Introduction Assessment of risk both for pregnancy morbidity and thrombosis in the presence of anti-phospholipid antibodies (aPL) is still a challenge in Systemic Lupus Erythematosus (SLE) patients. The Global Antiphospholipid Syndrome Score (GAPSS) takes into account the aPL profile (criteria and non-criteria aPL), the conventional cardiovascular risk factors and the autoimmune antibody profile. An adjusted model of the score (aGAPSS) excluding anti-phosphatidylserine/Prothrombin (aPS/PT), suggests that the score is able to stratify patients for their rate of events making it widely applicable in daily clinical practice. Objective To validate the aGAPSS in a multicentric cohort of SLE patients in Argentina. Patients and methods consecutive SLE patients with and without thrombotic events from seven Rheumatologist centers were included. Traditional cardiovascular risk factors, aPL antibodies and medications received (aspirin, hydroxychloroquine and anticoagulation) were collected. The score aGAPSS was calculated for each patient at the last visit by adding together the points corresponding to the risk factors: 1 for hypertension, 3 for dyslipidemia, 4 for LA and B2GPI (IgM or IgG) antibodies and 5 for aCL (IgM or IgG) antibodies. The discriminative ability of the aGAPSS was calculated by measuring the area under the receiver operating characteristic curve (AUC). Multivariate logistic regression analysis was performed to examine the impact of multiple cardiovascular risk factors and laboratory parameters on the occurrence of thrombosis. Results Two hundred and ninety-six SLE patients were included. One-hundred and twenty-one patients (40.9%) presented thrombotic and/or pregnancy complications. Median aGAPSS was significantly higher in patients who experienced an event (thrombosis and/or pregnancy morbidity) compared with those without [4 (IQR 1–9) versus 1 (IQR 0–5); p < 0.001]. The best cut off point for the diagnosis of thrombosis and/or pregnancy complications was aGAPSS ≥4. Multivariate logistic regression analysis showed that aCL antibodies [OR 2.1 (95% CI 1.16–3.90); p = 0.015] were an independent risk factors for thrombotic events. Conclusions This score is a simple tool, easy to apply to SLE patients in daily practice. The use of the aGAPSS could change the non-pharmacologic and pharmacologic treatment in higher risk patients to improve their survival.
Introdução: A COVID-19, infecção causada pelo vírus SARS-CoV-2, disseminou-se rapidamente ao redor do mundo, sendo declarada, em março de 2020, situação de pandemia pela World Health Organization. Também nesse mês foi identificado o primeiro caso no Amazonas e logo depois se determinou estado de calamidade pública (Fundação de Vigilância em Saúde do Amazonas — FVS-AM). O isolamento social e o uso de máscaras estão relacionados à redução do contágio, porém a flexibilização dessas medidas implica a ocorrência de novas ondas de disseminação (Wiersinga et al, 2020). A doença desencadeia quadros clínicos predominantemente respiratórios de gravidade variável, apresentando sintomas brandos, como tosse, ou afecções mais graves que podem levar à morte (Thompson et al, 2020). Preconiza-se a gestação como fator de risco para COVID-19, uma vez que as alterações fisiológicas no sistema imunológico e cardiorrespiratório durante a gravidez seriam capazes de tornar a gestante mais suscetível a desenvolver agravos durante a infecção (Dashraath et al, 2020). O surgimento das vacinas mostra-se eficaz em reduzir o número de óbitos (Patel et al, 2021). Objetivo: Comparar a taxa de óbitos em gestantes infectadas pelo SARS-CoV-2 durante a disseminação do vírus, entre março de 2020 e maio de 2021, antes do início da vacinação, bem como após o início, a partir de junho de 2021, até o mês de março de 2022. Materiais e métodos: Estudo descritivo, observacional, transversal, com o uso de dados obtidos no Portal de Transparência COVID-19 da FVS-AM. Foram coletados dados referentes a óbitos por COVID-19 em gestantes, por faixa etária, entre março de 2020, início da pandemia, a 23 de março de 2022, data de última atualização dos dados. Essas informações foram divididas em dois períodos: antes e depois do início da vacinação contra COVID-19. Por serem dados disponibilizados em plataforma pública, não foi necessária a aprovação em Comitê de Ética em Pesquisa. Resultados e conclusão: Entre março de 2020 e maio de 2021, período anterior à vacinação contra COVID-19, foram identificados 2.447 casos de infecção por SARS-CoV-2, com maior prevalência em gestantes de 20 a 29 anos (47,28%), e 44 óbitos (índice de letalidade: 1,80%), que acometeram principalmente gestantes entre 30 e 39 anos (59,09%), sendo a maior taxa de letalidade por faixa etária (3,26%). Após o início da vacinação, entre junho de 2021 e março de 2022, foram constatados 377 casos de COVID-19, dos quais quatro evoluíram para óbitos (índice de letalidade: 1,06%). A faixa etária com maior quantidade de casos e óbitos foi a de 20 a 29 anos (53,31 e 50%, respectivamente), enquanto a maior taxa de letalidade acometeu a faixa de 15 a 19 anos (1,89%). Pode-se observar que a quantidade de óbitos reduziu consideravelmente comparando-se os dois períodos (90,9%). O principal fator responsável pela redução de casos e óbitos é a vacinação desse grupo de risco. Assim, conclui-se que a vacinação é eficaz em reduzir a mortalidade por essa doença, devendo ser incentivada.
