SUMMARY OBJECTIVE: The aim of this study was to evaluate the factors that are most correlated with the levels of functional disability in patients with fibromyalgia. METHODS: This is a cross-sectional descriptive study in which 42 patients diagnosed with fibromyalgia according to the criteria of the American College of Rheumatology reported their status using the following questionnaires: the Beck Depression Inventory, the Perceived Stress Scale 14, the Revised Fibromyalgia Impact Questionnaire, the Visual Analog Pain Scale, and the Health Assessment Questionnaire. RESULTS: Moderate to severe levels of depression (Beck Depression Inventory: 22.35±10.39), moderate to severe functional disability (Health Assessment Questionnaire: 1.28±0.58), and high levels of stress (Perceived Stress Scale 14: 31.59±10.02) were found. The correlation adjusted by multiple regression as a function of the Health Assessment Questionnaire indicated a negligible to weak positive correlation with perceived stress (r=0.11), while a moderately strong positive correlation was observed with the Visual Analog Pain Scale (r=0.55). Regarding physical exercise, one of the pillars of the treatment, a moderate negative correlation was found with the Health Assessment Questionnaire (r=-0.4). CONCLUSION: The pain levels were moderately influenced by depression severity. The factors most linked to functional disability are due to the pain levels but not to the perception of stress.

Abstract Background: Current pacemakers allow for the continuous recording of the occurrence of arrhythmic events. One of the most frequent arrhythmias after implantation of a device is atrial fibrillation (AF), an important risk factor for embolic events. The frequency of this arrhythmia in pacemaker patients has not been widely studied. Objectives: This study aimed to evaluate the prevalence, incidence, and predictors of the occurrence of AF in patients with double-chamber pacemakers and without a history of atrial fibrillation prior to implantation. Methods: A dynamic, retrospective, and prospective cohort study was carried out with 186 patients undergoing biannual follow-up of the double-chamber pacemaker, without previous AF, in a single service, between 2016 and 2018. Clinical data were collected from the medical records and the telemetry of the device and the prevalence, incidence rate, relative risk by univariate analysis (by chi-square), and risk ratio were calculated by multivariate analysis (by Cox regression); values of p<0.05 were considered significant. Results: There was a prevalence of 25.3% FA, with an incidence of 5.64 cases / 100 persons-year. The median time for the development of arrhythmia was 27.5 months. Multivariate analysis identified 5 statistically significant predictors: male gender, OR: 2.54 [1.04–6.15]; coronary artery disease, OR: 2.98 [1.20–7.41]; hypothyroidism, OR: 3.63 [1.46–9.07]; prior heart surgery, OR: 2.67 [1.01–7]; and left atrial enlargement, OR: 2.72 [1.25–5.92]. Conclusions: The prevalence and incidence of AF in this population are high. Risk factors for AF were: male gender, coronary artery disease, hypothyroidism, prior heart surgery, and left atrial enlargement.

Abstract The Disease Activity Score 28 (DAS28) shows discrepancies when using erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) scores to assess rheumatoid arthritis (RA). This study aimed to verify the agreement between the DAS28-CRP and DAS28-ESR scores in patients with RA from the south of Brazil. A unicentric cross-sectional study was performed (n = 56). The diagnosis of the patients followed the American College of Rheumatology/ European League Against Rheumatism criteria, and their DAS28 were calculated. The DAS28- ESR score was higher than the DAS28-CRP (DAS28-ESR mean 4.8±1.6; DAS28-CRP mean 4.3±1.4) for 83.9% of the patients. The DAS28-CRP and DAS28-ESR scores showed a very strong correlation (Pearson’s coefficient = 0.922; P<0.0001, 95% CI +0.87 to +0.95, statistical power 100%). Spearman’s correlation coefficient (0.49; P=0.0001, 95% CI +0.25 to +0.67, statistical power 47.54%) showed a moderate correlation between the unique components of the DAS28 formulas. There was agreement between the tests in only 36 of the patients (64.29%). Among the discordant categories, DAS28-ESR overestimated the classification in 16 patients (28.5%). The Kappa coefficient between the categories was 0.465 (SE 0.084, 95% CI +0.301 to +0.630), showing a moderate degree of agreement between the instruments. Although the DAS28-ESR and DAS28-CRP were highly correlated, they differed significantly in terms of patient categorization and should not be used interchangeably.

