Abstract Background A cost of illness (COI) study aims to evaluate the socioeconomic burden that an illness imposes on society as a whole. This study aimed to describe the resources used, patterns of care, direct cost, and loss of productivity due to systemic lupus erythematosus (SLE) in Brazil. Methods This 12-month, cross-sectional, COI study of patients with SLE (ACR 1997 Classification Criteria) collected data using patient interviews (questionnaires) and medical records, covering: SLE profile, resources used, morbidities, quality of life (12-Item Short Form Survey, SF-12), and loss of productivity. Patients were excluded if they were retired or on sick leave for another illness. Direct resources included health-related (consultations, tests, medications, hospitalization) or non-health-related (transportation, home adaptation, expenditure on caregivers) hospital resources. Costs were calculated using the unit value of each resource and the quantity consumed. A gamma regression model explored cost predictors for patients with SLE. Results Overall, 300 patients with SLE were included (92.3% female, mean [standard deviation (SD)] disease duration 11.8 [7.9] years), of which 100 patients (33.3%) were on SLE-related sick leave and 46 patients (15.3%) had stopped schooling. Mean (SD) travel time from home to a care facility was 4.4 (12.6) hours. Antimalarials were the most commonly used drugs (222 [74.0%]). A negative correlation was observed between SF-12 physical component and SLE Disease Activity Index (- 0.117, p = 0.042), Systemic Lupus International CollaboratingClinics/AmericanCollegeofRheumatology Damage Index (- 0.115, p = 0.046), medications/day for multiple co-morbidities (- 0.272, p < 0.001), SLE-specific drugs/day (- 0.113, p = 0.051), and lost productivity (- 0.570, p < 0.001). For the mental component, a negative correlation was observed with medications/day for multiple co-morbidities (- 0.272, p < 0.001), SLE-specific medications/day (- 0.113, p = 0.051), and missed appointments (- 0.232, p < 0.001). Mean total SLE cost was US$3,123.53/patient/year (median [interquartile range (IQR)] US$1,618.51 [$678.66, $4,601.29]). Main expenditure was medication, with a median (IQR) cost of US$910.62 ($460, $4,033.51). Mycophenolate increased costs by 3.664 times (p < 0.001), and inflammatory monitoring (erythrocyte sedimentation rate or C-reactive protein) reduced expenditure by 0.381 times (p < 0.001). Conclusion These results allowed access to care patterns, the median cost for patients with SLE in Brazil, and the differences across regions driven by biological, social, and behavioral factors. The cost of SLE provides an updated setting to support the decision-making process across the country. (COI whole (SLE Brazil 12month, 12month month 12 month, 12-month crosssectional, crosssectional cross sectional, sectional cross-sectional ACR 199 Criteria questionnaires (questionnaires records covering profile morbidities 12Item Item Survey SF12, SF12 SF , SF-12) healthrelated health related consultations, consultations (consultations tests medications hospitalization nonhealthrelated non transportation, transportation (transportation adaptation caregivers consumed Overall 30 92.3% 923 92 3 (92.3 female standard SD 118 11 8 11. 7.9 79 7 9 [7.9 years, years years) 10 33.3% 333 33 (33.3% SLErelated 4 15.3% 153 15 (15.3% schooling (SD 44 4. 12.6 126 6 (12.6 hours 222 (22 74.0%. 740 74.0% . 74 0 [74.0%]) SF-1 ( 0117 117 0.117 0.042, 0042 0.042 042 0.042) CollaboratingClinicsAmericanCollegeofRheumatology CollaboratingClinics AmericanCollegeofRheumatology 0115 115 0.115 0.046, 0046 0.046 046 0.046) medicationsday day comorbidities co 0272 272 0.272 0.001, 0001 0.001 001 0.001) SLEspecific specific drugsday 0113 113 0.113 0.051, 0051 0.051 051 0.051) 0570 570 0.570 0.001. 0232 232 0.232 US312353patientyear USpatientyear US 123 53 year interquartile IQR US161851 1 618 51 US$1,618.5 $678.66, 67866 678 66 [$678.66 $4,601.29. 460129 $4,601.29 601 29 $4,601.29]) medication (IQR US91062 910 62 US$910.6 $460, 460 ($460 $4,033.51. 403351 $4,033.51 033 $4,033.51) 3664 664 3.66 erythrocyte Creactive C reactive protein 0381 381 0.38 biological social factors decisionmaking decision making country 19 SF1 92.3 (92. 7. [7. 33.3 (33.3 15.3 (15.3 12. (12. 22 (2 74.0 [74.0%] SF- 011 0.11 004 0.04 04 027 27 0.27 000 0.00 00 005 0.05 05 057 57 0.57 023 23 0.23 patientyear 5 US16185 61 US$1,618. $678.66 6786 67 [$678.6 46012 $4,601.2 60 2 $4,601.29] US9106 91 US$910. $460 ($46 40335 $4,033.5 03 366 3.6 038 38 0.3 92. (92 [7 33. (33. 15. (15. (12 74. [74.0% 01 0.1 0.0 02 0.2 0.5 US1618 US$1,618 $678.6 [$678. 4601 $4,601. US910 US$910 $46 ($4 4033 $4,033. 36 3. 0. (9 [ (33 (15 (1 [74.0 US161 US$1,61 $678. [$678 $4,601 US91 US$91 $4 ($ 403 $4,033 (3 [74. US16 US$1,6 $678 [$67 $4,60 US9 US$9 $ 40 $4,03 [74 US1 US$1, $67 [$6 $4,6 US$ $4,0 US$1 $6 [$ $4,