Introdução: Em dezembro de 2019 foi identificado o agente responsável pela pandemia da COVID-19, declarada pela Organização Mundial de Saúde (OMS) em março de 2020. Trata-se de uma doença multissistêmica, que envolve citocinas pró-inflamatórias, sustentando o status de hiperinflamação. A gestação é considerada um fator de risco em virtude das mudanças fisiológicas, que geram alterações imunológicas, respiratórias, cardiovasculares e trombóticas. Estudos durante epidemias de MERS-CoV e SARS-CoV-1 revelaram o potencial de gravidade em gestantes infectadas, e o Centro de Controle de Doenças (CDC) dos Estados Unidos relatou maior frequência de uso de terapia intensiva, ventilação invasiva e maior período de internação em pacientes gravídicas. Além disso, um estudo brasileiro apontou taxa de letalidade de 12,7% em gestantes e puérperas, 3,4 vezes maior do que na população geral. A vacinação contra a COVID-19 transformou o cenário epidemiológico, sendo recomendada em qualquer período gestacional. Todavia, a disseminação de informações falsas e a ausência de consenso entre órgãos de saúde colaboram para a não adesão de grávidas, sustentando altos índices de internação e óbitos. Objetivos: Descrever as taxas de internação de gestantes e puérperas por SARS-CoV-2 e identificar a correlação com o status vacinal. Materiais e métodos: Trata-se de estudo epidemiológico descritivo retrospectivo, com dados disponibilizados pelo Ministério da Saúde de março de 2020 a março de 2022, por meio do Departamento de Informática do Sistema Único de Saúde (DataSUS) e da Fundação de Vigilância Sanitária do Amazonas (FVS-AM) sobre gestantes e puérperas e COVID-19. Resultados e conclusão: No Amazonas, ocorreram 2.824 casos de COVID-19 entre gestantes e puérperas no período citado, com 985 casos evoluindo para internação, culminando em 92 óbitos, e taxa de letalidade de 1,7%, mais frequente na faixa de 30 a 39 anos. Os principais sintomas nas hospitalizadas foram tosse, febre, dispneia, dor de garganta e saturação de O2<95%. Verificaram-se mais hospitalizações nas que apresentavam comorbidades como asma, doença cardíaca crônica, diabetes e obesidade. Iniciou-se em 12 de março de 2021 a vacinação contra a COVID-19 em gestantes, população correspondente a cerca de 45.920 mulheres, das quais 23 mil receberam a primeira dose (31,4%) e 14.408 (19,4%) a segunda, porcentagem baixa para o grupo. No primeiro ano de pandemia, ocorreram 786 internações e 79 óbitos nessa população, e no segundo ano, em contexto de imunização, a taxa de internação caiu para 199 e 13 óbitos. Gestantes e puérperas, portanto, devem ser orientadas e avaliadas sobre o risco de contágio, não havendo contraindicação para a vacinação delas contra a COVID-19. A vacinação de gestantes e puérperas torna-se importante não apenas para reduzir os riscos de contrair COVID-19, mas para diminuir as chances de um quadro grave da doença em caso de diagnóstico positivo, além de se observar, com a vacinação, queda nos casos de hospitalização e óbitos nessa população no Amazonas.