Abstract The aim of this study is the association between the scores of disease activity, functional capacity and quality of life among patients diagnosed with rheumatoid arthritis, under clinical treatment at the Regional University Hospital of Campos Gerais - Wallace Thadeu de Mello and Silva. The sample was composed by volunteer patients, who freely underwent 3 research questionnaires. With the results of the survey, the disease activity score was correlated to the functional capacity and the quality-of-life scores. A mean of 3.87 and 1.2 was observed for the disease activity and the functional capacity scores, respectively, yet not achieving a correlation between those two variables. A strong correlation between the disease activity and the “functional capacity”, “general health status” and “mental health” domains was found. The lowest average observed corresponded to “physical limitation”, from the quality-of-life questionnaire. There was no statistically significant correlation between disease activity and functional capacity, although disease activity seems to affect the mental health, general health status and functional capacity of patients.

Rheumatoid arthritis is an autoimmune inflammatory joint disease with global prevalence of 0.4% to 1.0%. Extra-articular manifestations increase its morbidity and severity, and cardiovascular diseases present the greatest risk. Therapeutic approaches have been used to treat rheumatoid arthritis, often involving the use of multiple classes of drugs with different mechanisms and forms of action. Corticosteroid therapy is widely used in this therapeutic combination; however, its use has been widely questioned because of its high toxicity and some negative effects, including the possibility of increased cardiovascular risk, depending on the dosage. Some studies have provided important insights into how glucocorticoids have an impact on cardiac complications in patients with rheumatoid arthritis. Most of these studies have concluded that exposure to these drugs at high or cumulative doses is associated with increased risk of death, as well as possibly being associated with the presence of a positive rheumatoid factor.

Abstract Introduction: Many publications on coronary surgery and carotid stenosis (CS) can be found, but we do not have enough information about the relationship between ischemic stroke, CS and non-coronary cardiac surgery. Objectives: To evaluate the incidence and risk factors associated with the stroke and CS ≥50% in patients undergoing non-coronary surgeries. Objectives: We assessed 241 patients, aged 40 years or older, between 2009 and 2016, operated in Santa Casa de Misericórdia de Ponta Grossa-PR, Brazil. We perform carotid Doppler in patients 40 years of age or older before any cardiac surgery as a routine. The incidence and possible risk factors for CS ≥50% and perioperative stroke were analyzed by univariate statistical analysis. Results: 11 patients (4.56%) presented perioperative stroke. The risk factor for stroke was CS ≥50%: OR=5.3750 (1.2909-22.3805), P=0.0208. Eighteen patients (7.46%) had CS ≥50% and their risk factors were extracardiac arteriopathy: OR=18.6607 (6.3644-54.7143), P<0.0001; COPD: OR=3.9040 (1.4491-10.5179), P=0.0071; diabetes mellitus: OR=2.9844 (1.0453-8.5204), P=0.0411; recent myocardial infarction: OR=13.8125 (1.8239-104.6052), P=0.0110; EuroSCORE II higher P=0.0056. Conclusion: The incidences of stroke and CS ≥50% were 4.56% and 7.46%, respectively. The risk factor for stroke was CS ≥50% and for CS ≥50% were extracardiac arteriopathy, COPD, diabetes mellitus, recent myocardial infarction and higher EuroSCORE II.

