year-old girl treated conservatively with a poor quickDASH; a 9-year-old girl treated surgically with the Eaton-Littler technique for a new dislocation with a partially modified quickDASH; a 13-year-old boy with two necessary closed reductions for a new dislocation and a very good final quickDASH; and a 12-year-old boy treated with closed reduction and percutaneous fixation with excellent final results with quickDASH. (4) Conclusions: In the absence of scientific evidence, conservative treatment and ligament reconstruction did not provide good functionality. In contrast, closed reduction with percutaneous fixation provided excellent results. Therefore, the authors would recommend closed reduction and percutaneous needle fixation as an elective method to treat TMC dislocations in pediatric and adolescent patients.

Reverse Ishiguro Extension Block Technique as an Alternative for Irreducible Osseous Mallet Finger.

Subacute or late-presenting unstable osseous mallet finger might be hard to reduce and, therefore, remain subluxed when using the traditional Ishiguro technique. In such cases, we suggest it is best to prioritize correction of joint subluxation over step-by-step adherence to the traditional Ishiguro technique. Specifically, we contend that carrying out the procedure in reverse order typically results in an easier and more stable reduction of both joint and fracture.

The loads developed by epicondylar and epitrochlear muscles across the elbow joint. A dynamic simulated model.

The radio-humeral joint has traditionally been believed to support most of the loads transmitted through the elbow. Load transfer through the elbow has been a controversial issue since the publication of the first biomechanical studies on the subject, most of which were based on extrinsic forces acting on the extended joint. The present study analyzes load distribution across the six different compartments in the elbow while the joint is flexed, as well as the intrinsic forces generated in the epicondylar and epitrochlear muscles. Ten cadaveric elbows were positioned at 90° of flexion, forearm in a neutral position and wrist at 0°. Tekscan sensors were used for measuring intraarticular pressures. Forces generated by epitrochlear muscles results in a series of loads that affect mainly the anteromedial facet (40%), followed by the posterolateral facet (34%) of the ulnohumeral joint, with the flexor carpi ulnaris generating the heaviest loads (43% on the anteromedial and 38% on the posterolateral facets). Conversely, the forces generated by the epicondylar muscles, similar in behavior but with an opposite direction, convey heavier loads to the elbow's anterolateral facet (45%), followed by the radiohumeral joint (26%) with the extensor carpi ulnaris generating the heaviest loads (54% on the anterolateral facet and 17% on the radiohumeral joint). Our results indicate that the elbow joint exhibits a characteristic load distribution pattern that depends on the muscles, as intrinsic forces are generated by the epicondylar and epitrochlear muscles. The anterior portion of the ulnohumeral joint is the area bearing the heaviest loads.

Gaps between research and recommendations in rheumatoid arthritis.

OBJECTIVES: To identify recommendations on the diagnosis and management of rheumatoid arthritis (RA) supported by low recommendation grades, to study the causes of this low grading, and to propose solutions. METHODS: A group of six rheumatologists, with extensive experience in the development of systematic reviews, reviewed national and international RA recommendations and practice guidelines. They identified all recommendations with a low level of evidence or recommendation grade (levels equivalent to 4, 5, or grades C or D of the Oxford Levels of Evidence), classified them by areas (diagnosis, follow-up, treatment, others), and analyzed plausible causes of low graduation. A Delphi was used to select 10 recommendations where it was most important to obtain quality evidence to support them. Subsequently, actions were proposed to improve evidence and recommendation grading. RESULTS: Fourteen documents were analyzed, in which 192 recommendations with low evidence/grade of recommendation were identified, most of which were on treatment. The two most frequent causes of this low level are the absence of studies and the discrepancy between the wording of the recommendation and the evidence used. Finally, the proposed solution to the critical recommendations is a list of unanswered research questions and possible designs to answer them. CONCLUSIONS: We propose to design and promote research that truly supports or rectifies clinical practice and, thus, bridges the gap between existing evidence and critical recommendations.

Efficacy and safety of glucocorticoids in rheumatoid arthritis: Systematic literature review. / Eficacia y seguridad de los glucocorticoides en la artritis reumatoide: revisión sistemática de la literatura.

OBJECTIVES: 1) To systematically and critically review the evidence on the characteristics, efficacy and safety of glucocorticoids (CS) in rheumatoid arthritis (RA); 2) to generate practical recommendations. METHODS: A systematic literature review was performed through a sensitive bibliographic search strategy in Medline, Embase and the Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of CS in patients with RA. Two reviewers performed the first selection by title and abstract. Then 10 reviewers selected the studies after a detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. In a nominal group meeting, based on the results of the systematic literature review, related recommendations were reached by consensus. RESULTS: A total of 47 articles were finally included. CS in combination with disease-modifying antirheumatic drugs help control disease activity and inhibit radiographic progression, especially in the short-to-medium term and in early RA. CS can also improve function and relieve pain. Different types and routes of administration are effective, but there is no standardized scheme (initial dose, tapering and duration of treatment) that is superior to others. Adverse events when using CS are very frequent and are dose-dependent and variable severity, although most are mild. Seven recommendations were generated on the use and risk management of CS. CONCLUSIONS: These recommendations aim to resolve some common clinical questions and aid in decision-making for CS use in RA.

