REVISTA BRASILEIRA DE REUMATOLOGIA BRAZILIAN JOURNAL OF RHEUMATOLOGY

ISSN 0482-5004 REVISTA BRASILEIRA DE REUMATOLOGIA BRAZILIAN JOURNAL OF RHEUMATOLOGY MARCH/APRIL t 7PMVNF t /VNCFS."3±0 "#3*- t 7PMVNF t /ÞNFSP www.reumatologia.com.br

REVISTA BRASILEIRA DE REUMATOLOGIA BRAZILIAN JOURNAL OF RHEUMATOLOGY Official Organ of Brazilian Society of Rheumatology Órgão Oficial da Sociedade Brasileira de Reumatologia Bimonthly Edition (Publicação Bimestral) Editors (Editores) Max Victor Carioca Freitas Universidade Federal do Ceará, Fotaleza, CE, Brazil Roberto Ezequiel Heymann Universidade Federal de São Paulo, São Paulo, SP, Brazil Editorial Board (Conselho Editorial) Acir Rachid Universidade Federal do Paraná, Curitiba, PR, Brazil Adil Muhib Samara Universidade Estadual de Campinas, Campinas, SP, Brazil Alexandre Wagner S Souza Universidade Federal de São Paulo, São Paulo, SP, Brazil Ari Stiel Radu Universidade de São Paulo, São Paulo, SP, Brazil Carlos Alberto von Muhlen Faculdade de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil Claudia Goldenstein-Schainberg Universidade de São Paulo, São Paulo, SP, Brazil Cláudio Arnaldo Len Universidade Federal de São Paulo, São Paulo, SP, Brazil Clóvis Artur Almeida da Silva Universidade de São Paulo, São Paulo, SP, Brazil Cristiano Augusto de Freitas Zerbini Hospital Heliópolis, São Paulo, SP, Brazil Daniel Feldman Polak Universidade Federal de São Paulo, São Paulo, SP, Brazil Durval Kraychete Escola Bahiana de Medicina e Universidade Federal da Bahia, Salvador, BA, Brazil Eduardo de Souza Meireles Universidade de São Paulo, São Paulo, SP, Brazil Eduardo Ferreira Borba Neto Universidade de São Paulo, São Paulo, SP, Brazil Emília Inoue Sato Universidade Federal de São Paulo, São Paulo, SP, Brazil Fernanda Rodrigues de Lima Universidade de São Paulo, São Paulo, SP, Brazil Fernando Queiroz da Cunha Universidade de São Paulo, Ribeirão Preto, SP, Brazil Francisco Airton Castro Rocha Universidade Federal do Ceará, Fortaleza, CE, Brazil Coeditors (Coeditores) Eloísa Silva Dutra de Oliveira Bonfá Universidade de São Paulo, São Paulo, SP, Brazil Hilton Seda Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, RJ, Brazil João Carlos Tavares Brenol Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Geraldo da Rocha Castelar Pinheiro Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil Gilberto Santos Novaes Pontifícia Universidade Católica de São Paulo, São Paulo, SP, Brazil Isídio Calich Universidade de São Paulo, São Paulo, SP, Brazil Ivânio Alves Pereira Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil Jamil Natour Universidade Federal de São Paulo, São Paulo, SP, Brazil João Francisco Marques Neto Universidade Estadual de Campinas, Campinas, SP, Brazil José Goldenberg Universidade Federal de São Paulo, São Paulo, SP, Brazil José Roberto Provenza Universidade Estadual de Campinas, Campinas, SP, Brazil Jozélio Freire de Carvalho Centro Médico Aliança, Salvador, BA, Brazil Lais V. Lage Universidade de São Paulo, São Paulo, SP, Brazil Lilian Tereza Lavras Costallat Universidade Estadual de Campinas, Campinas, SP, Brazil Luís Eduardo Coelho Andrade Universidade Federal de São Paulo, São Paulo, SP, Brazil Luiz Fernando de Souza Passos Universidade Federal do Amazonas, Manaus, AM, Brazil Marcelo de Medeiros Pinheiro Universidade Federal de São Paulo, São Paulo, SP, Brazil Maria Odete E. Hilário Universidade Federal de São Paulo, São Paulo, SP, Brazil Marta Maria das Chagas Medeiros Universidade Federal do Ceará, Fortaleza, CE, Brazil Mittermayer Barreto Santiago Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil Paulo Louzada-Junior Universidade de São Paulo, Ribeirão Preto, SP, Brazil Ricardo Fuller Universidade de São Paulo, São Paulo, SP, Brazil Simone Appenzeller Universidade Estadual de Campinas, Campinas, SP, Brazil Maurício Levy Neto Universidade de São Paulo, São Paulo, SP, Brazil Milton Helfenstein Jr. Universidade Federal de São Paulo, São Paulo, SP, Brazil Natalino H. Yoshinari Universidade de São Paulo, São Paulo, SP, Brazil Nílzio Antônio da Silva Universidade Federal de Goiás, Goiânia, GO, Brazil Percival Degrava Sampaio-Barros Universidade de São Paulo, São Paulo, SP, Brazil Ricardo M. Xavier Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Rina Dalva P. N. Giorgi Hospital do Servidor Público Estadual de São Paulo "Francisco Morato de Oliveira", São Paulo, SP, Brazil Roger A. Levy Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil Rosa Maria Rodrigues Pereira Universidade de São Paulo, São Paulo, SP, Brazil Rozana Mesquita Ciconelli Universidade Federal de São Paulo, São Paulo, SP, Brazil Samuel Katsuyki Shinjo Universidade de São Paulo, São Paulo, SP, Brazil Sebastião Cézar Radominski Universidade Federal do Paraná, Curitiba, PR, Brazil Sheila Knupp de Oliveira Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil Simone Appenzeller Universidade de Campinas, Campinas, SP, Brazil Vera Lúcia Szejnfeld Universidade Federal de São Paulo, São Paulo, SP, Brazil Wiliam H. Chahade Hospital do Servidor Público Estadual de São Paulo "Francisco Morato de Oliveira", São Paulo, SP, Brazil International Editorial Board (Conselho Editorial Internacional) Ariel Masetto Université de Sherbrooke, Sherbrooke, Canada Arthur Kavanaugh University of California, San Diego, USA Bernardo Pons Estel Universidad Nacional de Rosario, Rosario, Argentina Claudio Galarza Maldonado Hospital Monte Sinai, Cuenca, Equador Ernest Choy King's College, London, UK Jordi Antón López Hospital Sant Joan de Déu, Barcelona, Spain José Antonio Melo Gomes Instituto Português de Reumatologia, Lisboa, Portugal Juan Manuel Anaya Corporación de Investigaciones Biológicas, Medellín, Colômbia Luis Javier Jara Universidad Nacional Autonoma de Mexico, Mexico City, Mexico Mario Cardiel Instituto Nacional de la Nutrición "Salvador Zubiran", Morrelia, Mexico Mario Garcia-Carrasco Facultad de Medicina, BUAP, Puebla, Mexico Mário Viana de Queiroz Universidade Clássica de Lisboa, Lisboa, Portugal Marvin Fritzler University of Calgary, Calgary, Canada Munther Khamashta St. Thomas Hospital, London, UK H Ralph Schumacher Jr University of Pennsylvania, Philadelphia, USA Ricardo Cervera Segura Hospital Clinic, Barcelona, Spain Richard J Wakefield Chapel Allerton Hospital, Leeds, UK Thomas Dörner Charite Hospital, Berlin, Germany Yehuda Shoenfeld Chaim Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel

BSR Office (Secretaria SBR) Rogério Quintiliano Amaral Av. Brigadeiro Luiz Antonio, 2.466 conjs. 93-94 CEP 01402-000 São Paulo, SP Fone/fax: 55 (11) 3289-7165 E-mail: rbreumatol@terra.com.br; sbre@terra.com.br website: www.reumatologia.com.br Brazilian Journal of Rheumatology is listed in Web of Science, MEDLINE, LILACS, SciELO, Scopus and Index Copernicus databases. BJR is affiliated to the International Committee of Medical Journal Editors. A Revista Brasileira de Reumatologia é indexada nas bases de dados Web of Science, MEDLINE, LILACS, SciELO, Scopus e Index Copernicus. A RBR é fi liada ao International Committee of Medical Journal Editors. Brazilian Journal of Rheumatology (BJR) is an official publication of the Brazilian Society of Rheumatology (BSR) in partnership with Elsevier Editora Ltda. and is dedicated to the medical community in Brazil and Latin America. Edited by Brazilian Society of Rheumatology. Published by Elsevier Editora Ltda. 2013. Tradução Translation: Stela Maris Costalonga American Journal Experts All rights reserved and protected by law 9.610-19/02/98. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from BSR and the Publisher. BJR receives finnancial support from Fundos Remanescentes da Sociedade Brasileira de Reumatologia. A Revista Brasileira de Reumatologia (RBR) é uma publicação ofi cial da Sociedade Brasileira de Reumatologia (SBR) em conjunto com Elsevier Editora Ltda., distribuída exclusivamente à classe médica do Brasil e da América Latina. Editada por Sociedade Brasileira de Reumatologia. Publicada por Elsevier Editora Ltda. 2013. Todos os direitos reservados e protegidos pela lei 9.610-19/02/98. Nenhuma parte desta publicação poderá ser reproduzida, sem autorização prévia, por escrito, da Elsevier Editora Ltda. e da SBR, sejam quais forem os meios empregados: eletrônicos, mecânicos, fotográfi cos, gravação ou quaisquer outros. A RBR recebe auxílio fi nanceiro de Fundos Remanescentes da Sociedade Brasileira de Reumatologia. RJ: Tel.: 21 3970-9300 Fax: 21 2507-1991 SP: Tel.: 11 5105-8555 Fax: 11 5505-8908 Website: www.elsevier.com E-mail: periodicos@elsevier.com.br No responsibility is assumed by Elsevier or BSI for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verifi cation of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. A Elsevier não assume nenhuma responsabilidade por qualquer injúria e/ou danos a pessoas ou bens como questões de responsabilidade civil do fabricante do produto, de negligência ou de outros motivos, ou por qualquer uso ou exploração de métodos, produtos, instruções ou ideias contidas no material incluso. Devido ao rápido avanço no campo das ciências médicas, em especial, uma verifi cação independente dos diagnósticos e dosagens de drogas deve ser realizada. Embora todo o material de publicidade deva estar em conformidade com os padrões éticos (médicos), a inclusão nesta publicação não constitui uma garantia ou endosso da qualidade ou valor de tal produto ou das alegações feitas pelo seu fabricante. Content dedicated to the medical community. Material de distribuição exclusiva à classe médica.