Abstract Objective To develop the second evidence-based Brazilian Society of Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN). Methods Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of Rheumatology participate in the development of this guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion. Results All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy. Conclusion This consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil. evidencebased evidence LN. . (LN) 2 guideline performed remission doubling endstage end stage disease relapse infections mortality. mortality mortality) Assessment GRADE (GRADE 82 ≥82 favor conditional intervention diagnosis, (diagnosis opinion involvement but procedure parameters developed TRR (TRR ±10% 10 (±10 24h 24 25 months 50 08 0 8 0. g24 g g/2 1 period ±V, V ±V , (±V) MMF, (MMF) cyclophosphamide TAC, (TAC) therapy AZA (AZA adherence dosage biopsyrebiopsy rebiopsy biopsy/rebiopsy Brazil (LN ≥8 ±10 (±1 5 g2 g/ (±V (MMF (TAC ≥ ±1 (± ± (

Abstract Background: Lupus nephritis (LN) is a major source of morbidity and mortality in patients with systemic lupus erythematosus (SLE), with 10–25% of patients progressing to end-stage renal disease (ESRD). Objective: This study aims to elucidate the predictive capabilities of 24-h proteinuria (24PTU) and serum creatinine (sCr) after 12 months of treatment with respect to long-term renal outcomes in LN in a single-center cohort of LN patients. Methods: A retrospective analysis was performed on 214 patients diagnosed with LN followed in our center. Values of 24PTU and sCr were assessed at baseline and after 3, 6 and 12 months, and after 5 years and/or the last evaluation. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 for 3 months or longer. End-stage renal disease (ESRD) was defined as the need for permanent dialysis. Receiver operating characteristics curves (ROC) were used to test the best cut-off value of 24PTU and sCr at 12 months who predict bad long-term renal outcomes. Results: The mean follow-up period was 11.2 ± 7.2 years. The best cut-off values for 24PTU and sCr as predictor of CKD were, respectively, 0.9 g/24 h and 0.9 mg/dL. ROC curve for 24PTU had a slightly lower performance than ROC curve for sCr as predictor for CKD (PTU AUC = 0.68; sCr AUC = 0.70), but sensitivity and specificity were better for 24PTU (24PTU: sensitivity = 63.5%, specificity = 71.2%; sCr: sensitivity = 54.8%, specificity = 75.3%). When the outcome was ESRD the best cut-off points were 0.9 g/24hs and 1.3 mg/dL for 24PTU and sCr, respectively, and the curve performance was better for 24PTU (PTU AUC = 0.72; sCr AUC = 0.61). Conclusions: In this ethnically diverse population with LN followed for a long time (> 10 years), levels of 24PTU > 0.9/day at 12 months was a good predictor of bad long-term renal outcome. The serum creatinine > 0.9 mg/dL and > 1.3 mg/dL at 12 months were also good predictors of CKD and ESRD, respectively. Patients with 24PTU < 0.9 g/day and sCr < 1.3 mg/dL at 12 months are not likely to develop ESRD because of the high negative predictive values (NPV) (93.2% and 82%). 24PTU and sCr are relevant as components for a treat-to-target strategy for LN treatment, since their high NPV corroborates their importance as good predictors of long-term renal outcome.

Resumo A febre chikungunya tem se tornado um importante problema de saúde pública nos países onde ocorrem as epidemias, visto que metade dos casos evolui com artrite crônica, persistente e incapacitante. Os dados na literatura sobre terapêuticas específicas nas diversas fases da artropatia ocasionada pela infecção pelo vírus chikungunya (CHIKV) são limitados, não existem estudos randomizados de qualidade que avaliem a eficácia das diferentes terapias. Há algumas poucas publicações sobre o tratamento das manifestações musculoesqueléticas da febre chikungunya, porém com importantes limitações metodológicas. Os dados atualmente disponíveis não permitem conclusões favoráveis ou contrárias a terapêuticas específicas, bem como uma adequada avaliação quanto à superioridade entre as diferentes medicações empregadas. O objetivo deste trabalho foi elaborar recomendações para o tratamento da febre chikungunya no Brasil. Foi feita uma revisão da literatura com seleção de artigos baseados em evidência, nas bases de dados Medline, SciELO, PubMed e Embase e de resumos de anais de congressos, além da opinião dos especialistas para dar apoio às decisões tomadas para definir as recomendações. Para a definição do grau de concordância foi feita uma metodologia Delphi, em duas reuniões presenciais e várias rodadas de votação on line. Este artigo refere-se à parte 2 das Recomendações da Sociedade Brasileira de Reumatologia para Diagnóstico e Tratamento da Febre Chikungunya, que trata especificamente do tratamento.

Abstract Chikungunya fever has become an important public health problem in countries where epidemics occur because half of the cases progress to chronic, persistent and debilitating arthritis. Literature data on specific therapies at the various phases of arthropathy caused by chikungunya virus (CHIKV) infection are limited, lacking quality randomized trials assessing the efficacies of different therapies. There are a few studies on the treatment of musculoskeletal manifestations of chikungunya fever, but these studies have important methodological limitations. The data currently available preclude conclusions favorable or contrary to specific therapies, or an adequate comparison between the different drugs used. The objective of this study was to develop recommendations for the treatment of chikungunya fever in Brazil. A literature review was performed via evidence-based selection of articles in the databases Medline, SciELO, PubMed and Embase and conference proceedings abstracts, in addition to expert opinions to support decision-making in defining recommendations. The Delphi method was used to define the degrees of agreement in 2 face-to-face meetings and several online voting rounds. This study is part 2 of the Recommendations of the Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia - SBR) for the Diagnosis and Treatment of chikungunya fever and specifically addresses treatment.