BACKGROUNDViral infections can not only be a trigger, but a worsening factor in the context of immune mediated rheumatic diseases (IMRDs). Thus, it is important to measure the impact of the new coronavirus SARS-CoV-2 infection, also known as COVID-19, in IRMDs' activity. This study has the objective of testing the association between SARS-CoV-2 infection and increase in disease activity in rheumatoid arthritis patients at the research center located in Manaus, Amazonas state. METHODSIt is a prospective observational study with a comparison group, based on the analysis of data from patients with rheumatoid arthritis of Project Reumacov, organized by the Brazilian Society of Rheumatology, localized in Manaus, Amazonas. Case and control groups included, respectively, patients with and without current or previous suspected SARS-CoV-2 infection according to Brazilian Ministry of Health criteria. There was a presential visit to collect the clinical disease activity index (CDAI) at the moment of inclusion. Previous CDAI was obtained from most recent records until six months before the presential visit, prioritizing a value before COVID-19 symptoms in the case group. It was analyzed the association between SARS-CoV-2 infection and increase in CDAI. Chi-squared and Fisher tests were used in the statistical analysis. The study was approved by the ethical committee.
Background: various clinical entities, such as autoimmune diseases, infections, neoplasms and drugs can manifest with vasculitic lesions on the skin. Due to the heterogeneity of causes, they often represent a diagnostic challenge. The aim of this study is to describe the etiology of cutaneous vasculitis (CV) and to assess the clinical, histological and laboratory characteristics found in these patients. Material and methods: a retrospective study was carried out with a review of the medical records of patients over 16 years old with CV by clinical and / or histological diagnosis evaluated in the period 2010-2018. Results: 74 patients were included. 69% are women with a mean age at diagnosis of 41 years (SD 16.5, range 16 -75). The most frequent causes associated with CVs were autoimmune diseases (AID) in 50% of the patients evaluated. In 29.7% of the cases, an underlying cause could not be identified. In 2.7% of the cases it was associated with neoplasms, another 2.7% with drugs, and 12% with other etiologies. 76% of the patients presented non-severe clinical forms, with palpable purpura predominant in 65% of the cases. Among the biopsied patients, 76% were leukocytoclastic vasculitis (LCV). As associated extracutaneous manifestations, joint involvement predominated (43.2%). In vasculitis associated with AID, 33% presented renal involvement, while this was not observed in any of the patients with idiopathic vasculitis. 78% of the patients received systemic glucocorticoids. Conclusion: In our center, the most common etiology of CV was associated with AID. Most of the patients were women. Clinically, non-severe skin manifestations predominated and VLC was the most frequent finding in biopsies.
BACKGROUNDSpondyloarthritis (SpA) is a group of inflammatory disorders that share clinical manifestations, genetic associations and pathogenic mechanisms, typically difficult to be diagnosed without evaluation by a rheumatologist. The SpA group includes ankylosing spondylitis (AS), psoriatic arthritis (PAs), reactive arthritis (ReA), enteropathic arthritis (EA) and undifferentiated spondyloarthritis (US). The difficulty in evaluating these diseases by nonrheumatologists and the lack of strategies for referring the suspected patient to the specialist result in a delay in the diagnosis of the disease and lead to subsequent investigations and unnecessary treatments, resulting in high costs and increased morbidity. METHODSObservational cross-sectional design based on the extraction and analysis of data from medical records of individuals affected by SpA, in the period from 2016 to 2020. RESULTSA total of 122 participants were included, 69.57% were male with a mean age of 46.76 ± 13.05 years; of which 78 participants had AS (63.93%), 37 PAs (30.33%), 4 EA (3.27%), 1 US (0.81%), 1 nonradiographic axial SpA (0.81 %) and 1 ReA (0.81%), with a mean time from onset of joint symptoms to diagnosis of the disease of 5.88 ± 8.36 years and with a mean time from onset of extra-articular symptoms to diagnosis of 4.09 ± 10.64 years. The predominant clinical form was axial in 54 (44.26%), peripheral in 31 (25.41%) and mixed in 37 (30.27%) of the participants. As for joint related clinical manifestations, there was the occurrence of: low back pain in 93 (76.23%), pain in the buttocks in 29 (23.77%), neck pain in 58 (47.54%), thigh pain in 26 (21.31 %), lower limb arthritis in 73 (59.83%), upper limb arthritis in 48 (39.34%), enthesitis in 39 (31.97%) and dactylitis in 19 (15.57%) of the participants. As for extra-articular clinical manifestations, the following were present in the sample: anterior uveitis in 18 (14.75%), inflammatory bowel disease in 8 (6.55%), psoriasis in 37 (30.33%) and urethritis in 7 (5.73%) participants. CONCLUSIONThere is a great delay in the diagnosis of SpA in the state of Amazonas, following global trends. However, the sample studied demonstrates that there are differences in the prevalence of clinical manifestations of the disease compared to international groups, which should be taken into account in the evaluation of patients suspected of SpA and in the creation of screening and referral tools.
