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A literature search of articles from 2002-2019 was performed using Medline, Embase, Cochrane, LILACS, IBECS, CRD, and Epistemonikos databases, to analyze the effects of Cognitive-Behavioral Therapy (CBT) in the treatment of fibromyalgia. Twenty-seven articles were selected in which CBT was performed exclusively by specialist physicians, associated or not with conventional pharmacological treatment and/or physical exercise. In most articles, CBT worked with self-knowledge and cognitive restructuring, attempting to reduce pain perception, and it showed a general improvement in daily activities by decreasing patient’s limitations, such as morning stiffness. The literature showed significant correlations of CBT in pain processing over time. When CBT was compared to conventional pharmacological therapy, a certain superiority of CBT could be observed concerning the quality of life, catastrophizing, and acceptance of pain. However, when they were simultaneously applied, this improvement in quality of life was not observed.

Introduction: Rheumatoid arthritis (RA) is a chronic systemic rheumatic disease which is usually treated with corticosteroids and immunobiologicals. The goal of this article is to carry out an assessment of disease activity indices in a cohort of patients with rheumatoid arthritis. Patients and Methods: This is a prospective cohort study. Individuals from the Initial Rheumatoid Arthritis Brasilia Cohort, which is an incident cohort of early RA diagnosed patients, were monitored at the Rheumatology Service of the Hospital Universitario de Brasilia (HUB), University of Brasilia (UnB), Brazil. A cross-sectional analysis was carried out from 2017 to 2018 to evaluate patients with 15 or more years of follow-up, through a direct interview and review of medical records. The main focus of the study is on the assessment of disease activity, based on the indices: 28-joint Disease Activity Score based on Creactive protein (DAS 28 CPR) and based on erythrocyte sedimentation rate (DAS 28 ESR), Clinical Disease Activity Index (CDAI), and Simple Disease Activity Index (SDAI). The reference remission criteria used were the Composite Disease Activity Indices. Results: 107 patients were evaluated, mostly women, mean age of 55.1 years. Concerning the disease characteristics, 75.5% of the patients were positive for rheumatoid factor and 12 (11.3%) had documented erosive disease. The mean Health Assessment Questionnaire (HAQ) at the time of assessment was 0.6 (median 0.35). The indices analyzed showed: DAS28-ESR 48.6% of patients were in remission and 12.1% had low activity levels, DAS28-CRP 55.1% and 11.2%, SDAI 42% and 26.1%, CDAI 41.1% and 27.1%. These remission and low disease activity levels are higher than those generally found in the literature. Conclusion: This study presents a cohort of patients with RA who started treatment at an early stage of the disease and who achieved higher rates of remission and lower disease activity than those reported in the literature.

A evolução da pandemia de COVID-19 trouxe a necessidade urgente de pesquisassobre medidas eficientes para seu manejo clínico. Estudos prévios haviam demonstrando quealguns antimaláricos (AM), como a cloroquina e a hidroxicloroquina, apresentam açãoantiviral efetiva contra determinadas linhagens. Ademais, estudos demonstraram quepacientes portadores de doença reumática imunomediada (DRIM) apresentaram menorincidência de COVID-19, outrossim os que desenvolveram a patologia, não evoluíram comformas graves, mesmo apresentando outras comorbidades preditoras de pior desfechoclínico. Por conseguinte, levantou-se a hipótese de um efeito protetor dos AM contra a COVID-19. No atual cenário, ergueu-se uma intensa discussão sobre o assunto. Atualmente, o usoprofilático de AM foi desencorajado por estudos criteriosos. O presente estudo tem comoobjetivo principal avaliar a frequência de sintomas gripais e COVID-19 em pacientes usuárioscrônicos de AM em virtude do tratamento de DRIM. Metodologia: O trabalho é umdesdobramento do Projeto Mário Pinotti II, sendo um estudo de coorte transversal com grupocontrole a partir do recorte dos participantes referentes ao Distrito Federal. O tamanhoamostral foi de 638 pessoas, com n de 373 pacientes com DRIM e de 265 contactantes diretosnão portadores de DRIM - grupo controle. Ambos grupos foram entrevistados por meio decontato telefônico semanal, sendo analisadas características sociodemográficas, detalhes douso dos AM, das doenças de base e de demais comorbidades. Também foram abordadosaspectos relacionados aos sintomas da COVID-19, de demais síndromes gripais, e dadosepidemiológicos em ambos grupos. Os dados foram armazenados na plataforma RedCaponline. Foram definidos como COVID-19 positivos aqueles com demonstração da infecção porPCR em orofaringe ou sorologia confirmatória. Os dados levantados foram analisados com ouso do software SPSS 20.0 e STATA 12. Resultados: O grupo de pacientes contou com 91,7%de mulheres e 8,3% de homens, com média de idade de 45,5 anos. Quanto à co-habitação,11,5% dos pacientes moram sozinhos/com mais um habitante e 88,4% moram com 2 ou maispessoas. As DRIM mais incidente foi Lúpus Eritematoso Sistêmico (60,4%). O espectro desintomas gripais avaliados entre os dois grupos mostrou comportamento distinto (p=0,019) -pacientes com DRIM obtiveram maior frequência de 1 ou mais sintomas gripais (36,2% versus24,9%). O grupo pacientes apresentou maior frequência de positividade para COVID-19 doque o grupo controle (p0,001). Não houve diferença no número de internações hospitalaresentre os grupos (p=1,000). Quanto a sintomas gripais que se correlacionam comcaracterísticas epidemiológicas individuais - as quais diferiam entre os grupos - não houveimpacto na frequência dos sintomas (p=0,001). Por fim, os pacientes com DRIM apresentaramfrequência de sintomas gripais 66% maior do que o grupo controle. Discussão/conclusão:Apesar de pesquisas prévias e de estudos realizados no início da pandemia demonstrarempossível efeito protetor de AM contra a COVID-19 e suas formas graves, estudos mais recentese mais criteriosos desacreditaram esse uso, levando inclusive à revogação da aplicação de AMno manejo clínico da doença pela FDA americana. Os resultados do presente estudo estão deacordo com essa nova visão, pois foi evidenciado que não houve frequência menor dedesenvolvimento de síndromes gripais e de COVID-19 em pacientes usuários crônicos de AMquando comparados ao grupo controle de contactantes intra-domicilares não usuários damedicação.

