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Dourado E, Mazeda C, Freitas R, Martins P, Melo AT, Saraiva L, Guimarães F, Costa E, Almeida DE, Dinis S, Pinto AS, Daniel A, Genrinho I, Couto M, Rodrigues M, Santiago T, Salvador MJ, Duarte AC, Cordeiro A, Santos MJ, Fonseca JE, Cordeiro I, Resende C. Predictors of myositis in systemic sclerosis. Rheumatology (Oxford) 2024:keae089. [PMID: 38321583 DOI: 10.1093/rheumatology/keae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Eduardo Dourado
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- Serviço de Reumatologia, Centro Hospitalar Baixo Vouga, Centro Académico Clínico Egas Moniz, Aveiro, Portugal
- Centro de Investigação em Reumatologia de Aveiro, Centro Académico Clínico Egas Moniz, Aveiro, Portugal
| | - Carolina Mazeda
- Serviço de Reumatologia, Centro Hospitalar Baixo Vouga, Centro Académico Clínico Egas Moniz, Aveiro, Portugal
- Centro de Investigação em Reumatologia de Aveiro, Centro Académico Clínico Egas Moniz, Aveiro, Portugal
- EpiDoc Unit, Nova Medical School, NOVA University Lisbon, Lisboa, Portugal
| | - Raquel Freitas
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | - Patrícia Martins
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Ana Teresa Melo
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Liliana Saraiva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Francisca Guimarães
- Serviço de Reumatologia, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal
| | - Emanuel Costa
- Serviço de Reumatologia, Hospital de Braga, Braga, Portugal
| | | | - Sara Dinis
- Serviço de Reumatologia, Unidade Local de Saúde da Guarda, Guarda, Portugal
| | - Ana Sofia Pinto
- Serviço de Reumatologia, Unidade Local de Saúde da Guarda, Guarda, Portugal
| | - Alexandra Daniel
- Serviço de Reumatologia, Hospital Distrital de Leiria, Leiria, Portugal
| | - Inês Genrinho
- Serviço de Reumatologia, Centro Hospitalar Tondela-Viseu
| | - Maura Couto
- Serviço de Reumatologia, Centro Hospitalar Tondela-Viseu
| | - Marília Rodrigues
- Serviço de Reumatologia, Hospital Distrital de Leiria, Leiria, Portugal
| | - Tânia Santiago
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Maria João Salvador
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | | | - Ana Cordeiro
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | - Maria José Santos
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | - João Eurico Fonseca
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
| | - Inês Cordeiro
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Catarina Resende
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
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Costa FM, Campanilho-Marques R, Dourado E, Bandeira M, Correia B, Melo AT, Saraiva F, Barreira SC, Fonseca JE. Cancer-associated myositis before and after the COVID-19 pandemic onset: a changing trend. Clin Exp Rheumatol 2024; 42:316-320. [PMID: 38488097 DOI: 10.55563/clinexprheumatol/jv9ey8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES During the COVID-19 pandemic, there was a significant impact on the management of non-COVID-19 related diseases, potentially increasing the incidence of paraneoplastic syndromes such as cancer-associated myositis (CAM).The aim of this study is to determine the incidence of CAM in our cohort before and after the COVID-19 pandemic onset. METHODS We included patients with idiopathic inflammatory myopathy (IIM), diagnosed between June 2016 and June 2023. The patients were divided into two groups according to the date of IIM diagnosis. RESULTS We included 132 patients; 65.1% (n=86) were diagnosed prior to and 34.9% (n=46) after the COVID-19 pandemic. The most common IIM was dermatomyositis (DM) before and after the COVID-19 pandemic onset (p=0.750). The most frequent myositis-specific antibody (MSA) before the COVID-19 pandemic was anti-Mi2 (15.1%). After the COVID-19 pandemic onset, anti-TIF1γ was the most common MSA (21.7%), with a significantly higher relative prevalence (p=0.006). The incidence of CAM was significantly higher after the COVID-19 pandemic onset (11 vs. 3 new cases, p<0.002). Patients with CAM more frequently had anti-TIF1γ-positivity (p<0.001) and a diagnosis after the pandemic (p=0.001) than non-CAM-IIM patients. No significant differences were found regarding vaccination status or previous COVID-19 infection in CAM and non-CAM-IIM patients. Diagnosis after the COVID-19 pandemic was an independent predictor of CAM among IIM patients (OR 0.012, 95% CI 0.000-0.400, p=0.013), regardless of age, sex or previous COVID-19 infection. CONCLUSIONS There was a significant increase in the incidence of CAM after the COVID-19 pandemic. IIM diagnosis after the COVID-19 pandemic was an independent predictor of CAM.
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Affiliation(s)
- Filipa M Costa
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Raquel Campanilho-Marques
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Eduardo Dourado
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisbon; Serviço de Reumatologia, Unidade Local de Saúde da Região de Aveiro; and Centro de Investigação em Reumatologia de Aveiro, Centro Académico Clínico Egas Moniz, Aveiro, Portugal
| | - Matilde Bandeira
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Bianca Correia
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal.
