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Cunha-Miranda L.,Instituto Portugues Of Reumatologia
Acta Reumatologica Portuguesa | Year: 2010

Introduction: Work related musculoskeletal diseases (WRMSDs) have a huge social and economic impact being a public health problem. Objectives: To determine the prevalence of WRMSDs in Portuguese active workers. Methods: A questionnaire was sent by regular mail to the occupational physician of 822 large dimension companies in Portugal (over 250 employees). This questionnaire was addressed to the physician and contemplated data on file from the occupational medical doctor of clinically relevant WRMSDs (rather than addressing workers complaints). A reply form and a telephone reminder were used to assure a higher number of respondents. Results: Of the selected 822 companies, 515 responded (response rate of 62.3%) involving a total population of 410 496 workers. The prevalence of clinically relevant WRMSD was of 5.9% (24 269 cases). The more prevalent WRMSD were back pain with a prevalence of low back pain of 2.27% (n=9310, 38.4% of total WRMSD). Dorsal pain 0.82% (n= 3379, 13.9% of total WRMSDs) and cervical pain 1.13% (n=4651, 19.2% of total WRMSD). Back pain accounts for 4.22% (n= 17340) and a total of 74.9% of all WRMSDs. Regarding the upper limb we found a prevalence of 1.61% (n= 6493). From this total, shoulder tendonitis was 0.59%(n= 2398, 9.9% of total WRMSDs), carpal tunnel syndrome 0.29% (n=1170, 4.8% of total WRMSDs), elbow tendonitis 0.29% (n=1202, 5% of total WRMSDs) and hand tendonitis 0.44% (n=1823, 7.5% of total WRMSDS). A lower prevalence was observed in the lower limbs with lower limb tendonitis of 0.08% (n=336, 0.01% of total WRMSDs). Discussion/Conclusion: Our work was representative of 11% of the working Portuguese population. We have found a prevalence of clinically relevant WRMSD of 5,9%. If we extrapolate for the total of the working population we would have 220 467 workers with WRMSDs. Our data are in conflict with national social security services regarding these diseases with much lower reported diseases that proves the inefficacy of the national reporting system. There are clear differences in our data when compared with the literature. We found a higher number of back pain, and in proportion of cervical pain, and lower numbers of upper and lower limb WRMSDs. In the upper limb we found a higher level of hand tendonitis and a decrease of elbow tendonitis and carpal tunnel syndrome. This work was a first effort to characterize WRMSDs in Portugal. Due to the study design we believe that further studies aimed for higher risk populations should be performed.

Roux C.,University of Paris Descartes | Hofbauer L.C.,Dresden University of Technology Medical Center | Ho P.R.,Amgen Inc. | Wark J.D.,Royal Melbourne Hospital | And 11 more authors.
Bone | Year: 2014

Denosumab has been shown to reduce new vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis. In subjects who were treatment-naïve or previously treated with alendronate, denosumab was associated with greater gains in bone mineral density (BMD) and decreases in bone turnover markers when compared with alendronate-treated subjects. This trial was designed to compare the efficacy and safety of denosumab with risedronate over 12. months in postmenopausal women who transitioned from daily or weekly alendronate treatment and were considered to be suboptimally adherent to therapy.In this randomized, open-label study, postmenopausal women aged ≥. 55. years received denosumab 60. mg subcutaneously every 6. months or risedronate 150. mg orally every month for 12. months. Endpoints included percentage change from baseline in total hip BMD (primary endpoint), femoral neck, and lumbar spine BMD at month 12, and percentage change from baseline in sCTX-1 at months 1 and 6. Safety was also assessed.A total of 870 subjects were randomized (435, risedronate; 435, denosumab) who had a mean (SD) age of 67.7 (6.9) years, mean (SD) BMD T-scores of -1.6 (0.9), -1.9 (0.7), and -2.2 (1.2) at the total hip, femoral neck, and lumbar spine, respectively, and median sCTX-1 of 0.3. ng/mL at baseline. At month 12, denosumab significantly increased BMD compared with risedronate at the total hip (2.0% vs 0.5%), femoral neck (1.4% vs 0%), and lumbar spine (3.4% vs 1.1%; p. <. 0.0001 at all sites). Denosumab significantly decreased sCTX-1 compared with risedronate at month 1 (median change from baseline of -78% vs -17%; p. <. 0.0001) and month 6 (-61% vs -23%; p. <. 0.0001). Overall and serious adverse events were similar between groups.In postmenopausal women who were suboptimally adherent to alendronate therapy, transitioning to denosumab was well tolerated and more effective than risedronate in increasing BMD and reducing bone turnover. © 2013 The Authors.