INSTRUCTIONS TO AUTHORS The Brazilian Journal of Rheumatology (BJR), an official organ of Sociedade Brasileira de Reumatologia (Brazilian Society of Rheumatology), was founded in 1957 and is published bimonthly. The journal publishes original articles, review articles, brief communications, case reports and letters to the editors. To submit a manuscript, please access the site http://ees.elsevier.com/bjr. Format of the manuscript The manuscript can be submitted in Portuguese or English, double spaced, with 2.5 cm margins. Unconventional abbreviations, medical jargon and telegraphic style should not be used in the text. Citation of drugs and pharmaceutical products must be done using pharmacological nomenclature, without any mention to commercial names. Manuscript structure Manuscript*, Title Page*, Cover Letter, and Author Agreement* must be submitted in separate files. Tables and Figures should be numbered as cited in the text and sent in separate files with corresponding titles and legends. (*required files) Title page The title page should contain: a) the full title; b) the full name of the authors and their most important academic degree; c) the department and institution where the study was originated; d) the full address and e-mail of the corresponding author; e) conflict of interest and relevant financial agencies; f) a running title with no more than 60 characters. Author Agreement It is the document where the authors declare that the manuscript is original, in addition to approve the manuscript object of the submission, the authorship and the order of authors listed. It must be signed by all authors. Below is presented an example. Dear Editor, We, the undersigned, declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere. We would like to draw the attention of the Editor to the following publications of one or more of us that refer to aspects of the manuscript presently being submitted. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We understand that the Corresponding Author is the sole contact for the Editorial process. He/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. (Signature of all authors) Original article The original article should contain: the title page, the abstract page with keywords, introduction, material and methods or patients and methods, results and discussion, acknowledgements, references, tables, figures and figure legends. Original articles should not exceed 5,000 words including references and excluding the title page, abstract, tables and legends. It is allowed up to six figures or tables and 50 references. Abstract page The abstract page should contain: a) objective, methods, results and conclusions, with no more than 250 words; b) three to five keywords. Introduction As the aim of this section is to define the purpose and the reasons for the accomplishment of the work, we do not recommend a large literature review. Patients and methods or Material and methods This section should include enough information that allows the reproduction of the work and, when it is relevant, the approval by the institutional Committee of Ethics. The methods employed in the statistical analysis should always be quoted. Results They should be clear and concise. Tables and graphics should not duplicate information. Discussion It should be concise, interpreting the results in the context of the present literature. Please do not exceed the limit of half the number of pages of the complete work. Acknowledgments Only to people who contributed; i.e., with techniques, discussion and sending patients. Financial help should be referred in the title page. References They should be quoted in the text in Arabic numerals, superscript, with no brackets. Numbering should be sequencial, according to the quotation order in the text. Please quote all the authors in works with until six authors; after six authors, quote the first six followed by the expression et al. Reference Manager or Endnote programs are strongly recommended for use adopting the Vancouver style. Examples for reference citation are presented below. Authors should consult NLM s Citing Medicine for additional information on the reference formats. Printed article 1. Rivero MG, Salvatore AJ, Gomez-Puerta JA, Mascaro JM, Jr., Canete JD, Munoz-Gomez J et al. Accelerated nodulosis during methotrexate therapy in a patient with systemic lupus erythematosus and Jaccoud s arthropathy. Rheumatology (Oxford) 2004; 43(12):1587-8. Reference retrieved from electronic address 2. Cardozo JB, Andrade DMS, Santiago MB. The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clin Rheumatol 2008. Available from: http://www.springerlink. com.w10069.dotlib.com. br/content/l05j4j3332041225/fulltext.pdf. [Accessed in February 24, 2008]. Book 3. Murray PR, Rosenthal KS, Kobayashi GS, Pfaller MA. Medical microbiology. 4th ed. St. Louis: Mosby; 2002. Tables and figures Each Table or Figure should be numbered with Arabic numerals and sent in an individual file (.jpg,.tif,.png,.xls,.doc) with minimum of 300 dpi. Titles and legends should be in the same Table/Figure file to wich they refer. Tables and Figures should include enough information so the reader can understand them without going to the text. Photomicrographies should include the appropriated scale. Review article Reviews, preferentially systematic, may be submitted to BJR. They should cover deeply any interesting theme for the rheumatologist. They do not present a standard structure, neither introduction or conclusion. Please send abstracts without subdivisions with three to five keywords. Review articles should not exceed 6,000 words including references and excluding the title page, abstract, tables and legends. It is allowed up to five figures or tables and 70 references. Case report Must have six authors at most. They should include an abstract and keywords, without subdivisions. The text, however, should present the following sections: introduction, which should be concise; case report, containing the description and the evolution of the clinical case, laboratory exams, illustrations and tables (that substitute the sections material and methods and results); and discussion. It should not exceed 1,500 words including references and excluding the title page, abstract, tables and legends. It is allowed up to two figures or tables and 15 references. Brief communication It covers a point or a specific detail. It should present an abstract with no more than 250 words and three to five keywords. The text does not include subdivisions, and should not exceed 2,500 words including references and excluding the title page, abstract, tables and legends. It is allowed up to three figures or tables and 25 references.

Rules for applying the appropriate tense in scientific writing Context or section Abstract Introduction Methods, materials used, and results Discussion/Conclusion Attribution Description of Tables and Figures Established knowledge, previous results etc. Appropriate verb tense Past tense Most present tense (established facts, previous published data) Past tense Mixture of past and present, sometimes future tense Past tense Ex.: Andrade et al. reported that... Present tense Present tense General rules to obtain a good scientific writing: 1. Use active voice. 2. Setences must be short, clear and objective. 3. Units of measurement are abbreviated when use with numerical values (e.g., 1 mg), but are not abbreviated if used without numerical values. Systeme International d'únites (SI units) must be used. Remember to leave a space between the number and unit (e.g., 10 mg/dl), except for the percentage mark that follows the number without space (e.g., 70%). The plural form of units of measurement is the same as the singular form (e.g., 1 ml, 10 ml; 1 h, 10 h). Spell out numbers at the beginning of a sentence. 4. Define abbreviations the first time they appear. Avoid abbreviations in tittles and abstracts. 5. Do not use contractions (e.g., doesn't, can't etc.). Recommended book: Rogers SM. Mastering scientific and medical writing: a self-help guide. Berlin: Springer; 2007. Legal and ethical considerations According to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (International Committee of Medical Journal Editors February 2006). Conflict of interest Public trust in the peer review process and the credibility of published articles depend in part on how well conflict of interest is handled during writing, peer review, and editorial decision making. Conflict of interest exists when an author (or the author s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion. Informed consent Patients have a right to privacy, that should not be infringed without informed consent. Identifying information, including patients names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve. However, an informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. When informed consent has been obtained it should be indicated in the published article. Ethical treatment When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed. Clinical trials registry Clinical trials must be registered according to WHO recommendation at www. who.int/ictrp/en/. The definition of clinical trial include preliminary trials (phase I): any study with prospective recruiting of subjects to undergo any health-related intervention (drugs, surgical procedures, equipment, behavioral therapies, food regimen, changes in health care) to evaluate the effects on clinical outcomes (any biomedical or health-related parameter, including pharmacokinetics measurements and adverse reactions). The BJR has the right not to publish trials not complying with these and other legal and ethical standards determined by international guidelines. Financing and support The authors should also inform if they received financing or support from institutions like CNPq, CAPES, SBR Remaining Funds, Graduated Institutions, Laboratories etc.