Resumo A febre chikungunya tem se tornado um importante problema de saúde pública nos países onde ocorrem as epidemias. Até 2013, as Américas haviam registrado apenas casos importados quando, em outubro desse mesmo ano, foram notificados os primeiros casos na Ilha de Saint Martin, no Caribe. No Brasil, os primeiros relatos autóctones foram confirmados em setembro de 2014 e até a semana epidemiológica 37 de 2016 já haviam sido registrados 236.287 casos prováveis de infecção pelo chikungunya vírus (CHIKV), 116.523 confirmados sorologicamente. As mudanças ambientais causadas pelo homem, o crescimento urbano desordenado e o número cada vez maior de viagens internacionais têm sido apontados como os fatores responsáveis pela reemergência de epidemias em grande escala. Caracterizada clinicamente por febre e dor articular na fase aguda, em cerca de metade dos casos existe evolução para a fase crônica (além de três meses), com dor persistente e incapacitante. O objetivo deste trabalho foi elaborar recomendações para diagnóstico e tratamento da febre chikungunya no Brasil. Para isso, foi feita revisão da literatura nas bases de dados Medline, SciELO e PubMed, para dar apoio às decisões tomadas para definir as recomendações. Para a definição do grau de concordância foi feita uma metodologia Delphi, em duas reuniões presenciais e várias rodadas de votação on line. Foram geradas 25 recomendações, divididas em três grupos temáticos: (1) diagnóstico clínico, laboratorial e por imagem; (2) situações especiais e (3) tratamento. Na primeira parte estão os dois primeiros temas e o tratamento na segunda.

Abstract Chikungunya fever has become a relevant public health problem in countries where epidemics occur. Until 2013, only imported cases occurred in the Americas, but in October of that year, the first cases were reported in Saint Marin island in the Caribbean. The first autochthonous cases were confirmed in Brazil in September 2014; until epidemiological week 37 of 2016, 236,287 probable cases of infection with Chikungunya virus had been registered, 116,523 of which had serological confirmation. Environmental changes caused by humans, disorderly urban growth and an ever-increasing number of international travelers were described as the factors responsible for the emergence of large-scale epidemics. Clinically characterized by fever and joint pain in the acute stage, approximately half of patients progress to the chronic stage (beyond 3 months), which is accompanied by persistent and disabling pain. The aim of the present study was to formulate recommendations for the diagnosis and treatment of Chikungunya fever in Brazil. A literature review was performed in the MEDLINE, SciELO and PubMed databases to ground the decisions for recommendations. The degree of concordance among experts was established through the Delphi method, involving 2 in-person meetings and several online voting rounds. In total, 25 recommendations were formulated and divided into 3 thematic groups: (1) clinical, laboratory and imaging diagnosis; (2) special situations; and (3) treatment. The first 2 themes are presented in part 1, and treatment is presented in part 2.

RESUMO Introdução: Pacientes com artrite reumatoide (AR) têm 30 a 60% mais chances de desenvolver doenças cardiovasculares (DCV) do que a população geral. A síndrome metabólica (SM), definida por um conjunto de fatores de risco cardiovasculares, confere maior risco de DCV e diabete. A associação da SM com AR ainda não está totalmente esclarecida e sua prevalência varia de 19 a 63% entre os estudos. Objetivos: Avaliar a prevalência de SM numa população de pacientes com AR acompanhada num hospital do Nordeste brasileiro e analisar associações de fatores demográficos e clínicos com SM. Pacientes ambulatoriais com AR foram transversalmente avaliados com relação a dados demográficos, clínicos, laboratoriais e antropométricos. Os critérios para definir SM foram os adotados pelo NCEPIII (2005) e IDF (2006). Resultados: Foram estudados 110 pacientes com AR, 97,3% mulheres com média de 55,5 anos (DP = 12,9) e duração da doença de 11,2 anos (DP = 7,3). As prevalências de SM do NCEPIII (2005) e IDF (2005) foram, respectivamente, 50% e 53,4%. Idade avançada (57,9 ± 11,9 versus 52,9 ± 13,5; p = 0,04) e carga tabágica > 20 maços ano (29% versus 9%; p = 0,008) estiveram associadas com SM. Os principais componentes da SM foram obesidade abdominal (98,1%), hipertensão arterial (80%) e HDL baixo (72,2%). Conclusões: Pacientes com AR de um serviço terciário do Nordeste brasileiro apresentaram alta prevalência de SM. Chama atenção a quase totalidade dos pacientes com SM e obesidade abdominal, o que traz implicações práticas importantes. Além dos componentes de SM, idade e tabagismo se mostrarem associados com SM.

ABSTRACT Introduction: Patients with rheumatoid arthritis (RA) are 30-60% more likely to develop cardiovascular disease (CV) than the general population. Metabolic syndrome (MS), defined by a number of cardiovascular risk factors, confers a greater risk of CVdisease and diabetes. The association of MS with RA is not yet fully understood and its prevalence varies from 19-63% across studies. Objectives: To assess the prevalence of MS in a population of RA patients followed in a hospital in Northeastern Brazil and analyze associations of demographic and clinical factors with MS. Methods: Outpatients with RA were evaluated in a cross-sectional study regarding demographic, clinical, laboratory and anthropometric data. The criteria for defining MS were those adopted by NCEPIII (2005) and IDF (2006). Results: 110 patients with RA were studied; 97.3% were female, with a mean age of 55.5 years (SD = 12.9) and duration of illness of 11.2 years (SD = 7.3). The MS prevalence from NCEPIII (2005) and IDF (2005) were, respectively, 50% and 53.4%. Advanced age (57.9 ± 11.9 versus 52.9 ± 13.5; p = 0.04) and smoking load> 20 packs/year (29% versus 9%, p = 0.008) were associated with MS. The major components of the metabolic syndrome were abdominal obesity (98.1%), hypertension (80%) and low HDL cholesterol (72.2%). Conclusions: RA patients in a tertiary center in Northeastern Brazil showed high prevalence of MS. It is worth noting that almost all patients had MS and abdominal obesity, which has important practical implications. In addition to the components of MS, age and smoking were associated with this syndrome.

