2023 Brazilian Society of Rheumatology guidelines for the treatment of systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is a rare chronic autoimmune disease with heterogeneous manifestations. In the last decade, several clinical trials have been conducted to evaluate new treatment options for SSc. The purpose of this work is to update the recommendations of the Brazilian Society of Rheumatology in light of the new evidence available for the pharmacological management of SSc. METHODS: A systematic review including randomized clinical trials (RCTs) for predefined questions that were elaborated according to the Patient/Population, Intervention, Comparison, and Outcomes (PICO) strategy was conducted. The rating of the available evidence was performed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. To become a recommendation, at least 75% agreement of the voting panel was needed. RESULTS: Six recommendations were elaborated regarding the pharmacological treatment of Raynaud's phenomenon, the treatment (healing) and prevention of digital ulcers, skin involvement, interstitial lung disease (ILD) and gastrointestinal involvement in SSc patients based on results available from RCTs. New drugs, such as rituximab, were included as therapeutic options for skin involvement, and rituximab, tocilizumab and nintedanib were included as therapeutic options for ILD. Recommendations for the pharmacological treatment of scleroderma renal crisis and musculoskeletal involvement were elaborated based on the expert opinion of the voting panel, as no placebo-controlled RCTs were found. CONCLUSION: These guidelines updated and incorporated new treatment options for the management of SSc based on evidence from the literature and expert opinion regarding SSc, providing support for decision-making in clinical practice.

Influence of anthropogenic activities on metals, sugars and PAHs in PM10 in the city of Fez, Morocco: Implications on air quality.

Particulate matter (PM) is an important component in the atmosphere, affecting air quality, health, radiation balance, and global climate. To assess regional air quality in the city of Fez, an intensive field campaign was carried out in the autumn of 2019 in the Middle Atlas region of Morocco. Aerosol sampling was performed simultaneously at two urban sites in the city of Fez: (1) Fez University (FU), a sub-urban site, and (2) Fez Parc (FP), an urban site located in the city center of Fez, using PM10 collectors. Various laboratory analyses were carried out, including PM mass, trace metals, inorganic ions, OC/EC, sugar compounds, and PAHs. The results indicate that the PM10 mass (61 ng m-3) was comparable at both sites, with a 37-107 ng m-3 range. Most of the 19 investigated PAHs at the FU site (10.2 ± 6.2 ng m-3) were low-molecular-weight PAHs, while the most abundant PAHs at the FP site (6.9 ± 3.8 ng m-3) were mainly higher-molecular-weight PAHs. A diagnostic ratio analysis at both sites indicated that PAHs originated from fossil fuel combustion and traffic emissions from diesel engines, with Ant/(Ant + Phe) and Flu/(Flu + Pyr) ratios averaging 0.22 and 0.84, respectively. PMF analysis identified traffic emissions as a major source (30%), with secondary inorganic aerosols (20%) and biomass burning (14%). Polar plots highlight the dominance of local anthropogenic activities in PM pollution, with vehicular emissions, industrial activities, and biomass burning. This study shows that local sources and combustion processes significantly contribute to PM10 sources in Morocco, providing insights into air pollution mitigation in North Africa.

Multi-elemental analysis of particulate matter PM2.5 and PM10 by ICP OES.

The complexity of aerodynamic particulate matter's (PM) matrices poses a challenge for the extraction and quantification of metals, especially for analytes with low concentration. Aiming to solve this issue, a precise and accurate protocol with the ultrasound extraction combined with microwave radiation digestion (USMW), was applied to PM samples with excellent compensations in sample throughput, digestion efficiency, and energy consumption. After the digestion and extraction procedures, the inorganic analytes, including rare earth elements, were determined by ICP OES. Two types of particulate matter sampled from two stations, Gobernacion (GOB10 and GOB2.5) and Milan (MIL10), corresponding to PM2.5 and PM10, were digested with a combination between HF, HNO3, and H3BO3. The absolute limits of detection ranged from 0.42 pg m-³ for V, to 3459 pg m-³ for As. The accuracy of the experimental study was assessed using two certified reference materials (CRMs), Coal Fly Ash (NIST1633b) and Fly Ash (BCR176). The method presented good accuracy, with recoveries ranging from 90 to 115%, except for Al (120%) and Fe (123%). Considering the replicates for the determination of analyte elements, the repeatability was below 10% for the relative standard deviation (RSD). A cloud point extraction (CPE) procedure, with parameters optimized for the determination of Pd and Pt, was successfully applied in digested PM samples with detection limits of 1.43 and 2.05 pg m-³ for Pd and Pt in MIL10 sample, respectively, and 76.6 pg m-³ for Pd and 110 pg m-³ for Pt, in samples GOB10 and GOB2.5, respectively.

