Coronary Inflammation by Computed Tomography Pericoronary Fat Attenuation and Increased Cytokines in Young Male Anabolic Androgenic Steroid Users

BACKGROUND

Anabolic androgenic steroid (AAS) abuse has been associated with coronary artery disease (CAD). Pericoronary fat attenuation (pFA) is a marker of coronary inflammation, which is key in the atherosclerotic process.

OBJECTIVE

To evaluate pFA and inflammatory profile in AAS users.

METHODS

Twenty strength-trained AAS users (AASU), 20 AAS nonusers (AASNU), and 10 sedentary controls (SC) were evaluated. Coronary inflammation was evaluated by mean pericoronary fat attenuation (mPFA) in the right coronary artery (RCA), left anterior descending coronary artery (LAD), and left circumflex (LCx). Interleukin (IL)-1 (IL-1), IL-6, IL-10, and TNF-alpha were evaluated by optical density (OD) in a spectrophotometer with a 450 nm filter. P<0.05 indicated statistical significance.

RESULTS

AASU had higher mPFA in the RCA (-65.87 [70.51-60.70] vs. -78.07 [83.66-72.87] vs.-78.46 [85.41-71.99] Hounsfield Units (HU), respectively, p<0.001) and mPFA in the LAD (-71.47 [76.40-66.61] vs. -79.32 [84.37-74.59] vs. -82.52 [88.44-75.81] HU, respectively, p=0.006) compared with AASNU and SC. mPFA in the LCx was not different between AASU, AASNU, and SC (-72.41 [77.17-70.37] vs. -80.13 [86.22-72.23] vs. -78.29 [80.63-72.29] HU, respectively, p=0.163). AASU compared with AASNU and SC, had higher IL-1, (0.975 [0.847-1.250] vs. 0.437 [0.311-0.565] vs. 0.530 [0.402-0.780] OD, respectively, p=0.002), IL-6 (1.195 [0.947-1.405] vs. 0.427 [0.377-0.577] vs. 0.605 [0.332-0.950] OD, p=0.005) and IL-10 (1.145 [0.920-1.292] vs. 0.477 [0.382-0.591] vs. 0.340 [0.316-0.560] OD, p<0.001). TNF-α was not different between the AASU, AASNU, and SC groups (0.520 [0.250-0.610] vs. 0.377 [0.261-0.548] vs. 0.350 [0.182-430]), respectively.

CONCLUSION

Compared with ASSNU and controls, AASU have higher mPFA and higher systemic inflammatory cytokines profile suggesting that AAS may induce coronary atherosclerosis through coronary and systemic inflammation.

Respiratory failure in systemic sclerosis

Systemic sclerosis (SSc) can lead to dyspnea and respiratory failure through multiple mechanisms, making a precise diagnosis particularly challenging, especially amid the current COVID-19 pandemic. In this report, we present a case involving a 26-year-old female who had previously undiagnosed SSc. She experienced acute respiratory failure necessitating orotracheal intubation. Following an extensive evaluation, the patient exhibited skin thickening, kidney failure, thrombocytopenia, microangiopathic anemia, and an antinuclear antibody with a nuclear fine speckled pattern at a titer of 1:320. A diagnosis of SSc complicated by scleroderma renal crisis (SRC) was established. The patient's condition improved after undergoing hemodialysis, receiving an angiotensin-converting enzyme inhibitor, and undergoing cyclophosphamide treatment. Subsequently, she demonstrated sustained improvement during a follow-up period of 20 months.

Food consumption based on processing level (according to Nova system) during the COVID-19 pandemic among adolescents with immunocompromised conditions: a case-control study

The COVID-19 pandemic impacts on eating habits among adolescents may be more relevant in pediatric patients with immunocompromised chronic diseases. This case-control study conducted between June and October 2020 aimed to: (i) describe dietary patterns of adolescents with chronic conditions compared to healthy controls and (ii) determine associations between food consumption, health-related quality of life (HRQL) and sleep quality during the COVID-19 pandemic. Participants (184 immunocompromised and 58 healthy adolescents, aged 14.3 [SD 2.5]) responded to HRQL and sleep validated instruments (PedsQL and PSQI) and three 24 h food recalls via online software. Adjusted linear and logistic regressions were used to assess differences in dietary patterns and associations between food consumption (according to Nova classification) and HRQL and sleep quality. Adolescents with gastrohepatic, rheumatic, and kidney diseases had an improved dietary pattern vs. their healthy peers, showing greater consumption of unprocessed and minimally processed foods (unstandardized coefficient (b) = 7.35%[95%CI 1.59; 13.1]; b = 15.10%[95%CI 7.00; 23.1]; and b = 11.2%[95%CI 5.68; 16.8]), and lower consumption of ultraprocessed foods (b = -7.53%[95%CI-12.90; -2.18]; b = -11.4%[95%CI-18.90; -3.94]; b = -10.8%[95%CI-16.00; -5.68]). Consumption of culinary ingredients was associated with reduced psychological HRQL in controls (standardized coefficient (β) = -0.26[95%CI-0.52; -0.004]), and processed food consumption was associated with improved sleep latency in immunocompromised participants (β = 0.16[95%CI 0.01; 0.31]). These findings suggest diet quality may play a role in HRQL and sleep quality in this population, and may be relevant for clinical practitioners and policy makers when considering the importance of dietary quality in immunocompromised youths.

Symptomatic fractures in systemic sclerosis: A case-control study

This case-control study analyzed risk factors for symptomatic fractures in a group of 52 patients with systemic sclerosis compared with a group of 104 patients without fractures, matched for sex and age, who were attended at a single systemic sclerosis outpatient clinic from 2010 to 2020. Fractures affected predominantly vertebral (65.4%), rib (13.5%), and hip (7.7%) joints, while the mean age of fracture was 55.3 ± 9.5 years. Age at disease onset, age at diagnosis, disease duration, age at menarche, and age at menopause were similar in both groups, and 58.9% of the patients were menopausal at the time of the fracture. The presence of fractures had a significant association with densitometric osteoporosis (p < 0.001), lower weight (p = 0.032), and bone mineral index (p = 0.044), anti-RNA polymerase III (p = 0.040), use of corticosteroids (p = 0.019), and bisphosphonates (p < 0.001), as well as with densitometric T-scores of lumbar spine (p < 0.001), femoral neck (p = 0.025), and total hip (p = 0.013). Multivariate analysis showed that the variables significantly associated with fractures were high doses of corticosteroids (odds ratio = 4.10; 95% confidence interval = 1.290-13.090; p = 0.017), bisphosphonates (odds ratio = 3.91; 95% confidence interval = 1.699-8.984; p = 0.001), negative anti-Scl70 (OR = 0.34; 95% confidence interval = 0.124-0.943; p = 0.038), and lumbar T-score (odds ratio = 0.39; 95% confidence interval = 0.034-0.460; p = 0.010). In conclusion, symptomatic fractures were associated predominantly with lower bone mineral density of lumbar spine and use of high doses of corticosteroids and bisphosphonates in this cohort.

Emotional, hyperactivity and inattention problems in adolescents with immunocompromising chronic diseases during the COVID-19 pandemic

OBJECTIVE

To assess factors associated with emotional changes and Hyperactivity/Inattention (HI) motivated by COVID-19 quarantine in adolescents with immunocompromising diseases.

METHODS

A cross-sectional study included 343 adolescents with immunocompromising diseases and 108 healthy adolescents. Online questionnaires were answered including socio-demographic data and self-rated healthcare routine during COVID-19 quarantine and validated surveys: Strengths and Difficulties Questionnaire (SDQ), Pittsburgh Sleep Quality Index (PSQI), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0).

RESULTS

The frequencies of abnormal emotional SDQ scores from adolescents with chronic diseases were similar to those of healthy subjects (110/343 [32%] vs. 38/108 [35%], p = 0.548), as well as abnormal hyperactivity/inattention SDQ scores (79/343 [23%] vs. 29/108 [27%], p = 0.417). Logistic regression analysis of independent variables associated with abnormal emotional scores from adolescents with chronic diseases showed: female sex (Odds Ratio [OR = 3.76]; 95% Confidence Interval (95% CI) 2.00‒7.05; p < 0.001), poor sleep quality (OR = 2.05; 95% CI 1.08‒3.88; p = 0.028) and intrafamilial violence during pandemic (OR = 2.17; 95% CI 1.12‒4.19; p = 0.021) as independently associated with abnormal emotional scores, whereas total PedsQL score was inversely associated with abnormal emotional scores (OR = 0.95; 95% CI 0.93‒0.96; p < 0.0001). Logistic regression analysis associated with abnormal HI scores from patients evidenced that total PedsQL score (OR = 0.97; 95% CI 0.95‒0.99; p = 0.010], changes in medical appointments during the pandemic (OR = 0.39; 95% CI 0.19-0.79; p = 0.021), and reliable COVID-19 information (OR = 0.35; 95% CI 0.16‒0.77; p = 0.026) remained inversely associated with abnormal HI scores.

CONCLUSION

The present study showed emotional and HI disturbances in adolescents with chronic immunosuppressive diseases during the COVID-19 pandemic. It reinforces the need to promptly implement a longitudinal program to protect the mental health of adolescents with and without chronic illnesses during future pandemics.

Characteristics of Older Patients with Takayasu's Arteritis: A Two-Center, Cross-Sectional, Retrospective Cohort Study

BACKGROUND

Few studies have assessed elderly patients with Takayasu's arteritis (TAK).

OBJECTIVES

To evaluate the progression of TAK in different age groups and its possible effects on drug treatment and disease activity.