Resumo Introdução: O Disease Activity Score 28 (DAS28) e versões têm sido usados para medir atividade da artrite reumatoide (AR), mas não existe consenso sobre qual é o melhor. Objetivos: Determinar a correlação entre os índices (DAS28 VHS, DAS28 PCR, SDAI e CDAI) e avaliar a concordância dos estratos de atividade com o uso de diferentes pontos de corte. Métodos: Pacientes com artrite reumatoide foram avaliados transversalmente com coleta de dados para cálculo do DAS28 (VHS e PCR), SDAI e CDAI, com o uso de pontos de cortes diferentes para definição de remissão, atividade leve, moderada e alta. Correlações de Pearson foram calculadas para medidas contínuas e concordância (teste de kappa) para os estratos (remissão, atividade leve, moderada e alta). Resultados: De 111 pacientes incluídos, 108 foram mulheres, média de 55,6 anos, tempo de doença de 11 anos. DAS28 (VHS) foi significantemente maior do que DAS28 (PCR) (4 vs. 3,5; p < 0,001) e os valores permaneceram maiores após estratificação por idade, sexo, tempo doença, fator reumatoide e HAQ. Correlações entre índices variaram de 0,84 a 0,99, com melhor correlação entre SDAI e CDAI. Concordâncias entre estratos de atividade variaram de 46,8% a 95,8%. DAS28 (PCR) com ponto de corte para remissão de 2,3 subestimou atividade da doença em 45,8% quando comparado com DAS28 (VHS). SDAI e CDAI apresentaram concordância de 95,8%. Os quatro índices mostraram associação com tempo de doença e HAQ. Conclusões: Embora os índices de atividade apresentem boa correlação, mostram discrepâncias nos estratos de atividade. Tornam-se necessários mais estudos para definir melhor índice e melhores pontos de corte.

Abstract Introduction: The Disease Activity Score 28 (DAS28) and its versions have been used to measure rheumatoid arthritis activity, but there is no consensus about which one is the best. Objectives: Determine the correlation among indexes (DAS28 ESR, DAS28 CRP, SDAI and CDAI) and evaluate agreement of activity strata using different cut-off points. Methods: Rheumatoid arthritis patients were cross-sectionally evaluated with data collection to calculate the DAS28 (ESR and CRP), SDAI and CDAI, using different cut-offs for defining remission, mild, moderate and high activity. Pearson correlations were calculated for continuous measures and agreement (kappa test) for the strata (remission, mild, moderate and high activity). Results: Of 111 patients included, 108 were women, age 55.6 years, 11-year disease duration. DAS28 (ESR) was significantly higher than DAS28 (CRP) (4.0 vs. 3.5; p < 0.001) and the values remained higher after stratification by age, gender, disease duration, rheumatoid factor and HAQ. Correlations among indexes ranged from 0.84 to 0.99, with better correlation between SDAI and CDAI. Agreements among activity strata ranged from 46.8% to 95.8%. DAS28 (CRP) with cut-off point for the remission of 2.3 underestimated disease activity by 45.8% compared with DAS28 (ESR). SDAI and CDAI showed agreement of 95.8%. The four indexes were associated with disease duration and HAQ. Conclusions: Although the activity indexes show good correlation, they show discrepancies in activity strata, thus requiring more researches to define a better index and better cut-off points.

Realizamos uma revisão com agregação de resultados dos ensaios randomizados que compararam intervenção coronariana percutânea (ICP) com cirurgia de revascularização miocárdica (CRM). Os 25 ensaios selecionados envolveram 12.305 pacientes dos quais 11.103 pertenciam a estudos em multiarteriais e 1.212 pertenciam a estudos em lesão única de descendente anterior (DA). Nos estudos em multiarteriais a ICP mostrou uma tendência a menor mortalidade precoce (1,2% versus 2%) e menor incidência de acidente vascular cerebral (AVC): 0,7% versus 1,65%. Não houve diferença na mortalidade intermediária (3,8% versus 3,8%). Houve tendência à superioridade da CRM na mortalidade tardia (10,5% versus 9,6%). A diferença deveu-se exclusivamente aos estudos da era balão, tendendo a inverter-se na era stent (9,6% versus 9,9%). Nos estudos de lesão única de DA não houve diferença significativa em nenhum desfecho. A agregação de resultados de nove estudos que avaliaram a mortalidade tardia em diabéticos mostrou diferença favorável à cirurgia (21,3% versus 15,9%). Dois estudos que avaliaram lesão de tronco não mostraram diferença significativa na mortalidade em um ano (3,9% versus 4,7%). A incidência de nova revascularização foi consistentemente maior na ICP, apesar de progressiva melhora dos resultados na era stent.