Treatment data from the Brazilian fibromyalgia registry (EpiFibro).

BACKGROUND: EpiFibro (Brazilian Epidemiological Study of Fibromyalgia) was created to study patients with fibromyalgia (FM). Patients were included since 2011 according to the classification criteria for FM of the American College of Rheumatology of 1990 (ACR1990). OBJECTIVE: To analyze the therapeutic measures prescribed by Brazilian physicians. MATERIALS AND METHODS: Cross-sectional study of a multicenter cohort. The therapeutic measures were described using descriptive statistics. RESULTS: We analyzed 456 patients who had complete data in the registry. The mean age was 54.0 ± 11.9 years; 448 were women (98.2%). Almost all patients (98.4%) used medications, 62.7% received health education, and less than half reported practicing physical exercise; these modalities were often used in combination. Most patients who practiced exercises practiced aerobic exercise only, and a significant portion of patients combined it with flexibility exercises. The most commonly used medication was amitriptyline, followed by cyclobenzaprine, and a minority used medication specifically approved for FM, such as duloxetine and pregabalin, either alone or in combination. Combinations of two or three medications were observed, with the combination of fluoxetine and amitriptyline being the most frequent (18.8%). CONCLUSION: In this evaluation of the care of patients with FM in Brazil, it was found that the majority of patients are treated with a combination of pharmacological measures. Non-pharmacological methods are underused, with aerobic exercise being the most commonly practiced exercise type. The most commonly prescribed single drug was amitriptyline, and the most commonly prescribed combination was fluoxetine and amitriptyline. Drugs specifically approved for FM are seldom prescribed.

Treatment data from the Brazilian fibromyalgia registry (EpiFibro)

Abstract Background: EpiFibro (Brazilian Epidemiological Study of Fibromyalgia) was created to study patients with fibromyalgia (FM). Patients were included since 2011 according to the classification criteria for FM of the American College of Rheumatology of 1990 (ACR1990). Objective: To analyze the therapeutic measures prescribed by Brazilian physicians. Materials and methods: Cross-sectional study of a multicenter cohort. The therapeutic measures were described using descriptive statistics. Results: We analyzed 456 patients who had complete data in the registry. The mean age was 54.0 ± 11.9 years; 448 were women (98.2%). Almost all patients (98.4%) used medications, 62.7% received health education, and less than half reported practicing physical exercise; these modalities were often used in combination. Most patients who practiced exercises practiced aerobic exercise only, and a significant portion of patients combined it with flexibility exercises. The most commonly used medication was amitriptyline, followed by cyclobenzaprine, and a minority used medication specifically approved for FM, such as duloxetine and pregabalin, either alone or in combination. Combinations of two or three medications were observed, with the combination of fluoxetine and amitriptyline being the most frequent (18.8%). Conclusion: In this evaluation of the care of patients with FM in Brazil, it was found that the majority of patients are treated with a combination of pharmacological measures. Non-pharmacological methods are underused, with aerobic exercise being the most commonly practiced exercise type. The most commonly prescribed single drug was amitriptyline, and the most commonly prescribed combination was fluoxetine and amitriptyline. Drugs specifically approved for FM are seldom prescribed.(AU)

Work disability in fibromyalgia and other soft tissue disorders: analysis of preventive benefits in Brazil from 2006 to 2015.

