Diretrizes para o diagnóstico da artrite reumatoide

Translation, transcultural adaptation into Brazilian Portuguese and concurrent validity of the rheumatoid arthritis assessment scale (RAKAS-13/Brazil)

BACKGROUND

Knowledge of patients about Rheumatoid Arthritis (RA) is a necessary aspect to better approach self-management support in a patient-centered manner. The research instrument known as the Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS), consisting of 13 items, is simple, reliable and reproducible, and can be applied in both clinical practice and research protocols.

OBJECTIVE

This study aimed to translate and culturally adapt the RAKAS vocabulary into Brazilian Portuguese and to evaluate its concurrent validity.

METHODS

The RAKAS was translated into Brazilian Portuguese and administered to 52 elderly women with RA recruited between May 2021 and May 2022. Concurrent validity was assessed using the Spearman's correlation coefficient between RAKAS and Patient Knowledge Questionnaire (PKQ).

RESULTS

The participants considered RAKAS-13/BRAZIL easy to understand and did not report any doubts in answering the final version. Concurrent validity of the RAKAS-13/BRAZIL was low compared to the PKQ (ρ = 0.283, p = 0.038).

CONCLUSION

The Brazilian Portuguese version of the RAKAS (RAKAS-13/BRASIL) proved to be a questionnaire that was easy and quick to administer to assess patient knowledge about Rheumatoid Arthritis, despite its low correlation with the PKQ in the present study.

Brazilian Portuguese version and content validity of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH)

INTRODUCTION

The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a personalized, progressive 12-week exercise program for people with hand problems due to rheumatoid arthritis (RA). Patients are provided with two guidance documents, the 'Patient Exercise Booklet' and the 'Personal Exercise Guide', to continue the exercises independently at home.

OBJECTIVE

This study aimed to translate and culturally adapt the SARAH protocol into Brazilian Portuguese and validate its content.

METHODS

The guidance documents 'Patient Exercise Booklet' and 'Personal Exercise Guide' of the SARAH program were translated and culturally adapted to Brazilian Portuguese. The content validity was obtained by calculating the content validity index (CVI).

RESULTS

The Brazilian version of the SARAH protocol reached semantic, idiomatic, conceptual, and cultural equivalences. The CVI was greater than 0.8, corresponding to a satisfactory index. The verbal comprehension was 4.9, showing good verbal comprehension of the target population.

CONCLUSION

The Brazilian Portuguese version of the SARAH protocol is available to Brazilian people with compromised hands due to RA with satisfactory content validity.

Hematological markers and ultrasound 7-joint inflammation score as add-on tools in the assessment of inflammation in rheumatoid arthritis patients

Background

Rheumatoid arthritis (RA) is an autoimmune disease characterized by synovial inflammation and joint destruction that eventually induces severe disability. Inflammation is the key determinant and primary underlying mechanism leading to disability and increased mortality in patients with RA. This study aimed to correlate the hematological markers and ultrasound 7-joint inflammation score to disease activity in rheumatoid arthritis patients.

Results

The current study involved 54 RA patients diagnosed according to the 2010 ACR/EULAR classification criteria for RA and thirty healthy control subjects. There were 48 females (88.9%) and 6 males (11.1%). The age of patients ranged from 32 to 60 years, with a mean of 46.04 ± 5.65 years. Using disease activity score 28-ESR, total white blood cell count and absolute lymphocytic count were significantly lower in RA patients with high disease activity. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, mean platelet volume, ESR, and CRP were significantly higher in patients with high disease activity using disease activity score 28 CRP. Also, a statistically significant positive correlation was detected between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and both clinical disease activity scores. Red cell distribution width but not platelet distribution width was significantly higher in RA patients but both parameters had no association or correlation with clinical disease activity scores. Neutrophil-to-lymphocyte ratio was found to have a statistically significant positive correlation with the tenosynovitis score by powered Doppler ultrasound. There were statistically significant positive correlations between disease activity score 28 ESR and CRP and synovitis and tenosynovitis scores by greyscale and powered Doppler ultrasound using the ultrasound 7 score.

Conclusion

Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and mean platelet volume could be potential inflammatory markers for follow-up of disease activity in RA patients. The ultrasound 7 score is a simple and practical scoring system for use in the detection of inflammation, even subclinically in RA patients, which may help the physician in his clinical decisions. The combined use of both hematological markers and the ultrasound 7 score may be of great value.