Em um contexto de pandemia pelo COVID-19 em que mais de 150 milhões de casos jáocorreram, busca-se avaliar o comportamento das síndromes gripais e do COVID-19 napopulação com doenças reumatológicas em uso de imunossupressores convencionaissintéticos no Distrito Federal. Por meio de um questionário aplicado em entrevistastelefônicas, os pacientes foram acompanhados durante 12 semanas em 5 contatos paraavaliar a presença de sintomas gripais ou casos confirmados de COVID-19. Os dados coletadosforam analisados descritivamente, feitas associações entre duas variáveis categóricasutilizando-se os testes de Qui-Quadrado e teste exato de Fisher, e realizadas comparações demédias entre dois grupos por meio de testes não paramétricos de Mann-Whitney e de Kruskal-Wallis. Foram estimadas regressões Binomiais Negativas simples (univariada) e múltiplas(multivariada). Para todos os testes estatísticos foram utilizados um nível de significância de5%. As análises estatísticas foram realizadas com o uso do software estatístico SPSS 20.0 eSTATA 12. Um total de 373 pacientes foram incluídos no estudo, 170 faziam uso deimunossupressores, a maioria era do sexo feminino (91,7%, n=342) com a média de idade de45,7 anos. Em relação às comorbidades no grupo em uso de imunossupressores 20% (n=33)tinham hipertensão arterial sistêmica, 11,5% (n=19) tinham doença renal, 7,3% (n=12) tinhamdoença pulmonar, 6,1% (n=10) tinham cardiopatia e 5,5% (n=9) tinham diabetes mellitus. Nomodelo multivariado final a idade (p=0,001) e uso de imunossupressor (p=0,003) foramsignificativas. Observou-se que a frequência de sintomas gripais foi 66,0% maior em pacientesque faziam uso de imunossupressores comparativamente àqueles que não faziam uso dessamedicação. Não se obteve diferença significativa no número de casos por COVID-19. Dessaforma, o uso de imunossupressores convencionais sintéticos associou-se a uma maiorfrequência de sintomas gripais.

