RESUMO
BACKGROUND: Juvenile idiopathic arthritis (JIA) comprises a whole spectrum of chronic arthritis starting before 16 years of age. The study aims to explore the clinical and demographic descriptors, treatment, and disease progression of enthesitis-related arthritis (ERA) in comparison with juvenile-onset spondyloarthritis (SpA). METHODS: Cross-sectional analysis of consecutive patients in two dedicated clinics, with a single visit and retrospective case-notes review. Arthritis, enthesitis and sacroiliitis were evaluated by scoring disease activity and damage. Continuous variables were reported by median, interquartile range; categorical variables were reported by the frequency comparison of the two groups. RESULTS: Thirty-three cases were included, being 23 (69.7%) with ERA. The median age at diagnosis was 12.5 y (SpA) vs. 9 y (ERA) (p < 0.01); the time from symptom onset to diagnosis was 5.5 y (SpA) vs. 1.5 y (ERA) (p < 0.03). In both groups, the predominant presentation was a single joint or < 5 lower limb joints and asymmetric involvement, with a high frequency of enthesitis. There was a higher frequency of mid-tarsal and ankle synovitis in the ERA group and hip involvement in those with SpA. The comparison of the frequency of spine symptoms at presentation, 30% SpA vs. 21.7% ERA (p = 0.7), was not significant, and radiographic progression to spinal involvement occurred in 43.5% of ERA patients. The median time for spinal progression and age at onset was 2.2 and 12 y for ERA, and 4 and 16.5 y for SpA, respectively. Activity and damage scores were not significantly different between the groups. Treatment comparison resulted in 91.3% of ERA and 100% SpA being treated, predominantly with NSAIDs in both groups, followed by DMARDs and biologics, with a higher frequency of biologics in SpA. CONCLUSION: The main differences were the late diagnoses of SpA, and the hip and spine involvement, with higher frequency of biologic treatment in juvenile-onset SpA compared to ERA.
Assuntos
Antirreumáticos , Artrite Juvenil , Progressão da Doença , Espondilartrite , Humanos , Estudos Transversais , Artrite Juvenil/complicações , Artrite Juvenil/tratamento farmacológico , Artrite Juvenil/diagnóstico , Criança , Adolescente , Feminino , Masculino , Estudos Retrospectivos , Espondilartrite/complicações , Espondilartrite/tratamento farmacológico , Espondilartrite/diagnóstico , Antirreumáticos/uso terapêutico , Entesopatia/etiologia , Entesopatia/diagnóstico por imagem , Sacroileíte/diagnóstico por imagem , Idade de Início , AdultoRESUMO
INTRODUCTION/OBJECTIVES: Enthesitis is a cardinal feature of spondylarthritis (SpA), and the pelvis is a common site of enthesitis. This study aimed to establish the association between pelvic enthesis involvement on pelvic X-ray and SpA diagnosis through a radiographic enthesis index (REI) and to assess the reliability and accuracy of this REI. MATERIALS AND METHODS: The participants were SpA patients and a control group composed of patients with chronic lumbar pain without SpA. Three blinded observers assessed each pelvic radiography three times. Three zones were used: Zone I (ZI), the iliopubic ramus; Zone II (ZII), the pubic symphysis, and Zone III (ZIII), the ischiopubic ramus. A grading system was created from 0 to 3 [Grade 0, normal; Grade 1, minimal changes (subcortical bone demineralization and/or periosteal wishkering, seen as radiolucency and trabeculation of the cortical bone upon tendon insertion); Grade 2, destructive changes (Grade 1 findings and erosions at the enthesis site); and Grade 3, findings of Grade 2 plus >2 mm whiskering out of the cortical bone) for the REI. The sum of the results of the three zones was called the total REI. For statistical analysis, we used the weighted kappa statistic adjusted for prevalence and bias using Gwet's agreement coefficient. RESULTS: We enrolled 161 patients, 111 of them with SpA (39.6 % with axial SpA and 47.7 % with peripheral SpA) and 50 without SpA. In the SpA group, 36.7 % and 25.7 % had REI Grades 2 and 3 in ZIII, respectively, while only 6 % of the controls had these grades. For ZI, the frequency of Grades 1 to 3 was 42.3 % in the SpA group (8.1 %, 14.4 %, and 19.8 %, respectively), compared to only 2 % in the controls. ZII was unaffected in most of the patients with SpA (82.9 %) and in the controls (98 %). In the control group, Grade 0 was the most common REI grade in all three zones. The agreement was almost perfect for each zone and between the independent readers. The ROC-curve analysis showed that the highest performance areas were the total REI, ZIII, and ZI. Most (75 %) of the SpA patients without sacroiliitis on X-ray were REI-positive. The sensitivity of the REI for SpA diagnosis was 82 %, while the sensitivity of sacroiliitis on X-ray was 38.7 %. CONCLUSIONS: The assessment of pelvic enthesis using the REI on pelvic radiography may be useful for SpA diagnosis. Total REI, ZIII, and ZI had the highest accuracy and almost perfect reliability. The REI is especially helpful in patients without sacroiliitis on imaging.