BACKGROUND: Fibromyalgia is a common chronic disease characterized by persistent diffuse pain, fatigue, sleep disorders and functional symptoms. The disease can have negative consequences in personal and social life, in addition to significant public health expenses caused by treatment and work leave. The purpose of this article is to evaluate the number of social security benefits granted due to incapacity for work in Brazil in patients with ICD M79 and variants in the period 2006-2015. There has been no previous study with data referring to work withdrawals caused by fibromyalgia in Brazil. METHODS: Data for this study were obtained through an official Social Security platform. The disability and retirement benefits were analyzed. RESULTS: A total of 95,882 social security disability benefits were granted to ICD M79 and variants in the period from 2006 to 2015. Regarding gender, 69,420 benefits (72.3%) were granted to women and 26,562 (27.7%) to men. Regarding the types of benefits, we found 93,556 (97.5%) temporary withdrawals from work and 2426 (2.5%) permanent withdrawals. When comparing the initial and final years, we observed a significant reduction in the number of awards: 15,562 in 2006 to 6163 in 2015. CONCLUSION: Fibromyalgia was an important cause of withdrawal due to incapacity for work in Brazil, with consequent public health expenditure. These data may serve as a basis for new studies and can alert professionals of the need for adequate management of fibromyalgia to reduce work withdrawal and its consequences.

Capilaroscopia periungueal: relevância para a prática reumatológica / Nailfold capillaroscopy: relevance to the practice of rheumatology

A capilaroscopia periungueal é um método simples, de baixo custo, e de extrema relevância na avaliação de pacientes com fenômeno de Raynaud ou portadores de doenças do espectro da esclerose sistêmica (ES). Além de sua importância para o diagnóstico precoce da ES, constitui instrumento útil na identificação de pacientes esclerodérmicos com risco elevado para o desenvolvimento de complicações vasculares, viscerais e de óbito. A inclusão da capilaroscopia nos novos critérios para classificação da ES do Colégio Americano de Reumatologia (ACR) e da Liga Europeia Contra o Reumatismo (Eular) dá novo impulso para a utilização e disseminação do método. No presente artigo, pretendemos apresentar uma revisão didática, não sistemática, sobre o tema, com ênfase nos avanços recentemente descritos.

Nailfold capillaroscopy is a simple, low-cost method, that is extremely important in the evaluation of patients with Raynaud's phenomenon and of patients with systemic sclerosis (SSc) spectrum diseases. Besides its importance for the early diagnosis of SSc, nailfold capillaroscopy is a useful tool to identify scleroderma patients with high risk for development of vascular and visceral complications and death. The inclusion of capillaroscopy in the new classification criteria for SSc of the American College of Rheumatology (ACR) and European League Against Rheumatism (Eular) gives a new impetus to the use and dissemination of the method. In this paper, we present a didactic, non-systematic review on the subject, with emphasis on advances recently described.

[Nailfold capillaroscopy: relevance to the practice of rheumatology]. / Capilaroscopia periungueal: relevância para a prática reumatológica.

Nailfold capillaroscopy is a simple, low-cost method, that is extremely important in the evaluation of patients with Raynaud's phenomenon and of patients with systemic sclerosis (SSc) spectrum diseases. Besides its importance for the early diagnosis of SSc, nailfold capillaroscopy is a useful tool to identify scleroderma patients with high risk for development of vascular and visceral complications and death. The inclusion of capillaroscopy in the new classification criteria for SSc of the American College of Rheumatology (ACR) and European League Against Rheumatism (Eular) gives a new impetus to the use and dissemination of the method. In this paper, we present a didactic, non-systematic review on the subject, with emphasis on advances recently described.

Influence of the curing mode on the degree of conversion of a dual-cured self-adhesive resin luting cement beneath ceramic.