IntroductionHip fractures are an important health problem worldwide, and several factors are associated with the mortality. This study aimed to investigate the factors associated with hip fractures in the elderly, based on studies on the population residing in Brazil, and the relationship of fractures with mortality.MethodProspective and retrospective primary observational studies including hospitalized men and/or women aged 60 or older presenting hip fracture due to bone fragility were selected on the Databases. Independent researchers conducted the study selection process and data extraction. A meta-analysis was performed to determine the hospital mortality rate at 90 days, six months, and one year. The Newcastle-Ottawa scale (NOS) was used to assess the quality of the included studies, and the meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).ResultTwenty-five studies totalizing 3,949 patients were included in the systematic review. The population was mainly composed of women (2,680/67.86%). Most patients were in the age group of 70 to 80 years old. Meta-analysis findings: 1) hospital mortality (19 studies, n = 3,175), 10.22% (95% CI 7.27–14.17%; I2 88%); 2) 90-day mortality (3 studies, n = 543), 9.74% (95% CI 3.44–24.62%; I2 90%); 3) six-month mortality (3 studies, n = 205), 24.78% (95% CI 17.07–34.51%; I2 51%); 4) one-year mortality (13 studies, n = 2,790), 21.88% (95% CI 17.5–26.99%; I2 88%). The factors most related to mortality in the studies were: 1) demographic: Older age, male sex; 2) Attributed to clinical conditions: high scoring in preoperative risk scores, comorbidities, neurological/cognitive disorders, functional status; and 3) hospital factors: preoperative period and infections.ConclusionThis review identified variables, including functional status and cognitive changes, related to hip fracture mortality. Knowing these predictors allows for early intervention and planning to adapt health systems to the growing demands of the elderly population.

Background There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann–Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren’s syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03–2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19–6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31–3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46–0.98). Conclusion Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR – 9KTWX6).

Background In early 2020, the COVID-19 pandemic paralyzed the world and exposed the fragility of health systems in the face of mass illness. Health professionals became protagonists, fulfilling their mission at the risk of physical and mental illness. The study aimed to evaluate absenteeism indirectly related to SARS-CoV-2 infection in a large population of health care professionals. Methods An observational longitudinal repeated measures study was performed, including workers linked to 40 public university hospitals in Brazil. All causes of absenteeism were analyzed, focusing on those not directly attributed to COVID-19. Results for the same population were compared over two equivalent time intervals: prepandemic and during the pandemic. Findings A total of 32,691 workers were included in the study, with health professionals comprising 82.5% of the sample. Comparison of the periods before and during the pandemic showed a 26.6% reduction in work absence for all causes, except for COVID-19 and mental health-related absence. Concerning work absence related to mental health, the odds ratio was 39.0% higher during the pandemic. At the onset of the pandemic, there was an increase in absenteeism (all causes), followed by a progressive reduction until the end of the observation period. Interpretation Work absence related to mental illness among health care professionals increased during the COVID-19 pandemic, highlighting the need for health care managers to prioritize and implement support strategies to minimize absenteeism.

Rheumatoid arthritis (RA) is a chronic and autoimmune systemic inflammatory disease that can cause irreversible joint deformities, with increased morbidity and mortality and a significant impact on the quality of life of the affected individual. The main objective of RA treatment is to achieve sustained clinical remission or low disease activity. However, up to 40% of patients do not respond to available treatments, including bDMARDs. New therapeutic targets for RA are emerging, such as Janus kinases (JAKs). These are essential for intracellular signaling (via JAK-STAT) in response to many cytokines involved in RA immunopathogenesis. JAK inhibitors (JAKi) have established themselves as a highly effective treatment, gaining increasing space in the therapeutic arsenal for the treatment of RA. The current recommendations aim to present a review of the main aspects related to the efficacy and safety of JAKis in RA patients, and to update the recommendations and treatment algorithm proposed by the Brazilian Society of Rheumatology in 2017.

ObjectivesTo evaluate risk factors associated with unfavourable outcomes: emergency care, hospitalisation, admission to intensive care unit (ICU), mechanical ventilation and death in patients with immune-mediated rheumatic disease (IMRD) and COVID-19.MethodsAnalysis of the first 8 weeks of observational multicentre prospective cohort study (ReumaCoV Brasil register). Patients with IMRD and COVID-19 according to the Ministry of Health criteria were classified as eligible for the study.Results334 participants were enrolled, a majority of them women, with a median age of 45 years; systemic lupus erythematosus (32.9%) was the most frequent IMRD. Emergency care was required in 160 patients, 33.0% were hospitalised, 15.0% were admitted to the ICU and 10.5% underwent mechanical ventilation; 28 patients (8.4%) died. In the multivariate adjustment model for emergency care, diabetes (prevalence ratio, PR 1.38; 95% CI 1.11 to 1.73; p=0.004), kidney disease (PR 1.36; 95% CI 1.05 to 1.77; p=0.020), oral glucocorticoids (GC) (PR 1.49; 95% CI 1.21 to 1.85; p50 years (PR 1.89; 95% CI 1.26 to 2.85; p=0.002), no use of tumour necrosis factor inhibitor (TNFi) (PR 2.51;95% CI 1.16 to 5.45; p=0.004) and methylprednisolone pulse therapy (PR 2.50; 95% CI 1.59 to 3.92; pConclusionsAge >50 years and immunosuppression with GC and cyclophosphamide were associated with unfavourable outcomes of COVID-19. Treatment with TNFi may have been protective, perhaps leading to the COVID-19 inflammatory process.