METHODS

This cross-sectional and retrospective cohort study included 66 TAK patients. Patients were interviewed and data of the 12 preceding months were collected from electronic medical records. The patients were divided into four quartiles according to current age and compared for clinical and laboratory data, treatment, comorbidities, disease status, and functional status. Statistical significance was set at p<0.05.

RESULTS

The groups were Q1(22-36 years, n=16), Q2(37-42 years, n=18), Q3(43-49 years, n=17), and Q4(51-66 years, n=15). The frequency of patients with disease activity, fatigue, comorbidities and vascular impairments, and the TAK disease extent index were also comparable between the groups. With age, disease duration was longer (p=0.001), fewer patients used prednisone (Q1:43.8%, Q2:33.3%, Q3:11.8%, and Q4:6.7%; p=0.049) and immunosuppressive drugs [Q1:100.0%, Q2:66.7%, Q3:58.8%, and Q4:46.7%; Q1 versus Q3 (p=0.043), and Q1 versus Q4 (p=0.005) in post-hoc analyses], and patients had greater functional status impairment (Q2 versus Q3, p=0.003). In addition, the levels of disease damage, new TAK symptoms, and complications in the preceding 12 months were not different between the groups.

CONCLUSIONS

Older patients with TAK require minimal drug treatment, and have greater impairment of functional status, which may be attributed to aging-related factors.

Coronary inflammation by computed tomography pericoronary fat attenuation in young male anabolic androgenic steroid users

Background

The illicit use of anabolic androgenic steroids (AAS) has been associated with diminished cholesterol efflux mediated by HDL, remarkable decrease in high-density lipoprotein (HDL) plasma concentration and subclinical coronary artery disease (CAD). Inflammation is the key to the atherogenic process associated with atherosclerotic plaque vulnerability. The pericoronary mean fat attenuation (pFAM) has emerged as a marker of coronary inflammation and can predict future cardiovascular events, which is measurable from standard coronary computed tomography angiography (CCTA). However, whether AAS abuse has a role in pFAM in young male AAS users is unknown.

Purpose

The aim of this study was to evaluate whether AAS abuse could leads to higher pFAM and premature coronary inflammation in young male AAS users.

Methods

Twenty strength-trained AAS users (AASU) age 29±5 yr, 20 age-matched strength-trained AAS nonusers (AASNU), and 10 sedentary controls (SC) were enrolled in this study. Coronary inflammation was assessed by pFAM-CCTA in the right coronary artery (RCA), left anterior descending artery (LDA) and left circumflex coronary artery (Cx).

Results

pFAM in the RCA was significantly higher in AASU compared with AASNU and SC (−64.59±9.45 vs. −79.21±6.67 vs. −80.97±7,91 Hounsfield Units (HU), respectively, p&lt;0.001]. Also, the pFAM in the LAD was higher in AASU compared with AASNU and SC (−72.83±7.21 vs. −79.41±6.72 vs. −80.97±7.72 HU, p=0.006). However, no difference to pFAM in the Cx between AASU, AASNU and SC (−74.30±5.85 vs. −79.77±7.13 vs. −78.19±5.82 HU, respectively, p=0.069) was found.

Conclusion

This study indicates that AAS abuse may be associated with higher pFAM and premature coronary inflammation in the RCA and LAD. The higher pFAM may be linked to early development of CAD in young AAS users.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Fundação Zerbini

The Autoinflammatory Diseases Alliance Registry of monogenic autoinflammatory diseases

Objective

The present manuscript aims to describe an international, electronic-based, user-friendly and interoperable patient registry for monogenic autoinflammatory diseases (mAIDs), developed in the contest of the Autoinflammatory Diseases Alliance (AIDA) Network.

Methods

This is an electronic platform, based on the Research Electronic Data Capture (REDCap) tool, used for real-world data collection of demographics, clinical, laboratory, instrumental and socioeconomic data of mAIDs patients. The instrument has flexibility, may change over time based on new scientific acquisitions, and communicate potentially with other similar registries; security, data quality and data governance are corner stones of the platform.

Results

AIDA project will share knowledge and expertise on mAIDs. Since its start, 118 centers from 24 countries and 4 continents have joined the AIDA project. Fifty-nine centers have already obtained the approval from their local Ethics Committees. Currently, the platform counts 337 users (122 Principal Investigators, 210 Site Investigators, 2 Lead Investigators, and 3 data managers). The Registry collects baseline and follow-up data using 3,748 fields organized into 21 instruments, which include demographics, patient history, symptoms, trigger/risk factors, therapies, and healthcare information for mAIDs patients.

Conclusions

The AIDA mAIDs Registry, acts both as a research tool for future collaborative real-life studies on mAIDs and as a service to connect all the figures called to participate. On this basis, the registry is expected to play a pivotal role in generating new scientific evidence on this group of rare diseases, substantially improving the management of patients, and optimizing the impact on the healthcare system. NCT 05200715 available at https://clinicaltrials.gov.

Development and implementation of the AIDA international registry for patients with Schnitzler's syndrome

Objective

The present paper describes the design, development, and implementation of the AutoInflammatory Disease Alliance (AIDA) International Registry specifically dedicated to patients with Schnitzler's syndrome.

Methods

This is a clinical physician-driven, population- and electronic-based registry implemented for the retrospective and prospective collection of real-life data from patients with Schnitzler's syndrome; the registry is based on the Research Electronic Data Capture (REDCap) tool, which is designed to collect standardized information for clinical research, and has been realized to change over time according to future scientific acquisitions and potentially communicate with other existing or future similar registries.

Results

Since its launch, 113 centers from 23 countries in 4 continents have been involved. Fifty-seven have already obtained the approval from their local Ethics Committees. The platform counts 324 users (114 Principal Investigators, 205 Site Investigators, 2 Lead Investigators, and 3 data managers) at current (April 28th, 2022). The registry collects baseline and follow-up data using 3,924 fields organized into 25 instruments, including patient's demographics, history, clinical manifestations and symptoms, trigger/risk factors, laboratory, instrumental exams, therapies, socioeconomic information, and healthcare access.

Conclusions

This International Registry for patients with Schnitzler's syndrome facilitates standardized data collection, enabling international collaborative projects through data sharing and dissemination of knowledge; in turn, it will shed light into many blind spots characterizing this complex autoinflammatory disorder.

Development and Implementation of the AIDA International Registry for Patients With VEXAS Syndrome

Objective

The aim of this paper is to present the AutoInflammatory Disease Alliance (AIDA) international Registry dedicated to Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome, describing its design, construction, and modalities of dissemination.

Methods

This Registry is a clinical, physician-driven, population- and electronic-based instrument designed for the retrospective and prospective collection of real-life data. Data gathering is based on the Research Electronic Data Capture (REDCap) tool and is intended to obtain real-world evidence for daily patients' management. The Registry may potentially communicate with other on-line tools dedicated to VEXAS syndrome, thus enhancing international collaboration and data sharing for research purposes. The Registry is practical enough to be easily modified to meet future needs regarding VEXAS syndrome.

Results

To date (April 22^nd, 2022), 113 Centers from 23 Countries in 4 continents have been involved; 324 users (114 Principal Investigators, 205 Site Investigators, 2 Lead Investigators, and 3 data managers) are currently able to access the registry for data entry (or data sharing) and collection. The Registry includes 4,952 fields organized into 18 instruments designed to fully describe patient's details about demographics, clinical manifestations, symptoms, histologic details about skin and bone marrow biopsies and aspirate, laboratory features, complications, comorbidities, therapies, and healthcare access.

Conclusion

This international Registry for patients with VEXAS syndrome will allow the achievement of a comprehensive knowledge about this new disease, with the final goal to obtain real-world evidence for daily clinical practice, especially in relation to the comprehension of this disease about the natural history and the possible therapeutic approaches. This Project can be found on https://clinicaltrials.gov NCT05200715.

Age-related reference data of bone microarchitecture, volumetric bone density, and bone strength parameters in a population of healthy Brazilian men: an HR-pQCT study

In a cross-sectional cohort of 340 healthy Brazilian men aged 20 to 92 years, data on density, structure, and strength of the distal radius and tibia were obtained using high-resolution peripheral quantitative computed tomography (HR-pQCT) to develop age- and site-specific reference curves. Age-dependent changes differed between the sites and bone compartments (trabecular and cortical).

INTRODUCTION

The aim of this study was to establish age-related reference curves for bone densities, microarchitectural properties, and estimated failure load measured by HR-pQCT (distal radius and tibia) in men. Also, to correlate bone stiffness with the other HR-pQCT parameters, areal bone mineral density (BMD) by DXA and trabecular bone score (TBS).

METHODS

Healthy Brazilian men (n = 340) between the ages of 20 and 92 years were recruited. Non-dominant radius and left tibia were scanned using HR-pQCT (Xtreme CT I). Standard and automated segmentation methods were performed, and bone strength estimated by FE analysis. Bone mineral density at lumbar spine, total hip, femoral neck, and TBS were measured using DXA (Hologic, QDR4500).

RESULTS

Age-related reference curves were constructed at the distal radius and tibia for volumetric bone density, morphometry, and estimated bone strength parameters. There was a linear relationship with age only for thickness measurements of distal radius (trabecular: R² 0.108, p<0.001; cortical: R² 0.062, p=0.002) and tibia (trabecular: R² 0.109, p<0.001; cortical: R² 0.063, p=0.010), and bone strength at distal radius (R² 0.157, p<0.001). The significant correlations (p <0.05) found by Pearson's correlations (r) between bone stiffness and all other variables measured by HR-pQCT and DXA showed to be stronger at the tibia site than the distal radius.