| | - Ana Teresa Melo
- Unidade de Reumatologia, Centro Hospitalar e Universitário Lisboa Central, Lisbon, Portugal
| | - Fernando Saraiva
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Sofia C Barreira
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - João Eurico Fonseca
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), and Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
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Oliveira Ramos F, Rodrigues AM, Melo AT, Aguiar F, Brites L, Azevedo S, Duarte AC, Gomes JAM, Furtado C, Mourão AF, Sequeira G, Cunha I, Figueira R, Santos MJ, Fonseca JE. Influence of the timing of biological treatment initiation on Juvenile Idiopathic Arthritis long-term outcomes. Arthritis Res Ther 2023; 25:177. [PMID: 37735435 PMCID: PMC10512498 DOI: 10.1186/s13075-023-03166-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) treatment is aimed at inducing remission to prevent joint destruction and disability. However, it is unclear what is the long-term impact on health-related outcomes of the timing of biological disease-modifying antirheumatic drug (bDMARD) initiation in JIA. Our aim was to evaluate the long-term impact of the time between JIA onset and the initiation of a bDMARD in achieving clinical remission, on physical disability and health-related quality of life (HRQoL). METHODS Adult JIA patients registered in the Rheumatic Diseases Portuguese Register (Reuma.pt) and ever treated with bDMARD were included. Data regarding socio-demographic, JIA-related characteristics, disease activity, physical disability (HAQ-DI), HRQoL (SF-36), and treatments were collected at the last visit. Patients were divided into 3 groups (≤ 2 years, 2-5 years, or > 5 years), according to the time from disease onset to bDMARD initiation. Regression models were obtained considering remission on/off medication, HAQ-DI, SF-36, and joint surgeries as outcomes and time from disease onset to bDMARD start as an independent variable. RESULTS Three hundred sixty-one adult JIA patients were evaluated, with a median disease duration of 20.3 years (IQR 12.1; 30.2). 40.4% had active disease, 35.1% were in remission on medication, and 24.4% were in drug-free remission; 71% reported some degree of physical disability. Starting a bDMARD > 5 years after disease onset decreased the chance of achieving remission off medication (OR 0.24; 95% CI 0.06, 0.92; p = 0.038). Patients who started a bDMARD after 5 years of disease onset had a higher HAQ and worse scores in the physical component, vitality, and social function domains of SF-36, and more joint surgeries when compared to an earlier start. CONCLUSION Later initiation of bDMARDs in JIA is associated with a greater physical disability, worse HRQoL, and lower chance of drug-free remission in adulthood.
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Affiliation(s)
- Filipa Oliveira Ramos
- Pediatric Rheumatology Unit, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.
- Unidade de Investigação Em ReumatologiaInstituto de Medicina Molecular, Lisbon, Portugal.
- Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Center, Lisbon, Portugal.
| | - Ana Maria Rodrigues
- Centre for Chronic Diseases (CEDOC), Nova Medical School, Lisbon, Portugal
- Comprehensive Health Research Centre, Nova Medical School, Lisbon, Portugal
| | - Ana Teresa Melo
- Pediatric Rheumatology Unit, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Unidade de Investigação Em ReumatologiaInstituto de Medicina Molecular, Lisbon, Portugal
| | - Francisca Aguiar
- Young Adult and Pediatric Rheumatology Unit, Centro Hospitalar Universitário São João, University of Medicine of Porto University, Porto, Portugal
| | - Luísa Brites
- Rheumatology Department, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Soraia Azevedo
- Rheumatology Department, Unidade Local de Saúde Do Alto Minho, Ponte de Lima, Portugal
| | | | | | - Carolina Furtado
- Rheumatology Department, Hospital Do Divino Espírito Santo, Ponta Delgada, Portugal
| | - Ana Filipa Mourão
- Centre for Chronic Diseases (CEDOC), Nova Medical School, Lisbon, Portugal
- Rheumatology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Graça Sequeira
- Rheumatology Department, Centro Hospitalar Universitário Do Algarve, Faro Unit, Faro, Portugal
| | - Inês Cunha
- Rheumatoloy Department, Centro Hospitalar Do Baixo Vouga, Aveiro, Portugal
| | - Ricardo Figueira
- Rheumatoloy Department, Hospital Central Do Funchal, Funchal, Portugal
| | - Maria José Santos
- Unidade de Investigação Em ReumatologiaInstituto de Medicina Molecular, Lisbon, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Center, Lisbon, Portugal
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
| | - João Eurico Fonseca
- Pediatric Rheumatology Unit, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Unidade de Investigação Em ReumatologiaInstituto de Medicina Molecular, Lisbon, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Center, Lisbon, Portugal
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Dourado E, Melo AT, Campanilho-Marques R, Bandeira M, Martins P, Fraga V, Ferraro JL, Saraiva A, Sousa M, Parente H, Soares C, Correia AM, Esperança Almeida D, Paiva Dinis S, Pinto AS, Oliveira Pinheiro F, Seabra Rato M, Beirão T, Samões B, Santos B, Mazeda C, Chícharo AT, Faria M, Neto A, Lourenço MH, Brites L, Rodrigues M, Silva-Dinis J, Madruga Dias J, C Araújo F, Martins N, Couto M, Valido A, Santos MJ, Barreira S, Fonseca JE. The idiopathic inflammatory myopathies module of the Rheumatic Diseases Portuguese Register. ARP Rheumatol 2023; 2:188-199. [PMID: 37728117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
AIMS To characterise the idiopathic inflammatory myopathies (IIM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/myositis) and the patients in its cohort. METHODS Reuma.pt is a web-based system with standardised patient files gathered in a registry. This was a multicentre open cohort study, including patients registered in Reuma.pt/myositis up to January 2022. RESULTS Reuma.pt/myositis was designed to record all relevant data in clinical practice and includes disease-specific diagnosis and classification criteria, clinical manifestations, immunological data, and disease activity scores. Two hundred eighty patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years. Patients were classified as having definite (N=57/118, 48.3%), likely (N=23/118, 19.5%), or possible (N=2/118, 1.7%) IIM by 2017 EULAR/ACR criteria. The most common disease subtypes were dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), and myositis in overlap syndromes (N=41/280, 14.6%). The most common symptoms were proximal muscle weakness (N=180/215, 83.7%) and arthralgia (N=127/249, 52.9%), and the most common clinical signs were Gottron's sign (N=75/184, 40.8%) and heliotrope rash (N=101/252, 40.1%). Organ involvement included lung (N=78/230, 33.9%) and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%). Cancer was found in 11/127 patients (8.7%), most commonly breast cancer (N=3/11, 27.3%). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), and mycophenolate mofetil (N=56/280, 20.0%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125). CONCLUSIONS Reuma.pt/myositis adequately captures the main features of inflammatory myopathies' patients, depicting, in this first report, a heterogeneous population with frequent muscle, joint, skin, and lung involvements.