INSTRUÇÕES PARA OS AUTORES A Revista Brasileira de Reumatologia (RBR), órgão oficial da Sociedade Brasileira de Reumatologia, foi fundada em 1957 e é publicada bimestralmente. A revista publica artigos originais, artigos de revisão, comunicações breves, relatos de casos e cartas aos editores. O manuscrito deve ser submetido online através do site http://ees.elsevier.com/bjr. Apresentação do manuscrito O manuscrito pode ser submetido em português ou inglês, em espaço duplo, com margens de 2,5 cm. No texto não devem ser empregadas abreviaturas não convencionais, gírias (jargões) médicas ou redação tipo telegráfica. A citação de medicamentos e produtos farmacêuticos deve ser feita utilizando-se apenas a nomenclatura farmacológica, sem menção do nome comercial. Estrutura do manuscrito Manuscript*, Title Page*, Cover Letter e Author Agreement* devem ser enviados em arquivos individuais. Tabelas e figuras devem ser numeradas conforme citadas no texto e enviadas em arquivos separados, com títulos e legendas correspondentes. (*arquivos obrigatórios) Página do título Deve conter: a) título do artigo; b) nome completo dos autores e sua titulação mais importante; c) departamento(s) e instituição(ões) onde se originou o trabalho; d) nome, endereço completo e e-mail válido do autor responsável para correspondência; e) conflito de interesse e agências financiadoras relevantes; f) título resumido com no máximo 60 caracteres. Author Agreement É o documento no qual os autores declaram a originalidade do manuscrito, além de aprovarem o artigo objeto da submissão, a autoria e a ordem da lista de autores. Deve ser assinado por todos os autores. A seguir é apresentado um modelo. Caro Editor, Os autores, abaixo assinados, declaram que este manuscrito é original, não foi publicado antes e não se encontra submetido para qualquer outra publicação. Gostaríamos de pedir a atenção do Editor para a presente publicação de nós autores, referente a aspectos do presente manuscrito submetido. Confirmamos que o manuscrito foi lido e aprovado por todos os autores signatários e que não há nenhum outro autor a fazer parte senão os listados. Confirmamos também que a ordem dos autores listada no manuscrito foi aprovada por todos. Entendemos que o Autor para Correspondência será o único contato para o processo editorial. Ele será o único responsável pela comunicação com os demais autores acerca do progresso da submissão, da revisão do manuscrito e de sua aprovação final. (Assinatura de todos os autores) Artigo Original Deve conter: página do título, página de resumo com palavras-chave, introdução, material e métodos ou pacientes e métodos, resultados e discussão, agradecimentos, referências, tabelas, figuras e legendas das figuras. Não deve exceder 5.000 palavras, incluindo-se as referências e excluindo-se a página do título, resumo, tabelas e legendas. Pode exibir até seis figuras ou tabelas e até 50 referências. Página de resumo Deve conter: a) objetivo, métodos, resultados e conclusões, não excedendo 250 palavras; b) três a cinco palavras-chave. Introdução A finalidade dessa seção é definir o propósito e as razões para a realização do trabalho. Não se recomenda extensa revisão da literatura. Pacientes e métodos ou Material e métodos Deve incluir informações suficientes que permitam a reprodução do trabalho e, quando pertinente, a aprovação pelo Comitê de Ética institucional. Os métodos empregados na análise estatística devem sempre ser citados. Resultados Devem ser claros e concisos. Tabelas e gráficos não devem duplicar informações. Discussão Deve ser concisa, interpretando os resultados no contexto da literatura atual. É conveniente não ultrapassar a metade do número de páginas do trabalho completo. Agradecimentos Apenas às pessoas que contribuíram, por exemplo, com técnicas, discussão e envio de pacientes. Auxílio financeiro deve ser referido na página do título. Referências Devem ser citadas no texto em algarismos arábicos, sobrescritos e depois da pontuação, sem parênteses ou colchetes. A numeração deve ser sequencial, de acordo com a ordem de citação no texto. Nas referências com mais de seis autores, devem ser citados os seis primeiros, seguidos pela expressão et al. Sugere-se a utilização dos programas Reference Manager ou Endnote, seguindo-se o estilo Vancouver. Exemplos de referência para diferentes formatos são apresentados a seguir. Os autores devem consultar o NLM s Citing Medicine para mais informações sobre os formatos das referências. Artigo de revista 1. Rivero MG, Salvatore AJ, Gomez-Puerta JA, Mascaro JM, Jr., Canete JD, Munoz-Gomez J et al. Accelerated nodulosis during methotrexate therapy in a patient with systemic lupus erythematosus and Jaccoud s arthropathy. Rheumatology (Oxford) 2004; 43(12):1587-8. Artigo extraído de endereço eletrônico 2. Cardozo JB, Andrade DMS, Santiago MB. The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clin Rheumatol 2008. Available from: http://www.springerlink.com.w10069.dotlib.com.br/ content/l05j4j3332041225/fulltext. pdf. [Accessed in February 24, 2008]. Livro 3. Murray PR, Rosenthal KS, Kobayashi GS, Pfaller MA. Medical microbiology. 4th ed. St. Louis: Mosby; 2002. Tabelas e Figuras Cada tabela ou figura deverá ser numerada em algarismo arábico e enviada em arquivo separado (.jpg,.tif,.png,.xls,.doc) com 300 dpi no mínimo. Título e legenda devem estar no mesmo arquivo da figura ou tabela a que se referem. Tabelas e ilustrações devem ser autoexplicativas, com informações suficientes para sua compreensão sem que se tenha de recorrer ao trabalho. Fotomicrografias devem incluir a escala apropriada. Artigo de Revisão Revisões, preferencialmente sistemáticas, podem ser submetidas à RBR, devendo abordar com profundidade um tema de interesse para o reumatologista. Não apresentam estruturação padronizada, prescindindo de introdução ou discussão. Devem apresentar resumo sem subdivisões, com três a cinco palavras-chave, e não devem exceder 6.000 palavras, incluindo-se as referências e excluindo-se a página do título, resumo, tabelas e legendas. Podem exibir até cinco figuras ou tabelas e até 70 referências. Relato de Caso Deve incluir resumo e palavras-chave, sem necessidade de subdivisões. O texto, porém, apresenta as seguintes seções: introdução, que deve ser concisa; relato de caso, contendo a descrição e a evolução do quadro clínico, exames laboratoriais, ilustrações e tabelas (que substituem as seções material e métodos e resultados); e discussão. Deve conter no máximo seis autores, e não deve exceder 1.500 palavras, incluindo-se as referências e excluindo-se a página do título, resumo, tabelas e legendas. Pode exibir até duas figuras ou tabelas e até 15 referências. Comunicação breve Aborda um ponto ou detalhe específico de um tema. Deve incluir resumo com no máximo 250 palavras, e três a cinco palavras-chave. O texto não necessita subdivisões, deve ter até 2.500 palavras incluindo-se as referências e excluindo-se a página do título, resumo, tabelas e legendas. Pode exibir até três figuras ou tabelas e até 25 referências.

Regras para aplicar tempos verbais apropriados de acordo com o contexto ou seção Contexto ou seção Resumo Introdução Métodos, materiais e resultados Discussão/Conclusão Atribuições Descrição de Tabelas e Figuras Conhecimento estabelecido e resultados prévios Tempo verbal apropriado Passado Presente, quando se referir a fatos estabelecidos e conhecimento prévio Passado Combinado de passado (quando se referir a resultados obtidos no trabalho) e presente (quando se referir a fatos estabelecidos e conhecimento prévio); às vezes pode ser utilizado o futuro (especialmente quando se referir a perspectivas de trabalhos a serem realizados) Passado Ex.: Andrade et al. relataram... Presente Presente Regras gerais para se obter uma boa escrita em um artigo científico: 1. Prefira a voz ativa. 2. As sentenças devem ser curtas, claras e objetivas. 3. A unidade de medida deve ser abreviada quando empregada com valores numéricos (p. ex., 1 mg), mas escrita por extenso quando separada de valor numérico. Utilize o Sistema Internacional de Unidades (SI units) para definir as unidades de medida. Lembre-se de deixar um espaço entre o número e a unidade (p. ex., 10 mg/dl), exceto quando for porcentagem, que deve estar junto (p. ex., 70%). O plural das unidades de medida é a mesma forma do singular (p. ex., 1 ml, 10 ml; 1 h, 10 h). Quando iniciarem a frase, os números devem estar por extenso, e não em algarismo arábico. 4. Defina a abreviação na primeira vez que aparecer no texto principal. Após a definição, use sempre a abreviação em vez da forma por extenso. Evite o uso de abreviações no título e no resumo. 5. Ao escrever em inglês, não utilize contrações (p. ex., prefira does not em vez de doesn't). Livro recomendado: Rogers SM. Mastering scientific and medical writing: a self-help guide. Berlin: Springer; 2007. Considerações éticas e legais A RBR segue as normas do Uniform Requirements for Manuscripts (URM) Submitted to Biomedical Journals desenvolvidas pelo The International Committee of Medical Journal Editors (ICMJE) fevereiro de 2006. Conflito de interesse A confiança pública no processo de revisão por pares e a credibilidade dos artigos publicados dependem, em parte, de como o conflito de interesse é administrado durante a redação, a revisão por pares e a decisão editorial. O conflito de interesse existe quando um autor (ou instituição do autor), revisor ou editor tem relações financeiras ou pessoais que influenciem de forma inadequada (viés) suas ações (tais relações são também conhecidas como duplo compromisso, interesses conflitantes ou fidelidades conflitantes). Essas relações variam entre aquelas com potencial insignificante até as com grande potencial para influenciar o julgamento, e nem todas as relações representam verdadeiro conflito de interesse. O potencial conflito de interesse pode existir dependendo se o indivíduo acredita ou não que a relação afete seu julgamento científico. Relações financeiras (tais como emprego, consultorias, posse de ações, testemunho de especialista pago) são os conflitos de interesse mais facilmente identificáveis e os mais suscetíveis de minar a credibilidade da revista, dos autores e da própria ciência. No entanto, podem ocorrer conflitos por outras razões, tais como relações pessoais, competição acadêmica e paixão intelectual. Consentimento informado Os pacientes têm o direito à privacidade, que não deve ser infringida sem o consentimento informado. A identificação de informações, incluindo os nomes dos pacientes, iniciais ou números no hospital, não devem ser publicadas em descrições, fotografias e genealogias, a menos que a informação seja essencial para os propósitos científicos e o paciente (ou responsável) dê o consentimento livre e esclarecido para a publicação. O consentimento informado para este propósito requer que o manuscrito a ser publicado seja mostrado ao paciente. Os autores devem identificar os indivíduos que prestam assistência a escrever e divulgar a fonte de financiamento para essa assistência. Detalhes identificadores devem ser omitidos se não são essenciais. O anonimato completo é difícil de se conseguir; no entanto, no caso de qualquer dúvida, o consentimento deve ser obtido. Por exemplo, mascarar a região ocular em fotografias de pacientes é uma proteção de anonimato inadequada. Se as características de identificação são alteradas para proteger o anonimato, como na linhagem genética, os autores devem garantir que as alterações não distorçam o significado científico. Quando o consentimento informado foi obtido, ele deve ser indicado no artigo publicado. Princípios éticos Ao relatar experimentos em seres humanos, os autores devem indicar se os procedimentos seguidos estiveram de acordo com os padrões éticos do comitê responsável por experimentação humana (institucional e nacional) e com a Declaração de Helsinki de 1975, revisado em 2000. Se houver dúvida se a pesquisa foi realizada em conformidade com a Declaração de Helsinki, os autores devem explicar a razão para sua abordagem e demonstrar que o corpo de revisão institucional aprovou explicitamente os aspectos duvidosos do estudo. Ao relatar experimentos com animais, os autores devem indicar se as orientações institucionais e nacionais para o cuidado e a utilização de animais de laboratório foram seguidas. Registro de ensaios clínicos Os ensaios clínicos devem ser registrados segundo recomendação da OMS em www.who.int/ictrp/en/. A definição de ensaios clínicos incluem ensaios preliminares (fase I): um estudo prospectivo com o recrutamento de indivíduos submetidos a qualquer intervenção relacionada à saúde (medicamentos, procedimentos cirúrgicos, aparelhos, terapias comportamentais, regime alimentar, mudanças nos cuidados de saúde) para avaliar os efeitos em desfechos clínicos (qualquer parâmetro biomédico e de saúde, inclusive medidas farmacocinéticas e reações adversas). A RBR tem o direito de não publicar trabalhos que não cumpram estas e outras normas legais e éticas explicitadas nas diretrizes internacionais. Financiamento e apoio Os autores devem, também, informar se receberam financiamento ou apoio de instituições como CNPq, CAPES, Fundos Remanescentes da SBR, instituições universitárias, laboratórios etc.

Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia) Founded on July 15, 1948 (Fundada em 15 de julho de 1948) Executive Board of Directors for the 2012 2014 Biennium Diretoria Executiva para o Biênio 2012 2014 President (Presidente) Walber Pinto Vieira, CE General secretary (Secretário geral) Francisco José Fernandes Vieira, CE 1st secretary (1º secretário) Lauredo Ventura Bandeira, SP 2nd secretary (2ª secretária) Rosa Maria Rodrigues Pereira, SP Treasurer (Tesoureiro) José Eyorand Castelo B. Andrade, CE Vice-treasurer (Vice-tesoureiro) José Roberto Provenza, SP Scientific director (Diretor científico) Mittermayer Barreto Santiago, BA Elected president (Presidente eleito) Cesar Emile Baaklini, SP Representatives of PANLAR Representantes junto à PANLAR Adil Muhib Samara, SP Antonio Carlos Ximenes, GO Fernando Neubarth, RS Maria Amazile Ferreira Toscano, SC Representatives of Ministry of Health Representante junto ao Ministério da Saúde Ana Patrícia de Paula, DF Mário Soares Ferreira, DF Representatives of AMB Representantes junto à AMB Eduardo de Souza Meirelles, SP Gustavo de Paiva Costa, DF Morton Aaron Scheinberg, SP Specialist Title Commission Comissão de Título de Especialista Coordinator (Coordenadora) Emília Inoue Sato, SP Members (Membros) Fernanda Rodrigues Lima, SP Gilda Aparecida Ferreira, MG Ines Guimarães Silveira, RS José Tupinambá Souza Vasconcelos, PI Marcelo de Medeiros Pinheiro, SP Mauro Goldfarb, RJ Nafice Costa Araujo, SP Rafael Navarrete, GO Valeria Valim Cristo, ES Wilton Silva dos Santos, DF Rheumatology Aid Fund to Rheumatology Research and Teaching Conselho do Fundo de Auxílio a Pesquisa e Ensino em Reumatologia Acir Rachid, PR Adil Muhib Samara, SP Antônio Carlos Ximenes, GO Caio Moreira, MG Cesar Emile Baaklini, SP Emília Inoue Sato, SP Fernando de Souza Cavalcanti, PE Fernando Neubarth, RS Geraldo da Rocha Castelar Pinheiro, RJ Geraldo Gomes de Freitas, PE Hilton Seda, RJ Iêda Maria Magalhães Laurindo, SP João Carlos Tavares Brenol, RS João Francisco Marques Neto, SP Nílzio Antônio da Silva, GO Sebastião Cezar Radominski, PR Walber Pinto Vieira, CE Wiliam Habib Chahade, SP Health Economy Commission Comissão de Economia da Saúde Coordinator (Coordenadora) Mirhelen Mendes de Abreu, SP Members (Membros) Ana Cristina de Medeiros Ribeiro, SP Claiton Viegas Brenol, RS Eduardo de Souza Meirelles, SP Jussara de Almeida L. Kochen, SP Rafael Mendonça da Silva Chakr, RS Epidemiology Commission Comissão de Epidemiologia Coordinator (Coordenadora) Eutilia Andrade Medeiros Freire, PB Members (Membros) Alessandra Souza Braz C. Andrade, PB Bernardo Matos da Cunha, DF Camila Cruz Leijoto, RJ Carlos Augusto F. de Andrade, RJ Jussara de Almeida L. Kochen, SP Mirhelen Mendes de Abreu, SP Pediatric Rheumatology Commission Comissão de Reumatologia Pediátrica Coordinator (Coordenador) Cláudio Arnaldo Len, SP Members (Membros) Adriana Maluf Elias Sallum, SP Ana Paula Vecchi, GO Andre de Souza Cavalcanti, PE Blanca Elene Rios Gomes Bica, RJ Carlos Nobre Rabelo Jr., CE Claudia Saad Magalhães, SP Clovis Artur Almeida da Silva, SP Cynthia Torres Franca da Silva, RJ Luciana Brandão Paim Marques, CE Marcia Bandeira, PR Maria Teresa R. A. Terreri, SP Tania Caroline Castro, SP Teresa Cristina Robazzi, BA Media Commission Comissão de Comunicação Social BSR Bulletin (Boletim SBR) Editorial Council (Conselho Editorial) Kaline Medeiros Costa Pereira, SP Edgard Torres dos Reis Neto, SP Editors (Editores) Tânia Carolina Monteiro de Castro, SP Frederico Augusto Gurgel Pinheiro, SP Collaborator (Colaborador) Plínio José do Amaral, SP Brazilian Journal of Rheumatology Revista Brasileira de Reumatologia Editors (Editores) Max Victor Carioca Freitas, CE Roberto Ezequiel Heymann, SP Coeditors (Coeditores) Eloísa Silva Dutra de Oliveira Bonfá, SP Hilton Seda, RJ João Carlos Tavares Brenol, RS Mittermayer Barreto Santiago, BA Paulo Louzada-Junior, SP Ricardo Fuller, SP Simone Appenzeller, SP BSR Website (Site SBR) Coordinators (Coordenadores) Marcelo Cruz Rezende, MS Maria Roseli Monteiro Callado, CE Ethics and Discipline Commission Comissão de Ética e Disciplina Coordinator (Coordenador) José Marques Filho, SP Members (Membros) Adriana Maria Kakehasi, MG Antonio Carlos Althoff, SC Henrique Josef, SP João Elias Moura Jr., SC José Geraldo Araújo Paiva, CE José Roberto Pereira Santos, ES Teaching and Medical Education Commission Comissão de Ensino e Educação Médica Coordinator (Coordenador) Francisco Airton Castro da Rocha, CE Members (Membros) Cesar Emile Baaklini, SP Charles Lubianca Kohem, RS Claudia Diniz Lopes Marques, PE Elaine Lira Medeiros de Bezerra, RN Elisa Martins das N. de Albuquerque, RJ Jozélia Rego, GO Marcelo Pimenta, GO

Maria José Pereira Vilar, RN Ricardo Machado Xavier, RS Congresses, Journeys, and Events Commission Comissão de Congressos, Jornadas e Eventos Coordinators (Coordenadores) Fernando Neubarth, RS Georges Basile Christopoulos, AL José Roberto Provenza, SP Commission of Relations with Groups of Patients Comissão de Relações com Grupos de Pacientes Coordinators (Coordenadores) Helenice Alves Teixeira Gonçalves, DF Members (Membros) Ana Maria Camargo Gallo, SC Ana Paula Espinula Gianordoli, ES Eduardo de Souza Meirelles, SP Luis Piva Junior, DF Valderílio Feijó Azevedo, PR Wanda Heloisa Rodrigues Ferreira, RJ Occupational Rheumatology Commission Comissão de Reumatologia Ocupacional Coordinator (Coordenador) Milton Helfenstein Junior, SP Members (Membros) Anna Beatriz Assad Maia, DF Antônio Techy, PR César Augusto Fávaro Siena, SP Marco Aurélio Goldenfum, RS BiobadaBrasil Comission Comissão do BiobadaBrasil Coordinator (Coordenador) David Cezar Titton, PR Members (Membros) Aline Ranzolin, PE André Luiz Shinji Hayata, SP Ines Guimarães da Silveira, RS Mirhelen Mendes de Abreu, SP Paulo Louzada-Junior, SP Roberto Ranza, MG Valéria Cristo Valim, ES Rheumatoid Arthritis Commission Comissão de Artrite Reumatoide Coordinator (Coordenadora) Licia Maria Henrique da Mota, DF Members (Membros) Bóris Afonso Cruz, MG Claiton Viegas Brenol, RS Geraldo da Rocha Castelar Pinheiro, RJ Ieda Maria Magalhães Laurindo, SP Jozélio Freire de Carvalho, BA Manoel Barros Bertolo, SP Max Victor Carioca Freitas, CE Nilzio Antônio da Silva, GO Paulo Louzada-Junior, SP Rina Dalva Neubarth Giorgi, SP Rodrigo Aires Corrêa Lima, DF Osteoarthrosis Commission Comissão de Osteoartrose Coordinator (Coordenador) Ibsen Bellini Coimbra, SP Members (Membros) Antônio Carlos dos Santos Novaes, SP Claudia Diniz Lopes Marques, PE Elda Matilde Hirose Pastor, SP Francisco Saraiva da Silva Júnior, CE Hilton Seda, RJ José Caetano Macieira, SE Reno Martins Coelho, RJ Ricardo Fuller, SP Vasculopathies Commission Comissão de Vasculopatias Coordinator (Coordenador) Roger Abramino Levy, RJ Members (Membros) Adriana Danowski, RJ Adriana Maria Kakehasi, MG Alexandre Wagner S. de Souza, SP Ana Beatriz S. Bacchiega de Freitas, RJ Andreas Funke, PR Carlos Ewerton Maia Rodrigues, CE Danieli Castro Oliveira de Andrade, SP Isabella Vargas de Souza Lima, BA Jozélia Rego, GO Manuella Lima Gomes Ochtrop, RJ Image Commission Comissão de Imagem Coordinator (Ccoordenador) José Alexandre Mendonça, SP Members (Membros) And rea B. Vannucci Lomonte, SP Cristiane Kayser Veiga da Silva, SP Iêda Maria Magalhães Laurindo, SP Inês Guimarães Silveira, RS Jamil Natour, SP Karine Rodrigues da Luz, SP Laura Maria C. Mendonça, RJ Simone Appenzeller, SP Verônica Silva Vilela, RJ Procedures Commission Comissão de Procedimentos Coordinator (Ccoordenador) Jamil Natour, SP Members (Membros) Geraldo da Rocha Castelar Pinheiro, RJ Luiza Helena Coutinho Ribeiro, SP Monique Sayuri Konai, SP Rita Nely Vilar Furtado, SP Lupus Commission Comissão de Lúpus Coordinator (Coordenador) Evandro Mendes Klumb, RJ Members (Membros) Cristina Costa Duarte Lanna, MG Eduardo Ferreira Borba Neto, SP Eloisa Silva Dutra de Oliveira Bonfá, SP Emília Inoue Sato, SP Francinne Machado Ribeiro, RJ João Carlos Tavares Brenol, RS Lilian Tereza Lavras Costallat, SP Luiz Carlos Latorre, SP Maria de Fátima Lobato da Cunha, PA Odirlei Andre Monticielo, RS Spinal Commission Comissão de Coluna Vertebral Coordinator (Coordenador) Marcos Renato de Assis, SP Members (Membros) Ari Stiel Radu Halpern, SP Carlos Appel da Silva, RS Jamil Natour, SP Jose Gerardo de Araújo Paiva, CE Luíza Helena Coutinho Ribeiro, SP Maria Amazile Ferreira Toscano, SC Renê Donizeti Ribeiro de Oliveira, SP Silvio Figueira Antonio, SP Osteomethabolic Diseases and Osteoporisis Commission Comissão de Doenças Osteometabólicas e Osteoporose Coordinator (Coordenador) Sebastião Cezar Radominski, PR Members (Membros) Ana Patricia de Paula, DF Caio Moreira, MG Charlles Heldan de Moura Castro, SP Cristiano Augusto de F. Zerbini, SP Elaine de Azevedo, SP Laura Maria C. de Mendonça, RJ Mailze Campos Bezerra, CE Marco Antonio Rocha Loures, PR Vera Lúcia Szejnfeld, SP Spondiloarthropathies Commission Comissão de Espondiloartropatias Coordinator (Coordenador) Célio Roberto Gonçalves, SP RBE Coordinator (Coordenador RBE) Percival Degrava Sampaio Barros, SP Members (Membros) Antonio Carlos Ximenes, GO Eduardo de Souza Meirelles, SP Gustavo Gomes Rezende, MG Ivânio Alves Pereira, SC Marcelo Medeiros Pinheiro, SP Mauro Waldemar Keisermann, RS Thelma Larocca Skare, PR Walber Pinto Vieira, CE Washington Alves Bianchi, RJ Psoriatic Arthritis Subcommission (Sub-Comissão de Artrite Psoriásica) Claudia Goldenstein-Schainberg, SP Roberto Ranza, MG Rubens Bonfiglioli, SP Sueli Coelho da Silva Carneiro, RJ Valderilio Feijó Azevedo, PR Pain, Fibromyalgia and Other Painful Syndromes of the Soft Parts Commission Comissão de Dor, Fibromialgia e Outras Síndromes Dolorosas de Partes Moles Coordinator (Coordenador) Marcelo Cruz Rezende, MS Members (Membros) Aline Ranzolin, PE Daniel Feldman Pollak, SP Eduardo dos Santos Paiva, PR José Eduardo Martinez, SP José Roberto Provenza, SP Marcos Aurélio Freitas Machado, SP Nilton Salles Rosa Neto, SP Rafael Mendonça da Silva Chakr, RS Roberto Ezequiel Heymann, SP Documentation and Historical Registry Commission Comissão de Documentação e Registro Histórico Coordinator (Coordenador) Joaquim Jaguaribe Nava Ribeiro, RJ