We carried out a review that included results of randomized trials that made a comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The 25 selected trials involved 12,305 patients, 11,103 of whom were from studies in patients with multi-vessel disease and 1,212 were from studies in patients with single lesion of the left anterior descending (LAD). In the studies of multi-vessel disease patients, the PCI showed a trend towards lower early mortality (1.2% versus 2%) and lower incidence of stroke: 0.7% versus 1.65%. There was no difference in the intermediate mortality (3.8% versus 3.8%). There was a trend towards the superiority of CABG in late mortality (10.5% versus 9.6%). The difference was exclusively due to "balloon era" studies, with a trend towards an inversion in the "stent era" (9.6% versus 9.9%). In studies of single lesion of LAD, there was no significant difference in any endpoint. The aggregation of results from nine studies that assessed late mortality in diabetic patients showed a difference in favor of surgery (21.3% versus 15.9%). Two studies that evaluated main coronary artery disease did not show a significant difference in mortality at one year (3.9% versus 4.7%). The incidence of repeat revascularization was consistently higher in PCI, despite the progressive improvement in results in the stent era.

OBJETIVO: O presente estudo tem por objetivo principal descrever uma série de nove casos de tuberculose (TB) renal em pacientes portadores de lúpus eritematoso sistêmico (LES) ocorridos em um período de seis anos em um hospital terciário do Nordeste brasileiro. MÉTODOS: Foram identificados nove pacientes portadoras de LES com baciloscopia e/ou cultura de urina positivas para Mycobacterium tuberculosis no período de outubro de 1998 a novembro de 2004, por intermédio dos registros do Serviço de Microbiologia do Hospital Universitário Walter Cantídio. Foram coletados dados demográficos, dados sobre o LES e sobre a TB renal das respectivas pacientes. RESULTADOS: Todas as pacientes eram do sexo feminino, com idade entre 19 e 58 anos. Quanto às características do LES, todas haviam tido nefrite lúpica em algum momento da evolução, das quais três haviam utilizado ciclofosfamida previamente à infecção. A dose média de prednisona antes do diagnóstico de TB renal variou entre 7, 5 e 20 mg/dia. O diagnóstico de TB renal foi feito por meio de cultura positiva em cinco pacientes e por intermédio de baciloscopia apenas em quatro pacientes. As manifestações laboratoriais mais freqüentes foram leucocitúria e hematúria. A recidiva da TB renal ocorreu em quatro pacientes. CONCLUSÃO: A ocorrência de TB renal em pacientes com LES deve ser suspeitada na presença de piúria estéril e/ou hematúria persistentes, em especial em populações de países em desenvolvimento.

OBJECTIVE: The main objective of the present study was to describe a series of nine cases of renal tuberculosis (TB) in patients diagnosed with systemic lupus erythematosus (SLE) over a period of six years at a tertiary-level hospital in Northeastern Brazil. METHODS: Nine SLE patients with renal TB confirmed by bacterioscopy (n=4) or urine culture (n=5) positive for M. tuberculosis between October 1998 and November 2004 were sampled from the records of the microbiology department of Hospital Universitário Walter Cantídio. Data were collected regarding demographics, SLE and renal TB. RESULTS: All patients were female, aged between 19 and 58 years and had a history of lupus nephritis. Three had been on cyclophosphamide therapy prior to TB infection. The average dose of prednisone administered before the diagnosis of renal TB ranged between 7.5 and 20 mg/day. The most common laboratory findings were leukocyturia and hematuria. Renal TB recurred in four patients. CONCLUSION: The occurrence of renal TB in SLE patients should be suspected in the presence of persistent sterile pyuria and/or hematuria, especially in developing countries.

INTRODUÇÃO: O uso de ciclofosfamida endovenosa é uma opção terapêutica nas formas graves de lúpus eritematoso sistêmico (LES). No entanto, a toxicidade e o perfil de risco ainda não estão adequadamente definidos. OBJETIVO: Avaliar sobre a ocorrência de alterações do sono em pacientes portadores de LES submetidos à terapia com ciclofosfamida endovenosa. MÉTODOS: Nós estudamos 30 casos consecutivos (27 do sexo feminino) com idade entre 14 e 53 anos (30,5 ± 10), em pulsoterapia com ciclofosfamida (mg) (média 948,27 ± 221,39). Os pacientes foram avaliados quanto à presença de sintomas depressivos, qualidade do sono e sonolência excessiva diurna (SED). A qualidade do sono foi estudada pelo índice de qualidade do sono de Pittsburgh (IQSP), a SED pela escala de sonolência de Epworth e os sintomas depressivos pelo Inventário de Depressão de Beck (21 itens). A gravidade da doença foi avaliada por intermédio do SLEDAI. RESULTADOS: O SLEDAI oscilou entre 2 e 46 (17 ± 11,4). Hipertensão (30%), anemia (23,3%), osteoporose (23,3%) e miocardiopatia (6,6%) foram as comorbidades mais observadas. Um paciente tinha história de convulsões (3,3%). Má qualidade do sono (PSQI e" 6) foi encontrada em 66,7% e SED (ESS > 10), em 30% dos pacientes. Sintomas de depressão (BDI > 19) estavam presentes em 40% dos casos. Os sintomas depressivos associaram-se à presença de má qualidade do sono (p = 0,03). CONCLUSÕES: Nosso estudo mostra que alterações do sono e sintomas depressivos são comuns em pacientes portadores de LES em pulsoterapia com ciclofosfamida. Esses achados são similares a outros estudos previamente relatados e são independentes do tipo de tratamento utilizado.

