Sex and body mass index impact on digit circumference for Leeds Dactylitis Index calculation.

OBJECTIVES: To estimate digit circumference and the impact of sex and body mass index (BMI) for the calculation of the Leeds Dactylitis Index (LDI) in psoriatic arthritis (PsA) patients with bilateral dactylitis. METHODS: Digit circumference of the hands and the foot were measured with a dactylometer and were studied according to sex and BMI (divided in 4 weight categories) in healthy Portuguese subjects, using Student's t-test and One-way ANOVA, respectively. The effect size of sex and BMI were calculated using Cohen's d test and Eta squared, respectively. Multiple linear regression was used to calculate the effect of sex and BMI, as well as their interaction, to create a formula to predict digit circumference. RESULTS: Fifty-nine participants (33 women, 26 men) with a mean BMI of 24.8 were included. Men's mean digit circumferences were statistically higher than those of women (p<0.001), with a large sex effect size in most of the digits. Differences in the mean circumference between the four BMI categories were statistically significant (p<0.05) for all digits, with a large BMI effect size. Sex and BMI were independent variables to predict mean digit circumference (p<0.001). A new tool (based on regression analysis) allowing to estimate the circumference of digits for males and females of different BMIs is presented. CONCLUSIONS: Our data allows the calculation of digit circumference for males and females of different BMIs in the Portuguese population; and shows that BMI influences digital circumference supporting BMI inclusion in LDI references tables.

Concomitant ischemic stroke and myocarditis as the initial clinical presentation of Takayasu arteritis.

Tayakasu arteritis (TA) is a chronic large-vessel systemic vasculitis more frequent in women. The pathogenesis of TA is not fully understood. Due to its silent and heterogenous nature, it is a challenging diagnosis, with no specific diagnostic tests. We report the case of a 45-year-old woman presenting with a concomitant ischemic stroke and myocarditis as an atypical presentation of Takayasu arteritis, revealing its heterogeneous nature. The pre-existent myocardial scar and dilated cardiomyopathy are is a reminder of how silent yet aggressive this vasculitis can be and the need of for high level of suspicion to detect and treat Takayasu arteritis early, avoiding late consequences. Corticosteroids (0.5-1.0mg/kg/day) are the mainstay treatment associated with steroid-sparing drugs, such as methotrexate or azathioprine.

A Rare Cause of Low Back Pain: A Challenging Diagnosis.

One of the rarest causes of low back pain is septic arthritis of a lumbar facet joint. We report the case of a 92-year-old diabetic woman with a history of four days of back pain, dysuria, and fever. Due to a sudden worsening of lumbar pain, she went to the emergency department. Physical exam revealed pain with pressure over the D12 vertebral apophyses and the lower-left paraspinal musculature. Laboratory data showed a normochromic normocytic anemia with a hemoglobin of 9.3 g/dL, white cell count of 14.61x10e3/µL (83.1% neutrophils), serum creatinine 1.46 mg/dL and C-reactive protein of 32.11 mg/dL. In urinalysis, nitrites and leukocyturia were identified. CT scan showed an acute D12 fracture and fat stranding at L5, with no irregularities in the discs or in other lumbar spaces. Escherichia coli was isolated in blood culture. Lumbar MRI confirmed the diagnosis of septic arthritis of an L5-S1 facet joint and L5 vertebrae osteomyelitis. The patient was successfully treated with intravenous ceftriaxone for eight weeks. As far as we know, this is the second report of septic arthritis of the facet joint caused by Escherichia coli.

Is Botulinum Toxin Useful in Systemic Sclerosis Related Peripheral Vasculopathy? A Literature Review / ¿Es la toxina botulínica útil en la vasculopatía periférica de la esclerosis sistémica? Una revisión sistemática

Introduction: In systemic sclerosis (SSc), peripheral vasculopathy presents typically as Raynaud Phenomenon (RP) and Digital Ulceration (DU). Over the last decade, botulinum toxin (BT) has been reported effective in this scenario. Our goal was to review existing literature evaluating the efficacy of BT on RP/DU in SSc. Materials and methods: We performed a search in Pubmed with the MeSH terms “systemic sclerosis” and “botulinum toxin”. Original studies evaluating BT in the treatment of SSc-associated RP/DU were considered for inclusion. Results were screened by title, abstract and full-text. Results: We identified 30 results, of which 5 original papers were included: 2 randomized controlled trials (RCT), 2 case series and 1 case control study, from a total of 133 patients. Only one RCT showed negative results, with worse blood flow in treated arm, but with lower dose of BT. Despite this, all 5 included studies reported improvement of at least 1 RP/hand function outcome measure. Concerning DU healing, resolution of baseline DU at the end of follow-up was reported in 75–100% of the patients, with 1 RCT showing superiority over placebo. The only reported adverse effect was transient hand weakness, affecting only 0–16.7% of patients. BT injection protocols were highly heterogeneous. Conclusion: Despite conflicting results in 1 RCT, evidence points BT as an option in the treatment of SSc-related peripheral vasculopathy. However, future larger prospective trials are necessary to corroborate this hypothesis.(AU)