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Affiliation(s)
- Eduardo Dourado
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
| | - Ana Teresa Melo
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
| | | | - Matilde Bandeira
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
| | - Patrícia Martins
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
| | | | | | | | | | | | | | | | | | | | | | | | | | - Tiago Beirão
- Centro Hospitalar de Vila Nova de Gaia / Espinho
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ana Valido
- Unidade Local de Saúde do Litoral Alentejano
| | | | - Sofia Barreira
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
| | - João Eurico Fonseca
- Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa
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5
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Marona J, Sepriano A, Ramiro S, Almeida D, Brites L, Couto M, Cunha I, Fernandes BM, Garcia J, Melo AT, Nóvoa T, Oliveira M, Pinto P, Santos MJ, Silva C, Fonseca JE, Araújo FC. Effectiveness of biosimilar infliximab CT-P13 compared to originator infliximab in biological-naïve patients with rheumatoid arthritis and axial spondyloarthritis: data from the Portuguese Register. ARP Rheumatol 2023; 2:132-140. [PMID: 37421191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
OBJECTIVES To compare the effectiveness of the infliximab biosimilar CT-P13 with originator infliximab over 24 months of follow-up in biological-naïve patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA). METHODS Biological-naïve patients from the Rheumatic Diseases Portuguese Register (Reuma.pt), with a clinical diagnosis of RA or axSpA, who were starting either the infliximab biosimilar CT-P13 or the originator infliximab after 2014 (date of market entry of CT-P13 in Portugal), were included. Patients on biosimilar and originator were compared regarding different response outcomes at 3 and 6 months, adjusting for age, sex and baseline C-reactive protein (CRP). The main outcome was the change in DAS28-erytrocyte sedimentation rate (ESR) for RA and the ASDAS-CRP for axSpA. Additionally, the effect of infliximab biosimilar vs originator on different response outcomes over 24 months of follow-up was tested with longitudinal generalized estimating equations (GEE) models. RESULTS In total, 140 patients were included, 66 (47%) of which with RA. The distribution of patients starting the infliximab biosimilar and the originator was the same between the two diseases (approximately 60% and 40%, respectively). From the 66 patients with RA, 82% were females, mean age was 56 years (SD 11) and mean DAS28-ESR 4.9 (1.3) at baseline. As for the patients with axSpA, 53% were males, mean age was 46 years (13) and mean ASDAS-CRP 3.7 (0.9) at baseline. There were no differences in efficacy between RA patients treated with the infliximab biosimilar and the originator, either at 3 months (∆DAS28-ESR: -0.6 (95% CI -1.3; 0.1) vs -1.2 (-2.0; -0.4)), or at 6 months (∆DAS28-ESR: -0.7 (-1.5; 0.0) vs -1.5 (-2.4; -0.7)). This was also true for patients with axSpA (∆ASDAS-CRP at 3 months: -1.6 (-2.0; -1.1) vs -1.4 (-1.8; -0.9) and at 6 months: -1.5 (-2.0; -1.1) vs -1.1 (-1.5; -0.7)). Results were similar with the longitudinal models over 24 months. CONCLUSION There are no differences in effectiveness between the infliximab biosimilar CT-P13 and the infliximab originator in the treatment of biological-naïve patients with active RA and axSpA in clinical practice.
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Affiliation(s)
- José Marona
- Rheumatology, Centro Hospitalar e Universitário Cova da Beira
| | | | | | | | | | - Maura Couto
- Rheumatology, Centro Hospitalar Tondela-Viseu
| | - Inês Cunha
- Rheumatology, Centro Hospitalar do Baixo Vouga
| | | | | | - Ana Teresa Melo
- Rheumatology and Metabolic Bone Diseases Department, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte
| | | | | | - Patrícia Pinto
- Rheumatology, Centro Hospitalar de Vila Nova de Gaia e Espinho
| | | | | | - João Eurico Fonseca
- Rheumatology and Metabolic Bone Diseases Department, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte
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6
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Bandeira M, Dourado E, Melo AT, Martins P, Fraga V, Ferraro JL, Saraiva A, Sousa M, Parente H, Soares C, Correia AM, Almeida DE, Dinis SP, Pinto AS, Oliveira Pinheiro F, Rato MS, Beirão T, Samões B, Santos B, Mazeda C, Chícharo AT, Faria M, Neto A, Lourenço MH, Brites L, Rodrigues M, Silva-Dinis J, Dias JM, Araújo FC, Martins N, Couto M, Valido A, Santos MJ, Barreira SC, Fonseca JE, Campanilho-Marques R. Predictors of cardiac involvement in idiopathic inflammatory myopathies. Front Immunol 2023; 14:1146817. [PMID: 36969246 PMCID: PMC10030705 DOI: 10.3389/fimmu.2023.1146817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
ObjectivesIdiopathic inflammatory myopathies (IIM) are a group of rare disorders that can affect the heart. This work aimed to find predictors of cardiac involvement in IIM.MethodsMulticenter, open cohort study, including patients registered in the IIM module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) until January 2022. Patients without cardiac involvement information were excluded. Myo(peri)carditis, dilated cardiomyopathy, conduction abnormalities, and/or premature coronary artery disease were considered.Results230 patients were included, 163 (70.9%) of whom were females. Thirteen patients (5.7%) had cardiac involvement. Compared with IIM patients without cardiac involvement, these patients had a lower bilateral manual muscle testing score (MMT) at the peak of muscle weakness [108.0 ± 55.0 vs 147.5 ± 22.0, p=0.008] and more frequently had oesophageal [6/12 (50.0%) vs 33/207 (15.9%), p=0.009] and lung [10/13 (76.9%) vs 68/216 (31.5%), p=0.001] involvements. Anti-SRP antibodies were more commonly identified in patients with cardiac involvement [3/11 (27.3%) vs 9/174 (5.2%), p=0.026]. In the multivariate analysis, positivity for anti-SRP antibodies (OR 104.3, 95% CI: 2.5-4277.8, p=0.014) was a predictor of cardiac involvement, regardless of sex, ethnicity, age at diagnosis, and lung involvement. Sensitivity analysis confirmed these results.ConclusionAnti-SRP antibodies were predictors of cardiac involvement in our cohort of IIM patients, irrespective of demographical characteristics and lung involvement. We suggest considering frequent screening for heart involvement in anti-SRP-positive IIM patients.