Assuntos
Entesopatia , Radiografia , Sacroileíte , Espondilartrite , Humanos , Entesopatia/diagnóstico por imagem , Feminino , Masculino , Espondilartrite/diagnóstico por imagem , Adulto , Sacroileíte/diagnóstico por imagem , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Pelve/diagnóstico por imagem , Índice de Gravidade de Doença , Ossos Pélvicos/diagnóstico por imagemRESUMO
Introducción.La Protuberancia Occipital Externa (POE) es una superficie convexa y lisa que tradicionalmente no presenta ningún tipo de irregularidades. La aparición de un entesofito en individuos ha llamado la atención de los investigadores. Objetivo.Determinar la prevalencia, longitud, edad y sexo de una exostosis en forma de gancho desarrollada a nivel de la POE. Metodología.Estudio observacional descriptivo realizado en radiografías laterales de cráneo de individuos jóvenes. De 5065 radiografías, 4017 radiografías cumplieron con los criterios. Se procedió a la detección de la presencia de un gancho óseo en la POE y su medición. Resultados.Se incluyeron personas de ambos sexos entre 13 a 45 años: 2902 mujeres y 1115 varones. De las 4017 radiografías observadas, el 67% presentó la excrecencia en la POE, con rangos desde 5 a 24 mm en longitud, 511 tenían una longitud de 5 mm o mayor, 903 entre 9 a 12 mm de longitud y 253 de 13 a 24mm. Se observó enmayor proporción en el sexo masculino que el femenino(68% vs 32%). En los individuos de 40 años y más, solo un paciente de sexo masculino mostró la presencia del entesofito. Conclusión.Se ha encontrado una alta frecuencia del desarrollo de una protuberancia ósea a nivel del POE en jóvenes y adultos jóvenesde sexo masculino. Este es el primer estudio de este tipo realizado en la población del Paraguay. Para comprender la razón del desarrollo de esta excrecencia ósea, es necesario ampliar el área de investigación. Palabras Clave:ganchos óseos;protuberancia; exostosis; entesopatía.
Introduction.The external occipital protuberance (EOP) is a smooth convex surface which commonly does not present any type of irregularities. The development of an enthesophyte in young population has attracted the attention of researchers. Objective.To determine the prevalence, size, age, and sex of individuals with bony projections that resembles a hook developed in EOP. Methodology.Descriptive observational study. 5065 lateral skull x-rays were observed. 4017 fulfilled all the criteria. The x-rays were reviewed for the presence of a bony excrescence in EOP, and they were measured. Results. From a both sexes population between 13 to 45 years old 2902 were female and 1115 were male. 67% X-rays presented the enthesophyte ranging from 5 24mm in length. 511 out of 1667 had an enthesophyte at or above 5 mm. There were 903 patients with an enthesophyte ranging from 9 12 mm in length and 254 had the protuberance ranging from 13 24 mm. Statistically significant range of 68% vs 32% between males and females were observed. From individuals of 40 years and above, just 1 male patient out of 32 showedthe enthesophyte. Conclusion.Significant association with the development of a bony protuberance at the POE in young and young adult male population has been found. This is the first study of this type in Paraguayan individuals. To expand the field of studies, future research is needed to better examine and understand the reason forthe development of this bony excrescence. Key words:bone hooks; protuberance;exostoses; enthesopathies.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Pinos Ortopédicos , Exostose , Entesopatia , PonteRESUMO
BACKGROUND: Interest in ultrasound (US) as a diagnostic tool in spondyloarthritis is growing. Although the literature has provided detailed description of normal lower-limb entheses for adults and children, validated normal US findings of the pediatric upper-limb (UL) entheses are lacking. OBJECTIVES: The aim of this study was to describe the sonographic characteristics of the UL entheses in healthy children to provide a basis for assessing pathologic findings in children with rheumatic diseases. METHODS: This is an observational, cross-sectional study. The recruited healthy children were grouped according to age: group 1, 3-9 years (n = 22); group 2, 10 to 13 years (n = 12); and group 3, 14 to 18 years (n = 9). The following UL