CONCLUSION

The current study expands the HR-pQCT worldwide database and presents an adequate methodology for the construction of reference data in other populations. Moreover, the correlation of bone strength estimated by FEA with other bone microstructural parameters provided by HR-pQCT helps to determine the contribution of each of these variables to fracture risk prediction in men.

Association of sarcopenia and oxygen uptake efficiency slope in male patients with heart failure: The skeletal muscle hypothesis in practice

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Background

Sarcopenia, a generalized loss of muscle mass and function, is a common comorbidity in patients with heart failure (HF). The skeletal muscle, through afferent nerve pathways, modulates the respiratory response during physical efforts. However, whether ventilatory behavior is affected by the presence of sarcopenia is still unknown.

Purpose

To evaluate the impact of sarcopenia in ventilatory parameters of patients with HF.

Methods

We enrolled 169 male patients with stable chronic HF with left ventricular ejection fraction &lt;40% (LVEF). Muscle strength was measured by handgrip dynamometer. Body composition was measured with dual-energy X-ray absorptiometry (DXA). Appendicular skeletal muscle (ASM) was comprised by lean muscle mass of both arms and legs. Sarcopenia was defined by handgrip strength and ASM/height2 lower than 27 kg and 7.0 kg/m2, respectively. Ventilation (VE), oxygen consumption (VO2), and carbon dioxide output (VCO2) were evaluated using breath-by-breath measurements during a cardiopulmonary exercise test performed on a cycle ergometer. Oxygen uptake efficiency slope (OUES) was calculated from data taken at exercise peak.

Results

Sarcopenia was identified in 29 patients (17.2%). Patients with sarcopenia had lower body mass index (BMI; 21.2±2.4 vs. 26.5±3.8 kg/m2, p&lt;0.0001) with higher C-reactive protein [CRP; 12.4 (2.8-22.4) vs. 2.4 (1.0-6.3) mg/L, p&lt;0.001] and brain natriuretic peptide [BNP; 949 (446-1722) vs. 374 (127-885) pg/mL, p&lt;0.001] compared to patients without sarcopenia, respectively. At the first ventilatory threshold, VE/VO2 (36.9±5.9 vs. 32.7±6.5, p=0.003) and VE/VCO2 (39.8±7.2 vs. 35.3±6.9, p=0.004) were higher in sarcopenic patients compared to those without sarcopenia. At the exercise peak, comparing to patients without sarcopenia, sarcopenic patients had lower OUES (1,186±295 vs. 1,634±564, p&lt;0.001), absolute VO2 (0.93±0.25 vs. 1.43±0.47 L/min, p&lt;0.0001), relative VO2 (16.2±5.0 vs. 19.5±6.5 ml/kg/min, p=0.011), and VE (47.3±10.1 vs. 63.0±18.2 L/min, p&lt;0.001), while VE/VCO2 (42.9±8.9 vs. 38.7±8.4, p=0.025) was increased and VE/VO2 (49.6±11.5 vs. 45.1±10.8, p=0.066) showed a tendency to be higher. OUES was positively correlated with total lean body mass (r=0.38; p&lt;0.0001), ASM/height2 (r=0.36; p&lt;0.0001), and handgrip strength (r=0.31; p&lt;0.001). In a multivariate logistic regression model using OUES as the dependent variable, ASM/height2 (OR, 1.466; 95% CI, 1.003–2.141; p=0.048), haemoglobin (OR, 0.346; 95% CI, 0.135–0.886; p=0.027), and creatinine (OR, 0.391; 95% CI, 0.166–0.918; p=0.031) were independently associated with OUES adjusted by age, BMI, LVEF, BNP, CRP, and beta-blocker use.

Conclusion

Our results suggest that sarcopenia, possibly by reducing thoracic skeletal muscle mass or inefficiently modulating ventilation through afferent pathways, is related to impaired ventilatory response during exercise in patients with HF.

High prevalence of fatigue in patients with Takayasu arteritis: a case–control study in a Brazilian centre

Objectives

Several studies have shown not only a high prevalence of fatigue but also a reduction in health-related quality of life (HRQoL) in patients with rheumatic diseases. Owing to insufficient research in this area, we aimed to assess the prevalence of fatigue and its contribution to impairment of HRQoL in patients with Takayasu arteritis (TAK).

Methods

This single-centre case–control study included 53 TAK patients who were matched by age, BMI and sex with 100 healthy individuals. Aside from the patients’ general data, the following information was collected: disease activity, level of activities of daily living (HAQ), physical activity levels and chronic fatigue.

Results

The TAK patients and healthy individuals were comparable in terms of current age, BMI and sex distribution. The median disease duration of TAK was 13.0 (7.0–20.0) years, and 11 (20.8%) patients had active disease. Compared with healthy individuals, patients with TAK had a higher prevalence of fatigue and lower HAQ score, physical activity level and intensity, and physical and psychosocial domains of the modified fatigue impact scale (P < 0.01). Moreover, TAK patients had increased fatigue rates compared with the healthy individuals (fatigue severity scale: odds ratio = 2.6; 95% CI = 1.2, 5.4; modified fatigue impact scale: odds ratio = 2.6; 95% CI = 1.2, 5.5). Fatigue was positively correlated with worsening HAQ, CRP levels, daily prednisone dose and disease activity, and negatively correlated with disease duration.

Conclusion

TAK patients have a higher prevalence of fatigue, which affects different aspects of the disease, including physical function. Thus, fatigue-focused treatments should also be considered in clinical practice.

Trial registration

The Brazilian Clinical Trials Registry (ReBEC), https://ensaiosclinicos.gov.br/, RBR-9n4z2hh.

Nutritional recommendations for patients undergoing prolonged glucocorticoid therapy

Glucocorticoid (GC) therapy is a common treatment used in rheumatic and autoimmune diseases, owing to its anti-inflammatory and immunosuppressive effects. However, GC therapy can also induce a number of adverse effects, including muscle and bone loss, hypertension, metabolic perturbations and increased visceral adiposity. We review available evidence in this area and provide nutritional recommendations that might ameliorate these adverse effects. Briefly, optimizing calcium, vitamin D, sodium and protein intake and increasing consumption of unprocessed and minimally processed foods, while decreasing the consumption of ultra-processed foods, might counteract some of the specific challenges faced by these patients. Importantly, we identify a dearth of empirical data on how nutritional intervention might impact health-related outcomes in this population. Further research is required to investigate the clinical and therapeutic efficacy of these theory-based recommendations.

Chronic inflammatory diseases, subclinical atherosclerosis, and cardiovascular diseases: Design, objectives, and baseline characteristics of a prospective case-cohort study ‒ ELSA-Brasil

OBJECTIVES

This analysis describes the protocol of a study with a case-cohort to design to prospectively evaluate the incidence of subclinical atherosclerosis and Cardiovascular Disease (CVD) in Chronic Inflammatory Disease (CID) participants compared to non-diseased ones.

METHODS

A high-risk group for CID was defined based on data collected in all visits on self-reported medical diagnosis, use of medicines, and levels of high-sensitivity C-Reactive Protein >10 mg/L. The comparison group is the Aleatory Cohort Sample (ACS): a group with 10% of participants selected at baseline who represent the entire cohort. In both groups, specific biomarkers for DIC, markers of subclinical atherosclerosis, and CVD morbimortality will be tested using weighted Cox.

RESULTS

The high-risk group (n = 2,949; aged 53.6 ± 9.2; 65.5% women) and the ACS (n=1543; 52.2±8.8; 54.1% women) were identified. Beyond being older and mostly women, participants in the high-risk group present low average income (29.1% vs. 24.8%, p < 0.0001), higher BMI (Kg/m2) (28.1 vs. 26.9, p < 0.0001), higher waist circumference (cm) (93.3 vs. 91, p < 0.0001), higher frequencies of hypertension (40.2% vs. 34.5%, p < 0.0001), diabetes (20.7% vs. 17%, p = 0.003) depression (5.8% vs. 3.9%, p = 0.007) and higher levels of GlycA a new inflammatory marker (p < 0.0001) compared to the ACS.

CONCLUSIONS

The high-risk group selected mostly women, older, lower-income/education, higher BMI, waist circumference, and of hypertension, diabetes, depression, and higher levels of GlycA when compared to the ACS. The strategy chosen to define the high-risk group seems adequate given that multiple sociodemographic and clinical characteristics are compatible with CID.

Development and implementation of the AIDA International Registry for patients with Periodic Fever, Aphthous stomatitis, Pharyngitis, and cervical Adenitis syndrome

OBJECTIVE

Aim of this paper is to illustrate the methodology, design, and development of the AutoInflammatory Disease Alliance (AIDA) International Registry dedicated to patients with the Periodic Fever, Aphthous stomatitis, Pharyngitis, and cervical Adenitis (PFAPA) syndrome.

METHODS

This is a physician-driven, non-population- and electronic-based registry proposed to gather real-world demographics, clinical, laboratory, instrumental and socioeconomic data from PFAPA patients. Data recruitment is realized through the on-line Research Electronic Data Capture (REDCap) tool. This registry is thought to collect standardized information for clinical research leading to solid real-life evidence. The international scope and the flexibility of the registry will facilitate the realization of cutting-edge study projects through the constant updating of variables and the possible merging and transfer of data between current and future PFAPA registries.