Study of intraarticular pressures in the elbow joints.

The purpose of this study was to describe pressure originating in the six elbow articular compartments after muscular contractions. Ten cryopreserved cadaveric arms were dissected and the insertional tendons and capsuloligamentous tissues were preserved. The specimens were placed in a custom-made device. Elbow position was established at 90° flexion with the forearm in a neutral position and the wrist extended at 0°. Tekscan sensors sere used for measuring intraarticular pressures. Without loading the elbow, the humeroradial joint received the lowest pressure, and, among the humeroulnar joints, the highest pressure was found in the anterolateral compartment. After loading the epitrochlear muscles to the maximum (5.0 kg), the pressure increased in the anteromedial joint (0.6 kg to 3.3 kg) and decreased in the posteromedial and anterolateral joints (4.2 kg to 0.3 kg and 4.2 kg to 0.9 kg, respectively). After the same loading in the epicondylar muscles, the pressure increased in the anterolateral and humeroradial joints (4.2 kg to 8.2 kg and 0.2 kg to 1.0 kg respectively), but decreased in the posterolateral joint (3.4 kg to 1.0 kg). The pressure distribution patterns among the humeroulnar compartments depend on the muscle geometries and their origins. Understanding these patterns can be useful in applying physiotherapeutic treatments for reinforcement of different muscular groups in order to decrease pressure in certain articular compartments.

Very Low Disease Activity, DAPSA Remission, and Impact of Disease in a Spanish Population with Psoriatic Arthritis.

OBJECTIVE: To examine the grade of agreement between very low disease activity (VLDA) and Disease Activity Index for Psoriatic Arthritis (DAPSA) remission, as well as their association with the effect of the disease as assessed by the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire in patients with psoriatic arthritis in routine clinical practice. METHODS: Posthoc analysis of data from a cross-sectional multicenter study. Patients were included who fulfilled the Classification for Psoriatic Arthritis (CASPAR) criteria with at least 1 year of disease duration and were treated with biological and/or conventional synthetic disease-modifying antirheumatic drugs according to routine clinical practice in Spain. Patients were considered in VLDA if they met 7/7 of the minimal disease activity criteria. DAPSA and clinical (c)DAPSA score ≤ 4 identified remissions. RESULTS: Of the 227 patients included in the original study, 26 (11.5%), 52 (22.9%), and 65 (28.6%) were in VLDA, DAPSA remission, and cDAPSA remission, respectively. There was a moderate agreement between VLDA and DAPSA remission (κ = 0.52) or cDAPSA remission (κ = 0.42). Patients with VLDA had less effect of the disease as measured by PsAID [mean total score (SD): VLDA 1.1 (1.2); DAPSA remission 1.3 (1.5); cDAPSA remission 1.7 (1.6)]. There was a moderate agreement between DAPSA remission or cDAPSA remission and PsAID < 4 (κ = 0.46 and κ = 0.58 respectively), while poor agreement (κ = 0.18) was found between VLDA and PsAID < 4. CONCLUSION: VLDA criteria seem to be more stringent for assessing a status of remission; however, DAPSA remission shows better correlation with a patient-acceptable symptoms state than VLDA does.

Recommendations for the Management of Comorbidity in Patients With Axial Spondyloarthritis in Clinical Practice. / Recomendaciones para el manejo de la comorbilidad en la práctica clínica en pacientes con espondiloartritis axial.

OBJECTIVES: To identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective. METHODS: A multidisciplinary group was selected (10 rheumatologists-six of them experts in AxSpA-, 2 general practitioners, an internist, a cardiologist, a gastroenterologist and a psychologist). In a first discussion meeting, the scope and users were established and a list of comorbidities was voted based on frequency and impact. The panelists had to defend the inclusion of each comorbidity/item in the document with consistent arguments. Four panelists and two methodologists developed systematic reviews on controversial topics. In a second meeting, the results of the reviews and the arguments concerning the items to be included were presented. After the meeting, the final document was drafted. RESULTS: The final document includes two checklists, one for health professionals and another for patients; they incorporate cardiovascular risk, renal comorbidities, gastrointestinal risk, lifestyle, risk of infections and vaccinations, pulmonary involvement, concomitant medication, psycho-affective disorders, osteoporosis, and risk of fracture. In addition, the document reflects the arguments favoring the inclusion of each item and how to record the items for subsequent collection. The panel considered it also appropriate to likewise establish «practices to avoid¼ applicable to comorbidity in AxSpA. CONCLUSIONS: Two checklists and a list of situations to avoid were generated to facilitate the management of comorbidities in AxSpA. In a future step, their utility and acceptance will be tested by a broad group of users that includes doctors, patients and nurses.