Members (Membros) Célio Roberto Gonçalves, SP Henrique Josef, SP José Eduardo Gonçalves, CE José Knoplich, SP José Marques Filho, SP Lauredo Ventura Bandeira, SP Lipe Goldenstein, BA Plínio José Amaral, SP Systemic Sclerosis Commission Comissão de Esclerose Sistêmica Coordinator (Coordenador) Percival Degrava Sampaio-Barros, SP Members (Membros) Adriana Fontes Zimmermann, SC Carolina de Souza Muller, PR Cláudia Tereza Lobato Borges, MA Cristiane Kayser Veiga da Silva, SP Eutília Andrade Medeiros Freire, PB Giselle Baptista Maretti, RJ João Francisco Marques Neto, SP Maria Cecília Fonseca Salgado, RJ Maria de Fátima Lobato da Cunha Sauma, PA Mário Newton Leitão de Azevedo, RJ Sheila Marcia de A. Fontenele, CE Sjögren Syndrome Commission (Comissão de Síndrome de Sjögren) Coordinator (Coordenadora) Valéria Valim Cristo, ES Members (Membros) Érica Vieira Serrano, ES Leandro Augusto Tanure, MG Sandra Gofinet Pasoto, SP Sandra Lucia Euzébio Ribeiro, AM Virginia Fernandes Moça Trevisani, SP Professional Defense Commission (Comissão de Defesa Profissional) Coordinators (Coordenadores) Francisco Deoclécio D. Rocha, RN Vander Fernandes, MT Members (Membros) Francisco Alves Bezerra Neto, RN Matheus Staufackar Carlos, RN Inês Cristina de Mello Lima, AL Mauro Furtado Cavalcante, PI Gout Commission (Comissão de Gota) Coordinator (Coordenador) Geraldo da Rocha Castelar Pinheiro, RJ Members (Membros) Adil Muhib Samara, SP Antonio José Lopes Ferrari, SP Ana Beatriz Vargas dos Santos, RJ Hellen Mary da Silveira de Carvalho, DF Endemic and Infectious Diseases Commission (Comissão de Doenças Endêmicas e Infecciosas) Coordinators (Coordenadores) Izaias Pereira da Costa, MS Sandra Lucia Euzébio Ribeiro, AM Members (Membros) Ana Carolina de Oliveira S. Montandon, GO Helena Lucia A. Pereira, AM Luiz Sergio Guedes Barbosa, MT Mauro Furtado Cavalcanti, PI Natalino Hajime Yoshinari, SP Rejane Maria R. de Abreu, CE Roberta de Almeida Pernambuco, SP Assisted Therapy Immunobiological Centers Commission (Comissão de Centros de Terapia Imunobiológica Assistida) Coordinator (Coordenador) Reno Martins Coelho, RJ Members (Membros) Adrian Nogueira Bueno, MG Ana Teresa Amoedo Medrado, BA Antonio Carlos Scafutto, MG Claudio Goldenstein Schainberg, SP Eliezer Rushansky, PE Evelin D. Goldenberg M. M. da Costa, SP José Eyorand Castelo B Andrade, CE José Roberto Silva Miranda, SP Manoel Barros Bertolo, SP Rafael de Oliveira Fraga, MG Ricardo Jorge de Percia Name, RJ Vander Fernandes, MT Supervisory Board (Conselho Fiscal) Fernando Neubarth, RS Iêda Maria Magalhães Laurindo, SP Geraldo da Rocha Castelar Pinheiro, RJ BSR Regionals Regionais SBR Rheumatology Society of Alagoas Sociedade Alagoana de Reumatologia Dra. Inês Cristina de Mello Rheumatology Society of Amazonas Sociedade Amazonense de Reumatologia Dra. Maria do Socorro A. de Souza Rheumatology Society of Bahia Sociedade Baiana de Reumatologia Dr. Mittermayer Barreto Santiago Rheumatology Society of Brasília Sociedade de Reumatologia de Brasília Dr. Cleandro Pires de Albuquerque Rheumatology Society of Santa Catarina Sociedade Catarinense de Reumatologia Dr. Gláucio Ricardo Werner de Castro Rheumatology Society of Ceará Sociedade Cearense de Reumatologia Dr. José Eyorand Castelo Branco de Andrade Rheumatology Society of Goiânia Sociedade Goiana de Reumatologia Dra. Ana Carolina Oliveira e Silva Montandon Rheumatology Society of Maranhão Sociedade Maranhense de Reumatologia Dra. Raquel Moraes da Rocha Nogueira Rheumatology Society Mato Grosso Associação Mato-Grossense de Reumatologia Dr. Vander Fernandes Rheumatology Society of Minas Gerais Sociedade Mineira de Reumatologia Dr. Rafael de Oliveira Fraga Rheumatology Society of São Paulo Sociedade Paulista de Reumatologia Dr. Paulo Louzada-Junior Rheumatology Society of Pará Sociedade Paraense de Reumatologia Dr. Otávio Augusto Gomes da Paz Rheumatology Society of Paraíba Sociedade Paraibana de Reumatologia Dra. Danielle Christinne Soares Egypto de Brito Rheumatology Society of Paraná Sociedade Paranaense de Reumatologia Dr. Eduardo Santos Paiva Rheumatology Society of Pernambuco Sociedade Pernambucana de Reumatologia Dra. Lílian David de Azevedo Valadares Rheumatology Society of Piauí Sociedade Piauiense de Reumatologia Dra. Aline do Socorro Miranda Ribeiro Rheumatology Society of Espírito Santo Sociedade de Reumatologia do Espírito Santo Dr. José Roberto Pereira Santos Rheumatology Society of Mato Grosso do Sul Sociedade de Reumatologia do Mato Grosso do Sul Dr. Marcelo Cruz Rezende Rheumatology Society of Rio de Janeiro Sociedade de Reumatologia do Rio de Janeiro Dr. Evandro Mendes Klumb Rheumatology Society of Rio Grande do Norte Sociedade de Reumatologia do Rio Grande do Norte Dr. Francisco Deoclécio Damasceno Rocha Rheumatology Society of Rio Grande do Sul Sociedade de Reumatologia do Rio Grande do Sul Dr. Marco Aurélio Goldenfum Rheumatology Society of Sergipe Sociedade Sergipana de Reumatologia Dra. Regina Adalva de Lucena Couto Ocea Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia) Avenida Brigadeiro Luiz Antonio, 2.466 conjs. 93-94 CEP: 01402-000 São Paulo, SP, Brasil Phone/Fax: 55 11 3289-7165 E-mail: rbreumatol@terra.com.br, sbre@terra.com.br Website: www.reumatologia.com.br

REVISTA BRASILEIRA DE REUMATOLOGIA www.reumatologia.com.br Volume 53. Number 2. March/April 2013 Volume 53. Número 2. Março/Abril 2013 CONTENTS SUMÁRIO Editorial Editorial Alexander and the Guidelines the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis Alexandre e as Diretrizes a importância da estratégia e as Diretrizes para diagnóstico e tratamento medicamentoso da artrite reumatoide Licia Maria Henrique da Mota, Geraldo da Rocha Castelar Pinheiro... 137 Antiphospholipid syndrome Síndrome do anticorpo antifosfolipídeo Adriana Danowski, Roger A. Levy... 139 Guidelines Documentos de Diretrizes Guidelines for the diagnosis of rheumatoid arthritis Diretrizes para o diagnóstico da artrite reumatoide Sociedade Brasileira de Reumatologia, Sociedade Brasileira de Pneumologia e Tisiologia, Colégio Brasileiro de Radiologia... 141 Guidelines for the drug treatment of rheumatoid arthritis Diretrizes para o tratamento da artrite reumatoide Sociedade Brasileira de Reumatologia... 158 Guidelines for the treatment of antiphospholipid syndrome Diretrizes para o tratamento da síndrome do anticorpo antifosfolipídeo Adriana Danowski, Jozelia Rego, Adriana M. Kakehasi, Andreas Funke, Jozelio Freire de Carvalho, Isabella V. S. Lima, Alexandre Wagner Silva de Souza, Roger A. Levy... 184 Original Articles Artigos Originais Resistance training versus weight-bearing aquatic exercise: a cross-sectional analysis of bone mineral density in postmenopausal women Treinamento de força versus hidroginástica: uma análise transversal comparativa da densidade mineral óssea em mulheres na pós-menopausa Sandor Balsamo, Licia Maria Henrique da Mota, Frederico dos Santos de Santana, Dahan da Cunha Nascimento, Lídia Mara Aguiar Bezerra, Denise Osti Coscrato Balsamo, João Lindolfo Cunha Borges, Ana Patrícia de Paula, Martim Bottaro... 193