Resumo Fundamento: A fibrilação atrial (FA) ocorre em 10-40% dos pacientes submetidos a cirurgia de revascularização miocárdica (RM), e eleva a mortalidade cardiovascular. Como o aumento dos átrios está associado ao aumento da incidência de FA, espera-se que pacientes com pressão venosa central (PVC) mais alta tenham maior distensão atrial, o que eleva a incidência dessa arritmia. Objetivo: Comparar a incidência de FA em pós-operatório de RM, seguindo duas estratégias de controle de PVC. Métodos: Estudo clínico randomizado controlado intervencionista. A amostra foi composta por 140 pacientes submetidos a RM entre 2011 e 2015. Os pacientes foram randomizados em dois grupos, G15 e G20, mantidos com PVC máxima de 15 cmH2O e 20 cmH2O, respectivamente. Resultados: Foram incluídos 70 pacientes em cada grupo. A incidência da arritmia em G15 foi de 8,57% e, no G20, de 22,86%, com redução de risco absoluto de 14,28% e número necessário para tratar (NNT) de 7 (p = 0,03). Mortalidade (G15 = 5,71%; G20 = 11,42%; p = 0,07), tempo de internamento (G15 = 7,14 dias; G20 = 8,21 dias; p = 0,36), número de enxertos (medianas: G15 = 3, G2 = 2; p = 0,22) e uso de circulação extracorpórea (G15 = 67,10%; G20 = 55,70%; p = 0,22) mostraram-se estatisticamente semelhantes. A idade (p = 0,04) e o tempo de internamento (p = 0,001) foram significativamente maiores nos pacientes que desenvolveram FA nos dois grupos. Conclusão: Manter a PVC com valores mais baixos nas primeiras 72h após a cirurgia de RM reduz o risco relativo de FA e pode ser uma ferramenta útil na prevenção da FA após RM.

Abstract Background: Atrial fibrillation (AF) takes place in 10-40% of patients undergoing coronary artery bypass grafting (CABG), and increases cardiovascular mortality. Enlargement of atrial chambers is associated with increased AF incidence, so patients with higher central venous pressure (CVP) are expected to have larger atrial distension, which increases AF incidence. Objective: To compare post-CABG AF incidence, following two CVP control strategies. Methods: Interventional, randomized, controlled clinical study. The sample comprised 140 patients undergoing CABG between 2011 and 2015. They were randomized into two groups, G15 and G20, with CVP maintained ≤ 15 cmH2O and ≤ 20 cmH2O, respectively. Results: 70 patients were included in each group. The AF incidence in G15 was 8.57%, and in G20, 22.86%, with absolute risk reduction of 14.28%, and number needed to treat (NNT) of 7 (p = 0.03). Mortality (G15 = 5.71%; G20 = 11.42%; p = 0.07), hospital length of stay (G15 = 7.14 days; G20 = 8.21 days; p = 0.36), number of grafts (median: G15 = 3, G2 = 2; p = 0.22) and cardiopulmonary bypass use (G15 = 67.10%; G20 = 55.70%; p = 0.22) were statistically similar. Age (p = 0.04) and hospital length of stay (p = 0.001) were significantly higher in patients who developed AF in both groups. Conclusion: Keeping CVP low in the first 72 post-CABG hours reduces the relative risk of AF, and may be useful to prevent AF after CABG.

ABSTRACT Introduction: In patients with mechanical prosthetic heart valves or atrial fibrillation requiring anticoagulation to prevent thromboembolic events, several factors influence adherence and anticoagulation complications. Objective: To evaluate the factors that interfere with the quality and complications of anticoagulation with vitamin K antagonists. Methods: A retrospective cohort study of 100 patients, in the period from 2011 to 2014, was performed. Anticoagulation conditions in the last year, regarding the presence of complications (embolisms/bleeding) and inadequate treatment were assessed: achievement of less than 8 annual prothrombin times and International Normalized Ratio outside therapeutic target in more than 40% of prothrombin times. Results: There were 31 complications (22 minor bleeding without hospitalization and 9 major complications: 7 bleeding with hospitalization and two emboli); 70 were with International Normalized Ratio outside the target in more than 40% of the tests and 36 with insufficient number of prothrombin times. Socioeconomic factors, anticoagulant type and anticoagulation reason had no relationship with complications or with inadequate treatment. There were more complications in patients with longer duration of anticoagulation (P=0.001). Women had more International Normalized Ratio outside the target range (OR 2.61, CI:1.0-6.5; P=0.04). Patients with lower number of annual prothrombin times had longer times of anticoagulation (P=0.03), less annual consultations (P=0.02) and less dose adjustments (P=0.003). Patients with longer duration of anticoagulation have more complications (P=0.001). Conclusion: There was a high rate of major complications and International Normalized Ratio was outside the goal. Less annual prothrombin times was related to longer duration of anticoagulation, less annual consultations and less dose adjustments. More major complications occurred in patients with longer duration of anticoagulation.