RESULTS

A total of 112 centers have already been involved from 23 countries and 4 continents starting from August 24th, 2021, to April 6th, 2022. In total 56/112 have already obtained the formal approval from their local Ethics Committees. The platform counts 321 users (113 principal investigators, 203 site investigators, two lead investigators, and three data managers). The registry collects retrospective and prospective data using 3,856 fields organized into 25 instruments, including PFAPA patient's demographics, medical histories, symptoms, triggers/risk factors, therapies, and impact on the healthcare systems.

CONCLUSIONS

The development of the AIDA International Registry for PFAPA patients will enable the on-line collection of standardized data prompting real-life studies through the connection of worldwide groups of physicians and researchers. This project can be found on https://clinicaltrials.gov NCT05200715.

Persistent symptoms and decreased health-related quality of life after symptomatic pediatric COVID-19: A prospective study in a Latin American tertiary hospital

OBJECTIVES

To prospectively evaluate demographic, anthropometric and health-related quality of life (HRQoL) in pediatric patients with laboratory-confirmed coronavirus disease 2019 (COVID-19).

METHODS

This was a longitudinal observational study of surviving pediatric post-COVID-19 patients (n=53) and pediatric subjects without laboratory-confirmed COVID-19 included as controls (n=52) was performed.

RESULTS

The median duration between COVID-19 diagnosis (n=53) and follow-up was 4.4 months (0.8-10.7). Twenty-three of 53 (43%) patients reported at least one persistent symptom at the longitudinal follow-up visit and 12/53 (23%) had long COVID-19, with at least one symptom lasting for >12 weeks. The most frequently reported symptoms at the longitudinal follow-up visit were headache (19%), severe recurrent headache (9%), tiredness (9%), dyspnea (8%), and concentration difficulty (4%). At the longitudinal follow-up visit, the frequencies of anemia (11% versus 0%, p=0.030), lymphopenia (42% versus 18%, p=0.020), C-reactive protein level of >30 mg/L (35% versus 0%, p=0.0001), and D-dimer level of >1000 ng/mL (43% versus 6%, p=0.0004) significantly reduced compared with baseline values. Chest X-ray abnormalities (11% versus 2%, p=0.178) and cardiac alterations on echocardiogram (33% versus 22%, p=0.462) were similar at both visits. Comparison of characteristic data between patients with COVID-19 at the longitudinal follow-up visit and controls showed similar age (p=0.962), proportion of male sex (p=0.907), ethnicity (p=0.566), family minimum monthly wage (p=0.664), body mass index (p=0.601), and pediatric pre-existing chronic conditions (p=1.000). The Pediatric Quality of Live Inventory 4.0 scores, median physical score (69 [0-100] versus 81 [34-100], p=0.012), and school score (60 [15-100] versus 70 [15-95], p=0.028) were significantly lower in pediatric patients with COVID-19 at the longitudinal follow-up visit than in controls.

CONCLUSIONS

Pediatric patients with COVID-19 showed a longitudinal impact on HRQoL parameters, particularly in physical/school domains, reinforcing the need for a prospective multidisciplinary approach for these patients. These data highlight the importance of closer monitoring of children and adolescents by the clinical team after COVID-19.

Poor Sleep quality and health-related quality of life impact in adolescents with and without chronic immunosuppressive conditions during COVID-19 quarantine

OBJECTIVE

To assess the possible factors that influence sleep quality in adolescents with and without chronic immunosuppressive conditions quarantined during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This cross-sectional study included 305 adolescents with chronic immunocompromised conditions and 82 healthy adolescents. Online surveys were completed, which included questions on socio-demographic data and self-rated healthcare routine during COVID-19 quarantine and the following validated questionnaires: the Pittsburgh Sleep Quality Index (PSQI), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0), and Pediatric Outcome Data Collection Instrument (PODCI).

RESULTS

The median current age [14 (10-18) vs. 15 (10-18) years, p=0.847] and frequency of female sex (62% vs. 58%, p=0.571) were similar in adolescents with chronic conditions compared with healthy adolescents. The frequency of poor sleep quality was similar in both groups (38% vs. 48%, p=0.118). Logistic regression analysis, including both healthy adolescents and adolescents with chronic conditions (n=387), demonstrated that self-reported increase in screen time (odds ratio [OR] 3.0; 95% confidence interval [CI] 1.3-6.8; p=0.008) and intrafamilial violence report (OR 2.1; 95% CI 1.2-3.5; p=0.008) were independently associated with poor sleep quality in these adolescents. However, the PODCI global function score was associated with a lower OR for poor sleep quality (OR 0.97; 95% CI 0.94-0.99; p=0.001). Further logistic regression, including only adolescents with chronic conditions (n=305), demonstrated that self-reported increase in screen time (OR 3.1; 95% CI 1.4-6.8; p=0.006) and intrafamilial violence report (OR 2.0; 95% CI 1.2-3.4; p=0.011) remained independently associated with poor quality of sleep, whereas a lower PODCI global function score was associated with a lower OR for sleep quality (OR 0.96; 95% CI 0.94-0.98; p<0.001).

CONCLUSION

Self-reported increases in screen time and intrafamilial violence report impacted sleep quality in both healthy adolescents and those with chronic conditions. Decreased health-related quality of life was observed in adolescents with poor sleep quality.

Constraints of Weight Loss as a Marker of Bariatric Surgery Success: An Exploratory Study

Purpose

The aim of this exploratory study was to investigate whether the degree of weight loss properly reflects improvements in cardiometabolic health among patients who underwent Roux-en-Y gastric bypass.

Methods

In this ancillary analysis from a clinical trial, patients were clustered into tertiles according to the magnitude of the percentage weight loss (1st tertile: “higher weight loss”: −37.1 ± 5.8%; 2nd tertile: “moderate weight loss”: −29.7 ± 1.4%; 3rd tertile: “lower weight loss”: −24.2 ± 2.3%). Delta changes (9 months after surgery-baseline) in clustered cardiometabolic risk (i.e., blood pressure index, fasting glucose, high-density lipoprotein [HDL] and triglycerides [TG]), glycated hemoglobin (HbA1c), homeostasis model assessment (HOMA-IR), and C-reactive protein (CRP) were calculated.

Results

A total of 42 patients who had complete bodyweight data (age = 40 ± 8 year; BMI = 47.8 ± 7.1 kg/m²) were included. Surgery led to substantial weight loss (−37.9 ± 11.3 kg, P < 0,001), and clinically significant improvements in blood pressure index (−17.7 ± 8.2 mmHg, P < 0.001), fasting glucose (−36.6 ± 52.5 mg/dL, P < 0.001), HDL (9.4 ± 7.1 mg/dL, P < 0.001), TG (−35.8 ± 44.1 mg/dL P < 0,001), HbA1c (−1.2 ± 1.6%, P < 0.001), HOMA-IR (−4.7 ± 3.9 mg/dL, P < 0.001) and CRP (−8.5 ± 6.7 μg/mL P < 0.001). Comparisons across tertiles revealed no differences for cardiometabolic risk score, fasting glucose, HbAc1, HOMA-IR, blood pressure index, CRP, HDL, and TG (P > 0.05 for all). Individual variable analysis confirmed cardiometabolic improvements across the spectrum on weight-loss. There were no associations between weight loss and any dependent variable.

Conclusion

Weight loss following bariatric surgery does not correlate with improvements in cardiovascular risk factors. These findings suggest that weight loss alone may be insufficient to assess the cardiometabolic success of bariatric surgery, and the search for alternate proxies that better predict surgery success are needed.

Incidence and risk factors for osteoporotic non-vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing and Health (SPAH) study

We ascertained the incidence of non-vertebral fracture in a low-income Brazilian elderly cohort. To the best of our knowledge, this is the first population-based study to demonstrate the frequency of non-vertebral fracture in elderly Latin Americans. Age, prior fracture, and bone mineral density (BMD) at hip were predictors of fracture.

INTRODUCTION

No data on incidence of osteoporotic non-vertebral fracture have been reported in low-income countries where the population's aging has been faster. Even in developed countries, currently available prospective data on major fracture rates beyond hip are scarce. The aim of this study is to describe the incidence and risk factors for non-vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

Seven hundred seven older adults (449 women, 258 men) were evaluated at baseline and after a mean follow-up of 4.3 ± 0.8 years. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. New non-vertebral fracture (hip, proximal humerus, rib, forearm) was determined during the follow-up. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of non-vertebral fracture was 1562.3/100,000 (1085.7-2248.1/100,000) person-years (pyr) in women and 632.8/100,000 (301.7-1327.3/100,000) in men. Concerning to hip fractures, the incidence was 421.2/100,000 (210.7-842.3/100,000) pyr in women and 89.9/100,000 (12.7-638.5/100,000) in men. In a multivariate analysis, age (RR 2.07, 95% CI 1.13-3.82, p = 0.019, each 10-year increase), prior non-vertebral fracture (RR 3.08, 95% CI 1.36-6.95, p = 0.007), and total hip BMD (RR 1.68, 95% CI 1.11-2.56, p = 0.015, each 1 SD decrease) were predictors of new non-vertebral fracture. In men, fitting a model of risk factors for fracture was prevented by the limited number of events in male sample.

CONCLUSION

This is the first population-based study to ascertain the incidence of major non-vertebral fractures in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, and hip BMD were predictors of the short-term incidence of fracture.

Poor physical activity levels and cardiorespiratory fitness among patients with childhood-onset takayasu arteritis in remission: a cross-sectional, multicenter study

BACKGROUND

It is currently unknown whether patients with childhood-onset Takayasu disease (c-TA) are prone to physical inactivity and poor aerobic capacity. In this study, we assessed physical activity levels and cardiorespiratory fitness along with health-related quality of life (HRQL) and various traditional and non-traditional risk factors in patients with c-TA vs. healthy controls.