Recommendations for infectious disease screening in migrants to Western Europe with inflammatory arthropathies before starting biologic agents. Results from a multidisciplinary task force of four European societies (SIR, SER, SIMET, SEMTSI) facing the largest impact of the flow of migrants today.

OBJECTIVES: Inflammatory arthritis needs infectious disease screening before starting a biologic agent, however, few data are known about migrant patients, who represent a peculiar population which requires a multidisciplinary approach among international health specialists and should also be considered by health authorities. For this reason, the Italian and Spanish Societies of Rheumatology (SIR and SER) and Tropical Medicine (SIMET and SEMTSI) promoted a multidisciplinary task force in order to produce specific recommendations about screening and advices to be considered in migrant patients with inflammatory arthritis candidate to receive biological therapy, according to their geographical origin. METHODS: The experts provided a prioritised list of research questions and the eligible spectrum of inflammatory arthritis, biologic drugs and infectious disease were defined in order to perform a systematic literature review. A search was made in Medline, Embase and Cochrane library, updated to March 2015. Ubiquitous infections and HBV, HCV, HIV and tuberculosis that are already considered in national and international recommendations, were not included. The strength of each recommendation was determined. RESULTS: The task force members agreed on 7 overarching principles. The risk of reactivation of selected potentially latent infectious disease was addressed in migrants with inflammatory arthritis candidates for biologics was considered and 15 potentially relevant infections were identified. CONCLUSIONS: Fifteen disease-specific recommendations were formulated on the basis of high level of agreement among the experts panel.

Minimal disease activity and impact of disease in psoriatic arthritis: a Spanish cross-sectional multicenter study.

BACKGROUND: Patients with psoriatic arthritis (PsA) experience functional impairment and reduced quality of life, and thus patient global assessment in PsA is explained mainly by the physical, but also by the psychological, aspect of the disease. To assess the prevalence of minimal disease activity (MDA) in Spanish patients with PsA, we examined their characteristics and the association between MDA and the impact of the disease as assessed by the PsA Impact of Disease (PsAID) questionnaire. METHODS: A cross-sectional multicenter study was carried out in patients who fulfilled the Classification for Psoriatic Arthritis (CASPAR) criteria with at least 1 year of disease duration, and who were treated with biological or conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs) according to routine clinical practice in Spain. Patients were considered in MDA if they met at least 5/7 of the MDA criteria. The association between MDA and the recently developed PsAID questionnaire was also recorded. RESULTS: Of 227 patients included, 133 (58.6%) were in the MDA state (52% with antitumor necrosis factor (anti-TNF)α monotherapy, 24% with csDMARD monotherapy, and 24% with anti-TNFα in combination with csDMARD). Using multivariate logistic regression analysis, male gender (odds ratio (OR) 2.74, p = 0.001), a sedentary lifestyle (OR 3.13, p = 0.002), familial history of PsA (OR 0.38, p = 0.036), C-reactive protein (CRP) level (OR 0.92, p = 0.010), and use of corticoids (OR 0.33, p = 0.007) were considered features related to MDA. MDA patients had a significantly lower impact of the disease according to PsAID (mean total score (SD): MDA 3.3 (3.1) vs. non-MDA 7.1 (5.2); p < 0.001). CONCLUSIONS: Nearly 60% of Spanish PsA patients achieve MDA in routine clinical practice. MDA remains one of the most useful therapeutic targets for PsA since patients who reached this state also had a significantly lower impact of disease according to PsAID.

Standards of care for patients with spondyloarthritis.

To define and give priory to standards of care in patients with spondyloarthritis (SpA). A systematic literature review on SpA standards of care and a specific search in relevant and related sources was performed. An expert panel was established who developed the standards of care and graded their priority (high, mild, low, or no priority) following qualitative methodology and Delphi process. An electronic survey was sent to a representative sample of 167 rheumatologists all around the country, who also gave priority to the standards of care (same scale). A descriptive analysis is presented. The systematic literature review retrieved no article specifically related to SpA patients. A total of 38 standards of care were obtained-12 related to structure, 20 to process, and 6 to result. Access to care, treatment, and safety standards of care were given a high priority by most of rheumatologists. Standards not directly connected to daily practice were not given such priority, as standards which included a time framework. The standards generated for the performance evaluation (including patient and professionals satisfaction) were not considered especially important in general. This set of standards of care should help improve the quality of care in SpA patients.