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Affiliation(s)
- Matilde Bandeira
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- *Correspondence: Matilde Bandeira,
| | - Eduardo Dourado
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Ana Teresa Melo
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Patrícia Martins
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Vanessa Fraga
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | | | - André Saraiva
- Serviço de Reumatologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Marlene Sousa
- Serviço de Reumatologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Hugo Parente
- Serviço de Reumatologia, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal
| | - Catarina Soares
- Serviço de Reumatologia, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal
| | | | | | - Sara Paiva Dinis
- Serviço de Reumatologia, Unidade Local de Saúde da Guarda, Guarda, Portugal
| | - Ana Sofia Pinto
- Serviço de Reumatologia, Unidade Local de Saúde da Guarda, Guarda, Portugal
| | | | - Maria Seabra Rato
- Serviço de Reumatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Tiago Beirão
- Serviço de Reumatologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Beatriz Samões
- Serviço de Reumatologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Bernardo Santos
- Serviço de Reumatologia, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Carolina Mazeda
- Serviço de Reumatologia, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | | | - Margarida Faria
- Serviço de Reumatologia, Hospital Nélio Mendonça, Serviços de Saúde da Região Autónoma da Madeira, Funchal, Portugal
| | - Agna Neto
- Serviço de Reumatologia, Hospital Nélio Mendonça, Serviços de Saúde da Região Autónoma da Madeira, Funchal, Portugal
| | | | - Luísa Brites
- Serviço de Reumatologia, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Marília Rodrigues
- Serviço de Reumatologia, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Joana Silva-Dinis
- Serviço de Reumatologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - João Madruga Dias
- Serviço de Reumatologia, Centro Hospitalar de Médio Tejo, Tomar, Portugal
| | - Filipe C. Araújo
- Serviço de Reumatologia, Hospital CUF Cascais, Cascais, Portugal
| | - Nádia Martins
- Serviço de Reumatologia, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Maura Couto
- Serviço de Reumatologia, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Ana Valido
- Serviço de Reumatologia, Unidade Local de Saúde do Litoral Alentejano, Santiago do Cacém, Portugal
| | - Maria José Santos
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | - Sofia Carvalho Barreira
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - João Eurico Fonseca
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
| | - Raquel Campanilho-Marques
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisboa, Portugal
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Melo AT, Dourado E, Campanilho-Marques R, Bandeira M, Barreira SC, Costa J, Pimenta R, Antunes-Duarte S, Cordeiro I, Fonseca JE. Myositis Multidisciplinary Clinic in a Tertiary Referral Center. J Multidiscip Healthc 2023; 16:1127-1139. [PMID: 37131932 PMCID: PMC10149065 DOI: 10.2147/jmdh.s404017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/28/2023] [Indexed: 05/04/2023] Open
Abstract
Background Idiopathic inflammatory myopathies (IIM) are a rare heterogeneous group of diseases characterised by chronic skeletal muscle inflammation, but other organs are also frequently involved. IMM represent a diagnostic challenge and a multidisciplinary approach is important to ensure successful diagnosis and adequate follow-up of these patients. Objective To describe the general functioning of our multidisciplinary myositis clinic, highlighting the benefits of multidisciplinary team management in patients with confirmed or suspected IIM and to characterise our clinical experience. Methods Description of the organization of a dedicated multidisciplinary myositis outpatient clinic, supported by IMM specific electronic assessment tools and protocols based on our Portuguese Register - Reuma.pt. In addition, an overview of our activity between 2017 and 2022 is provided. Results An IIM multidisciplinary care clinic, based on a close collaboration between Rheumatologists, Dermatologists and Physiatrist is detailed in this paper. One hundred and eighty-five patients were assessed in our myositis clinic; 138 (75%) of those were female, with a median age of 58 [45-70] years. At the last appointment, 130 patients had a confirmed IIM diagnosis, and the mean disease duration was 4 [2-6] years. The most frequent diagnosis was dermatomyositis (n = 34, 26.2%), followed by antisynthetase syndrome (n = 27, 20.8%) and clinically amyopathic/paucimyopathic dermatomyositis (n = 18, 13.8%). Twenty-four patients (18.5%) were on monotherapy and 94 (72.3%) were on combination therapy. Conclusion A multidisciplinary approach is important to ensure the correct diagnosis and follow-up of these patients. A myositis clinic, with a standardised practice at a tertiary hospital level, contributes to a standardization of care and opens research opportunities.