Resumo Introdução A hipertensão arterial sistêmica é uma doença crônica de alta prevalência e com baixas taxas de controle. Este estudo objetivou analisar o controle da pressão arterial em idosas hipertensas acompanhadas em uma Unidade de Saúde da Família e os fatores associados. Métodos Estudo transversal, com análise de dados de prontuários de 190 idosas hipertensas. Foram consideradas controladas as pacientes com nível de pressão arterial menor do que 140/90 mmHg. Para a análise estatística, calcularam-se a razão de prevalência e o intervalo de confiança de 95% para a ocorrência de controle ou não da presão arterial, segundo a associação de alguns fatores. As análises multivariadas foram conduzidas por meio de regressão logística. Resultados Das 190 pacientes em acompanhamento, 108 (56,8%) apresentavam a pressão arterial controlada. Na análise de regressão logística, as variáveis possuir mais de 70 anos (p = 0,033) e residir na área mais afastada da unidade de saúde (p = 0,002) estiveram associadas ao não controle da pressão arterial. Conclusão Embora o percentual de controle da pressão arterial seja elevado na população estudada quando comparado com dados da literatura, medidas devem ser implantadas para o aumento desse percentual, para evitar futuras complicações.

Abstract Introduction Hypertension is a chronic disease with high prevalence and low control rates. This study aimed to analyze the blood pressure control in hypertensive elderly followed up in a Family Health Unit and its associated factors. Methods Cross-sectional study, with patient records analysis of 190 hypertensive elderly women. Patients’ blood pressure was considered to be under control if lower than 140/90mmHg. For statistical analysis, we calculated the prevalence ratio and 95% confidence interval for controlled and not controled blood pressure, according to the association of some factors. Multivariate analyzes were conducted using logistic regression. Results Of the 190 patients followed up, 108 (56.8%) had controlled blood pressure. In logistic regression analysis, the variables of being older than 70 years (p = 0.03) and reside in the area furthest from the facility (p = 0.002) were associated with uncontrolled blood pressure. Conclusion Although the control rate in this population is high when compared with literature, measurements should be implemented to increase this rate and avoid future complications.

ABSTRACT OBJECTIVE: The aim of the present study was to investigate the factors associated with chronic post-sternotomy pain in heart surgery patients. METHODS: Between January 2013 and February 2014, we evaluated 453 patients with >6 months post-sternotomy for cardiac surgery at a surgical outpatient clinic. The patients were allocated into a group with chronic post-sternotomy pain (n=178) and a control group without pain (n=275). The groups were compared for potential predictors of chronic post-sternotomy pain. We used Cox proportional hazards regression to determine which independent variables were associated with the development of chronic post-sternotomy pain. RESULTS: In total, 39.29% of the patients had chronic poststernotomy pain. The following factors were significantly associated with chronic post-sternotomy pain: (a) use of the internal thoracic artery in coronary bypass grafting (P =0.009; HR=1.39; 95% CI, 1.08 to 1.80); (b) a history of antidepressant use (P =0.0001; HR=2.40; 95% CI, 1.74 to 3.32); (c) hypothyroidism (P =0.01; HR=1.27; 95% CI, 1.03 to 1.56); (d) surgical wound complication (P =0.01; HR=1.69; 95% CI, 1.08 to 2.63), and (e) patients on disability benefits or scheduled for a consultative medical examination for retirement (P =0.0002; HR=2.05; 95% CI, 1.40 to 3.02). CONCLUSION: The factors associated with chronic poststernotomy pain were: use of the internal thoracic artery; use of antidepressants; hypothyroidism; surgical wound complication, and patients on disability benefits or scheduled for a consultative examination.