Advances in the diagnosis of autoimmune diseases based on citrullinated peptides/proteins

Introduction: Autoimmune diseases are still one of the hard obstacles associated with humanity. There are many exogenous and endogenous etiological factors behind autoimmune diseases, which may be combined or dispersed to stimulate the autoimmune responses. Protein citrullination represents one of these factors. Harnessing specific citrullinated proteins/peptides could early predict and/or diagnose some of the autoimmune diseases. Many generations of diagnostic tools based on citrullinated peptides with comparable specificity/sensitivity are available worldwide.Areas covered: In this review, we discuss the deimination reaction behind the citrullination of most known autoantigens targeted, different generations of diagnostic tools based on citrullinated probes with specificity/sensitivity of each as well as newly developed assays. Furthermore, the most advanced molecular analytical tools to detect the citrullinated residues in the biological fluid and their performance are also evaluated, providing new avenues to early detect autoimmune diseases with high accuracy.Expert opinion: With the current specificity/sensitivity tools available for autoimmune disease detection, emphasis must be placed on developing more advance and effective, early, rapid, and simple diagnostic devices for autoimmune disease monitoring (similar to a portable device for sugar test at home). The molecular analytical devices with dual and/or multiplexe functions should be more simplified and invested in clinical laboratories.

Força de preensão palmar e desempenho funcional em mulheres de meia-idade e idosas com artrite reumatoide

RESUMO A força de preensão palmar em mulheres com artrite reumatoide pode estar comprometida devido à presença de deformidades e restrições funcionais impostas pela doença. Existem poucas informações na literatura sobre a diferença de força de preensão e funcionalidade em mulheres adultas e idosas com artrite reumatoide. O objetivo foi comparar a força de preensão palmar, capacidade funcional, e fadiga entre mulheres adultas (meia idade) e idosas com artrite reumatoide e verificar a associação destas variáveis nas duas faixas etárias. Participaram mulheres com artrite reumatoide, acima de 45 anos, com marcha independente, divididas em grupo de adultas (45 a 59 anos) e idosas (60 anos e mais). Foram mensuradas a força de preensão palmar (dinamômetro Jamar®), capacidade funcional (velocidade de marcha) e fadiga (Functional Assessment of Chronic Illness Therapy); feitas comparações entre grupos de idade pelo teste t-Student independente, e associação entre as variáveis, em cada grupo, pelo teste de correlação de Pearson. Foi verificado nível de significância de 5% e a força de preensão palmar foi maior no grupo de idosas (p=0,01). No grupo de adultas, houve associação entre capacidade funcional e fadiga (r=0,53; p=0,01) e no grupo de idosas, houve associação entre força de preensão palmar e velocidade de marcha (r=0,51; p=0,02). Os resultados demonstraram que as idosas estavam em melhores condições musculares. Parâmetros indicados, como marcadores de desempenho funcional e muscular em idosas demonstraram estar associados, confirmando o uso destes marcadores nesta condição específica.

An Overview of the Intrinsic Role of Citrullination in Autoimmune Disorders

A protein undergoes many types of posttranslation modification. Citrullination is one of these modifications, where an arginine amino acid is converted to a citrulline amino acid. This process depends on catalytic enzymes such as peptidylarginine deiminase enzymes (PADs). This modification leads to a charge shift, which affects the protein structure, protein-protein interactions, and hydrogen bond formation, and it may cause protein denaturation. The irreversible citrullination reaction is not limited to a specific protein, cell, or tissue. It can target a wide range of proteins in the cell membrane, cytoplasm, nucleus, and mitochondria. Citrullination is a normal reaction during cell death. Apoptosis is normally accompanied with a clearance process via scavenger cells. A defect in the clearance system either in terms of efficiency or capacity may occur due to massive cell death, which may result in the accumulation and leakage of PAD enzymes and the citrullinated peptide from the necrotized cell which could be recognized by the immune system, where the immunological tolerance will be avoided and the autoimmune disorders will be subsequently triggered. The induction of autoimmune responses, autoantibody production, and cytokines involved in the major autoimmune diseases will be discussed.