Introducción: En la esclerosis sistémica (ES), la vasculopatía periférica se presenta normalmente como fenómeno de Raynaud (FR) y ulceración digital (UD). En el último decenio se ha reportado la efectividad de la toxina botulínica (TB) en este escenario. Nuestro objetivo fue revisar la literatura existente que evalúa la eficacia de la TB en el FR/UD en la ES. Materiales y métodos: Realizamos una búsqueda en Pubmed con los términos MeSH «esclerosis sistémica» y «toxina botulínica». Se consideraron para inclusión los estudios originales que evaluaban la TB en el tratamiento del FR/UD asociados a ES. Se cribaron los resultados por título, resumen y texto completo. Resultados: Identificamos 30 resultados, de los cuales se incluyeron 5 documentos originales: 2 ensayos controlados aleatorizados (ECA), 2 series de casos y un estudio de control de caso, de un total de 133 pacientes. Únicamente un ECA reflejó resultados negativos con peor flujo sanguíneo en el brazo tratado, aunque con menor dosis de TB. A pesar de ello, los 5 estudios incluidos reportaron una mejora de al menos una medida del resultado FR/función de la mano. En cuanto a la sanación de la UD, la resolución de la UD basal al final del seguimiento se reportó en el 75-100% de los pacientes, y un ECA reflejó superioridad con respecto al placebo. El único efecto adverso reportado fue debilidad transitoria en la mano, que afectó únicamente al 0-16,7% de los pacientes. Los protocolos de inyección de la TB fueron altamente homogéneos. Conclusión: A pesar de los resultados conflictivos en un ECA, la evidencia apunta a la TB como opción para el tratamiento de la vasculopatía periférica asociada a la ES. Sin embargo, son necesarios ensayos prospectivos futuros más amplios para corroborar esta hipótesis.(AU)

Infective endocarditis - why should rheumatologists be aware?

Infective endocarditis has a wide range of clinical manifestations, making the diagnosis complex. Musculoskeletal symptoms whose prevalence is not negligible are often underestimated. This clinical case is about a 44-year-old female patient with previous aortic and mitral valvuloplasty for rheumatic fever valve disease referred to the outpatient Rheumatology department for the migratory onset of pain and swelling of the left lateral malleolus, right wrist, right first finger and left fifth distal phalanx associated with painful punctate lesions of the digital pulps and lateral edge of the feet and migratory and painful erythematous papules lasting for three months. The susceptibility for IE combined with the finding of spleen infarcts, Osler's nodes and a microorganism from HACEK group on blood cultures supported the diagnosis of subacute infectious endocarditis. Other diagnoses were ruled out. The patient was treated with intravenous antibiotic therapy with complete resolution. This case aims to illustrate the difficulty in diagnosing subacute infective endocarditis, the importance of multidisciplinary work and to briefly review the musculoskeletal manifestations of infective endocarditis described in the literature.

Is Botulinum Toxin Useful in Systemic Sclerosis Related Peripheral Vasculopathy? A Literature Review.

INTRODUCTION: In systemic sclerosis (SSc), peripheral vasculopathy presents typically as Raynaud Phenomenon (RP) and Digital Ulceration (DU). Over the last decade, botulinum toxin (BT) has been reported effective in this scenario. Our goal was to review existing literature evaluating the efficacy of BT on RP/DU in SSc. MATERIALS AND METHODS: We performed a search in Pubmed with the MeSH terms "systemic sclerosis" and "botulinum toxin". Original studies evaluating BT in the treatment of SSc-associated RP/DU were considered for inclusion. Results were screened by title, abstract and full-text. RESULTS: We identified 30 results, of which 5 original papers were included: 2 randomized controlled trials (RCT), 2 case series and 1 case control study, from a total of 133 patients. Only one RCT showed negative results, with worse blood flow in treated arm, but with lower dose of BT. Despite this, all 5 included studies reported improvement of at least 1 RP/hand function outcome measure. Concerning DU healing, resolution of baseline DU at the end of follow-up was reported in 75-100% of the patients, with 1 RCT showing superiority over placebo. The only reported adverse effect was transient hand weakness, affecting only 0-16.7% of patients. BT injection protocols were highly heterogeneous. CONCLUSION: Despite conflicting results in 1 RCT, evidence points BT as an option in the treatment of SSc-related peripheral vasculopathy. However, future larger prospective trials are necessary to corroborate this hypothesis.