OBJECTIVE: To evaluate the effect of the delayed photoactivation and ceramic barrier on the degree of conversion (DC) of self-adhesive resin cement. MATERIALS AND METHODS: Circular specimens (5 mm in diameter × 1 mm in thickness) of the RelyX U-100 resin cement were made using the following curing protocols (n = 10): (G1) 40 s beneath a IPS Empress II ceramic; (G2) 40 s of direct photocuring; (G3) 80 s beneath the ceramic; (G4) 80 s of direct photocuring; (G5) self-curing; (G6) 5 min in the absence of light (self-curing) followed by transceramic photocuring for 40 s; (G7) 5 min in the absence of light (self-curing) followed by transceramic photocuring for 80 s. All the specimens were photoactivated by LED (800 mW/cm(2)). After 24 h of dry storage, the DC was measured by FTIR, on the top surface of the specimens. Data were submitted to one-way ANOVA and Tukey test (p ≤ 0.05). RESULTS: Direct photocuring with no ceramic interposition, regardless of the curing time (40 s and 80 s) promoted the highest conversion mean (56.79 ± 1.19 and 59.98 ± 2.93, respectively) and the 5 min delay time for the transceramic photocuring presented a similar mean compared to the immediate transceramic photocuring. The DC was influenced by the ceramic barrier, decreasing the conversion values (49.72 ± 1.91 for 40 s and 52.36 ± 2.50 for 80 s), with no statistical difference from the groups with the previous 5 min of photoactivation delay. The self-cure only showed the worst DC values. CONCLUSION: Direct photocuring provided a higher degree of conversion for the self-adhesive resin cement. The delayed light activation did not influence the degree of conversion for the resin cement tested.

Knoop hardness and effectiveness of dual-cured luting systems and flowable resin to bond leucite-reinforced ceramic to enamel.

PURPOSE: The aim of this study was to evaluate the Knoop microhardness and microshear bond strength (MSBS) of dual-cured luting systems and flowable resin bonded to leucite-reinforced ceramics and enamel. MATERIALS AND METHODS: Eighty bovine incisors were randomly divided into four groups per test (microhardness and microshear; n = 10) according to the bonding procedure: Excite DSC/Variolink, Clearfil SE Bond/Panavia F, Adper Scotchbond Multi-Purpose Plus/RelyX ARC, and Adper Single Bond 2/Filtek Z350 Flow. For the KHN measurement, the cement was applied on the enamel surface and light-cured through a ceramic disk (5 mm diameter × 1.2 mm thick). Five indentations were performed in each specimen and measured at HMV-2. For the microshear test, two cylinders of a leucite-reinforced ceramic (1 mm diameter × 2 mm height) were bonded to the enamel substrate in accordance with the bonding procedures previously established. One cylinder was tested 24 hours after cementation, and the other was subjected to thermocycling (2000 cycles) and then submitted to an MSBS test. The data from the hardness and bond strength tests were subjected to one- and two-way repeated-measures analysis of variance (ANOVA), respectively, and to Tukey's test (α= 0.05). RESULTS: Scotchbond/RelyX ARC presented higher values of bond strength, while Single Bond/Z350 Flow showed lower values. The thermocycling promoted a reduction in the bond strength values for all groups. Panavia F presented higher values of KHN, and the flowable resin presented the lowest. RelyX ARC and Variolink presented intermediate values on hardness evaluation. CONCLUSIONS: For ceramic cementation, dual-cured resin luting systems promoted more reliable bonding and microhardness values than the flowable resin.

Síndrome de Felty e Calazar: um desafio para o reumatologista / Felty's syndrome and Kala-azar: a challenge for the rheumatologist

Os autores relatam o caso de uma paciente com artrite reumatoide que evoluiu com grave neutropenia e esplenomegalia, sendo firmado o diagnóstico de Síndrome de Felty, que posteriormente desenvolveu Calazar. Ambas têm apresentação clínica e laboratorial semelhantes, tornando o diagnóstico diferencial difícil. O relato deste caso objetiva chamar a atenção para o reconhecimento da infecção por leishmaniose visceral em pacientes portadores de doenças reumáticas, assim como a possibilidade de um paciente com Calazar mimetizar um quadro de doença reumática sistêmica.