METHODS

c-TA patients with non-active disease (n = 17) and age- and sex-matched healthy controls (n = 17) were enrolled in the study. We assessed physical activity levels, aerobic capacity, body composition, systemic inflammation, cardiometabolic markers, disease-related parameters, and HRQL.

RESULTS

c-TA patients showed greater time spent in sedentary behavior (P = 0.010), and lower moderate-to-vigorous physical activity (P > 0.001) and lower step counts per day (P > 0.001). VO2peak (P < 0.001) and chronotropic response (P = 0.016) were significantly lower in patients with c-TA and they had worse HRQL in physical domain (P < 0.001), lower bone mineral content and density, and higher insulin levels vs. healthy controls (all P ≤ 0.05).

CONCLUSIONS

c-TA patients exhibited reduced physical activity levels and aerobic capacity, worse cardiometabolic risk factors and HRQL parameter compared with healthy peers. Physical inactivity and aerobic deconditioning emerge as potentially novel risk factors for c-TA. The role of physical activity interventions in preventing poor outcomes and improving HRQL in c-TA remains to be explored.

Is there an association between upper limb claudication and handgrip strength in Takayasu arteritis?

Limb vascular claudication and hand muscle weakness are common symptoms of Takayasu arteritis (TAK). However, no studies have correlated these two symptoms. Therefore, the aim of the study was to evaluate handgrip strength and its correlation with both upper-limb vascular claudication and imaging of the vessels. This cross-sectional study compared 36 patients with TAK who were matched by age, gender, and body mass index with 36 individuals without TAK (CTR). Hand strength (assessed with handgrip dynamometer), functional capacity (Health Assessment Questionnaire, HAQ), upper-limb vascular claudication symptoms (patients' selfreported form), and disease activity (Indian Takayasu Clinical Activity Score [ITAS] 2010; Physician Global Assessment [PGA], C-reactive protein, and erythrocyte sedimentation rate) were evaluated as well as vessel imaging (e.g., angiotomography or angioresonance) and blood pressure. The median age of the patients was 42.0 years (35.5-51.5 years), whereas the mean disease duration was 13.1±6.8 years. No patient had active disease. Compared to the CTR, the patients with TAK showed reduced strength in the left-hand (22.9±5.9 vs 26.3±5.6 kg; p=0.014) and increased HAQ scores [0.50 (0.12-0.87) vs 0.00 (0.00-0.00); p<0.001]. Both groups had comparable blood pressure. Among patients with TAK, lefthand strength was inversely correlated with HAQ (Spearman correlation: rho=-0.584; p<0.001) and positively correlated with right-hand strength (rho=0.644; p<0.001). Moreover, neither hand's strengths in the patients were correlated with subclavian stenosis imaging, blood pressure or limb vascular claudication. The reduction of strength in the upper left limb is inversely related to the functional capacity (HAQ score) of TAK. This reduction appears unrelated to classical vascular claudication, vessel imaging or blood pressure.

Increased modifiable cardiovascular risk factors in patients with Takayasu arteritis: a multicenter cross-sectional study

BACKGROUND

Modifiable cardiovascular risk factors (MCRFs), such as those related to aerobic capacity, muscle strength, physical activity, and body composition, have been poorly studied in Takayasu arteritis (TAK). Therefore, the aim of the study was to investigate MCRFs and their relationships with disease status and comorbidities among patients with TAK.

METHODS

A multicenter cross-sectional study was conducted between 2019 and 2020, in which 20 adult women with TAK were compared with 16 healthy controls matched by gender, age, and body mass index. The following parameters were analyzed: aerobic capacity by cardiopulmonary test; muscle function by timed-stands test, timed up-and-go test, and handgrip test; muscle strength by one-repetition maximum test and handgrip test; body composition by densitometry; physical activity and metabolic equivalent by IPAQ, quality of life by HAQ and SF-36; disease activity by ITAS2010 and NIH score; and presence of comorbidities.

RESULTS

Patients with TAK had a mean age of 41.5 (38.0-46.3) years, disease duration of 16.0 (9.5-20.0) years, and a mean BMI of 27.7±4.5 kg/m². Three out of the 20 patients with TAK had active disease. Regarding comorbidities, 16 patients had systemic arterial hypertension, 11 had dyslipidemia, and two had type 2 diabetes mellitus, while the control group had no comorbidities. TAK had a significant reduction in aerobic capacity (absolute and relative VO₂ peak), muscle strength in the lower limbs, increased visceral adipose tissue, waist-to-hip ratio, reduced walking capacity, decreased weekly metabolic equivalent, and quality of life (P< 0.05) as compared to controls. However, there were no correlations between these MCRFs parameters and disease activity.

CONCLUSIONS

TAK show impairment in MCRFs; therefore, strategies able to improve MCRF should be considered in this disease.

Changes in Eating Habits and Sedentary Behavior During the COVID-19 Pandemic in Adolescents With Chronic Conditions

Introduction: Among healthy adolescents, school closures and home confinement were shown to increase unhealthier eating habits and sedentary behavior. It remains unknown to which extent the pandemic has impacted the lifestyle of adolescents with chronic conditions. Thus, the aim of this study is to report on the impact of the COVID-19 outbreak on eating habits and sedentary behavior among adolescents with multiple chronic conditions (n = 347) from a tertiary, referral hospital vs. healthy peers. Methods: This observational study was conducted in São Paulo (Brazil) between July and October 2020, period in which a set of social distancing measures to contain the pandemic. Results: The main findings of this study were that adolescents with chronic conditions and health peers showed important changes in eating habits (e.g., more often cooking and eating in front of television than before quarantine). Also, 86.8% of adolescents with chronic conditions and 91.6% of healthy adolescents reported increasing screen time during pandemic. No major differences were observed between patients and controls. Conclusions: Adolescents with chronic conditions and healthy peers exposed to pandemic showed substantial changes in lifestyle, stressing the need for specific care to mitigate poor eating habits and excessive sedentary behavior for patients and healthy adolescents.

The influence of acute exercise on bone biomarkers: protocol for a systematic review with meta-analysis

BACKGROUND

Bone is a plastic tissue that is responsive to its physical environment. As a result, exercise interventions represent a potential means to influence the bone. However, little is currently known about how various exercise and participant characteristics interact to influence bone metabolism. Acute, controlled, interventions provide an in vivo model through which the acute bone response to exercise can be investigated, typically by monitoring circulating bone biomarkers. Currently, substantial heterogeneity in factors such as study design, quality, exercise, and participant characteristics render it difficult to synthesize and evaluate the available evidence. Using a systematic review and meta-analytic approach, the aim of this investigation is to quantify the effect of an acute exercise bout on circulating bone biomarkers as well as examine the potential factors that may moderate this response, e.g., variation in participant, exercise, and sampling characteristics.

METHODS

This protocol was designed in accordance with the PRISMA-P guidelines. Seven databases (MEDLINE, Embase, Sport Discus, Cochrane CENTRAL, PEDro, LILACS, and Ibec) will be systematically searched and supplemented by a secondary screening of the reference lists of all included articles. The PICOS (Population, Intervention, Comparator, Outcomes and Study Design) approach was used to guide the determination of the eligibility criteria. Participants of any age, sex, training, or health status will be considered for inclusion. We will select studies that have measured the bone biomarker response before and after an acute exercise session. All biomarkers considered to represent the bone metabolism will be considered for inclusion, and sensitivity analyses will be conducted using reference biomarkers for the measurement of bone resorption and formation (namely β-CTX-1 and P1NP). Multi-level, meta-regression models within a Bayesian framework will be used to explore the main effect of acute exercise on bone biomarkers as well as potential moderating factors. The risk of bias for each individual study will be evaluated using a modified version of the Downs and Black checklist while certainty in resultant outcomes will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

A better understanding of the bone metabolic response to an acute bout of exercise has the potential to advance our understanding of the mechanisms through which this stimulus impacts bone metabolism, including factors that may moderate this response. Additionally, we will identify current gaps in the evidence base and provide recommendations to inform future research.

SYSTEMATIC REVIEW REGISTRATION

This protocol was prospectively registered in the Open Science Framework Registry ( https://osf.io/6f8dz ).

The Bone Metabolic Response to Exercise and Nutrition

Bone (re)modeling markers can help determine how the bone responds to different types, intensities, and durations of exercise. They also might help predict those at risk of bone injury. We synthesized evidence on the acute and chronic bone metabolic responses to exercise, along with how nutritional factors can moderate this response. Recommendations to optimize future research efforts are made.

The disparity of measuring bone mineral content using bioimpedance and dual-energy absorptiometry in the context of hyperparathyroidism

Introduction:

Body composition is critical for the evaluation of patients with Chronic Kidney Disease (CKD) and can be obtained from either multifrequency bioelectrical impedance analysis (BIA) or dual-energy absorptiometry (DXA). Although the discrepancy between the results obtained from both methods has already been described, reasons are unknown, and might be related to secondary hyperparathyroidism, which is associated with bone loss.

Methods:

We have evaluated 49 patients (25 males and 24 females): 20 with CKD not on dialysis and 29 on maintenance hemodialysis [18 with severe hyperparathyroidism (HD-SHPT) and 11 submitted to parathyroidectomy (HD-PTX)]. All patients underwent DXA and BIA.