BACKGROUND: Pulse i.v. cyclophosphamide is a therapeutic option in severe forms of systemic lupus erythematosus (SLE). However, the overall toxicity and risk profile are yet to be adequately defined. OBJECTIVE: To evaluate the occurrence of sleep disturbances in SLE patients subjected to i.v. cyclophosphamide. METHODS: We studied thirty consecutive SLE patients (27 female) age range 14 to 53 years (mean 30.5 ± 10 years) that received i.v. cyclophosphamide (mg) (mean 948.27 ± 221.39). Depressive symptoms, quality of sleep, and the presence of excessive daytime sleepiness were evaluated. Disease severity was assessed by the SLEDAI. Quality of sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI) and excessive daytime sleepiness (EDS) by the Epworth Sleepiness Scale (ESS). Depressive symptoms were evaluated using the 21-item Beck Depression Inventory (BDI). RESULTS: SLEDAI values ranged from 2 to 46 (mean 17 ± 11.4). The most common comorbidities were systemic arterial hypertension (30%), anemia (23.3%), osteoporosis (23.3%), and cardiomyopathy (6.6%). Seizures occurred in one patient (3.3%). Poor quality of sleep (PSQI e" 6) and EDS (ESS >10) were found in 66.7% and 30% of the patients, respectively. Depressive symptoms (BDI >19) were present in 40% of the patients and were associated with poor sleep quality (P = 0.03). CONCLUSIONS: Our findings show an increased prevalence of poor sleep quality and depressive symptoms in SLE patients receiving pulse i.v. cyclophosphamide. These findings were similar to other previously reported series of SLE patients regardless of the therapies used.

A fratura do quadril causa grande morbidade e mortalidade e envolve alto custo, sendo reconhecida como um problema de saúde pública. Sua incidência varia amplamente entre vários países e mesmo entre cidades de uma mesma região. O objetivo do estudo foi determinar a taxa de incidência de fratura de quadril na cidade de Fortaleza, Ceará, Brasil. Foram identificados prospectivamente todos casos de fratura de fêmur, em indivíduos acima de 45 anos, atendidos nos hospitais públicos e privados da cidade de Fortaleza no período de julho de 2001 a junho de 2002. Seiscentos e setenta e três pacientes fraturaram o fêmur, sendo 382 provenientes da cidade de Fortaleza. A incidência anual de fratura de quadril na cidade de Fortaleza em indivíduos acima de 60 anos foi de 21,7/10 mil habitantes (13/10 mil no sexo masculino e 27,7/10 mil no sexo feminino). As fraturas de quadril foram mais freqüentes no sexo feminino e aumentaram progressivamente com a idade. A taxa de incidência do quadril na cidade de Fortaleza foi uma das mais baixas quando comparadas com estudos realizados em várias partes do mundo.

Hip fractures involve high morbidity and mortality and extensive treatment costs and are thus considered an important public health issue. Hip fracture incidence varies greatly between countries and even between cities in the same region. This study aimed to determine hip fracture incidence in Fortaleza, Ceará State, Brazil. Hip fracture cases were identified prospectively in patients aged 45 and over attending private and public hospitals in Fortaleza from July 2001 to June 2002. The study identified 673 patients with hip fractures, 382 of whom from Fortaleza. Annual hip fracture incidence in Fortaleza for patients over 60 years was 21.7/10,000 inhabitants (13.0/10,000 for men and 27.7/10,000 for women). Hip fractures were more frequent among women and with advancing age. Hip fracture incidence in Fortaleza was very low compared to rates reported from other parts of the world.

A fratura do quadril causa grande morbidade e mortalidade e envolve alto custo, sendo reconhecida como um problema de saúde pública. Sua incidência varia amplamente entre vários países e mesmo entre cidades de uma mesma região. O objetivo do estudo foi determinar a taxa de incidência de fratura de quadril na cidade de Fortaleza, Ceará, Brasil. Foram identificados prospectivamente todos casos de fratura de fêmur, em indivíduos acima de 45 anos, atendidos nos hospitais públicos e privados da cidade de Fortaleza no período de julho de 2001 a junho de 2002. Seiscentos e setenta e três pacientes fraturaram o fêmur, sendo 382 provenientes da cidade de Fortaleza. A incidência anual de fratura de quadril na cidade de Fortaleza em indivíduos acima de 60 anos foi de 21,7/10 mil habitantes (13/10 mil no sexo masculino e 27,7/10 mil no sexo feminino). As fraturas de quadril foram mais freqüentes no sexo feminino e aumentaram progressivamente com a idade. A taxa de incidência do quadril na cidade de Fortaleza foi uma das mais baixas quando comparadas com estudos realizados em várias partes do mundo.

Hip fractures involve high morbidity and mortality and extensive treatment costs and are thus considered an important public health issue. Hip fracture incidence varies greatly between countries and even between cities in the same region. This study aimed to determine hip fracture incidence in Fortaleza, Ceará State, Brazil. Hip fracture cases were identified prospectively in patients aged 45 and over attending private and public hospitals in Fortaleza from July 2001 to June 2002. The study identified 673 patients with hip fractures, 382 of whom from Fortaleza. Annual hip fracture incidence in Fortaleza for patients over 60 years was 21.7/10,000 inhabitants (13.0/10,000 for men and 27.7/10,000 for women). Hip fractures were more frequent among women and with advancing age. Hip fracture incidence in Fortaleza was very low compared to rates reported from other parts of the world.