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Affiliation(s)
- Ana Teresa Melo
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Correspondence: Ana Teresa Melo, Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, EPE, R. Prof. Egas Moniz, Lisboa, 1700, Portugal, Tel +351 217805139, Email
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Matilde Bandeira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia C Barreira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - José Costa
- Physical Medicine and Rehabilitation Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rita Pimenta
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sofia Antunes-Duarte
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Inês Cordeiro
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - João E Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Investigation Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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Martins P, Dourado E, Melo AT, Samões B, Sousa M, Freitas R, Lourenço MH, Fernandes B, Costa E, Parente H, Martins F, Fonseca JE, Cordeiro I, Romão VC, Khmelinskii N, Campanilho-Marques R. Clinical characterisation of a multicentre nationwide cohort of patients with antisynthetase syndrome. ARP Rheumatol 2022; 1:190-196. [PMID: 35891592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Antisynthetase syndrome (ASyS) is characterised by the association of inflammatory myopathy, interstitial lung disease (ILD), arthritis, Raynaud's phenomenon (RP) or mechanic's hands (MH), with the presence of anti-aminoacyl-tRNA-synthetase antibodies (anti-ARS). It has been suggested that different anti-ARS may be associated with distinct clinical pictures. OBJECTIVE To characterise the clinical and immunological features of a multicentric nationwide cohort of ASyS patients. METHODS This is a multicentre retrospective cohort study including patients with ASyS from nine Portuguese rheumatology centres. Data on patients' demographics, signs and symptoms, laboratory results, pulmonary imaging findings and treatment with immunomodulators were collected. Comparison between patients with different anti-ARS antibodies was made using the Chi-square test for categorical variables and Student's t-test or Man-Whitney test for continuous variables, considering anti-Jo1 positive patients as the reference group. RESULTS Seventy patients were included (70% female) with a median age in years at disease onset of 52 (15-75) years and median follow-up time of 3 years (range 0-32). The three most common clinical manifestations were ILD (n=53, 75.7%), followed by arthritis (n=43, 61.4%) and myositis (n=37, 52.9%). Forty-three patients were positive for anti-Jo1 (61.4%), 11 for anti-PL12 (15.7%), 10 for anti-PL7 (14.3%), 4 for anti-EJ (5.7%), and 2 for anti-OJ (2.9%) antibodies. Antibody co-positivity with anti-Ro52 antibodies was found in 15 patients (21.4%) and was more prevalent in anti-Jo1 patients. ILD prevalence was similar in the different anti-ARS subgroups, without statistically significant differences. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis (p =< 0.05) and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients (p =< 0.05). RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients (p =< 0.05). Malignancies were reported in four (5.7%) patients, none of whom were anti-Ro52-positive, and one of such patients had a double malignancy. Only three deaths were reported. Corticosteroids were the most frequently prescribed therapy and the use of immunosuppressive drugs was decided according to the type of predominant clinical manifestation. CONCLUSION The three most common clinical manifestations were ILD, followed by arthritis and myositis. Patients positive for anti-PL7 antibodies had significantly lower risk of presenting arthritis and those positive for anti-PL-12 antibodies had a significantly lower risk of presenting myositis than the reference group of anti-Jo1 positive patients. RP was more frequently found in patients positive for anti-PL-12 than in anti-Jo1-positive patients. Corticosteroids were the most frequently prescribed therapy. These results are generally concordant with data retrieved from international cohorts.
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Affiliation(s)
- Patrícia Martins
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Eduardo Dourado
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Ana Teresa Melo
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Beatriz Samões
- Serviço de Reumatologia, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Marlene Sousa
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Freitas
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | - Maria Helena Lourenço
- Serviço de Reumatologia, Centro Hospitalar Lisboa Ocidental, Hospital Egas Moniz, Lisboa, Portugal
| | - Bruno Fernandes
- Serviço de Reumatologia, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - Emanuel Costa
- Serviço de Reumatologia, Hospital de Braga, Braga, Portugal
| | - Hugo Parente
- Serviço de Reumatologia, Unidade Local de Saúde Do Alto Minho, Ponte de Lima, Portugal
| | - Frederico Martins
- Serviço de Reumatologia, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - João Eurico Fonseca
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Inês Cordeiro
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Vasco C Romão
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Nikita Khmelinskii
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
| | - Raquel Campanilho-Marques