entheses were examined: (1) supraspinatus, (2) common flexor, (3) common extensor, and (4) triceps. Ultrasound examination was performed in B mode for morphology and structural abnormalities, and power Doppler was applied to detect vascularization within the enthesis and cartilage sites. RESULTS: Forty-three children with a median age of 9 years (6-13 years) were included; 55% were boys. A total of 344 entheses were evaluated; all of them presented a homogeneous hyperechoic fibrillar pattern. Tendon insertion thickness at the bone attachment site increased with age and was greater in males. No signs of chronic enthesopathy were detected. Doppler signal was observed in children from groups 1 and 2, but not in any of the patients in group 3. In group 1, intraentheses signal was detected in the common extensor tendon insertion as an isolated signal (n = 2 patients), whereas intracartilage signal was detected in the supraspinatus (n = 1 patient) and the triceps (n = 1 patient). In group 2, intracartilage signal was detected in the common extensor (n = 2 patients) and the common flexor (n = 2 patients). Interobserver agreement for the entheses' thickness was as follows: intracorrelation coefficient class (ICC) of 0.86 (95% confidence interval [CI], 0.84-0.92) for the supraspinatus enthesis, ICC of 0.83 (95% CI, 0.83-0.90) for the common extensor enthesis, ICC of 0.96 (95% CI, 0.91-0.97) for the common flexor enthesis, and ICC of 0.94 (95% CI, 0.89-0.95) for the triceps enthesis. The κ index was 0.93 for the detection of the power Doppler signal. Intraobserver agreement was good for all evaluated entheses: ICC of 0.85 (95% CI, 0.83-0.91) for supraspinatus, ICC of 0.86 (95% CI, 0.84-0.91) for common extensor entheses, ICC of 0.89 (95% CI, 0.86-0.93) for common flexor entheses, and ICC of 0.96 (95% CI, 0.90-0.97) for evaluation of triceps entheses. The κ index was 0.91 for the detection of Doppler signal. CONCLUSIONS: The current study provides a comprehensive description of the structural appearance and vascularization of UL entheses on healthy children. This information can be useful as reference for interpretation of pathological findings in children with musculoskeletal diseases in clinical practice.
Assuntos
Entesopatia , Tendões , Adulto , Criança , Pré-Escolar , Entesopatia/diagnóstico por imagem , Humanos , Lactente , Masculino , Tendões/diagnóstico por imagem , Ultrassonografia , Ultrassonografia Doppler , Extremidade SuperiorRESUMO
BACKGROUND: The severity of nail disease, the presence of arthralgia and fatigue are predictors of development of psoriatic arthritis (PsA) in patients with psoriasis (Pso). In children, little is known about the musculoskeletal (MSK) impairment in patients with Pso and its effect on health-related quality of life (HRQoL). OBJECTIVES: To determine the frequencies of pain and MSK inflammation (i.e., arthritis, enthesitis, and sacroiliitis) among children and adolescents with Pso and its relationship to HRQoL and fatigue. METHODS: Pediatric patients with Pso underwent a rheumatologic physical examination to evaluate synovitis, enthesalgia, sacroiliac joint (SIJ) pain and tender points of fibromyalgia. The core set of domains recommended by the GRAPPA - OMERACT to be measured in PsA studies was assessed. Ultrasound (US) was performed in clinical cases of enthesitis, and magnetic resonance imaging (MRI) was performed in cases of SIJ pain. RESULTS: Forty-three participants (10 ± 2.9 years old) were evaluated. Pain on palpation of the entheses was observed in 10 (23.2%) patients and pain on SIJ palpation was observed in 3 (7%). No patient presented with synovitis; one presented with enthesitis on US, but MRI did not confirm sacroiliitis in any case. Patients with MSK pain had greater skin disease severity (PASI 5.4 vs. 2, p < 0.01), worse fatigue, and lower HRQoL scores on all instruments used. The estimated risk of HRQoL impairment was eight times higher in the presence of MSK pain, which was an independent predictive factor. With a NAPSI greater than 30, the probability of pain was greater than 80%. CONCLUSION: MSK pain is frequent among children with Pso, related to the severity of skin and nail disease, and negatively affects HRQoL. The typically used complementary exams might not detect the inflammatory process caused by Pso.