Results:

The median age and body mass index (BMI) were 49 years and 25.6 kg/m², respectively. Patients exhibited low bone mineral content (BMC) measured by DXA, particularly those from the HD-SHPT group. The largest BMC measurement disagreement between DXA and BIA was found in the HD-SHPT group (p=0.004). Factors independently associated with this discrepancy in BMC measurement were serum phosphate (p=0.003) and patient group (p=0.027), even after adjustments for age, BMI, and gender (adjusted r2=0.186). PTX attenuated this difference.

Discussion:

BIA should be interpreted with caution in patients with SHPT due to a loss of accuracy, which can compromise the interpretation of body composition.

Successful endovascular correction of common carotid pseudoaneurysm secondary to Behçet's disease: case report and review of the literature

Behçet's disease (BD) is a chronic, multisystemic, inflammatory disease characterised by recurrent mucocutaneous, ocular, musculoskeletal, central nervous system, gastrointestinal and vascular manifestations, which may affect blood vessels of any size (1). Venous involvement is more common, but arterial involvement accounts for the major cause of mortality (2, 3). Choosing the adequate technique and timing for correcting aneurysms in BD is still challenging. The authors report a case of a 37-year-old male patient with common carotid pseudoaneurysm at the time of diagnosis, which was successfully treated by an endovascular stent placement after adequate immunosuppression. A review of the literature about this issue was also done.

Is there a reliable association between patient-reported limb claudication and vascular imaging methods in Takayasu arteritis?

Vessel imaging in Takayasu arteritis (TAK) is often performed in clinical practice following laboratory test abnormalities or clinical symptoms, such as limb claudication. Conversely, the association between limb claudication and vessel imaging manifestations has not been assessed. This observational, cross-sectional study analyzed 139 adult TAK patients from 2000 to 2018. Their arterial vessel imaging information (especially significant stenosis and occlusion data) was registered and crosschecked with clinical and laboratory data. When vessel imaging was performed, the median age and disease duration of the patients were 38 (27.3-47.0) and 5.0 (1.0-12.0) years, respectively. There was no association between arterial abnormalities and demographic data, constitutional symptoms or laboratory parameters. Limb claudication was reported in 42 patients (30.2%): 17.3% reported it in the upper left limb (ULL), 12.2% reported it in the upper right limb (URL), 12.9% reported it in the lower left limb (LLL), and 12.2% reported it in the lower right limb (LRL). When crossmatched with imaging, both ULL and URL were associated with left vertebral artery stenosis/occlusion, and URL was associated with right iliac artery stenosis/occlusion, but no other association was found. In contrast, both LLL and LRL claudication were associated with infrarenal aortic, left iliac and right iliac artery stenosis/ occlusion (p<0.05). Moreover, the ULL and URL claudication symptoms were significantly associated with each other (p<0.001). Upper limb claudication was associated only with left vertebral artery stenosis/occlusion, whereas the subclavian arteries were not, suggesting that the symptom might not be fully explained by limb ischemia. In contrast, lower limb claudication was associated especially with infrarenal aortic and/or iliac arteries stenosis/occlusion.

P1415PARATHYROIDECTOMY IMPROVES MUSCULAR FUNCTION BUT NOT MUSCLE MASS IN HEMODIALYSIS PATIENTS WITH SEVERE HYPERPARATHYROIDISM

Background and Aims

Increased levels of parathyroid hormone (PTH) are associated with a negative impact on the bone-muscle axis including sarcopenia with muscle weakness and muscle atrophy and osteoporosis, and it is possible that treating hyperparathyroidism (HPT) can ameliorate these disturbances. However, the effects of parathyroidectomy (PTX) on muscle mass, strength and performance, and physical activity have not been thoroughly investigated. This study aims to evaluate the impact of PTX on muscle (mass, strength, and performance), physical activity, body fat and resting energy expenditure (REE) in patients on hemodialysis with severe HPT.

Method

We are prospectively evaluating muscle mass strength, performance and physical activity of 30 patients before and after 6 months of PTX by using Actigraph GT3X accelerometer, timed-up-and-Go (TuG), Sit-to-Stand-to-Sit (STS) and muscle strength tests [handgrip (HGS), supine (SP) and leg press (LP)]. Body composition changes were assessed by dual-energy x-ray absorptiometry (DXA), and REE was examined by indirect calorimetry.

Results

At 6 months after PTX, 11 patients who already completed the protocol, showed a significant drop in PTH [1445 (1363-1937) vs. 54 (23-132) pg/mL; p = 0.002] and alkaline phosphatase [306 (235-744) vs. 77.5 (52-100] U/L); p = 0.002], a significant increase of number of steps/day [4321 (3384 – 6317) vs. 5950 (3918 – 7159); p = 0.04] and improvements of strength tests: HGS (27 ±14 vs. 31 ±15 kg; p = 0.01); SP (27 ±15 vs. 31 ±17 kg; p = 0.01] and LP [27 (2-36) vs. 36 (24-89) kg; p 0.04]. In addition, there was a significant reduction of TuG [10 (8-15) vs. 8 (7-11) seconds; p = 0.01], and a tendency towards STS improvement [6 (0-7) vs. 8 (7-11); p = 0.06]. A significant increase in body weight (66 ± 12 vs. 68 ± 14 Kg; p = 0.02), body mass index [24 (21–26) vs. 26 (21–28) kg/m2; p 0.001], and bone mineral content (BMC) [1.8 (1.3-2) vs. 2.1 (1.7-2.7); p=0.002] was seen. However, lean body mass (LBM) decreased [40.4 (38-55) vs. 39 (37-51) Kg; p=0.001], whereas fat mass (FAT) increased [18 (17-28) vs. 24 (17–30) kg; p = 0.02]. No change was noted in skeletal muscle index (SMI) and in REE [1580 (1193–1988) vs. 1473 (1326 - 1786) kcal/day; p = 0.7). We noticed a tendency toward an increase in IGF-1 levels [180 (141-207) vs. 223 (151-281) µg/L; p = 0.08], but no significant variation was found in serum albumin, insulin and HOMA index.

Conclusion

In hemodialysis patients with secondary hyperparathyroidism undergoing PTX, there were marked improvements of muscular function and bone mass, but not of muscle mass. Our findings suggest that PTH-associated sarcopenia is mediated not only by a decrease in muscle mass but also by muscle dysfunction. The long-term effect of PTX on muscle status remains to be further examined.

Muscular Atrophy and Sarcopenia in the Elderly: Is There a Role for Creatine Supplementation?

Sarcopenia is characterized by a loss of muscle mass, quality, and function, and negatively impacts health, functionality, and quality of life for numerous populations, particularly older adults. Creatine is an endogenously produced metabolite, which has the theoretical potential to counteract many of the morphological and metabolic parameters underpinning sarcopenia. This can occur through a range of direct and indirect mechanisms, including temporal and spatial functions that accelerate ATP regeneration during times of high energy demand, direct anabolic and anti-catabolic functions, and enhanced muscle regenerating capacity through positively impacting muscle stem cell availability. Studies conducted in older adults show little benefit of creatine supplementation alone on muscle function or mass. In contrast, creatine supplementation as an adjunct to exercise training seems to augment the muscle adaptive response to the training stimulus, potentially through increasing capacity for higher intensity exercise, and/or by enhancing post-exercise recovery and adaptation. As such, creatine may be an effective dietary strategy to combat age-related muscle atrophy and sarcopenia when used to complement the benefits of exercise training.

P4539Android to gynoid fat ratio and its association with functional capacity in male patients with heart failure

Background

Obesity may have a protective role in patients with heart failure with reduced ejection fraction (HFrEF), a phenomenon known as obesity paradox. However, some patients can also present sarcopenic obesity with similar exercise intolerance as lean patients with muscle wasting. However, the impact of body fat distribution on exercise intolerance in HFrEF is unknown.

Purpose

To study the association between android to gynoid fat ratio and functional capacity (VO2 peak) in male patients with HFrEF.

Methods

We enrolled 118 male with HFrEF with left ventricular ejection fraction (LVEF) <40%, mean age of 56±7 years old. Body composition was measured with dual x-ray absorptiometry. Android and gynoid fat were measured and the ratio between them was calculated (A/G ratio). Appendicular lean mass (ALM) was calculated as the lean muscle mass of both arms and legs divided by the height squared. Sarcopenic obesity was defined according to Foundation for the National Institutes of Health criteria (ALM adjusted for body mass index <0.789 for men). Muscle strength was assessed using the handgrip dynamometer (cutoff point for sarcopenia was defined as proposed by European Working Group on Sarcopenia in Older People). Blood sample was used to measure metabolic and hormonal parameters.

Results

Of those 118 patients, 15 (12.7%) showed sarcopenic obesity. In our cohort, the median A/G ratio was 0.55. A/G ratio >0.55 was detected in 60 patients. Weight and BMI were higher in patients with A/G ratio >0.55 (P<0.001). Absolute peak VO2 was similar between patients with A/G ratio lower or higher than 0.55 (1.48±0.40 vs. 1.43±0.40 L/min, P=0.559), while relative peak VO2 was lower in patients with A/G ratio >0.55 (18.7±5.3 vs. 22.5±6.1 mL/kg/min, P<0.001). LVEF, total cholesterol, LDL, haemoglobin, and IGF-1 were similar between patients with A/G ratio lower or higher than 0.55 (P>0.05). On the other hand, HDL, total testosterone, free testosterone, and DHEA were lower in patients with A/G ratio >0.55 (P<0.05). Logistic regression analysis showed A/G Ratio >0.55 to be independently associated with reduced peak VO2 (L/min) adjusted for age, BMI, LVEF, presence of sarcopenia, anabolic hormones, and haemoglobin (odds ratio 3.895, 95% CI 1.030–14.730, p=0.045).