Case report of a patient with rheumatoid arthritis who developed severe neutropenia, splenomegaly and was diagnosed with Felty's syndrome. The patient later developed Kala-azar. Both diseases have similar clinical and laboratory presentation, making the differential diagnosis difficult. The present case report aims at drawing attention to the identification of visceral Leishmaniasis infection in patients with rheumatic diseases, as well as possibility of a patient with Kala-azar mimicking a set of symptoms of systemic rheumatic disease.

Felty's syndrome and Kala-azar: a challenge for the rheumatologist.

Case report of a patient with rheumatoid arthritis who developed severe neutropenia, splenomegaly and was diagnosed with Felty's syndrome. The patient later developed Kala-azar. Both diseases have similar clinical and laboratory presentation, making the differential diagnosis difficult. The present case report aims at drawing attention to the identification of visceral Leishmaniasis infection in patients with rheumatic diseases, as well as possibility of a patient with Kala-azar mimicking a set of symptoms of systemic rheumatic disease.

Avaliação da produção de espécies reativas de oxigênio por granulócitos de sangue periférico de pacientes com fibromialgia primária / Assessment of reactive oxygen species production by peripheral blood granulocytes from primary fibromyalgia patients

Obejetivo: avaliar anormalidades bioquímicas que possam estar relcionadas à fibromialgia, mais especificamente o metabolismo oxidante de granulócitos de pacientes com fibromialgia primária (FMP). Métodos: foram selecionados 10 pacientes (9 mulheres e 1 homem) portadores de FMP, com idade entre 20 e 40 anos, de acordo com os critérios do Colégio Americano de Reumatologia, que não apresentavam qualquer outra doença de curso agudo ou crônico e estavam sem utilizar medicamentos no mínimo durante duas semanas. Controles normais (n = 19) pareados por sexo e idade foram selecionados. Os granulócitos de pacientes e controles foram separados do sangue periférico e utilizados como célula de trabalho. A produção de espécies reativas de oxigênio (ERO) foi determinada por meio de ensaio de quimioluminescência dependente de luminol. Resultados: demonstramos, pela primeira vez, uma produção significantemente elevada de ERO (3,2 vezes maior) em granulócitos de sangue periférico de pacientes com FMP (< 0,05). Conclusões: estes resultados demonstraram um comportamento anormal dos granulócitos de pacientes com FMP, em que uma produção aumentada de espécies reativas do oxigênio foi observada. Estudos futuros serão necessários para melhor esclarecer estes resultados, delineando uma nova perspectiva na compreensão e abordagem destes pacientes

Sildenafil no tratamento da hipertensão pulmonar associada a lúpus eritematoso sistêmico e síndrome antifosfolipídio / Sildenafil for treatment of pulmonary hypertension in association with systemic lupus erythematosus and anti-phospholipid syndrome

Hipertensão pulmonar grave é uma doença debilitante, com expectativa de vida reduzida, que acomete adultos jovens. Complicações pleuropulmonares no lúpus eritematoso sistêmico ocorrem em 50 por cento a 70 por cento dos pacientes. A hipertensão pulmonar grave no lúpus eritematoso sistêmico é rara e tem prognóstico reservado. Descreve-se, pela primeira vez, um paciente com hipertensão pulmonar grave associada a lúpus eritematoso sistêmico e síndrome antifosfolipídio secundário que apresentou boa resposta ao uso do sildenafil oral, após falha do tratamento convencional com corticosteróides, ciclofosfamida, warfarin e diltiazem.

Polineuropatia periférica no lúpus eritematoso sistêmico: terapêutica com "pulses" de metilprednisolona e ciclofosfamida / Peripheral polyneuropathy in systemic lupus erythematosus: methylprednisolone and cyclophosphamide pulse therapy

Os autores relatam um caso de polineuropatia sensitivomotora em uma paciente de 17 anos com lúpus eritematoso sistêmico (LES) e altos títulos de anticorpos anticardiolipina IgG. A terapêutica com metilprednisolona e ciclofosfamida resultou em significativa melhora clínica e reduçäo dos títulos de anticorpos