Lack of association between interleukin-18 polymorphisms and rheumatoid arthritis Ausência de associação entre os polimorfismos do gene interleucina-18 e artrite reumatoide Ticiana Della Justina Farias, Luisa Matos do Canto, Mayara Delagnelo Medeiros, Aline Fernanda Rodrigues Sereia, Lia Kubelka Fernandes de Carlos Back, Filipe Martins de Mello, Adriana Fontes Zimmermann, Ivânio Alves Pereira, Yara Costa Netto Muniz, Andrea Rita Marrero, Ilíada Rainha de Souza... 199 Review Articles Artigos de Revisão What a rheumatologist needs to know about yellow fever vaccine O que o reumatologista deve saber sobre a vacina contra febre amarela Ana Cristina Vanderley Oliveira, Licia Maria Henrique da Mota, Leopoldo Luís dos Santos-Neto, Pedro Luiz Tauil... 206 Update on the treatment of calcinosis in dermatomyositis Atualização na terapêutica da calcinose em dermatomiosite Samuel Katsuyuki Shinjo, Fernando Henrique Carlos de Souza... 211 Case Reports Relatos de Caso Chondrolysis of the hip in an adolescent: clinical and radiological outcomes Condrólise de quadril em uma adolescente: evolução clínica e radiológica Ana Paula Sakamoto, Larissa Lucati Ramos, Artur da Rocha Corrêa Fernandes, Maria Teresa Terreri 215 Mesenteric vasculitis in a juvenile systemic lupus erythematosus patient Vasculite mesentérica em paciente com lúpus eritematoso sistêmico juvenil Adão F. Albuquerque-Netto, Erica G. Cavalcante, Adriana M. E. Sallum, Nádia E. Aikawa, Uenis Tannuri, Clovis Artur Almeida da Silva... 219 Erratum Errata The quality of life of patients with lúpus erythematosus influences cardiovascular capacity in 6-minute walk test Qualidade de vida de pacientes com lúpus eritematoso influencia a capacidade cardiovascular em teste de caminhada de 6 minutos [Rev Bras Reumatol 2013;53(1):75-87] Sandor Balsamo, Dahan da Cunha Nascimento, Ramires Alsamir Tibana, Frederico Santos de Santana, Licia Maria Henrique da Mota, Leopoldo Luiz dos Santos-Neto... 223

REV BRAS REUMATOL. 2013;53(2):137 138 REVISTA BRASILEIRA DE REUMATOLOGIA www.reumatologia.com.br Editorial Alexander and the Guidelines the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis Alexander and the Guidelines the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis Alexander III, who would enter History as the Great, son of Philip II and Olympias, was born in Pella, the capital of the Ancient Greek Kingdom of Macedon, in the year 356 b.c. When he died, at the age of 33 years, somewhere in Babylon, he had conquered all the world then known and had the following titles King of Macedon, King of Greece, Lord of Asia, Shahanshah of Persia, Pharaoh of Egypt and Hegemon of the Hellenic League. As his greatest legacy, Alexander had fused the Greek culture to the Eastern culture, forming the base of the later called Hellenistic Civilization, which influenced profoundly several aspects of the current Western culture. 1 But why are we writing about Alexander, the Great, in a scientific editorial on the guidelines for rheumatoid arthritis (RA)? Because Alexander was, more than a great conqueror, a brilliant strategist, maybe the greatest in entire History. The word strategy comes from the ancient Greek (stratos, army, and ago, leadership or command ), and designated the military commander at the time of Athenian democracy. Currently, the term strategy can be understood as a way to plan the future, integrated in the decision making process and based on a formalized procedure that articulates results. Using the figure of a great strategist to illustrate the elaboration and publication of guidelines is part of the strategy of the Brazilian Society of Rheumatology (SBR) to spread and implant knowledge based on scientific evidence for the diagnosis and treatment of RA in Brazil. Rheumatoid arthritis is a chronic systemic disease, usually progressive, that affects 0.5% 1% of the world population, characterized by inflammatory involvement of the synovial membrane, mainly in peripheral joints. The daily fight of rheumatologists against that disease comprises treating the pain and preventing or delaying both structural joint damage and functional and labor disability, in addition to preventing early mortality of the patients. Success in this battle depends mainly on the adoption of proper strategies, including early diagnosis and adequate treatment as soon as possible in the RA natural history. The SBR, through its Rheumatoid Arthritis Committee, has elaborated over the past two years four consensual documents guiding the diagnosis and treatment of RA in Brazil, including peculiarities such as management of comorbidities and vaccination of patients immunosuppressed by the disease and its treatment. 2 5 Consensus documents are educational instruments, rather than normative guidelines, that allow their authors to add information originating from experience and experts opinion to scientific evidence. If, as a publication, the consensus loses in grade of recommendation and level of evidence, it gains as an educational tool to prize the experience of those who deal with daily practice difficulties in managing the disease. 6,7 The Guidelines Project of the Brazilian Medical Association (AMB) and the Federal Board of Medicine (CFM), was aimed at producing diagnostic, therapeutic and, when applicable, preventive guidance, based on scientific evidence, conciliating information of the medical area to standardize management that helps physician s reasoning and decision making. The documents present the grade of recommendation and level of scientific evidence published, preserving in its elaboration the autonomy of the authors, medical experts, of the texts. 8 Thus, that was the strategy of the Rheumatoid Arthritis Committee when elaborating both documents presented in this issue of the Revista Brasileira de Reumatologia the Guidelines for the Diagnosis of RA 9 and the Guidelines for the Medicamentous Treatment of RA. 10 The elaboration of the texts carefully followed the recommendations of the AMB and the CFM, the result being evidence-based responses to the following questions: Are the new 2010 ACR/EULAR classification criteria for RA superior to the 1987 classification criteria of the early phase of disease? Are genetic markers (search for HLA-DRB1 alleles shared epitope and PTPN22 genes) 0482-5004/$ - see front matter. 2013 Elsevier Editora Ltda. All rights reserved.

138 REV BRAS REUMATOL. 2013;53(2):137 138 useful to characterize patients with poorer prognosis of RA? Is it feasible to treat the disease to achieve remission? Does the use of corticosteroids in the early phase of disease improve the patient s prognosis? Although the personality and some actions of Alexander the Great might be questioned, studying how he managed his armies and his actions to conquer Persia and Asia, including the historical battles of Gaugamela, Issus, Granicus and Hydaspes, leads us to conclude that there is a close relationship between the success achieved by Alexander and the proper use of the entire management process, formally conceived and used to a specific purpose, i.e., the implementation of strategies. 11 We hope that, by reading and applying the strategies proposed by the guidelines currently published, rheumatologists, and, to a lesser extent, their patients, can be as victorious in their fight against RA as was the magnificent strategist Alexander in his many battles. And it happened afterwards that Alexander, the son of Philip the Macedonian, who first reigned in Greece having come from the land of Kittim, struck Darius the king of the Persians and the Medes. He appointed many battles, and took hold of all the fortifications and he executed the kings of the earth. And he passed through even to the ends of the earth. And he received the spoils of many nations. And the earth was silenced in his sight. Maccabees 1, 1-3 Licia Maria Henrique da Mota Medical School, Universidade de Brasília (UnB), Brasília, DF, Brazil Brazilian Society of Rheumatology Rheumatoid Arthritis Committee E-mail: liciamhmota@gmail.com Geraldo da Rocha Castelar Pinheiro Discipline of Rheumatology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil REFERENCES 1. Bose P. Alexander the Great s Art of Strategy. Crows Nest, N.S.W: Allen & Unwin; 2003. 2. Mota LMH, Cruz BA, Brenol CV, Pereira IA, Fronza LS, Bertolo MB, et al. 2011 Consensus of the Brazilian Society of Rheumatology for diagnosis and earlyassessment of rheumatoid arthritis. Rev Bras Reumatol. 2011;51(3):199-219. 3. da Mota LM, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al.; Brazilian Society of Rheumatology. 2012 Brazilian Society of Rheumatology Consensus for the treatment of rheumatoid arthritis. Rev Bras Reumatol. 2012;52(2):152-74. 4. Pereira IA, Mota LM, Cruz BA, Brenol CV, Fronza LS, Bertolo MB, et al.; Brazilian Society of Rheumatology. 2012 Brazilian Society of Rheumatology Consensus on the management of comorbidities in patients with rheumatoid arthritis. Rev Bras Reumatol. 2012;52(4):474-95. 5. Brenol CV, Mota LCH, Cruz BA, Pileggi GS, Pereira IA, Rezende LS, et al. Consenso 2012 da Sociedade Brasileira de Reumatologia sobre vacinação em pacientes com artrite reumatoide. Rev Bras Reumatol. 2013;53(1):4-23. 6. da Mota LM. Considerations about the 2011 consensus of the Brazilian Society of Rheumatology for diagnosis and early assessment of rheumatoid arthritis. Rev Bras Reumatol. 2011;51(3):197-8. 7. Mota LM. On mosaics and consensus: Gaudí, Brazil and rheumatoid arthritis. Rev Bras Reumatol. 2012;52(2):133-4. 8. Projeto Diretrizes. [Accessed on: 22 fevereiro 2013] Available from: http://www.projetodiretrizes.org.br. 9. Mota LMH, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al., Sociedade Brasileira de Reumatologia, Sociedade Brasileira de Pneumologia e Tisiologia, Colégio Brasileiro de Radiologia. Diretrizes para o diagnóstico da artrite reumatoide. Rev Bras Reumatol. 2013;53(2):141-57. 10. Mota LMH, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al., Sociedade Brasileira de Reumatologia. Diretrizes para o tratamento da artrite reumatoide. Rev Bras Reumatol. 2013;53(2):158-83. 11. Rodrigues RC. Alexandre, o Grande, e a informação para o planejamento estratégico. Inf Soc. 2007;17(2):74-85.