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Universitário Lisboa Norte; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa
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Melo AT, Bernardo M, Pinheiro F, Rodrigues M, Torres R, Mourão AF, Carvalho S, Nascimento J, Sousa S, Santos MJ, Soares C, Cabral M, Marques RC, Reis PC, Ramos FO. Assessment of the outcomes of SARS-CoV-2 infection in children and young people followed at Portuguese pediatric rheumatology clinics. ARP Rheumatol 2022; 1:205-209. [PMID: 36056926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Coronavirus Disease 2019 (COVID-19) generally appears to have milder clinical symptoms and fewer laboratory abnormalities in children. It remains unknown whether children and young people with inflammatory chronic diseases who acquire SARS-CoV-2 infection have a more severe course, due to either underlying disease or immunosuppressive treatments. OBJECTIVES To assess the epidemiological features and clinical outcomes of children and young people with inflammatory chronic diseases followed at Pediatric Rheumatology Clinics who were infected with SARS-CoV-2. METHODS A multicentric prospective observational study was performed. Data on demographic variables, clinical features and treatment were collected between March 2020 and September 2021, using the Rheumatic Diseases Portuguese Register (Reuma.pt) and complemented with data from the hospital clinical records. RESULTS Thirty-four patients were included, 62% were female, with a median age of 13 [8-16] years and a median time of inflammatory chronic disease of 6 [3-10] years. The most common diagnoses were juvenile idiopathic arthritis (n=22, 64.7%), juvenile dermatomyositis (n=3, 8.8%) and idiopathic uveitis (n=3, 8.8%). Twenty patients were on conventional synthetic disease modifying drugs (csDMARDs) and 10 on biologic DMARDs (bDMARDs). Five patients had an active inflammatory disease at the time of infection (low activity). Seven patients had an asymptomatic infection while 27 patients (79%) had symptoms: cough (n=12), fever (n=11), rhinorrhea (n=10), headache (n=8), malaise (n=8), fatigue (n=7), anosmia (n=5), myalgia (n=5),dysgeusia (n=4), odynophagia (n=4), chest pain (n=2), diarrhea (n=2), arthralgia (n=1), vomiting (n=1) and conjunctivitis (n=1). No patient required hospitalization or directed treatment, and all recovered without sequelae. In 8 patients there was a change in the baseline medication during the infection: suspension of bDMARDs (n=4), reduction of bDMARDs (n=1), suspension of csDMARDs (n=4) and reduction of csDMARDs (n=2). Only in one patient with juvenile dermatomyositis (who discontinued bDMARDs and csDMARDs), the underlying disease worsened. CONCLUSIONS This is the first study involving children with inflammatory chronic diseases followed at Rheumatology Clinics and SARS-CoV-2 infection in Portugal. In our cohort, mild illness was predominant, which is consistent with the literature. There was no need for hospitalization or specific treatment, and, in most cases, no worsening of the underlying disease was identified.
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Affiliation(s)
- Ana Teresa Melo
- Unidade de Reumatologia Pediátrica, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa; Serviço de Reumatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Miguel Bernardo
- Serviço de Pediatria, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Filipe Pinheiro
- Unidade de Reumatologia Pediátrica e do Jovem Adulto, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Mariana Rodrigues
- Unidade de Reumatologia Pediátrica e do Jovem Adulto, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Rita Torres
- Serviço de Reumatologia, Centro Hospitalar Lisboa Ocidental, Lisboa; Comprehensive Health Research Centre, Nova Medical School
| | - Ana Filipa Mourão
- Serviço de Reumatologia, Centro Hospitalar Lisboa Ocidental, Lisboa; Comprehensive Health Research Centre, Nova Medical School
| | - Sónia Carvalho
- Serviço de Reumatologia, Centro Hospitalar do Médio Ave, Unidade de Famalicão, Portugal
| | - João Nascimento
- Unidade de Reumatologia Pediátrica, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Sandra Sousa
- Serviço de Reumatologia, Hospital Garcia de Orta, Almada, Portugal
| | | | - Catarina Soares
- Serviço de Reumatologia, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal
| | - Marta Cabral
- Unidade de Reumatologia Pediátrica, Hospital da Luz, Lisboa; Serviço de Pediatria, Hospital Fernando Fonseca, Amadora, Portugal
| | - Raquel Campanilho Marques
- Unidade de Reumatologia Pediátrica, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa; Serviço de Reumatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Patrícia Costa Reis
- Unidade de Reumatologia Pediátrica, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa; Departamento de Pediatria, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Filipa Oliveira Ramos
- Unidade de Reumatologia Pediátrica, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa; Serviço de Reumatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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Dourado E, Melo AT, Pacini G, Pankow A, Klemm P, Cruz-Machado AR. Rheumatology residency in a European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases centre: opportunities and challenges. Clin Exp Rheumatol 2022; 40 Suppl 134:63-65. [DOI: 10.55563/clinexprheumatol/2s2c31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Eduardo Dourado
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisbon, and Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisbon, Portugal. (ERN-ReCONNET Full Member).