Systematic review on the effectiveness of immunosuppressants and biological therapies in the treatment of autoimmune posterior uveitis.

OBJECTIVES: To analyze the effectiveness of immunosuppressants and biological therapies in autoimmune posterior uveitis, chronic anterior uveitis associated with juvenile idiopathic arthritis, and macular edema. METHODS: Systematic review. We conducted a sensitive literature search in Medline (from 1961) and EMBASE (from 1980) until October 2007. Selection criteria were as follows: (1) population: autoimmune posterior uveitis, chronic anterior uveitis in juvenile idiopathic arthritis, and macular edema; (2) intervention: immunosuppressive and biologic therapies; (3) outcomes: visual acuity, Tyndall, vitreous haze, macular edema, pars planitis, and retinal vasculitis. There were no limitations regarding study design. The quality of each study was evaluated using the Jadad's scale and Oxford Levels of Evidence. RESULTS: Two hundred sixty-five articles were selected for detailed review of the 4235 found in the initial search: 128 records were on immunosuppressants, 105 on biological therapies, and 32 on macular edema. Overall, both the immunosuppressive and the biologic therapies appeared effective in the treatment of autoimmune posterior uveitis, except for daclizumab in uveitis related to Behçet's disease, and for etanercept in any uveitis. In the treatment of macular edema, the drugs tested were also effective. CONCLUSIONS: Based on the evidence collated, immunosuppressants and biological therapies (except for daclizumab in Behçet and etanercept) may be effective in autoimmune uveitis and macular edema. No superiority may be inferred from this review.

On the nature of ionic liquids and their effects on lipases that catalyze ester synthesis.

Free and immobilized lipases from Candida antarctica (CALA and CALB), Thermomyces lanuginosus (TLL) and Rhizomucor miehei (RML) were used as catalysts in the synthesis of butyl propionate by transesterification in reaction media consisting in nine different ionic liquids. Enzyme activities were clearly dependent on the nature of the ions, the results being improving as the alkyl chain length of the imidazolium cation increased, and as a function of the type of anion ([PF(6)], [BF(4)] or [ethylsulphate]). The best synthetic activity (655.5U/mg protein at 40 degrees C) was obtained when free CALB were assayed in the water-miscible IL cocosalkyl pentaethoxy methyl ammonium methosulfate ([CPMA][MS]), and was clearly related with the water content of the medium. The synthetic activity of free CALB in [CPMA][MS] was enhanced with the increase in temperature, while practically no effect was obtained for TLL. The ability of free CALB to synthesize aliphatic esters of different alkyl chain lengths, using different alkyl vinyl esters and 1-alkanols as substrates, was also studied in [CPMA][MS], the best results (4500U/mg protein) being obtained for the synthesis of hexyl butyrate.

How good is to switch between biologics? A systematic review of the literature.

UNLABELLED: Despite the biological rationale for switching between TNF-antagonists, there is not a definitive answer from a clinical point of view. METHODS: We performed a systematic review. The strategy for the literature search included synonyms for the active drugs, trade names, and different synonyms for biologic therapies, plus the words "switch" or "switching", limited to studies in humans. The time limit was March 1st 2007. From 256 initial hits in Medline and Embase, plus 13 abstracts from rheumatology meetings, we finally included 33 studies. RESULTS AND DISCUSSION: The most frequently died switches are those between etanercept and infliximab. The mean number of patients studied per type of switch was 126. There are, apart from retrospective observational studies and cases series, 5 prospective cohorts from biologic registries, 1 randomised open-label clinical trial and 1 phase IV clinical trial, all seven of which are of moderate to good quality. There results are promising but not excellent. Any switch, especially those between monoclonal antibodies, have an effect size that is usually lower than that of a first biologic. When the switch is due to an adverse event with the first TNF-antagonist, however, the response rate of the second one is high. Perhaps the best alternative when a first TNF-antagonist fails is to start a different type of biologic, and leave the switch to another TNF-antagonist in the case of adverse event to the previous one.

As contribuições da neuropsicologia para a pesquisa da reabilitação dos esquizofrênicos / The contributions of neuropsychology in the research of rehabilitation of schizofrenic patients

As avaliações neuropsicológicas que pareciam úteis apenas para análise de disfunções ou lesões cerebrais podem ser também instrumentos de previsão de competência social e de competência social e de aferição da eficiência de terapias em pacientes esquizofrênicos. Somaðse ainda o fato de poderem ser ótimo paradigma para futuras abordagens de modificações de aspectos cognitivos nãoðhígidos. Este artigo contempla uma ampla revisão bibliográfica deste tema na década de 90