ResumoObjetivo:O objetivo do presente trabalho foi avaliar os fatores de risco para acidente vascular encefálico isquêmico em pacientes submetidos à cirurgia cardíaca.Métodos:Entre janeiro de 2010 e dezembro de 2012, foram analisados prospectivamente 519 pacientes consecutivos submetidos à cirurgia cardíaca. A amostra foi dividida em dois grupos: os pacientes com acidente vascular encefálico isquêmico (AVEi) trans e pós-operatório foram alocados no grupo GAVEi (n=22) e os demais pacientes no grupo CControle (n=497). As seguintes variáveis foram comparadas entre os grupos: sexo, idade, estenose carotídea >70%, diabetes em uso de insulina, doença pulmonar obstrutiva crônica, arteriopatia periférica, função renal, angina instável, função do ventrículo esquerdo, infarto agudo do miocárdio recente, hipertensão arterial pulmonar, uso de circulação extracorpórea. Acidente vascular encefálico isquêmico foi definido como presença de sintomas de duração maior que 24 horas associados à alteração em tomografia de crânio. As variáveis foram comparadas, por meio do teste exato de Fisher, Qui quadrado, teste t de Student e regressão logística.Resultados:Verificou-se a ocorrência de acidente vascular encefálico isquêmico em 4,2% dos pacientes e os fatores de risco estatisticamente significativos foram: estenose carotídea de 70% ou mais (P=0,03; OR 5,07; IC 95%: 1,35 a 19,02), diabetes em uso de insulina (P=0,04; OR 2,61; IC 95%: 1,10 a 6,21) e arteriopatia periférica (P=0,03; OR 2,61; IC 95%: 1,08 a 6,28).Conclusão:Foram fatores de risco para acidente vascular encefálico isquêmico: estenose carotídea de 70% ou mais, presença de diabetes em uso de insulina e presença de arteriopatia periférica.

AbstractObjective:The purpose of this study was to evaluate the risk factors for ischemic stroke in patients undergoing cardiac surgery.Methods:From January 2010 to December 2012, 519 consecutive patients undergoing cardiac surgery were analyzed prospectively. The sample was divided into two groups: patients with stroke per and postoperative were allocated in Group GS (n=22) and the other patients in the group CCONTROL (n=497). The following variables were compared between the groups: gender, age, carotid stenosis > 70%, diabetes on insulin, chronic obstructive pulmonary disease, peripheral arteriopathy, unstable angina, kidney function, left ventricular function, acute myocardial infarction, pulmonary arterial hypertension, use of cardiopulmonary bypass. Ischemic stroke was defined as symptoms lasting over 24 hours associated with changes in brain computed tomography scan. The variables were compared using Fisher’s exact test, Chi square, Student’s t-test and logistic regression.Results:Stroke occurred in 4.2% of patients and the risk factors statistically significant were: carotid stenosis of 70% or more (P=0.03; OR 5.07; IC 95%: 1.35 to 19.02), diabetes on insulin (P=0.04; OR 2.61; IC 95%: 1.10 to 6.21) and peripheral arteriopathy (P=0.03; OR 2.61; 95% CI: 1.08 to 6.28).Conclusion:Risk factors for ischemic stroke were carotid stenosis of 70% or more, diabetes on insulin and peripheral arteriopathy.

O objetivo deste estudo foi descrever um caso de um paciente com doença de Alzheimer (DA) simultaneamente sob uso de medicação anti-TNF-α para artrite reumatoide (AR). Paciente masculino, 81 anos, caucasiano, professor aposentado. Diagnosticado com AR em 2008 e DA em 2011. O tratamento com donepezila foi iniciado em 2011, e o uso de etanercept instituído em 2012. O paciente foi tratado anteriormente com adalimumab em 2010 durante 18 meses. Em 2013, participou de um ensaio clínico visando a avaliar uma estratégia não farmacológica complementar para a DA, apresentando melhora cognitiva significativa ao longo do período de seguimento. Sugere-se a hipótese de um efeito sinérgico do agente anti-TNF-α utilizado para tratamento da AR como causa da melhor resposta cognitiva do paciente, indicando possível utilidade dessa classe medicamentosa na abordagem terapêutica da DA.