GO-DACT: a phase 3b randomised, double-blind, placebo-controlled trial of GOlimumab plus methotrexate (MTX) versus placebo plus MTX in improving DACTylitis in MTX-naive patients with psoriatic arthritis.

OBJECTIVES: To assess the efficacy of golimumab in combination with methotrexate (MTX) versus MTX monotherapy in psoriatic arthritis (PsA) dactylitis. METHODS: Multicentre, investigator-initiated, randomised, double-blind, placebo-controlled, parallel-design phase 3b trial in 11 Portuguese rheumatology centres. Patients with PsA along with active dactylitis and naive to MTX and biologic disease-modifying antirheumatic drugs (bDMARDs) were randomly assigned to golimumab or placebo, both in combination with MTX. The primary endpoint was Dactylitis Severity Score (DSS) change from baseline to week 24. Key secondary endpoints included DSS and Leeds Dactylitis Index (LDI) response, and changes from baseline in the LDI and MRI dactylitis score. Analysis was by intention-to-treat for the primary endpoint. RESULTS: Twenty-one patients received golimumab plus MTX and 23 MTX monotherapy for 24 weeks. One patient from each arm discontinued. Patient inclusion was halted at 50% planned recruitment due to a favourable interim analysis. Median baseline DSS was 6 in both arms. By week 24, patients treated with golimumab plus MTX exhibited significantly greater improvements in DSS relative to MTX monotherapy (median change of 5 vs 2 points, respectively; p=0.026). In the golimumab plus MTX arm, significantly higher proportions of patients achieved at least 50% or 70% improvement in DSS and 20%, 50% or 70% improvement in LDI in comparison to MTX monotherapy. CONCLUSIONS: The combination of golimumab and MTX as first-line bDMARD therapy is superior to MTX monotherapy for the treatment of PsA dactylitis. TRIAL REGISTRATION NUMBER: NCT02065713.

First steps to understand productivity loss in Portuguese patients with rheumatoid arthritis.

Rheumatoid Arthritis (RA), in consequence of joint inflammation and damage, is known to lead to productivity loss. Developments during the 21st century, such as biologic treatments, allowed remission/low disease activity to be achieved in more RA patients. Despite this, evidence is equivocal concerning work outcomes improvement. Our goal was to evaluate work status and productivity in a Portuguese population with RA from 3 Rheumatology Departments through the questionnaire Work Productivity and Activity Impairment General Health (WPAI).

Leprosy presenting as remitting seronegative symmetrical synovitis with pitting oedema syndrome - a case report.

BACKGROUND: Leprosy typically manifests with skin and peripheral nerve involvement. Musculoskeletal complaints are the third most common, and can be the sole presenting manifestation. They range from arthralgia/arthritis in reactional states to full mimics of systemic rheumatic diseases. Remitting Seronegative Symmetrical Synovitis with Pitting Oedema syndrome has only been described once in a patient with already diagnosed Leprosy. CASE REPORT: A 68-year-old male, from an endemic region of familial amyloid polyneuropathy, presented with an inaugural Remitting Seronegative Symmetrical Synovitis with Pitting Oedema like syndrome, more that 20 years after travelling to Leprosy endemic areas. Arthritis would resurface whenever oral prednisone was tapered, so methotrexate was started, controlling the complaints. Only one year later, after the appearance of peripheral neuropathy and skin lesions, it was possible to diagnose Leprosy, through the identification of Mycobacterium leprae bacilli in a peripheral nerve biopsy. CONCLUSION: This report is an example of the heterogeneity of manifestations of Leprosy, namely rheumatic, and the challenge of diagnosing it when typical complaints are absent. It is also a reminder that this disease should be considered whenever a patient with a combination of skin/neurologic/rheumatic complaints has travelled to endemic countries in the past.

The GO-DACT protocol: a multicentre, randomized, double-blind, parallel-group study to compare the efficacy of golimumab in combination with methotrexate (MTX) versus MTX monotherapy.

The GO-DACT is an investigator-initiated, national, multicentric randomized placebo-controlled double-blinded trial, that assesses dactylitis as primary endpoint. Psoriatic arthritis patients naïve to methotrexate and biologic disease modifying anti-rheumatic drugs, with at least one active dactylitis, were assigned to golimumab in combination with methotrexate or placebo in combination with methotrexate, for 24 weeks. Both clinical (dactylitis severity score and the Leeds dactylitis index) and imaging (high resolution magnetic resonance imaging), among others, were assessed as outcomes. The main objective of GO-DACT is to provide evidence to improve the treatment algorithm and care of psoriatic arthritis patients with active dactylitis. In this manuscript we describe the GO-DACT protocol and general concepts of the methodology of this trial.