REV BRAS REUMATOL. 2013;53(2):139 140 REVISTA BRASILEIRA DE REUMATOLOGIA www.reumatologia.com.br Editorial Antiphospholipid syndrome The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombosis, gestational morbidity and presence of elevated and persistently positive levels of antiphospholipid antibodies. 1 The treatment of APS is controversial, especially because of the absence of good quality clinical studies. In the primary prevention of thrombosis, clinical studies report different results. 2,3 The association of risk factors with thrombotic events and the type and number of positive antiphospholipid antibodies are current concepts and should be considered in the therapeutic decision, be it medicamentous or a change in lifestyle. Full anticoagulation for undetermined time is indicated for secondary prevention, but the therapeutic target is still discussed. Although retrospective studies have suggested a lower number of recurrences with an elevated international normalized ratio (INR), prospective studies do not corroborate such findings. 4,5 However, the inclusion of patients with arterial thrombosis in those protocols was small, making the definitive conclusion about the target INR in APS difficult. The obstetric questions have also generated discussion: teratogenicity associated with warfarin 6 and the dosing of heparin in patients with vascular APS have little scientific evidence. 7 International efforts aimed at designing and conducting good quality prospective studies for patients with antiphospholipid antibodies, such as the creation of a multicenter data bank, have been observed. 8 Thus, new perspectives arise and, in the near future, we will have answers based on better evidence regarding the treatment of APS, including the use of hydroxychloroquine for primary prevention, the use of new anticoagulants, and biologic therapy. In face of the need to improve understanding and treatment, and to establish recommendations for rheumatologists and other specialists about the management of APS, the Committee of Vasculopathies and APS of the Brazilian Society of Rheumatology (SBR), with the support of the Brazilian Medical Association (AMB), publishes this guideline, elaborated from nine relevant and controversial clinical questions related to the treatment of APS, based on the best scientific evidence available. Once finished this first publication, our committee proceeds to the objectives established for the next two years: elaboration and publication of guidelines for the diagnosis of APS and elaboration and publication of guidelines and manuals for patients with Granulomatosis with Polyangiitis and Takayasu s Artheritis. In addition, the committee has been working along with AMB to include the following tests in the table of procedures: IgM/IgG anti-beta 2-glycoprotein I test; IgA anticardiolipin test; antiproteinase 3 test; and antimyeloperoxidase test. REFERENCES Adriana Danowski Hospital Federal dos Servidores do Estado (HFSE), Rio de Janeiro, RJ, Brazil E-mail: adrid@globo.com Roger A. Levy Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil 1. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update to the classification for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006;4:295-306. 2. Tarr T, Lakos G, Bhattoa HP, Shoenfeld Y, Szegedi G, Kiss E. Analysis of risk factors for the development of thrombotic complications in antiphospholipid antibody positive lupus patients. Lupus. 2007;16:39-45. 3. Erkan D, Harrison MJ, Levy RA, Peterson M, Petri M, Sammaritano L, et al. Aspirin for primary thrombosis prevention in the antiphospholipid syndrome: a randomized, double-blind, placebo-controlled trial in asymptomatic antiphospholipid antibodypositive individuals. Arthritis Rheum. 2007;56:2382-91. 4. Finazzi G, Marchioli R, Brancaccio V, Schinco P, Wisloff F, Musial J, et al. A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS). J Thromb Haemost. 2005;3:848-53. 5. Crowther MA, Ginsberg JS, Julian J, Denburg J, Hirsh J, Douketis J, et al. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med. 2003;349:1133-8. 0482-5004/$ - see front matter. 2013 Elsevier Editora Ltda. All rights reserved.

140 REV BRAS REUMATOL. 2013;53(2):139 140 6. Levy RA, Jesús GR, Jesús NR. Obstetric antiphospholipid syndrome: still a challenge. Lupus. 2010;19:457-9. 7. Hunt BJ, Gattens M, Khamashta M, Nelson-Piercy C, Almeida A. Thromboprophylaxis with unmonitored intermediate-dose low molecular weight heparin in pregnancies with a previous arterial or venous thrombotic event. Blood Coagul Fibrinolysis. 2003;14:735-9. 8. APS ACTION AntiPhospholipid Syndrome Alliance For Clinical Trials and InternatiOnal Networking. D Erkan, MD Lockshin on behalf of APS ACTION members. Lupus. 2012;21:695-8.

REV BRAS REUMATOL. 2013;53(2):141 157 REVISTA BRASILEIRA DE REUMATOLOGIA www.reumatologia.com.br Guidelines Guidelines for the diagnosis of rheumatoid arthritis Diretrizes para o diagnóstico da artrite reumatoide Sociedade Brasileira de Reumatologia, Sociedade Brasileira de Pneumologia e Tisiologia, Colégio Brasileiro de Radiologia (Brazilian Society of Rheumatology, Brazilian Society of Pneumology and Tuberculosis, Brazilian College of Radiology) Projeto Diretrizes da Associação Médica Brasileira, São Paulo, SP, Brazil Participants Licia Maria Henrique da Mota*, Bóris Afonso Cruz, Claiton Viegas Brenol, Ivânio Alves Pereira, Lucila Stange Rezende-Fronza, Manoel Barros Bertolo, Max Vitor Carioca Freitas, Nilzio Antônio da Silva, Paulo Louzada-Junior, Rina Dalva Neubarth Giorgio, Rodrigo Aires Corrêa Lima, Ronaldo Adib Kairalla, Alexandre de Melo Kawassaki, Wanderley Marques Bernardo, Geraldo da Rocha Castelar Pinheiro Final elaboration 12 April 2012 Description of the evidence collection method A review of the scientific literature was performed with the Medline database. The search for evidence was based on actual clinical scenarios and used the following Medical Subject Headings (MeSH) terms: Arthritis, Rheumatoid, Diagnosis (Delayed Diagnosis OR Delay OR Early Rheumatoid Arthritis OR VERA), Prognosis, Criteria (American College of Rheumatology/European League Against Rheumatism OR ACR/EULAR OR classification), Comparative Study, Smoking (OR tobacco use disorder), Rheumatoid Factor, Anti-cyclic Citrullinated Peptide (or anti-ccp), HLA-DRB1 OR PTPN22 OR EPITOPE, extra-articular OR extraarticular OR systemic OR ExRA, Disease Progression, Radiography OR X RAY, ULTRASONOGRAPHY, and MAGNETIC RESONANCE Grades of recommendation and strength of evidence A: Most consistent experimental and observational studies. B: Less consistent experimental and observational studies. C: Case reports (uncontrolled studies). D: Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models. Objective To formulate guidelines for the management of rheumatoid arthritis (RA) in Brazil, with a focus on diagnosis. The aim of the present document is to summarise the current position of the Brazilian Society of Rheumatology on this topic to orient Brazilian doctors, particularly rheumatologists, to RA diagnosis in our country. Introduction Rheumatoid arthritis (RA) is a chronic, progressive, and systemic inflammatory disease that preferentially affects the synovial membranes of joints and eventually leads to bone and cartilage destruction 1 (D). RA affects 0.5% 1% of the adult population worldwide; the disease targets patients from every ethnic background 2 (D) and predominately affects females (2- or 3-fold more often than males). Although RA can occur at any age, it is more frequent among individuals in the fourth to sixth decades of life 3 (D). A Brazilian multicentre study conducted with samples from the various macro-regions found a prevalence of up to 1% in Brazil s adult population 4 (B), which corresponds to 1,300,000 people. As a chronic disease that causes irreversible joint damage, RA exacts high costs from both the patients and society at large 5 (B) 6,7 (D). * Corresponding author. E-mail: liciamhmota@gmail.com (L.M.H Mota) 0482-5004/$ - see front matter. 2013 Elsevier Editora Ltda. All rights reserved.

142 REV BRAS REUMATOL. 2013;53(2):141 157 In recent years, significant advances have been achieved in understanding the physiopathogenesis, diagnostic methods, and therapeutic management of RA. Among these advances, the recently attributed significance of the early disease stages or so-called early RA (first 12 months with RA symptoms) stands out as an acknowledged window of therapeutic opportunity 8 (B) 9,10 (D). However, despite all advances, the currently available (clinical, laboratory, and radiological) diagnostic and prognostic indicators are of limited value to early diagnoses and individual prognoses 11 (B). The demographic and clinical features of RA vary as a function of the affected population 12 (B). Most available data correspond to populations in Europe and the United States 13,14 (D). Few studies have been conducted on the Brazilian population 15,16 (B). RA affects mostly individuals within the economically productive age range, and the disease eventually imposes significant limitations on their functional ability that result in the loss of work abilities. For these reasons, the indirect costs associated with RA must be included in pharmacoeconomic studies 17 (B). In Brazil and industrialised countries, the costs associated with RA are high 18 (B). The impact of the expenses associated with RA is more remarkable in developing countries in which the financial resources allocated to healthcare are less robust. This situation points to the relevance of studies adapted to Brazilian conditions that assess the costs and allocation of resources for the diagnosis and treatment of RA 19 (B). RA diagnosis is based on clinical findings and complementary diagnostic tests. No single laboratory, imaging, or histopathological test alone can confirm a diagnosis. Several illnesses that present with arthritis must be considered in the differential diagnosis of RA 20-22 (D), as described in Table 1. Diagnosis is easier when RA presents with the well-known pattern and the full range of typical symptoms. Diagnosis might be difficult in the early stages of disease because the characteristic serologic and radiological alterations are often absent 23 (D). The clinical manifestations of RA can be classified as articular and extra-articular. As RA is a systemic disease, general symptoms such as fever, asthenia, fatigue, myalgia, and weight loss can appear before or concomitantly with the onset of the articular manifestations 24 (D). Articular manifestations Although the articular manifestations of RA might be reversible in the early stages, persistent and uncontrolled synovitis leads to bone and cartilage destruction and irreversible tendon and ligament injuries. The basic factor behind RA articular manifestations is synovial inflammation (synovitis), which can affect any diarthrodial joint in the body. The clinical complaints include pain, swelling, and motion limitations of the affected joints. A physical examination will disclose the presence of pain, increased joint volume, intraarticular effusion, heat, and eventual redness. Those findings might not be evident in deep joints such as the hips and shoulders 24 (D). The characteristic features of arthritis in RA are as follows 24 (D): a) Polyarticular affection: usually involving more than four joints. Nevertheless, RA might begin and eventually remain as mono- or oligoarthritis. b) Hand and wrist arthritis: affections of the wrist, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints are frequent from the very early disease stages. The distal interphalangeal (DIP) joints are seldom affected, a feature that distinguishes RA from other conditions such as osteoarthritis and psoriatic arthritis. c) Symmetric arthritis: symmetric affection of joints is a common finding, although not mandatorily absolute in cases of the PIP, MCP, and metatarsophalangeal (MTP) joints. d) Cumulative or additive arthritis: arthritis usually exhibits a cumulative pattern (progressive affection of new joints concomitant to inflammation of the previously affected ones). e) Morning stiffness: prolonged stiffness that appears in the morning, which is accompanied by a sensation of swelling, is near-universal feature of synovial inflammation. Unlike the short-lasting (5 10 minutes, as a rule) variety observed in osteoarthritis, in inflammatory diseases, stiffness tends to last for more than 1 hour. This phenomenon is associated with immobility that occurs concomitantly to the state of sleep or rest, rather than to a particular time of the day. The duration of stiffness tends to correlate with the degree of inflammation and is an important parameter in follow-up evaluations 25 (B) 26 (C). Extra-articular manifestations Although the articular manifestations are the most characteristic, other organs and systems can also be affected by RA. The most common extra-articular manifestations of Table 1 Differential diagnoses of arthritis. Classes of diseases Diseases Infections Spondyloarthritis Systemic rheumatic diseases Microcrystalline arthritis Endocrine diseases Neoplastic diseases Others Viral (e.g. dengue, human immunodeficiency virus HIV, parvovirus, cytomegalovirus, hepatitis), bacterial (e.g. N. gonorrhoeae, S. aureus), microbacterial, fungal, and others Reactive arthritis (Chlamydia, Salmonella, Shigella, Yersinia), ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis Systemic lupus erythematosus, polymyositis/dermatomyositis, systemic sclerosis, Sjögren s syndrome, Behçet s disease, rheumatic polymyalgia, systemic vasculitis, and others Gout, calcium pyrophosphate deposition disease, and others Hypothyroidism, hyperthyroidism Metastatic neoplastic disease, lymphoma, paraneoplastic syndromes, and others Osteoarthritis, haemochromatosis, amyloidosis, sarcoidosis, serum sickness

