Objective: to evaluate the prevalence of psychiatric disorders in female patients, diagnosed with Rheumatoid Arthritis and relate this disorder to disease activity. Methods: sectional trial study with female patients, aged 18 years old or older, diagnosed with Rheumatoid Arthritis (following American College of Rheumatology-ACR criteria), more than six months of disease and incapacity levels II and III. Disease activity was evaluated with DAS 28 (Disease Activity Score-28) (remission up to 2.6/ moderate activity 2.6 to 5.1/severe degree over 5.1). Psychiatric evaluation was conducted using SCID protocol; interviews were held to diagnose the presence of depression and anxiety disorders following the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). Statistical analysis included the Kruskal-Wallis test and the Kendall test with a significance level of 95%. Results: In the 107 patients analyzed, 36 subjects (33.7%) presented psychiatric disorders and 71(66.4%) no psychiatric disorders). Disease activity-DAS 28 score results; remission: 6 patients (5.6%); moderate activity: 59 patients (55.1%); severe disease: 42 patients (39.2%). The relationship between psychiatric disorders and disease activity (DAS 28) demonstrated: patients without psychiatric disorders-DAS 28 score: 4.56 and patients with psychiatric disorders, DAS 28 score: 5.43 (p=0.001). Conclusions: The prevalence of depression and anxiety disorders among 107 patients with Rheumatoid Arthritis was 33.7%. Disease activity, evaluated by the DAS 28 score, was higher in the group of patients with psychiatric disorders. No patients with psychiatric disorders were identified in the group in clinical remission.

RESUMO RESULTADOS:Os tipos de dor encontrados foram nociceptiva, neuropática e incidental, avaliadas utilizando-se a escala unidimensional de faces. Verificou-se a analgesia controlada pelo paciente (PCA) com metadona, via oral, em ambiente domiciliar na 1ª semana. Após esse período, o paciente retornava ao ambulatório para o cálculo da dose regular da metadona. Outros opióides utilizados foram codeína, tramadol, morfina e oxicodona. Além da dor, os pacientes apresentaram: constipação, náuseas, vômitos, delirium, alteração do sono e dispnéia. Os neurolépticos, corticóides e laxantes foram usados como fármacos adjuvantes. CONCLUSÕES: A analgesia controlada pelo paciente utilizando a metadona mostrou-se segura e eficaz pela não-ocorrência de efeitos colaterais significativos. O conhecimento clínico e farmacológico do anestesiologista na equipe multiprofissional proporcionou melhor atendimento para o alívio dos sintomas dos pacientes e humanização no período final de vida.

Objective: We describe a case of refractory myasthenia gravis with bulbar involvement and the nutritional treatment solutions proposed to treat the associated dysphagia and malnutrition. Methods: A 39-y-old woman with refractory myasthenia gravis was referred to our clinical nutrition unit for deteriorating dysphagia and progressive malnutrition.Results: The first-line nutritional approach consisted of dietary counseling and thickened meals. Unfortunately, no adequate oral intake was achieved and an enteral nutrition treatment was proposed. A nasogastric tube was removed after a few days due to local pain and poor quality of life. Despite consistent weight loss and overt malnutrition, the patient refused percutaneous endoscopic gastrostomy placement. Neurologic symptoms did not show any improvement but unexpectedly the patient's weight started to increase to previous values. Anamnestic recall revealed that the patient learned by herself how to position the nasogastric tube that is now temporarily used for formula infusion coinciding with neurologic poussés. Conclusions: Current guidelines consider chronic neurologic diseases with associated dysphagia, where refractory myesthania gravis has also been considered, a unique category. Chronic neurogenic dysphagia with high risk of aspiration, long-term inability to obtain adequate oral intakes, and malnutrition are established indications for percutaneous endoscopic gastrostomy placement. However, patients may need different forms of nutritional intervention during the course of their illness and choices and indications should contemplate ethical reasons, clinical benefits, minimal risks, and acceptable quality of life. Minimally invasive intermittent enteral nutrition might be considered a possible clue for nutritional management of exacerbating dysphagia. Ó

Neuropsychiatric disorders associated with systemic lupus erythematosus are very common. Treatment generally consists of glucocorticoids and immunosuppressive therapy; however, some cases are unresponsive. Electroconvulsive therapy (ECT) is a recognized treatment modality in psychiatry and is an option for refractory cases of neuropsychiatric lupus. This report describes three cases of neuropsychiatric lupus that improved with ECT after failure of antipsychotics and immunosuppressive therapy. All cases met DSM-5 criteria for catatonia (case 1: agitation, stereotypies, and grimacing; case 2: stupor, mutism, and grimacing; case 3: agitation, mutism, and stereotypies); therefore, ECT was indicated. This case series shows that ECT can be a therapeutic option in patients with neuropsychiatric lupus, especially when associated with catatonia and unresponsive to conventional treatment.