OBJETIVOS: analisar características clínico-laboratoriais dos pacientes com nefrite lúpica que se submeteram à biópsia renal em um hospital universitário; correlacionar manifestações clínicolaboratoriais com os principais tipos de nefrite lúpica; determinar fatores associados ao desenvolvimento de insuficiência renal crônica (IRC). MÉTODOS: dados demográficos, clínicos, laboratoriais e histológicos de todos pacientes com diagnóstico de nefrite lúpica que realizaram biópsia renal no período de janeiro de 1997 a julho de 2002 foram avaliados retrospectivamente. RESULTADOS: Setenta e sete pacientes com nefrite lúpica realizaram 95 bióspias. Considerando apenas 76 amostras com resultados conclusivos, a glomerulonefrite (GMN) proliferativa difusa foi o tipo histológico mais prevalente (68,4%), seguido pela proliferativa focal (14,5%) e mesangial (7,9%). Hipertensão arterial, creatinina > 1,2g/dL, hipoalbuminemia (albumina < 2,6 g/dL) e síndrome nefrótica estiveram presentes por ocasião da primeira biópsia em, respectivamente, 43,8%, 48,7%, 55,2% e 15,6%. A GMN proliferativa difusa esteve mais associada com creatinina elevada (p = 0,002), hipoalbuminemia (p = 0,012), sedimento urinário ativo (p = 0,007), edema de membros inferiores (p = 0,01), hematúria (p = 0,003) e maior índice de atividade (0,0001). A forma mesangial foi a que mais evoluiu para remissão (66,7%), quando comparada com a forma proliferativa focal (12,5%) e difusa (12,8%) (p = 0,02). O tempo de seguimento médio dos pacientes foi de 29,3 ± 20,7 meses (mediana = 24,5 meses). Trinta por cento dos pacientes evoluíram para IRC. Creatinina elevada (OR = 11; IC 95%: 2,16-55,9), plaquetopenia (OR = 6,8; IC 95%: 1,43-32,19), hipoalbuminemia (OR = 6,42; IC 95%: 1,21-33,97) e índice de cronicidade = 2 (OR = 6,36; IC 95%: 1,02-39,57) foram associados com IRC. CONCLUSÕES: dados clínicos e histológicos são importantes para se avaliar o prognóstico dos pacientes com nefrite lúpica. Creatinina elevada, hipoalbuminemia, plaquetopenia e índice de cronicidade = 2 são fatores associados com evolução para IRC.

OBJECTIVE: To analyze the laboratory and clinical characteristics of patients diagnosed with lupus nephritis and submitted to renal biopsy at a university hospital; to correlate laboratory and clinical manifestations with the main types of lupus nephritis; to determinate factors associated with the development of chronic renal failure (CRF). METHODS: Retrospective evaluation of the demographic, clinical, laboratory and histological data of patients diagnosed with lupus nephritis and submitted to renal biopsy from January/1997 to July/2002. RESULTS:Seventy-seven patients with lupus nephritis were submitted to 95 renal biopsies. Considering only the samples with conclusive results (n=76), diffuse proliferative glomerulonephritis (DPGN) was the most prevalent histological type (68.4%), followed by the focal (14.5%) and mesangial (7.9%) types. Arterial hypertension, creatinine > 1.2 g/dL, hypoalbuminemia (albumin < 2.6 g/dL) and nephrotic syndrome were present on the first biopsy in 43.8%, 48.7%, 55.2% and 15.6% of the patients, respectively. DPGN was frequently associated with high creatinine levels (p = 0,002), hypoalbuminemia (p = 0,012), active urinary sediment (0,007), edema of the lower limbs (p = 0,01), hematuria (p = 0,003) and higher activity index (p = 0,0001). The mesangial form achieved remission more frequently (66.7%) when compared to focal (12.5%) and diffuse (12.8%) forms (p = 0,02). The average follow-up period was 29.3 ± 20.7 months (median = 24.5 months). 30% of the patients developed CRF. High creatinine levels (OR = 11; IC 95%: 2,16-55,9), thrombocytopenia (OR = 6,8; IC 95%: 1,43-32,19), hypoalbuminemia (OR= 6,42; IC 95%: 1,21-33,97) and a chronicity index = 2 (OR = 6,36; IC 95%: 1,02-39,57) were associated with CRF. CONCLUSIONS: Clinical and histological data are important when evaluating the prognosis of patients with lupus nephritis. High creatinine levels, thrombocytopenia, hypoalbuminemia and a chronicity index = 2 were found to be associated with progression to CRF.

OBJETIVO: A prevalência da infecção pelo vírus da hepatite C (VHC) é maior em pacientes submetidos à hemodiálise que na população em geral, possivelmente refletindo maior exposição a situações de risco. O estudo realizado teve por objetivo determinar a prevalência de anticorpos anti-VHC em pacientes em hemodiálise e identificar fatores relacionados às clínicas e aos pacientes, associados à transmissão do VHC. MÉTODOS: Realizou-se estudo transversal em 752 pacientes em hemodiálise em todas as 12 clínicas de Fortaleza, Ceará. Eles foram testados com anticorpos anti-VHC por ELISA de terceira geração. Foram entrevistados 663 pacientes quanto a aspectos sociodemográficos, clínicos e epidemiológicos. Fatores nosocomiais foram investigados utilizando-se questionário específico. Para a análise estatística foram aplicados o teste t de Student, o odds ratio e a regressão logística univariada e multivariada. RESULTADOS: A prevalência de anti-VHC foi de 52% (390/746; variando de 6% a 72%). A freqüência de infecção foi maior em pacientes previamente submetidos à diálise peritoneal (OR=1,76; IC 95% 1,12-2,76) e a transfusões de sangue (OR=2,75; IC 95% 1,25-6,03). O tempo de hemodiálise associou-se com positividade do anti-VHC (OR=1,47; IC 95% 1,35-1,61). Procedimentos nas clínicas associados à positividade do anti-VHC foram preparo prévio de heparina (OR=2,92; IC 95% 1,23-6,92), falha no uso ou troca de luvas (OR=5,73; IC 95% 1,75-18,72), desinfecção de máquinas de diálise (OR=2,79; IC 95% 1,57-4,96) e segregação em sala de diálise (OR=0,18; IC 95% 0,05-0,61). CONCLUSÕES: Os resultados mostraram elevada prevalência de anti-VHC em pacientes sob hemodiálise e a associação de fatores de transmissão nosocomial com a infecção pelo VHC.