| | - Ana Teresa Melo
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisbon, and Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisbon, Portugal. (ERN-ReCONNET Full Member)
| | - Giovanni Pacini
- Department of Experimental and Clinical Medicine and Division of Rheumatology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Italy. (ERN-ReCONNET Full Member)
| | - Anne Pankow
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Germany. (ERN-ReCONNET Full Member)
| | - Philipp Klemm
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Justus-Liebig-University Giessen, Campus Kerckhoff, Bad Nauheim, Germany. (ERN-ReCONNET Full Member)
| | - Ana Rita Cruz-Machado
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisbon, and Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, CAML, Lisbon, Portugal. (ERN-ReCONNET Full Member)
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Leal I, Jose P, Barão R, Mano S, Melo AT, Dourado E, Tenazinha C, Vaz C, Ferreira JF, Dinis S, Santos FC, Fernandes H, Khmelinskii N, Marques‐Neves C, de Sousa EV, Fonseca JE. Vision‐related quality of life in spondyloarthritis patients with history of acute anterior uveitis under treatment with golimumab: preliminary results of the GO‐VISION observational study. Acta Ophthalmol 2022. [DOI: 10.1111/j.1755-3768.2022.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ines Leal
- Ophthalmology Faculdade de Medicina de Lisboa Lisbon Portugal
| | - Patricia Jose
- Ophthalmology Faculdade de Medicina de Lisboa Lisbon Portugal
| | - Rafael Barão
- Ophthalmology Faculdade de Medicina de Lisboa Lisbon Portugal
| | - Sofia Mano
- Ophthalmology Faculdade de Medicina de Lisboa Lisbon Portugal
| | - Ana Teresa Melo
- Rheumatology Faculdade de Medicina de Lisboa Lisboa Portugal
| | - Eduardo Dourado
- Rheumatology Faculdade de Medicina de Lisboa Lisboa Portugal
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Azevedo S, Tavares-Costa J, Melo AT, Freitas R, Cabral M, Conde M, Aguiar F, Neto A, Mourão AF, Oliveira-Ramos F, Santos MJ, Peixoto D. Predictive factors of relapse after methotrexate discontinuation in juvenile idiopathic arthritis patients with inactive disease. ARP Rheumatol 2022; 1:12-20. [PMID: 35633573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To identify predictive factors of relapse after discontinuation of Methotrexate (MTX) in Juvenile Idiopathic Arthritis (JIA) patients with inactive disease. METHODS We conducted a prospective multicenter cohort study of patients diagnosed with JIA using real world data from the Portuguese national register database, Reuma.pt. Patients with JIA who have reached JADAS27 inactive disease and discontinued MTX before the age of 18 were evaluated. RESULTS A total of 1470 patients with JIA were registered in Reuma.pt. Of the 119 bionaive patients who discontinued MTX due to inactive disease, 32.8% have relapsed. Median time of persistence (using the Kaplan-Meier method and log-rank tests) with inactive disease was significantly higher in patients with more than two years of remission before MTX discontinuation and in those who did not use NSAIDs at time of MTX discontinuation. In Cox regression analyses and after adjustment for age at diagnosis, MTX tapering and JIA category, the use of NSAIDs at the time of MTX discontinuation (HR, 1.98 95%CI 1.03-3.82) and remission time of less than two years before suspension (HR, 3.12 95%CI 1.35-7.13) remained associated with relapse. No association was found between JIA category or the regimen of MTX discontinuation and the risk of relapse. CONCLUSIONS In this large cohort we found that the use of NSAIDs at the time of MTX discontinuation was associated with a two times higher likelihood of relapse. In addition, longer duration of remission before MTX withdrawal reduces the chance of relapse in bionaive JIA patients.
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Affiliation(s)
- Soraia Azevedo
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima
| | - José Tavares-Costa
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima
| | - Ana Teresa Melo
- Pediatric Rheumatology Unit, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa
| | - Raquel Freitas
- Rheumatology Department, Hospital Garcia de Orta, Almada
| | - Marta Cabral
- Pediatric Department, Hospital Prof. Doutor Fernando Fonseca, Amadora
| | - Marta Conde
- Pediatric Rheumatology Unit, Hospital Dona Estefânia, Centro Hospitalar Lisboa Central, Lisboa
| | - Francisca Aguiar
- Pediatric Rheumatology Unit, Centro Hospitalar Universitário São João, Porto
| | - Agna Neto
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa
| | - Ana Filipa Mourão
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa
| | - Filipa Oliveira-Ramos
- Pediatric Rheumatology Unit, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa
| | | | - Daniela Peixoto
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima
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Oliveira Ramos F, Rodrigues A, Magalhaes Martins F, Melo AT, Aguiar F, Brites L, Azevedo S, Duarte AC, Furtado C, Mourão AF, Sequeira G, Cunha I, Figueira R, Melo Gomes JA, Santos MJ, Fonseca JE. Health-related quality of life and disability in adults with juvenile idiopathic arthritis: comparison with adult-onset rheumatic diseases. RMD Open 2021; 7:rmdopen-2021-001766. [PMID: 34819385 PMCID: PMC8614144 DOI: 10.1136/rmdopen-2021-001766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/03/2021] [Indexed: 01/13/2023] Open
Abstract
Objective To compare physical disability, mental health, fatigue and health-related quality of life (HRQoL) across juvenile idiopathic arthritis (JIA) categories in adulthood and between JIA and adult-onset rheumatic diseases. Methods Cross-sectional analysis nested in a cohort of adult patients with JIA registered in the Rheumatic Diseases Portuguese Register (Reuma.pt). Physical disability (Health Assessment Questionnaire—Disability Index), mental health symptoms (Hospital Anxiety and Depression Scale), fatigue (Functional Assessment of Chronic Illness Therapy—Fatigue Scale (FACIT-F)) and HRQoL (EuroQol-5D (EQ5D) and Short Form (SF-36)) were compared across JIA categories. Patients with polyarticular JIA and enthesis-related arthritis (ERA) JIA were compared respectively to patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA), matched for gender and age, adjusted for disease duration and activity. Results 585 adult patients with JIA were included. Comparison across JIA categories showed that persistent oligoarthritis and patients with ERA reported a higher score in EQ5D and SF-36 physical component when compared with other JIA categories. Polyarticular JIA reported less disability and fatigue than patients with RA (median Health Assessment Questionnaire of 0.25 vs 0.63; p<0.001 and median FACIT-F score 42 vs 40; p=0.041). Polyarticular JIA had also better scores on EQ5D and all domains of SF-36, than patients with RA. Patients with ERA reported less depression and anxiety symptoms (0% vs 14.8%; p=0.003% and 9% vs 21.3%; p=0.002) and less fatigue symptoms (45 vs 41; p=0.01) than patients with SpA. Conclusion Persistent oligoarticular JIA and ERA are the JIA categories in adulthood with better HRQoL. Overall, adult polyarticular and patients with ERA JIA have lower functional impairment and better quality-of-life than patients with RA and SpA.