PubMed | Lisbon Academic Medical Center and Institute Medicina Molecular, Hospital Infante D Pedro, Leiden University, Hospital Garcia Of Orta and 8 more.
Type: Journal Article | Journal: Arthritis & rheumatology (Hoboken, N.J.) | Year: 2016

To evaluate whether use of comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) influences the retention of tumor necrosis factor inhibitors (TNFi) in patients with spondyloarthritis (SpA).Patients with SpA from the Rheumatic Diseases Portuguese Register who started treatment with their first TNFi between 2001 and 2014 were included in this study. Cox regression analysis was used to estimate the effect of comedication with csDMARDs on TNFi retention in 2 types of models: a model in which baseline (time-fixed) variables were included, and a second model incorporating time-varying variables, including sociodemographic features, measures of disease activity, measures of physical function, and cotreatment with other drugs (nonsteroidal antiinflammatory drugs and oral steroids). To control for possible confounding by indication, the effect of csDMARD comedication on TNFi retention was also tested after adjustment for the treatment propensity score.In total, 954 patients were included in the study, of whom 289 (30.3%) discontinued treatment with their first TNFi after a median follow-up time of 2.5 years (range 0.08-13 years). Inefficacy was the most common reason for TNFi discontinuation (55.7% of patients). In the multivariable analyses, comedication with csDMARDs had no measurable effect on TNFi retention, neither in the baseline model (hazard ratio [HR] 0.83, 95% confidence interval [95% CI] 0.59-1.16) nor during follow-up in the model adjusted for time-varying covariates (HR 1.07, 95% CI 0.68-1.68). The effect of csDMARD comedication remained nonsignificant after propensity score adjustment.Comedication with csDMARDs does not prolong TNFi retention in patients with SpA in clinical practice, suggesting that there is no benefit conferred by the concomitant use of these drugs.

Xavier J.M.,University of Lisbon | Xavier J.M.,Instituto Gulbenkian Of Ciencia | Shahram F.,Tehran University of Medical Sciences | Davatchi F.,Tehran University of Medical Sciences | And 11 more authors.
Arthritis and Rheumatism | Year: 2012

Objective Independent replication of the findings from genome-wide association studies (GWAS) remains the gold standard for results validation. Our aim was to test the association of Behçet's disease (BD) with the interleukin-10 gene (IL10) and the IL-23 receptor-IL-12 receptor β2 (IL23R-IL12RB2) locus, each of which has been previously identified as a risk factor for BD in 2 different GWAS. Methods Six haplotype-tagging single-nucleotide polymorphisms (SNPs) in IL10 and 42 in IL23R-IL12RB2 were genotyped in 973 Iranian patients with BD and 637 non-BD controls. Population stratification was assessed using a panel of 86 ancestry-informative markers. Results Subtle evidence of population stratification was found in our data set. In IL10, rs1518111 was nominally associated with BD before and after adjustment for population stratification (odds ratio [OR] for T allele 1.20, 95% confidence interval [95% CI] 1.02-1.40, unadjusted P [Punadj] = 2.53 × 10-2; adjusted P [Padj] = 1.43 × 10-2), and rs1554286 demonstrated a trend toward association (Punadj = 6.14 × 10-2; Padj = 3.21 × 10-2). Six SNPs in IL23R-IL12RB2 were found to be associated with BD after Bonferroni correction for multiple testing, the most significant of which were rs17375018 (OR for G allele 1.51, 95% CI 1.27-1.78, Punadj = 1.93 × 10-6), rs7517847 (OR for T allele 1.48, 95% CI 1.26-1.74, P unadj = 1.23 × 10-6), and rs924080 (OR for T allele 1.29, 95% CI 1.20-1.39, P = 1.78 × 10-5). SNPs rs10489629, rs1343151, and rs1495965 were also significantly associated with BD in all tests performed. Results of meta-analyses of our data combined with data from other populations further confirmed the role of rs1518111, rs17375018, rs7517847, and rs924080 in the risk of BD, but no epistatic interactions between IL10 and IL23R-IL12RB2 were detected. Results of imputation analysis highlighted the importance of IL23R regulatory regions in the susceptibility to BD. Conclusion These findings independently confirm, extend, and refine the association of BD with IL10 and IL23R-IL12RB2. These associations warrant further validation and investigation in patients with BD, as they may have implications for the development of novel therapies (e.g., immunosuppressive therapy targeted at IL-23p19). Copyright © 2012 by the American College of Rheumatology.