Assuntos
Doenças Musculoesqueléticas/complicações , Psoríase/complicações , Qualidade de Vida , Adolescente , Artralgia/complicações , Artralgia/diagnóstico , Artralgia/epidemiologia , Artrite/diagnóstico por imagem , Artrite Psoriásica/etiologia , Criança , Pré-Escolar , Estudos Transversais , Entesopatia/diagnóstico por imagem , Fadiga/complicações , Feminino , Fibromialgia/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Masculino , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/epidemiologia , Dor Musculoesquelética/diagnóstico , Doenças da Unha/complicações , Doenças da Unha/diagnóstico , Palpação , Sacroileíte/diagnóstico por imagem , Índice de Gravidade de Doença , UltrassonografiaRESUMO
Objetivo: Avaliar pacientes com fibromialgia e dor lombar, bus- cando características clínicas de espondiloatrites axiais. Méto- dos: Neste estudo transversal, cem pacientes com fibromialgia e idades entre 18 e 65 anos foram avaliados. A avaliação consis- tiu em um questionário baseado no braço clínico dos critérios Assessment of Spondyloarthritis International Society para diag- nóstico de espondiloatrites axiais e um questionário de impacto da fibromialgia (Revised Fibromyalgia Impact Questionnaire). Re- sultados: Quando o braço clínico da Assessment of Spondyloar- thritis International Society foi aplicado em pacientes com fibro- mialgia e dor lombar, 80% dos pacientes preencheram os critérios para diagnóstico de espondiloatrites axiais. As principais carac- terísticas de espondiloatrite axial foram dor lombar inflamatória, boa resposta a drogas anti-inflmatórias não esteroidais, artrite e entesite. Pacientes com critérios de espondiloatrites axiais posi- tivos apresentaram maiores níveis séricos de proteína C-reativa (p=0,00035). O valor médio do Revised Fibromyalgia Impact Ques- tionnaire para todos os pacientes avaliados foi 63,6, e não houve di- ferença entre os pacientes que preencheram os critérios e aqueles que não preencheram. Conclusão: Pacientes com fibromialgia e dor lombar frequentemente apresentam características clínicas de espondiloatrite axial, e aqueles que preencheram os crité- rios clínicos para espondiloatrites axiais também apresentaram maiores níveis séricos de proteína C-reativa.
Objective: To evaluate patients with fibromyalgia and back pain for clinical features of axial spondyloarthritis. Methods: In this cross-sectional study, one hundred fibromyalgia patients between 18 and 65 years old were assessed. The assessment consisted of a questionnaire based on the clinical arm ofthe Assessment of Spondyloarthritis International Society criteria for the diagnosis of axial spondyloarthritis and a questionnaire on the impact of fibromyalgia (Revised Fibromyalgia Impact Questionnaire). Re- sults: When the clinical arm of the Assessment of Spondyloarthri- tis International Society was applied in patients with fibromyal- gia and back pain, 80% of the patients met the clinical criteria for diagnosis of axial spondyloarthritis. The main features of axial spondyloarthritis in fibromyalgia patients were inflammatory back pain, good response to non-steroidal anti-inflammatory drugs (NSAIDs), arthritis, and enthesitis. Patients with positive axial spondyloarthritis criteria presented with higher C- reac- tive protein levels (p=0.00035). The mean value of the Revised Fibromyalgia Impact Questionnaire for all patients assessed was 63.6 and there was no difference between patients that met the criteria for axial spondyloarthritis and those who did not. Con- clusion: Patients with fibromyalgia and back pain often present clinical features of axial spondyloarthritis, and those who met the clinical criteria for axial spondyloarthritis also presented with higher levels of C-reactive protein.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fibromialgia/diagnóstico , Dor Lombar/diagnóstico , Espondiloartrite Axial/epidemiologia , Artrite , Psoríase , Uveíte , Proteína C-Reativa/análise , Doenças Inflamatórias Intestinais , Anti-Inflamatórios não Esteroides/uso terapêutico , Doença Crônica/epidemiologia , Epidemiologia Descritiva , Prevalência , Estudos Transversais , Inquéritos e Questionários , Distribuição por Sexo , Distribuição por Idade , Diagnóstico Diferencial , Dor Crônica/tratamento farmacológico , Dor Crônica/epidemiologia , Síndrome Mão-Pé , Entesopatia , Espondiloartrite Axial/diagnóstico , Anamnese/estatística & dados numéricosRESUMO
Akin to approaches encouraged by Verano (1997) in the Andes, and Ortner (2011, 2012) for general paleopathological studies, this article focuses on accurate descriptions and definitions of osteoarthritis, entheses, and long bone cross-sectional geometry. By evaluating these conditions as part of biological responses to abnormal skeletal changes and biomechanical stress, this research discusses each condition's pathogenesis. Further, this article emphasizes a "small data" approach to evaluating these conditions in ancient culturally and biologically related human populations, where the study samples must have good skeletal preservation, where estimates of age and sex need to be included as major factors, and where abnormalities need to be described and evaluated. This article also discusses global clinical and osteological research on ways scholars are currently trying to establish industry-wide methods to evaluate osteoarthritis, entheses, and long bone cross-sectional geometry. Recent studies have focused on rigorous evaluation of methodological techniques, recording protocols, and inter- and intra-observer error problems. Additionally, scholars have focused on physical intensity of movement using biomechanics, evaluated burials of known occupation, and used complex statistical methods to help interpret skeletal changes associated with these conditions. This article also narrows to focus on these conditions within thematic "small data" areas throughout the Andes. This research concludes with describing future directions to understand skeletal changes, such as more multidisciplinary studies between osteologists and pathologists, collaborations with living people to collect CT, x-rays, or computer-aided motion capture, and a stronger focus on how these conditions correlate with intense biomechanical changes in younger individuals.