Conclusion

Our data suggest that body fat distribution, particularly android and gynoid fat composition, might have an important adverse role on functional capacity in male patients with HFrEF.

Acknowledgement/Funding

FAPESP #2016/24306-0 and 2016/24833-0

P4132Decreased myocardial native T1 times and impaired myocardial contractility in young anabolic androgenic steroids users

Background

Anabolic androgenic steroids (AAS) have been associated with several injuries on the cardiovascular system. AAS abuse may have a direct toxic effect on the myocardium that could lead to cardiac function and structure alterations. Clinical and forensic cases have been reported myocardial fibrosis in AAS users. Myocardial fibrosis increases the risk of heart failure and sudden death. However, recent studies did not show evidence of focal myocardial fibrosis and diffuse myocardial fibrosis in AAS users using T1-mapping techniques. Thus, it remains unclear the association between AAS and cardiac structure alterations.

Purpose

The aim of this study was to evaluate cardiac structure by cardiovascular magnetic resonance (CMR) imaging with late-gadolinium enhancement (LGE), cardiac T1-mapping and extracellular volume measurements (ECV). Additionally, we also evaluated the cardiac contractility by CMR and echocardiography in young AAS users.

Methods

Twenty strength-trained AAS users (AASU) age 29±5 yr, 20 age-matched strength-trained AAS nonusers (AASNU), and 10 sedentary controls (SC) were enrolled. Cardiac structure was assessed by LGE, native T1-mapping and ECV. Cardiac contractility was evaluated as cardiac strain measured by CMR (feature tracking imaging technique) and echocardiography (speckle tracking technique).

Results

Global native T1 times [753 (683–870) vs 916 (815–1239) vs 1205 (825–1242) ms, respectively, p=0.03], and native T1 times at the left ventricle mid-ventricular slice [813 (695–1096) vs 922 (825–1095) vs 1140 (840–1322) ms, respectively, p=0.03] were lower in AASU compared with AASNU and SC. Mid-ventricular ECV was similar between AASU, AASNU and SC (22±6 vs 23±4 vs 24±4%, respectively, p=0.37). Focal myocardial fibrosis was found in 2 individuals (11%) of AASU. The mid anteroseptal and mid inferoseptal were the most affected segments. The total estimated mass of the LV mass was 1.25 g (0.65%). Three participants of SC showed focal myocardial fibrosis. The mid anterolateral, mid inferolateral and mid inferomedial were the most affected segments. The total estimated mass of the LV mass was 3.43 g (2.30%). In contrast, none of the AASNU had myocardial fibrosis. By CMR, AASU showed a lower medial radial strain (30±8 vs. 38±6%, p<0.01), medial circumferential strain (−17±3 vs −20±2%, p<0.01) and global longitudinal strain (−17±3 vs −20±3%, p<0.01) compared with AASNU. Echocardiography also demonstrated a lower 4CH longitudinal strain in AASU compared with AASNU (−15.5±3 vs −18.3±2%, p=0.03). Moreover, the AASU shower a higher left ventricle mass compared with AASNU and SC (185±20 vs 130±17 vs 112±14 g, respectively, p<0.01).

Conclusion

This study indicates that AAS abuse may be associated with decreased myocardial native T1 times, impaired myocardial contractility and focal myocardial fibrosis. These myocardial structural and functional alterations may be associated to unadapted cardiac hypertrophy in young AAS users.

Acknowledgement/Funding

Fundação de Amparo à Pesquisa do Estado de São Paulo [FAPESP], Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes).

Risk factors for bone loss in juvenile-onset systemic lupus erythematosus: a prospective study

OBJECTIVE

Juvenile-onset systemic lupus erythematosus (JoSLE) is associated with low bone mass for age and fractures; nevertheless, risk factors for bone impairment are poorly understood. The aim of this study was to evaluate risk factors for bone mass loss in JoSLE patients.

METHODS

Forty-nine female JoSLE patients were evaluated at baseline and after a 3.5-year follow-up regarding clinical, laboratory (including bone turnover markers), areal bone mineral density (aBMD) and bone microarchitecture parameters using high-resolution peripheral quantitative computed tomography (HR-pQCT). Based on the difference between final and baseline aBMD value, the patients were divided into three groups: aBMD gain (BG), aBMD loss (BL) and aBMD no change (NC).

RESULTS

The mean patient age was 18.7 ± 3.3 years. Sixty-one percent of patients presented with aBMD gain, 18.4% aBMD loss, and 20.4% remained stable during this follow-up period. Comparing the BL with the BG group, there was a higher frequency of alcohol consumption (p = 0.009), a higher frequency of inadequate calcium intake (p = 0.047) and lower levels of baseline procollagen type 1 amino-terminal propeptide (P1NP) (p = 0.036) in the BL group. Moreover, worsening of HR-pQCT parameters trabecular volumetric density (p = 0.003) and cortical thickness (p = 0.009) was observed in the BL group. In addition, a higher frequency of renal activity was observed comparing the BL + NC with the BG group (p = 0.036).

CONCLUSIONS

This is the first longitudinal study that has analyzed the risk factors of bone loss in JoSLE patients. The authors emphasize the importance of evaluating lifestyle habits and renal disease activity in these young women. Furthermore, this study suggests that trabecular and cortical compartments deteriorated, and low levels of P1NP may be a predictor of bone impairment in JoSLE.

Distal radius and tibia bone microarchitecture impairment in female patients with diffuse systemic sclerosis

Radius and tibia bone microarchitecture, analyzed through a high-resolution peripheral quantitative computed tomography, were significantly impaired in female patients with diffuse systemic sclerosis compared with healthy controls. Acroosteolysis, quality of life-grip strength, hand disability, and disease duration were significantly associated with this bone deterioration.

INTRODUCTION

The effect of diffuse systemic sclerosis (dSSc) on the bone is not completely understood. The objective of this study was to analyze the volumetric bone mineral density (vBMD), microarchitecture, and biomechanical parameters at the distal radius and tibia using high-resolution peripheral quantitative computed tomography (HR-pQCT, XtremeCT) in female patients with dSSc and identify clinical and laboratory variables associated with these parameters.

METHODS

Thirty-eight women with dSSc and 76 healthy controls were submitted to HR-pQCT at the distal radius and tibia. Clinical and laboratory findings, bone mineral density(BMD), nailfold capillaroscopy (NC), total passive range of motion(ROM), and quality of life (health assessment questionnaire-HAQ) were associated with HR-pQCT (Scanco Medical AG, Brüttisellen, Switzerland) parameters. Multiple linear regression models adjusted for clinical and laboratory variables, ROM and HAQ, were performed.

RESULTS

Density, microarchitecture, and biomechanical parameters at the distal radius and tibia were significantly impaired in dSSc patients compared with healthy controls (p < 0.001). Multiple linear regression models showed that lower trabecular density (Tb.vBMD) (radius R² = 0.561, p = 0.002; and tibia R² = 0.533, p = 0.005), and lower trabecular number (Tb.N) (tibia R² = 0.533, p = 0.005) were significantly associated with acroosteolysis. Higher trabecular separation (Tb.Sp) was associated with disease duration and higher HAQ-grip strength (radius R² = 0.489, p = 0.013), while cortical density (Ct.vBMD) was associated with ROM (radius R² = 0.294, p = 0.002).

CONCLUSION

Bone microarchitecture in patients with dSSc, analyzed through HR-pQCT, showed impairment of trabecular and cortical bone at distal radius and tibia. Variables associated with hand involvement (acroosteolysis, quality of life-grip strength, and ROM) and disease duration may be considered prognostic factors of this bone impairment.

Sympatho-Vagal Imbalance is Associated with Sarcopenia in Male Patients with Heart Failure

Background

Resting sympathetic hyperactivity and impaired parasympathetic reactivation after exercise have been described in patients with heart failure (HF). However, the association of these autonomic changes in patients with HF and sarcopenia is unknown.

Objective

The aim of this study was to evaluate the impact of autonomic modulation on sarcopenia in male patients with HF.

Methods

We enrolled 116 male patients with HF and left ventricular ejection fraction < 40%. All patients underwent a maximal cardiopulmonary exercise testing. Maximal heart rate was recorded and delta heart rate recovery (∆HRR) was assessed at 1^st and 2^nd minutes after exercise. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography. Dual-energy X-ray absorptiometry was used to measure body composition and sarcopenia was defined by the sum of appendicular lean muscle mass (ALM) divided by height in meters squared and handgrip strength.

Results

Sarcopenia was identified in 33 patients (28%). Patients with sarcopenia had higher MSNA than those without (47 [41-52] vs. 40 [34-48] bursts/min, p = 0.028). Sarcopenic patients showed lower ∆HRR at 1^st (15 [10-21] vs. 22 [16-30] beats/min, p < 0.001) and 2^nd min (25 [19-39] vs. 35 [24-48] beats/min, p = 0.017) than non-sarcopenic. There was a positive correlation between ALM and ∆HRR at 1^st (r = 0.26, p = 0.008) and 2^nd min (r = 0.25, p = 0.012). We observed a negative correlation between ALM and MSNA (r = -0.29, p = 0.003).

Conclusion

Sympatho-vagal imbalance seems to be associated with sarcopenia in male patients with HF. These results highlight the importance of a therapeutic approach in patients with muscle wasting and increased peripheral sympathetic outflow.