Effectiveness of a Referral Program for rheumatoid arthritis and axial spondyloarthritis Diagnosis at Primary Care Centers in Portugal - SIARA STUDY.

OBJECTIVES: Early diagnosis and treatment of Rheumatoid Arthritis (RA) and axial Spondylarthritis (axial SpA) can limit the impact of disease outcomes. This study evaluated the effectiveness of a referral program on the identification of patients with RA and axial SpA. METHODS: This was an observational, prospective, randomized (by clusters) study conducted in Portugal to evaluate the impact of the implementation of a set of referral support actions (RSA). The study was divided in two sub-studies, the RA sub-study and the axial SpA sub-study. 28 participating primary care units were randomly (by clusters) assigned to RSA or control group (with no intervention). Both RSA and control groups identified and referred patients with suspected RA or axial SpA to the rheumatology unit of the reference hospital. The primary objective was to evaluate the correct diagnosis of RA or axial SpA cases confirmed by the rheumatologist of the reference hospital. RESULTS: RA-Substudy: A total of 340 patients were recruited (144 in the RSA-exposed group; 196 in the control). RA diagnosis confirmation was 7.3% (95%CI, 2.1-12.5%) in RSA group versus 2.7% (95%CI, 0.0-5.7%) in control group RSA effect was positive but moderate (4.6%) and not statistically significant (95% CI, 0.0%-11.8%; p=0.222, adjusted for clustering effect). Rate of confirmed arthritis of any type was 16.9% (n=14/83) in the RSA group and 6.0% (n=5/83) in the control group. This difference was statistically significant and favorable to RSA group (OR=3.2; 95% CI 1.1-9.2; p=0.028). Axial SpA-Substudy: A total of 231 patients were recruited (108 in the RSA-exposed group; 123 in the control). Axial SpA diagnosis confirmation was 8.7% (95% CI, 2.1-15.4%) in RSA group versus 5.6% (95% CI, 0.0-11.73%) in control group. RSA effect was positive (3.1%) but not statistically significant (95% CI, -7.5- 12.9%; p=0.568, adjusted for clustering effect). CONCLUSIONS: This study showed a positive tendency for the RSA program, most relevantly on the diagnosis of patients with any type of arthritis in the RA sub-study. It is possible that a referral program more comprehensive than the one herein tested might improve early diagnosis of RA and SpA.

[Hospitalization of patients with systemic sclerosis: characteristics of a population]. / Hospitalização de doentes com Esclerose Sistémica: caracterização de uma população.

OBJECTIVES: The authors propose to characterize a population in the area of reference of the Hospital de São João (HSJ) in Oporto, with severe manifestations of Systemic Sclerosis (SS), and need of hospitalization in this institution. Given the lack of data referring to SS in inpatient set (and its inexistence in Portugal), this elements may obviate a parallelism with populations described in other countries, or even identify specificities of this population, that in the future, can be important to study measures directed to optimizing their care, in Portugal. METHODS: The cases were collected from a computerized database containing all discharge registers of the Rheumatology Department of HSJ from 1/1/2003 to 31/12/2008 (6 years), diagnosed of SS (ICD9-CM code of 710,1). All the 40 inpatient records, reporting to 25 patients, were submitted to medical review, and for each of them, fulfilled a clinical protocol, focusing on multiple epidemiological and clinical characteristics, relative to evolution, manifestations and therapies, reason and outcome of hospitalization, and co-morbidities. RESULTS: The characteristics found in this population approach, globally, to the ones described previously, in other countries. However, the prevalence and severity of the cutaneous lesions suggest a higher impact of the cutaneous attainment in this casuistic. It would be of all interest to develop studies that could properly evaluate this observation. DISCUSSION: It is essential to profoundly know the disease, and the individual and population particularities, so we can act adequately. This study may have put on evidence some problems that, in the future, will probably have major impact on personal life and public health care resources in Portugal. They reflect direct and indirect costs, explained by the high rate of recurrent and long hospitalizations, making use of more expensive diagnostic tests and treatments, and the risk of higher morbidity. Early intervention may be modifying of the natural course of the disease in the long term.

[Hip arthritis in an young adult - a diagnosis to consider]. / Coxartrose em adulto jovem - um diagnóstico a pesquisar.

Osteoarthritis is the most common articular degenerative disease and can be classified as primary or secondary. The last one must be excluded in the context of a young adult. Optimal management requires early diagnosis and awareness of the risk factors (more importantly «modifiable¼ ones) that can affect the prognosis. The authors present a case of a young man who complaint about mechanical groin pain because degenerative changes on hip joint. After patient assessment it was encountered ultrasonographic typical images of gout in the context of asymptomatic hyperuricemia.