Prevalence and factors associated with diagnosis of early rheumatoid arthritis in the south of Brazil

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease characterized by peripheral and symmetrical polyarthritis. It can be divided into Very Early Rheumatoid Arthritis (VERA) diagnosed up to 3 months of symptoms and late onset (Late Early Rheumatoid Arthritis - LERA), diagnosed between 3 and 12 months. Currently, it is recommended to evaluate the patient with joint symptoms as early as possible, and the first 12 weeks of manifestations represent the ideal phase for the diagnosis, favoring a better evolution of the treatment. The present study aimed to determine the prevalence of early diagnosis of rheumatoid arthritis, mean time of diagnosis and to determine possible associated factors in the municipality of Blumenau, Santa Catarina, Brazil.

METHODS

A cross-sectional study using the 1987 American College of Rheumatology diagnostic criteria to select patients attended at primary or secondary health care units in Blumenau, Santa Catarina, southern Brazil, in 2014. Diagnostic time was verified by self-report of the time elapsed between the onset of symptoms and the diagnosis made by a rheumatologist. To test the associations, the chi-square test, the Wald linear trend test and the Poisson regression analysis were used.

RESULTS

The mean time of diagnosis was 28 months. The prevalence of diagnosis up to 3 and 12 months was 27.7% and 64.8%, respectively. Obesity was associated with time diagnosis in both periods. The 0-4 years category of the variable education was associated only with the period up to 12 months.

CONCLUSION

The mean time of diagnosis was similar to the national context. Among socioeconomic factors, lower education was associated with the diagnosis of late onset RA. The anthropometric variable presented a progressive increase in the prevalence due to the longer time to diagnosis.

Cardiovascular risk and mannose binding lectin in patients with rheumatoid arthritis from southern Brazil

BACKGROUND

Mannose binding lectin (MBL) appears to be involved in susceptibility to rheumatoid arthritis (RA), in the inflammatory process and in the genesis of atherosclerotic disease.

OBJECTIVE

To study the association of MBL serum levels and its genotypic variation with carotid arteries intimal thickness (IMT) in RA patients from Southern Brazil.

METHODS

MBL serum levels, MBL2 genotyping and IMT were investigated in 90 RA patients along with their demographic, clinical and laboratory profile. MBL levels and MBL2 genotyping were evaluated in 90 healthy controls.

RESULTS

A significant lower MBL serum concentration was observed in patients with RA in relation to controls (528 ng/mL vs 937.5 ng/mL, p = 0.05, respectively). The median IMT in RA patients was 0.59 mm (0.51 to 0.85 mm). There was no correlation between levels of MBL with disease activity, erythrocyte sedimentation rate, autoantibodies presence or IMT (p = NS). A weak and negative correlation was found between MBL and CRP levels (Rho = -0.24; p = 0.02;). The MBL2 variant at codon 54 (variant B) and HYPA haplotype were the most frequently observed in the RA sample (67.5% and 31.7%). MBL2 wild type (A/A) were associated with lower IMT when compared with heterozygotes (A/O; p = 0.04) and low producers (O/O; p = 0.05). In addition, high producers genotypes had lower levels of CRP when compared with medium (p = 0.04) or with low producers (p = 0.05).

CONCLUSION

RA patients had lower MBL levels than controls. MBL were negatively associated with CRP serum levels; low MBL genotypes producers increased thickness of the IMT than high producers.

An Evaluation of Non-Surgical Periodontal Therapy in Patients with Rheumatoid Arthritis

aim of this study was to evaluate the efficacy of periodontal scaling and oral hygiene instruction for patients with mild chronic periodontitis and rheumatoid arthritis through clinical periodontal parameters and laboratory tests for CRP (C- reactive protein) and ESR (erythrocyte sedimentation rate). Twelve individuals with rheumatoid arthritis and 12 healthy individuals were evaluated, with a mean age of 45.38 and 46.75 respectively, all female and with mild, chronic periodontitis. The participants were evaluated clinically and periapical radiographs were taken (T1), after which periodontal treatment was instituted. After ninety days (T2), new clinical and laboratory data were obtained. Probing depth, bleeding index, and plaque indexes were observed in both groups, and the results demonstrated reductions but no statistical differences. Laboratory tests for CRP and ESR produced higher values for the rheumatoid arthritis group with T1- T2 reductions on the average, but the values were still higher than in the health group. We conclude that periodontal therapy in patients with rheumatoid arthritis and mild chronic periodontitis showed a improvement in the periodontal clinical parameters and laboratory tests that were evaluated.