The aim of this study was to describe a clinical case of a patient with Alzheimer's disease (AD) in use of an anti-TNF-α agent for rheumatoid arthritis (RA). The patient reported is an 81-year-old Caucasian man and retired teacher, diagnosed with RA in 2008 and AD in 2011. Treatment with donepezil was started in 2011 and the use of etanercept introduced in 2012. He was previously treated with adalimumab in 2010 for 18 months. In 2013, the subject was engaged in a clinical trial to assess a complementary non-pharmacological approach for AD, presenting significant cognitive improvement during the follow-up period. We propose the hypothesis of a synergistic effect of anti-TNF-α medication used for the treatment of RA as the cause of the improvement in cognitive response observed. These findings could suggest a possible use of this drug class in the therapeutic management of AD.

Objetivo Avaliar a eficácia da acupuntura no tratamento da fibromialgia, considerando-se como desfecho primário a resposta imediata da escala visual analógica (VAS) para avaliação da dor. Material e métodos Estudo randomizado, controlado e duplo-cego incluindo 36 pacientes portadores de fibromialgia (ACR 1990) selecionados no ambulatório de Reumatologia da Santa Casa de Misericórdia de Ponta Grossa, PR. Vinte e um pacientes foram submetidos a uma sessão de acupuntura, nos moldes da Medicina Tradicional Chinesa, e 15 pacientes foram submetidos a um procedimento placebo (acupuntura sham). Para avaliação da dor, os indivíduos preencheram uma Escala Visual Analógica (VAS) antes e imediatamente após o procedimento proposto. As médias na variação da VAS foram comparadas entre os grupos. Resultados A variação entre o valor da EVA final e da EVA inicial foi de –4,36±3,23 (P=0,0001) no grupo de tratamento e de –1,70±1,55 no grupo de controle (P=0,06). A diferença na amplitude de variação da EVA (EVA inicial – final) entre os grupos favoreceu o procedimento verdadeiro (P=0,005). O tamanho de efeito (effect size – ES) para o grupo de tratamento foi de d=1,7, o que é considerado um efeito grande. Embora com uma amostra reduzida, seu poder estatístico para esses resultados foi bastante relevante (94,8%). Conclusão A acupuntura mostrou ser eficaz na redução imediata da dor em pacientes portadores de fibromialgia, com um tamanho de efeito (effect size) bastante significativo.

Objective To evaluate the efficacy of acupuncture in the treatment of fibromyalgia, considering the immediate response of the visual analogue pain scale (VAS) as its primary outcome. Methods Randomized, controlled, double-blind study including 36 patients with fibromyalgia (ACR 1990) selected from the outpatient rheumatology clinic, Santa Casa de Misericórdia, Ponta Grossa, PR. Twenty-one patients underwent an acupuncture session, under the principles of the traditional Chinese medicine, and 15 patients underwent a placebo procedure (sham acupuncture). For pain assessment, the subjects completed a Visual Analogue Scale (VAS) before and immediately after the proposed procedure. The mean change in VAS was compared among groups. Results The variation between the final and initial VAS values was -4.36±3.23 (P=0.0001) in the treatment group and -1.70±1.55 in the control group (P=0.06). The difference in terms of amplitude of variation of VAS (initial – final VAS) among groups favored the actual procedure (P=0.005). The effect size (ES) for the treatment group was d=1.7, which is considered a large effect. Although small, the statistical power of the sample for these results was very relevant (94.8%). Conclusion Acupuncture has proven effective in the immediate pain reduction in patients with fibromyalgia, with a quite significant effect size.