Laires P.A.,Outcomes Research | Exposto F.,IMS Health | Mesquita R.,Merck And Co. | Martins A.P.,Outcomes Research | And 2 more authors.
European Journal of Health Economics | Year: 2013

Background: Despite the widespread availability of biologics across Europe, rheumatoid arthritis (RA) patients' access to these drugs differs significantly among countries. Objectives: To compare the proportion of RA patients treated with biologics across Europe and investigate the factors that most influence it, with focus on the Portuguese case, reportedly with low access rates to biologics. Methods: The biologics' market was characterized for 15 selected European countries. Variables potentially influencing patients' access to biologics (PAB) in RA were also collected, including demographic, disease, economic, funding and biologics' market-related data. A multivariable regression model identified the factors that best explain PAB. Based on these determinants, a cluster analysis was performed to group the countries with most similar behaviour regarding PAB allowing the evaluation of Portugal's relative position among these countries. Results: The regression model (R 2 = 0.953) indicated that PAB in selected countries is explained mostly by its gross domestic product (GDP) per capita, the usage of methotrexate (MTX) and the biologics' distribution channel. Current MTX usage in Portugal shows similarity with practice from UK, France, Germany or Spain 5 years before, explaining why PAB in Portugal stood at 7 % in 2010, 12 percentage points below the average of selected countries. Conclusions: Variations in RA PAB were found across selected countries with Portugal showing the lowest proportion. GDP per capita, biologics distribution channel and consumption of MTX appear to be the best explanatory factors for these fluctuations in European countries. © 2012 Springer-Verlag.

Cunha-Miranda L.,Instituto Portugues Of Reumatologia | Costa L.,Centro Hospitalar do Alto Minho | Ribeiro J.S.,Roche Holding AG
Acta Reumatologica Portuguesa | Year: 2010

Introduction: Rheumatoid arthritis is a chronic systemic inflammatory rheumatic disease whose characteristics have a clear impact on the life of the patient and his/her family. Doctor-patient relationship is increasingly based on communication and information transfer. In the case of chronic diseases and especially in RA, that information is fundamental for a better compliance, but also for the prevention of problems and the patient's better management of the disease on a daily basis. Objectives: To determine in a population of RA patients which are the principal sources of information about the disease, what unmet needs exist and the level of patient involvement in therapeutic decision. Methods: We applied a questionnaire in person and by telephone to a population of patients with rheumatoid arthritis fulfilling the criteria of the ACR, which were followed at several departments of rheumatology in mainland Portugal, about their expectations, the degree and type of information they expected, and their unmet needs. Results: A total of 223 RA patients filled in the questionnaire, 82.5% of which were female, mean age 55.13 +/- 14.49 years and whose mean duration of disease was above 5 years in 69.5% of the individuals. Of these, 17.5% found that RA had an impact on quality of life, 15.7% felt that RA affected their ability to enjoy life and 14.3% had difficulties in performing activities of daily living. Some activities were found to be more difficult for a patient with RA (on a scale of 0 to 10), such as gardening (6.36) and practicing sports (5.79). Other basic tasks were also considered difficult, as are the case of household chores (5.76) sleeping (5.08) walking (4.99) and working (4.86). Regarding the clinical impact of RA, as expected pain is almost a universal factor (87.9%), although the majority of patients also refer arthritis (78%), pain when moving (65.5%), fatigue (60.1%) and joint deformities (58.3%) as very common symptoms. Diminishing pain (81.2%), a general improvement of symptoms (73.1%) in a lasting way (57.4%) and reducing arthritis (59.2%) appeared as the main concerns of patients with RA. Regarding quality of information, 68.2% of patients consider they are well informed about the disease, but these numbers decrease if we consider information about treatment options (46.2%), the concept of remission (20.6%) or the recognition of the DAS 28 scale (17%). As preferred sources of information about the disease, 67.7% of individuals indicate their rheumatologist, 31.4% their general practitioner, 17% the Internet and 9% the attending nurse. The same order is obtained when asked about treatment information. As to the need for additional information, the patients refer «more information about therapies/treatments» (26.9%), «new scientific developments and social support» (17.5% each), «how to improve symptoms and live better in everyday life» (16.6%). «What is the disease» (6.7%) is referred last, being that only 8.1% of patients consider they are well informed. In what concerns discussion and participation in the process of clinical decision about medication, 56.1% of patients say that they share it with their doctors during their consultation. Conclusion: These results, which somewhat differ from the existing literature, demonstrate that there are important issues that should be considered in clinical practice, both relating to clinical issues and the unmet needs of our patients. We are unaware of the results coming from a treatment strategy designed to increase the RA patient's perception of their general state of health or of their perception of function. We should, however, keep in mind that pain, wellbeing and disease activity (as well as remission) should be important goals in therapeutic strategies that are to be increasingly shared with our patients.