OBJECTIVE: The prevalence of hepatitis C virus (HCV) is higher in patients on hemodialysis than in the general population, probably due to greater exposure to risk situations. The purposes of the study were to determine anti-HCV antibodies prevalence among hemodialysis patients and dialysis clinics and patients factors associated with HCV transmission. METHODS: A cross-sectional study was conducted in 752 hemodialysis patients in all 12 dialysis clinics of Fortaleza, Brazil, and were screened using third generation ELISA. Sociodemographic, clinical, and epidemiological data of 663 patients were collected through interviews. Nosocomial factors were assessed using a specific questionnaire tool. Statistical analysis was conducted using Student's t test, odds ratio and multivariate analysis. RESULTS: The prevalence of anti-HCV was 52% (390/746; ranged from 6% to 72%). The anti-HCV positivity was higher in patients who had previous peritoneal dialysis (OR=1.76; 95% CI 1.12-2.76) and blood transfusion (OR=2.75; 95% CI 1.25-6.03). Dialysis age has been associated with anti-HCV positivity (OR=1.47; 95% CI 1.35-1.61). Clinics practices associated with anti-HCV positivity were: previous preparing of heparin (OR=2.92; 95% CI 1.23-6.92), failure in gloves use or change (OR=5.73; 95% CI 1.75-18.72), unsatisfactory dialysis machine disinfection (OR=2.79; 95% CI 1.57-4.96), and patient isolation in dialysis room (OR=0.18; 95% CI 0.05-0.61). CONCLUSIONS: The results show high anti-HCV prevalence among hemodialysis patients and the association of nosocomial factors with new HCV infection cases.

OBJETIVO: A prevalência da infecção pelo vírus da hepatite C (VHC) é maior em pacientes submetidos à hemodiálise que na população em geral, possivelmente refletindo maior exposição a situações de risco. O estudo realizado teve por objetivo determinar a prevalência de anticorpos anti-VHC em pacientes em hemodiálise e identificar fatores relacionados às clínicas e aos pacientes, associados à transmissão do VHC. MÉTODOS: Realizou-se estudo transversal em 752 pacientes em hemodiálise em todas as 12 clínicas de Fortaleza, Ceará. Eles foram testados com anticorpos anti-VHC por ELISA de terceira geração. Foram entrevistados 663 pacientes quanto a aspectos sociodemográficos, clínicos e epidemiológicos. Fatores nosocomiais foram investigados utilizando-se questionário específico. Para a análise estatística foram aplicados o teste t de Student, o odds ratio e a regressão logística univariada e multivariada. RESULTADOS: A prevalência de anti-VHC foi de 52% (390/746; variando de 6% a 72%). A freqüência de infecção foi maior em pacientes previamente submetidos à diálise peritoneal (OR=1,76; IC 95% 1,12-2,76) e a transfusões de sangue (OR=2,75; IC 95% 1,25-6,03). O tempo de hemodiálise associou-se com positividade do anti-VHC (OR=1,47; IC 95% 1,35-1,61). Procedimentos nas clínicas associados à positividade do anti-VHC foram preparo prévio de heparina (OR=2,92; IC 95% 1,23-6,92), falha no uso ou troca de luvas (OR=5,73; IC 95% 1,75-18,72), desinfecção de máquinas de diálise (OR=2,79; IC 95% 1,57-4,96) e segregação em sala de diálise (OR=0,18; IC 95% 0,05-0,61). CONCLUSÕES: Os resultados mostraram elevada prevalência de anti-VHC em pacientes sob hemodiálise e a associação de fatores de transmissão nosocomial com a infecção pelo VHC.

OBJECTIVE: The prevalence of hepatitis C virus (HCV) is higher in patients on hemodialysis than in the general population, probably due to greater exposure to risk situations. The purposes of the study were to determine anti-HCV antibodies prevalence among hemodialysis patients and dialysis clinics and patients factors associated with HCV transmission. METHODS: A cross-sectional study was conducted in 752 hemodialysis patients in all 12 dialysis clinics of Fortaleza, Brazil, and were screened using third generation ELISA. Sociodemographic, clinical, and epidemiological data of 663 patients were collected through interviews. Nosocomial factors were assessed using a specific questionnaire tool. Statistical analysis was conducted using Student's t test, odds ratio and multivariate analysis. RESULTS: The prevalence of anti-HCV was 52% (390/746; ranged from 6% to 72%). The anti-HCV positivity was higher in patients who had previous peritoneal dialysis (OR=1.76; 95% CI 1.12-2.76) and blood transfusion (OR=2.75; 95% CI 1.25-6.03). Dialysis age has been associated with anti-HCV positivity (OR=1.47; 95% CI 1.35-1.61). Clinics practices associated with anti-HCV positivity were: previous preparing of heparin (OR=2.92; 95% CI 1.23-6.92), failure in gloves use or change (OR=5.73; 95% CI 1.75-18.72), unsatisfactory dialysis machine disinfection (OR=2.79; 95% CI 1.57-4.96), and patient isolation in dialysis room (OR=0.18; 95% CI 0.05-0.61). CONCLUSIONS: The results show high anti-HCV prevalence among hemodialysis patients and the association of nosocomial factors with new HCV infection cases.