Assuntos
Osso e Ossos , Entesopatia/história , Osteoartrite/história , Paleopatologia , Projetos de Pesquisa , Osso e Ossos/patologia , Difusão de Inovações , Entesopatia/patologia , Previsões , História Antiga , Humanos , Osteoartrite/patologia , Paleopatologia/tendências , Projetos de Pesquisa/tendências , América do SulRESUMO
BACKGROUND: The presence of enthesitis is associated with higher disease activity, more disability and incapacity to work and a poorer quality of life in spondyloarthritis (SpA). There is currently no consensus on which clinical score should be used to assess enthesitis in SpA. The objective of the present work was to compare the correlation of three enthesitis indices (MASES, SPARCC and LEI) with measures of disease activity and function in a heterogeneous population of patients with axial and peripheral SpA. METHODS: A cross-sectional study was conducted in three Brazilian public university hospitals; patients fulfilling ASAS classification criteria for peripheral or axial SpA were recruited and measures of disease activity and function were collected and correlated to three enthesitis indices: MASES, SPARCC and LEI using Spearman's Correlation index. ROC curves were used to determine if the the enthesitis indices were useful to discriminate patients with active disease from those with inactive disease. RESULTS: Two hundred four patients were included, 71.1% (N = 145) fulfilled ASAS criteria for axial SpA and 28.9% (N = 59) for peripheral SpA. In axial SpA, MASES performed better than LEI (p = 0.018) and equal to SPARCC (p = 0.212) regarding correlation with disease activity (BASDAI) and function (BASFI). In peripheral SpA, only MASES had a weak but statistical significant correlation with DAS28-ESR (rs 0.310 p = 0.05) and MASES had better correlation with functional measures (HAQ) than SPARCC (p = 0.034). CONCLUSION: In this sample composed of SpA patients with high coexistence of axial and peripheral features, MASES showed statistical significant correlation with measures of disease activity and function in both axial and peripheral SpA.
Assuntos
Entesopatia/diagnóstico , Índice de Gravidade de Doença , Espondilartrite/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite Psoriásica/epidemiologia , Brasil/epidemiologia , Estudos Transversais , Entesopatia/epidemiologia , Entesopatia/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Curva ROC , Espondilartrite/epidemiologia , Espondilite Anquilosante/epidemiologia , Estatísticas não Paramétricas , Adulto JovemRESUMO
Inflammatory bowel disease in children has increased worldwide during the last decades. Clinical presentations are diverse and extraintestinal manifestations are the presenting sign in 6-35 % of patients, the most common of them being peripheral arthritis. An atypical clinical presentation results in diagnosis delay and, added to the greater seriousness of inflammatory bowel disease phenotypes in children, it entails more intestinal complications and sequelae. We describe two cases of inflammatory bowel disease with an initial symptom of lameness due to peripheral arthritis and enthesitis, respectively.
La incidencia de enfermedad inflamatoria intestinal en la edad pediátrica se ha incrementado mundialmente en las últimas décadas. La forma de presentación puede ser diversa y, hasta en un 6-35 %, las manifestaciones extraintestinales pueden ser el debut; la artritis periférica es la más frecuente de estas. Una presentación atípica implica un retraso diagnóstico y, asociado a que el fenotipo de enfermedad inflamatoria intestinal es más grave en los niños, conlleva un incremento de las complicaciones intestinales y secuelas asociadas. Se presentan dos casos clínicos de enfermedad de Crohn cuya clínica inicial fue la claudicación de la marcha por una artritis periférica y una entesitis, respectivamente.