REV BRAS REUMATOL. 2013;53(2):141 157 143 RA include skin, eye, pleuropulmonary, heart, blood, neurological, and osteo-metabolic conditions. These occur more often in patients with severe and polyarticular disease, positive serology for the rheumatoid factor (RF) or cyclic citrullinated peptide antibodies (anti-ccp), and rheumatoid nodules 27 (B) 28 (D). Brazilian studies confirmed that the initial manifestations of RA include polyarticular affection with persistent synovitis in the hands, long-lasting morning stiffness, a large number of painful and swollen joints, and fatigue 15,16 (B). 1. Is diagnosis of RA within the first 12 months of symptoms (early RA) associated with better radiological and functional prognosis, compared to later diagnosis? The modern differentiation of RA from other joint diseases dates from 1907. As no pathognomonic traits allow a distinction among the various types of arthritis in their early stages, the exact moment at which RA begins to progress as a separate entity from other articular illnesses is unknown 12 (B). The definition of early RA is important from both the theoretical and practical perspectives, although the terms early and RA might be addressed independently, particularly because the criteria applied to these classifications are based on established RA 13 (D). Although controversial, early RA might be defined as the initial stage of disease or a window of therapeutic opportunity in which adequate therapy might modify the disease progression; the prognosis in this stage is better than that of later stages 14 (D). The required symptom duration for the definition of early RA varies widely in the specialised literature. Historically, any RA of a duration less than five years has been characterised as early 15 (B). However, together with the notion of a window of opportunity, the original length of early RA needed to be restricted. Starting in the early 90 s, early RA was consistently defined as the presence of symptoms for less than 24 months, with the main emphasis on the first 12 months of clinical manifestations 16 (B). The current indications are to assess patients with articular symptoms as soon as possible and to limit the early stage of RA to the first weeks or months of symptoms (as a rule, less than 12 months). In particular, the first 12 weeks are a critical period known as very early RA (VERA), while patients with more than 12 weeks but fewer than 12 months of articular symptoms are classified as so-called late early RA (LERA) 17 (B). The proportion of rheumatologists with opportunities to assess patients within the first six weeks of symptoms increased from 9% in 1997 to 17% in 2003; however, not every case is liable to such early assessment 18 (B). Even while admitting imprecisions in the definition of early RA, several authors have suggested that a substantial proportion of the cases with short-lasting (less than eight weeks) inflammatory arthritis exhibit spontaneous resolution, while only the few patients with persistent clinical manifestations progress into proper RA 19 (B) 20-22 (D). Thus, the establishment of clinical, serologic, or genetic markers that can identify patients who will progress to RA at the earliest stages and consequently will need appropriate treatments to reduce the odds of developing persistent disease and articular damage is of paramount importance. The average time for the first visit of RA patients with a rheumatologist is 17 months, and 19 months usually elapse before the first administration of disease-modifying antirheumatic drugs (DMARDs). Factors such as education, the number of swollen joints, age, and occupation are associated with such delays 29 (B). Arthritis is characterised by articular swelling that is associated with pain or stiffness. Cases that involve more than one articulation should be referred to a rheumatologist, ideally within the first six weeks following the onset of symptoms 30 (D). For cases in which articular swelling was present only during the first year of disease, the risk of articular erosion was reduced by five years (NNT: 4), compared to those patients with joint swelling throughout the follow-up period 31 (B). RA diagnosis within the first three months of VERA was predictive of clinical (American College of Rheumatology ACR) and radiological (Sharp score) remission 32 (B). The early identification of some factors allows clinicians to predict whether the RA lesions will exhibit radiological progression in the following 12 months. These factors include the Sharp score and modified Total Sharp Score (mtss), the presence of autoantibodies such as RF and anti-ccp, and increased acute-phase reactants such as an erythrocyte sedimentation rate (ESR) greater than 28 mm and an average C- reactive protein (CRP) level of 10 mg/l 33 (B). The higher the erosion score at the onset of treatment, the worse the 10-year radiological prognosis (Sharp score) 34 (B). Early (within the first year) calculations of the Sharp, erosion, and reduced joint space scores permitted predictions of the radiological progression of RA patients who were followed-up for three years 35 (B). In spite of the early (three to six months from the beginning of symptoms) administration of DMARD treatment, 63.6% of the patients exhibited erosion three years later due to constitutional factors such as the presence of autoantibodies (e.g. RF or anti-ccp) and the length of disease activity (CRP, joint swelling, and response to treatment) 36 (B). The duration of RA interferes with the functional prognosis, which is measured by means of the Health Assessment Questionnaire (HAQ) and is independent of the baseline values 37 (B). When DMARD treatment was initiated within the first year of disease (average symptom duration, six months), the radiological progression (Ratingen score) was reduced at the 5-year follow-up 38 (B). In patients with symptom durations less than 12 weeks who were treated for RA, the radiological progression (Sharpvan der Heijde score, SHS) was reduced after six years of follow-up. Sustained DMARD-induced remission was 8% higher (NNT: 13) in patients with symptom durations less than 12 weeks 39 (B). DMARD treatment of RA patients within the first year of disease induced better functional (Keitel Functional Test KFT) and clinical (joint swelling) progression at a 10-year

144 REV BRAS REUMATOL. 2013;53(2):141 157 follow-up, compared to those who were treated one to five years after disease onset 40 (B). Recommendation Diagnosis of RA with a symptom duration of less than 12 months (early RA) is of paramount importance because early diagnosis exerts beneficial effects on radiological and functional prognoses compared to later diagnosis. 2. Are the new 2010 ACR/European league against rheumatism (EULAR) classification criteria for RA superior to the 1987 classification criteria for the early disease stage? RA classifications were essentially based on the criteria formulated by the ACR in 1987 41 (B), which are described in Table 2. However, those criteria did not perform well in early RA cases 42 (B). The ACR classification criteria for RA were based on individuals with long-standing disease and, until then, were considered to be the standard for the selection of patients for clinical studies. These criteria exhibit 91% 94% sensitivity and 89% specificity for established RA. However, some of the items, such as radiological changes (erosions) and rheumatoid nodules, do not occur often in early RA. Thus, such criteria are suboptimal for the identification of individuals with early RA (40% 90% sensitivity, and 50% 90% specificity) 43 (B). Table 2 1987 American College of Rheumatology classification criteria for rheumatoid arthritis. Criteria Definition 1. Morning stiffness Morning stiffness lasting at least 1 hour before maximal improvement 2. Arthritis of 3 or more joint areas At least three joint areas simultaneously affected and observed by a physician. The possible areas include the right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints. 3. Arthritis of hand joints Arthritis in wrist, MCP, or PIP joint 4. Symmetric arthritis Simultaneous involvement of the same joint areas on both sides of the body. 5. Rheumatoid nodules Subcutaneous nodules over bony prominences, extensor surfaces, or in juxta-articular regions as observed by a physician 6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoid factor. 7. Radiographic changes Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs showing juxta-articular bone thinning or erosions For classification purposes, a patient shall be said to have rheumatoid arthritis if he/she has satisfied at least four or these seven criteria. Criteria 1 through 4 must have been present for at least six weeks. Modified from: Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;31:315-24. As a result, new RA classification criteria were needed, with a special focus on the early disease stages 14 (D). The new ACR/EULAR classification criteria can be applied to any patient, provided that two basic requirements are met as follows: 1) Evidence of active clinical synovitis in at least one joint at the time of examination. 2) Synovitis cannot be better explained by another disease. The new criteria (Table 3) are based on a score system that is calculated by direct addition. The clinical manifestations are grouped into the following four domains: joint involvement, serology, duration of symptoms, and acute-phase reactants. In questionable cases, the number of involved joints can be calculated by the use of imaging methods such as ultrasound (US) and magnetic resonance (MRI). A score > 6 is needed to classify a patient as having definite RA 44 (B). These criteria can be applied both prospectively and retrospectively, provided that the data were properly recorded. It is worth observing that whenever a patient exhibits typical erosions upon radiological examination and a clinical history compatible with RA (albeit non-documented), RA diagnosis can be directly established in a manner independent of the applicability of the classification criteria 14 (D). The new 2010 criteria were not developed for the purpose of diagnosis but rather of classification. The criteria basically serve to select homogeneous populations for studies. Clinical RA diagnoses are extremely complex and includes multiple features that are hard to reconcile with a single scoring system 14 (D). Eventually, the formal criteria might serve to guide clinical diagnoses. Several features of the new criteria must be subjected to careful analysis before they can be universally accepted. In particular, the criteria must be validated in different populations, including Brazilian early RA cohorts. In patients who use methotrexate and those with persistent RA, the discriminatory powers of the 2010 ACR/EULAR criteria were 76% and 87%, respectively, when the score was at least 6, and 63% and 46%, respectively, when it was < 6 45 (B). Assuming the need for methotrexate, a diagnostic gold standard, during the first year of follow-up, the 2010 ACR/EU- LAR criteria were able to diagnose 86% of the cases for which the score was at least 6 and 49% when it was < 6 45, compared to 87% and 41%, respectively, when the 1987 ACR criteria were used 46 (B). A comparison of the 2010 ACR/EULAR (score of at least 6) and 1987 ACR (score > 4) criteria relative to the diagnosis of patients with a disease duration of less than 12 months showed positive predictive values of 70.7% and 65.3%, respectively, and negative predictive values of 76.1% and 79.1%, respectively 47 (B). The discriminatory powers of the 2010 ACR/EULAR and 1987 ACR criteria during an 18-month follow-up period were compared and are shown in Table 4. The application of the 2010 ACR/EULAR criteria at disease onset detected more patients who required DMARD treatment than did the 1987 ACR criteria; the values were 62% and 38%, respectively, and more particularly with regard to the use of methotrexate during the 18-month follow-up, the values were 68% versus 42%, respectively. However, the 2010 ACR/EULAR criteria were associated with a higher rate of false-positive cases (8% versus 2% for the 1987 ACR criteria) 48 (B).