During the SARS-CoV-2 pandemic, it was interrogated whether systemic lupus erythematosus (SLE) patients with COVID-19 would be at risk of worse outcome due to chronic inflammatory autoimmune condition and use of immunosuppressants. The Amazon region receives intense ultraviolet radiation, factor that can influence high expression of SLE. With 415,846 cases of COVID-19 till September 2021, the state of Amazonas is an ideal environment to characterize the disease evolution in patients with SLE. This study seeks to describe the frequency and clinical course of COVID-19 in SLE patients followed at the Ambulatório Araújo Lima, in Manaus (AM). METHODSProspective observational study, based on data analysis from SLE patients of Project Mário Pinotti II, organized by the Brazilian Society of Rheumatology, in Manaus, capital of Amazonas state. We analyzed: gender, age, flu-like symptoms (asthenia, headache, coryza, diarrhea, dysgeusia, dysosmia, dyspnea, cough, sore throat, fever, nausea, dizziness and vomiting) and clinical outcome. We used the clinical criteria established by the Brazilian Ministry of Health to define COVID-19 confirmed case: flu-like-symptoms case associated with olfactory or gustatory dysfunction without any other previous cause. The study was approved by the Ethics Committee. RESULTSA total of 271 SLE patients were followed through 6 telephone evaluations, with 14 days of interval, from 28 April to 30 September 2020. The mean age was 38.36 ± 11.39 years, 252 (92.99%) were females and 19 (7.01%) males. In the 1st evaluation, 45 (17.79%) had COVID-19, the main symptoms were dysgeusia, dysosmia and headache; in the 2nd evaluation, 8 (3.19%) had COVID-19, the main symptoms dysgeusia, dysosmia and cough; in the 3rd evaluation, 2 (0.78%) had COVID-19, the main symptom dysgeusia; in 4th evaluation, 5 (1.91%) had COVID-19, the main symptoms dysgeusia, asthenia and fever; in the 5th evaluation, 3 (1.12%) had COVID-19, the main symptoms dysgeusia, dysosmia, asthenia, headache and cough; in the 6th evaluation, 1 (0.37%) had COVID-19, the main symptoms dysgeusia and dysosmia. In the 1st evaluation, 3 (8.89%) of COVID-19 patients were hospitalized and, in the 2nd, 1 (2.5%) was hospitalized. There was no need for intensive care or mechanical ventilation. There were no deaths. CONCLUSIONDysgeusia, dysosmia, headache, asthenia and cough were the most common symptoms among patients during the evaluations. Most cases were self-resolving, without need for hospitalization and no death. In this cohort, a high suspicion of COVID-19 infection was not uncommon, but with no severity.
Introducción: el lupus es una enfermedad compleja y varias veces de difícil abordaje. Alcanzar la remisión es uno de los objetivos, incorporando opciones terapéuticas. Objetivos: describir las características generales de los pacientes según el estado de la enfermedad y el uso de belimumab. Materiales y métodos: estudio de corte transversal, registro RELESSAR. Se definió el estado de la enfermedad como: remisión: SLEDAI=0 y sin corticoides; baja actividad de la enfermedad: SLEDAI >0 y ≤4 y sin corticoides; control no óptimo: SLEDAI >4 y cualquier dosis de corticoides. Resultados: se incluyeron 1.277 pacientes, 23,4% en remisión, 12,6% en baja actividad y 63,8% con control no óptimo. En este último grupo eran más jóvenes y con menor duración de la enfermedad; presentaban mayores índices de actividad y cronicidad, y mayor empleo de inmunosupresores. Solo el 22,3% de los pacientes con criterio potencial de uso de belimumab (lupus eritematoso sistémico activo a pesar del tratamiento estándar) lo recibía en ese momento. Las variables asociadas a hospitalizaciones fueron: terapia con corticoides, ciclofosfamida y mayor SLICC. Conclusiones: se refleja la complejidad del manejo de estos pacientes y se visualizan aspectos estructurales como la desigualdad. El uso del belimumab resultaría beneficioso en los pacientes seleccionados.
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