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Affiliation(s)
- Filipa Oliveira Ramos
- Rheumatology Department and Pediatric Rheumatology Unit, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal .,Faculdade de Medicina, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Ana Rodrigues
- Centre for Chronic Diseases (CEDOC), CHRC Campus Nova Medical School, Lisboa, Portugal
| | | | - Ana Teresa Melo
- Rheumatology Department and Pediatric Rheumatology Unit, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
| | - Francisca Aguiar
- Young Adult and Pediatric Rheumatology Unit, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Luisa Brites
- Rheumatology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Soraia Azevedo
- Rheumatology, Unidade Local de Saude do Alto Minho EPE, Viana do Castelo, Portugal
| | | | - Carolina Furtado
- Rheumatology, Hospital do Divino Espírito Santo, São Miguel, Ponta Delgada, Portugal
| | - Ana Filipa Mourão
- Centre for Chronic Diseases (CEDOC), CHRC Campus Nova Medical School, Lisboa, Portugal.,Rheumatology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Graça Sequeira
- Rheumatology, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Inês Cunha
- Rheumatology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
| | - Ricardo Figueira
- Rheumatology, Hospital Dr. Nélio Mendonça, Funchal, Madeira, Portugal
| | | | - Maria Jose Santos
- Faculdade de Medicina, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal.,Rheumatology, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Joao Eurico Fonseca
- Rheumatology Department and Pediatric Rheumatology Unit, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
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Barreira SC, Melo AT, Ponte C, Khmelinskii N. Macaroni sign and carotid occlusion in Takayasu's arteritis. Rheumatology (Oxford) 2021; 60:2029-2030. [PMID: 33140087 DOI: 10.1093/rheumatology/keaa520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/06/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sofia Carvalho Barreira
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - Ana Teresa Melo
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - Cristina Ponte
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - Nikita Khmelinskii
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal.,Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
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Melo AT, Campanilho-Marques R, Fonseca JE. Golimumab (anti-TNF monoclonal antibody): where we stand today. Hum Vaccin Immunother 2021; 17:1586-1598. [PMID: 33369527 PMCID: PMC8115761 DOI: 10.1080/21645515.2020.1836919] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/17/2020] [Accepted: 10/09/2020] [Indexed: 01/07/2023] Open
Abstract
Tumor necrosis factor (TNF) is a pro-inflammatory cytokine and its overexpression has been implicated in the pathophysiology of several chronic immune-mediated inflammatory diseases. Biological therapies, like TNF inhibitors, have been revolutionizing the course of these disorders. Golimumab is a transgenic anti-TNF monoclonal antibody that acts primarily by targeting and neutralizing TNF, thus preventing inflammation. It is approved for the treatment of Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Nonradiographic axial Spondyloarthritis, Juvenile Idiopathic Arthritis, and Ulcerative Colitis. Clinical trials are also being conducted in other conditions. This review charts the clinical development of golimumab and outlines the data that support its potential use across several Immune-mediated inflammatory diseases.
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Affiliation(s)
- Ana Teresa Melo
- Rheumatology Department, Hospital De Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
- Rheumatology Research Unit, Instituto De Medicina Molecular João Lobo Antunes, Faculdade De Medicina, Universidade De Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital De Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
- Rheumatology Research Unit, Instituto De Medicina Molecular João Lobo Antunes, Faculdade De Medicina, Universidade De Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Rheumatology Department, Hospital De Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
- Rheumatology Research Unit, Instituto De Medicina Molecular João Lobo Antunes, Faculdade De Medicina, Universidade De Lisboa, Lisbon, Portugal
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Martins P, Valido A, Melo AT, Santareno S, Sousa R, Inácio JR, Oliveira-Ramos F, Ponte C, Romeu JC. Posterior reversible encephalopathy syndrome and digital gangrene in a patient with granulomatosis with polyangiitis - a rare case report. Acta Reumatol Port 2020; 45:65-68. [PMID: 32578576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Patrícia Martins
- Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Centro Académico de Medicina de Lisboa
| | - Ana Valido
- Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Centro Académico de Medicina de Lisboa
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Martins P, Barreira SC, Melo AT, Campanilho-Marques R, Costa-Reis P, Fonseca JE, Oliveira-Ramos F. Transition in a paediatric rheumatology unit - experience from a tertiary unit. Acta Reumatol Port 2019; 44:320-321. [PMID: 32008033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The transition from paediatric to adult health care has been recognised as a priority in recent years. Health care transition (HCT) is defined as the process of moving from a paediatric to an adult model of health care with or without a transfer of follow up to a different clinician. In our centre, the transition begins around 11 years, when the patient education process starts and at the same time enable adolescents and young adults (AYA) to acquire knowledge to manage their disease. By the age of 18 the transfer to adult care is made. This study aims to evaluate the transition process and the transfer from paediatric to adult rheumatology care at our centre. We included 126 patients, 78 (61%) were female, with a mean age of 23.1±3.2 years. 104 patients (83%) were transferred to a young adult clinic. In our centre, the transition of care was associated with a high degree of satisfaction, with just a 10% decrease in patient satisfaction between paediatric and adult care. We had low drop out rate, which was associated with longer disease duration. Few patients had worsening of disease activity. Our data reinforce that education and training in transitional care and having a transition program are important to optimize health outcomes in AYA with chronic diseases.
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Affiliation(s)
- Patrícia Martins
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
| | - Sofia C Barreira
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
| | - Ana Teresa Melo
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
| | - Raquel Campanilho-Marques
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
| | - Patrícia Costa-Reis
- Departamento de Pediatria, Hospital de Santa Maria, CHULN, Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - João Eurico Fonseca
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
| | - Filipa Oliveira-Ramos
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação em Reumatologia, IMM, Faculdade de Medicina da Universidade Lisboa
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