A Randomized Trial of Zoledronic Acid to Prevent Bone Loss in the First Year after Kidney Transplantation

BACKGROUND

Bone and mineral disorders commonly affect kidney transplant (KTx) recipients and have been associated with a high risk of fracture. Bisphosphonates may prevent or treat bone loss in such patients, but there is concern that these drugs might induce adynamic bone disease (ABD).

METHODS

In an open label, randomized trial to assess the safety and efficacy of zoledronate for preventing bone loss in the first year after kidney transplant, we randomized 34 patients before transplant to receive zoledronate or no treatment. We used dual-energy x-ray absorptiometry (DXA), high-resolution peripheral quantitative computed tomography (HR-pQCT), and bone biopsies to evaluate changes in bone in the 32 evaluable participants between the time of KTx and 12 months post-transplant.

RESULTS

Both groups of patients experienced decreased bone turnover after KTx, but zoledronate itself did not affect this outcome. Unlike previous studies, DXA showed no post-transplant bone loss in either group; we instead observed an increase of bone mineral density in both lumbar spine and total hip sites, with a significant positive effect of zoledronate. However, bone biopsies showed post-transplant impairment of trabecular connectivity (and no benefit from zoledronate); HR-pQCT detected trabecular bone loss at the peripheral skeleton, which zoledronate partially attenuated.

CONCLUSIONS

Current immunosuppressive regimens do not contribute to post-transplant central skeleton trabecular bone loss, and zoledronate does not induce ABD. Because fractures in transplant recipients are most commonly peripheral fractures, clinicians should consider bisphosphonate use in patients at high fracture risk who have evidence of significantly low bone mass at these sites at the time of KTx.

Monocytes from male patients with ankylosing spondylitis display decreased osteoclastogenesis and decreased RANKL/OPG ratio

The present study investigates the osteoclastogenic capacity of peripheral blood mononuclear cells (PBMCs) in male patients with ankylosing spondylitis (AS). We demonstrated that monocytes from these patients display a lower capacity to generate osteoclasts compared to cells from healthy controls, and osteoclastogenesis was negatively correlated with disease duration.

INTRODUCTION

Ankylosing spondylitis (AS) is a disease characterized by new bone growth that leads to syndesmophyte formation but AS patients frequently present with low bone mineral density/fractures. Osteoclastogenesis in AS patients is poorly studied and controversial. The aim of this study is to determine if the osteoclastogenic capacity of PBMCs is different in AS patients compared to controls and the relationship between osteoclastogenesis and clinical/laboratory parameters.

METHODS

PBMCs from 85 male AS patients and 59 controls were tested for CD16+ cells and induced to differentiate into osteoclasts over 3 weeks in vitro. Serum levels of RANKL, osteoprotegerin (OPG), C-terminal telopeptide of type I collagen (CTX), and amino-terminal pro-peptide of type I collagen (P1NP) were also evaluated.

RESULTS

PBMCs from AS patients had fewer CD16+ cells and produced fewer osteoclasts compared to controls. Apoptosis occurred less frequently in osteoclasts obtained from AS patients than in osteoclasts from the controls. A lower RANKL/OPG and CTX/P1NP were observed in AS patients compared to controls. AS patients taking NSAIDs presented no difference regarding the number of OCs produced and the percentage of CD16+ cells compared to controls. However, patients taking TNF inhibitors (TNFi) presented lower OC numbers than controls. A negative correlation was demonstrated between the number of osteoclasts generated from PBMCs of AS patients and disease duration.

CONCLUSION

Monocytes from male AS patients display a lower capacity to generate osteoclasts in vitro compared to cells from controls. Osteoclastogenesis was negatively correlated with disease duration. This finding supports the idea that osteoclasts play a role in the physiopathology of bone disease in AS patients.

The trabecular bone score: Relationships with trabecular and cortical microarchitecture measured by HR-pQCT and histomorphometry in patients with chronic kidney disease

The trabecular bone score (TBS) is a novel tool using grayscale variograms of the lumbar spine bone mineral density (BMD) to assess trabecular bone microarchitecture. Studies in patients with chronic kidney disease (CKD) suggest it may be helpful in assessing fracture risk. However, TBS has not been validated as a measure of trabecular architecture against transiliac bone biopsy with histomorphometry in CKD patients. We hypothesized that TBS would reflect trabecular architecture at the iliac crest in CKD patients. We obtained tetracycline double labeled transiliac crest bone biopsy, areal BMD of the spine, total hip, femoral neck (FN) and spine TBS by dual energy X-ray absorptiometry (DXA), and cortical and trabecular volumetric density and microarchitecture by high resolution peripheral quantitative computed tomography (HR-pQCT) in CKD patients from two centers: twenty-two patients from Columbia University Medical Center, USA and thirty patients from Hospital das Clinicas - Universidade de São Paulo, Brazil. Two patients were excluded for outlier status. Univariate and multivariate relationships between TBS and measures from DXA, HR-pQCT and histomorphometry were determined. Patients were 50.2 ± 15.8 years old, 23 (46%) were men, and 33 (66%) were on dialysis. TBS was <1.31 in 21 (42%) patients and 22%, 14% and 10% had T-scores ≤ -2.5 at spine, FN and total hip respectively. In univariate regression, TBS was significantly associated with trabecular bone volume (BV/TV), trabecular width (Tb.Wi), trabecular spacing, cortical width but not with trabecular number or cortical porosity. FN Z-score and height were also associated with cancellous BV/TV and Tb.Wi, In multivariate analysis, TBS remained an independent predictor of BV/TV and Tb.Wi. There were no relationships between TBS and dynamic parameters from histomorphometry. These data suggest that TBS reflected trabecular microarchitecture and cortical width measured by bone biopsy in CKD patients. Future studies should address its utility in the identification of CKD patients who may benefit from fracture prevention strategies.

Consensus statement: osteoporosis prevention and treatment in Latin America-current structure and future directions

BACKGROUND

Osteoporosis is a common disorder affecting populations worldwide. In Latin America, an aging population combined with limited health care resources result in osteoporosis quickly becoming a condition of considerable magnitude with disproportionate morbidity and mortality.

AIM

To review the current state of prevention, diagnosis, and treatment of osteoporosis in Latin America and to develop strategies and recommendations that may be adopted in the region, an expert panel of clinicians and scientists was assembled to develop a consensus statement outlining future directions.

METHOD

The panel conducted a comprehensive literature review of publications mainly related to osteoporosis in Latin America, and at an in-person meeting developed a consensus position to address the relevant issues.

RESULTS

The epidemiology, burden, diagnosis, and treatment of osteoporosis in the region were discussed with particular attention to issues unique to the region. A series of recommendations were developed encompassing virtually all aspects of the disease, including improved public and health professional awareness, better diagnostic processes, improved access to care, and greater engagement by health policy makers, government, and a wide variety of private organizations.

CONCLUSIONS

The panel concluded that a comprehensive approach to osteoporosis prevention and treatment in Latin America is urgently needed.

Characteristics of 1555 childhood-onset lupus in three groups based on distinct time intervals to disease diagnosis: a Brazilian multicenter study

Objective The objective of this study was to compare demographic data, clinical/laboratorial features and disease activity at diagnosis in three different groups with distinct time intervals between onset of signs/symptoms and disease diagnosis. Methods A multicenter study was performed in 1555 childhood-onset systemic lupus erythematosus (American College of Rheumatology criteria) patients from 27 pediatric rheumatology services. Patients were divided into three childhood-onset systemic lupus erythematosus groups: A: short time interval to diagnosis (<1 month); B: intermediate time interval (≥1 and <3 months); and C: long time interval (≥3 months). An investigator meeting was held to define the protocol. Demographic data, SLICC classification criteria and SLEDAI-2 K were evaluated. Results The number of patients in each group was: A = 60 (4%); B = 522 (33.5%); and C = 973 (62.5%). The median age at diagnosis (11.1 (4.2-17) vs. 12 (1.9-17.7) vs. 12.5 (3-18) years, P = 0.025) was significantly lower in group A compared with groups B and C. The median number of diagnostic criteria according to SLICC (7 (4-12) vs. 6 (4-13) vs. 6 (4-12), P < 0.0001) and SLEDAI-2 K (18 (6-57) vs. 16 (2-63) vs. 13 (1-49), P < 0.0001) were significantly higher in group A than the other two groups. The frequency of oral ulcers in the palate (25% vs. 15% vs. 11%, P = 0.003), pleuritis (25% vs. 24% vs. 14%, P < 0.0001), nephritis (52% vs. 47% vs. 40%, P = 0.009), neuropsychiatric manifestations (22% vs. 13% vs. 10%, P = 0.008), thrombocytopenia (32% vs. 18% vs. 19%, P = 0.037), leucopenia/lymphopenia (65% vs. 46% vs. 40%, P < 0.0001) and anti-dsDNA antibodies (79% vs. 66% vs. 61%, P = 0.01) were significantly higher in group A compared with the other groups. In contrast, group C had a less severe disease characterized by higher frequencies of synovitis (61% vs. 66% vs. 71%, P = 0.032) and lower frequencies of serositis (37% vs. 33% vs. 25%, P = 0.002), proteinuria >500 mg/day (48% vs. 45% vs. 36%, P = 0.002) and low complement levels (81% vs. 81% vs. 71%, P < 0.0001) compared with groups A or B. Conclusions Our large Brazilian multicenter study demonstrated that for most childhood-onset systemic lupus erythematosus patients, diagnosis is delayed probably due to mild disease onset. Conversely, the minority has a very short time interval to diagnosis and a presentation with a more severe and active multisystemic condition.