Background Since the novel coronavirus disease outbreak, over 179.7 million people have been infected by SARS-CoV-2 worldwide, including the population living in dengue-endemic regions, particularly Latin America and Southeast Asia, raising concern about the impact of possible co-infections. Methods Thirteen SARS-CoV-2/DENV co-infection cases reported in Midwestern Brazil between April and September of 2020 are described. Information was gathered from hospital medical records regarding the most relevant clinical and laboratory findings, diagnostic process, therapeutic interventions, together with clinician-assessed outcomes and follow-up. Results Of the 13 cases, seven patients presented Acute Undifferentiated Febrile Syndrome and six had pre-existing co-morbidities, such as diabetes, hypertension and hypopituitarism. Two patients were pregnant. The most common symptoms and clinical signs reported at first evaluation were myalgia, fever and dyspnea. In six cases, the initial diagnosis was dengue fever, which delayed the diagnosis of concomitant infections. The most frequently applied therapeutic interventions were antibiotics and analgesics. In total, four patients were hospitalized. None of them were transferred to the intensive care unit or died. Clinical improvement was verified in all patients after a maximum of 21 days. Conclusions The cases reported here highlight the challenges in differential diagnosis and the importance of considering concomitant infections, especially to improve clinical management and possible prevention measures. Failure to consider a SARS-CoV-2/DENV co-infection may impact both individual and community levels, especially in endemic areas.

Hydroxychloroquine and chloroquine, also known as antimalarial drugs, are widely used in the treatment of rheumatic diseases and have recently become the focus of attention because of the ongoing COVID-19 pandemic. Rheumatologists have been using antimalarials to manage patients with chronic immune-mediated inflammatory rheumatic diseases for decades. It is an appropriate time to review their immunomodulatory and anti-inflammatory mechanisms impact on disease activity and survival of systemic lupus erythematosus patient, including antiplatelet effect, metabolic and lipid benefits. We also discuss possible adverse effects, adding a practical and comprehensive approach to monitoring rheumatic patients during treatment with these drugs.

Background The COVID-19 pandemic has resulted in social isolation, which has a potential negative impact on the educational routines (eg, the suspension of face-to-face appointments) and mental health of medical students. The Mario Pinotti II (MPII) study is a 24-week observational study that conducted scheduled telephone calls every 2 weeks to verify the occurrence of COVID-19 in patients with rheumatic diseases on chronic hydroxychloroquine therapy (from March 29, 2020, to September 30, 2020). The effects of voluntarily participating in a research project (ie, one that involves interactions via telephone contact with patients, professors, rheumatologists, and colleagues) on the daily lives and mental health of medical students requires evaluation. Objective As medical students are professionals in training and have a high level of responsibility in terms of handling the emotional and physical aspects of several diseases, this study aims to evaluate the impacts of the COVID-19 pandemic and participation in the MPII study on the educational routines and mental health of medical students. Methods A web-based survey was carried out to perform a cross-sectional comparative assessment of medical students who participated in the MPII study and their colleagues who were not involved in the MPII study. Participants from both groups were matched based on sex, age, and medical school. The web questionnaire was developed by a panel composed of graduate medical students, rheumatologists, medical school professors, and a psychology professor. The questionnaire included details on demographic and life habits data and evaluated participants' impressions of the MPII study and the impact of the COVID-19 pandemic on their educational routines and medical training. In addition, depression, anxiety, and stress were evaluated using the Brazilian version of the Depression, Anxiety, and Stress Scale (DASS)-21, and currently, the DASS-21 scores are grouped as those that indicate a low, moderate, or high risk of mental distress. This project was approved by the Federal University of São Paulo Ethics Committee (CAAE: 34034620.0.0000.5505). Results Data were collected from both medical student groups from July 20 to August 31, 2020. Data extraction was completed in September 2020. The data analysis is ongoing. We expect the results to be published in the first semester of 2021. Conclusions This study will provide insight into the effects of participating in a research project on depression, anxiety, and stress, which will be determined by applying the DASS-21 to a large sample of Brazilian undergraduate medical students. We will also evaluate the impact of the COVID-19 pandemic on medical students’ educational routines and medical training. International Registered Report Identifier (IRRID) DERR1-10.2196/24617