Martins M.D.C.,Instituto Nacional Of Saude Dr Ricardo Jorge | Faleiro L.L.,Instituto Portugues Of Reumatologia | Fonseca A.,Instituto Nacional Of Saude Dr Ricardo Jorge
Revista Portuguesa de Cardiologia | Year: 2012

Objective: To analyze the relationship between leptin and obesity expressed as body mass index (BMI) and certain components of the metabolic syndrome (MS) in an adult population. Methods: The study included 103 subjects, 42 men and 61 women, aged over 30 years, clinically defined as non-diabetic but with personal or family history of cardiovascular disease. All subjects underwent fasting blood measurements of leptin, insulin, glucose, glucose after ingestion of 75 g glucose, HDL cholesterol and triglycerides, and insulin resistance (IR) and BMI were calculated. Results: BMI as an index of overall adiposity was strongly associated with serum leptin. BMI rose as serum leptin levels increased from the first to the third tertile; the correlation between leptin and BMI was strong, r = 0.524 in men and r = 0.603 in women, with high statistical significance (p < 0.001 ); BMI was the best predictor of hyperleptinemia on ROC analysis, with area under the curve (AUC) = 0.81 in men and 0.84 in women. The association between leptin and obesity (BMI ≥ 30 kg/m2) showed high odds ratios (OR) in both sexes (10.11 in men, 6.00 in women) on univariate regression analysis and 9.30 in men and 8.21 in women on multivariate regression analysis. Hyperinsulinemia and IR strongly influenced hyperleptinemia. Leptin was the best predictor of IR in both sexes (AUC = 0.89 in men and 0.85 in women), and IR in men (AUC = 0.79) and hyperinsulinemia in women (AUC = 0.78) were the best predictors of hyperleptinemia after BMI. The correlations between leptin and IR, and leptin and insulinemia, were strong in both sexes. With regard to MS components, increased serum levels of the study variables were observed as leptin concentrations rose from the first to the third tertile (with the exception of HDL cholesterol, which decreased). Conclusion: Elevated serum leptin, particularly in obese individuals, should be taken as a warning sign of energy imbalance, poor diet, hyperinsulinemia, insulin resistance, or changes in other metabolic risk factors that are strongly associated with cardiovascular disease and type 2 diabetes. © 2011 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved.

Cunha-Miranda L.,Instituto Portugues Of Reumatologia
Acta Reumatologica Portuguesa | Year: 2015

Objective: Portuguese data concerning general population knowledge and prevalence about neuropathicpain (NeP) are sparse and many patients remain frequently undiagnosed as this disease is still under recognized among population. This study aimed to evaluate Portuguese perception about NeP and to characterize their knowledge and information sources. Additionally, the study had the exploratory objective of determining NeP prevalence. Materials and Methods: Epidemiological, cross-sectional study of a representative sample of the Portuguese population aged 18 years old or more, by direct application of a structured question naire. Demographic data and data on knowledge and perception about NeP were collected. It was also collected data about NeP diagnosis. Descriptive analysis and a logistic regression assuming a significance level of 0.05 were performed. Results: 1072 subjects were included, 47.9% male, mean±SD age 46.4±18.6 years old. 71.3% referred never having heard about NeP. The percentage of individuals who declared to know about NeP characteristics decreased as the specificity of the theme increased:24.8% referred knowing the disease's symptoms, 23.0% knew how it is treated and 15.6% knew which situations/ pathologies can cause NeP. The three most referred symptoms of the disease were itching (42.6%),numbness (33.6%) and joint pain (31.2%). An olderage and a higher educational level were associated witha higher knowledge about this pathology. A 3.2% auto referred prevalence of NeP was observed. Conclusions: The data highlight the lack of information about NeP in Portugal. Defining multi dimensio nalstrategies to improve people's awareness about NeP might improve early diagnosis and treatment of thisvery debilitating condition.

Non-traumatic osteonecrosis of the patella is a rare cause of knee pain that must be present in the diagnostic discussion of disability of the knee with subacute character. The author describes a case in which the characteristic images had an important role in defining the etiology of disabling knee pain, developing pathophysiological hypotheses that may have contributed to the clinical presentation, including situations of overuse of the joint.

Miguel C.,Instituto Portugues Of Reumatologia | Mediavilla M.J.,Instituto Portugues Of Reumatologia
Acta Medica Portuguesa | Year: 2011

Gout, one of the most prevalent rheumatic diseases in the world, results from deposition of uric acid crystals in several locations, particularly in joints, subcutaneous tissues and kidney. The classical treatments, although effective, are often poorly tolerated or contraindicated. Recently, new drugs have emerged for the treatment of hyperuricemia and gout, including febuxostat and uricase, which proved to be quite promising. Some drugs already used in other diseases, such as losartan, atorvastatin, fenofibrate and amlodipine also seem to have a role in monitoring the serum uric acid. This article reviews the pathophysiology, clinical management and current therapeutic options for Hyperuricemia and Gout. © 2011 CELOM.

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