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Patient global assessment (PGA) is included in almost all rheumatoid arthritis (RA) composite disease activity indices and definitions of remission. However, different PGA formulations exist and are used interchangeably in research and clinical practice. We investigated how five different PGA formulations used in four disease indices affect the remission rates. This was an ancillary analysis of data from a cross-sectional study in patients with RA. The data comprised the following: 28-joint counts, C-reactive protein, and five PGA formulations. Remission rate variation was assessed using five PGA formulations in each index (ACR/EULAR Boolean, CDAI, SDAI, and DAS28-CRP). PGA agreement was assessed by the following: Pearson's correlation; Bland-Altman plots; paired samples t test; and establishing the proportion of patients who scored (i) all formulations within an interval of 20 mm and (ii) each formulation ≤ 10 mm. This analysis included 191 patients. PGA formulations presented good correlations (≥ 0.65), but Bland-Altman plots showed clinically significant differences, which were statistically confirmed by comparison of means. Just over a half (51.8%) of patients scored all PGA formulations within a 20-mm interval. The proportion of those scoring ≤ 10 mm varied from 11.5 to 16.2%. When different formulations of PGA were used in each index, remission differences of up to 4.7, 4.7, 6.3, and 5.2% were observed. When formulations were used in their respective indices, as validated, the remission rates were similar (13.1, 13.6, 14.1, and 18.3%). Using PGA formulations interchangeably may have implications in the assessment of disease activity and in the attainment of remission, and this can impact upon management decisions.

Subcutaneous emphysema is the presence of air beneath the skin’s soft tissues. It can result from medical conditions, trauma or iatrogenic causes. The occurrence of subcutaneous emphysema after a dental procedure is rare. Although it is mostly a benign and self-limiting complication, the consequences may be severe and life-threatening. We report the case of a 20-year-old man who presented to the emergency department with swelling of his face and neck after dental treatment. The diagnosis of subcutaneous emphysema and pneumomediastinum was made based on physical examination and a computerized tomography scan.

BackgroundPatient global perception of disease activity is included in the different indices of disease activity in Rheumatoid Arthritis (RA). However, patients and physicians frequently disagree in their assessment of this parameter.ObjectivesWith this study we aim to evaluate the extent of this discrepancy and explore its determinants.MethodsConsecutive RA patients followed in a Tertiary Rheumatology Department were included in this cross-sectional study. Patient demographics and clinical data were collected through a standardized protocol which includes age, gender, educational level, disease duration, DAS283v (and its individual measures), Hospital Anxiety and Depression Scale (HADS), Happiness Scale (HS), Health Assessment Questionnaire (HAQ), Pain (VAS 0-100 mm),Fatigue (VAS 0-100 mm), Mobility and Deformity in patient perception (0-100mm). Physician (PhGA) and Patient Global Assessment of Disease Activity (PGA) were collected as VAS 0-100 mm at the same time. The discrepancy between Patients and Physicians (ΔGA) was defined as PGA minus PhGA. Correlations between ΔGA and other variables were evaluated through Pearson's Correlation Coefficient. Variables identified as correlated in the univariate analysis (p<0,05) were included in a linear regression stepwise model to identify independent predictors of this discrepancy. For all statistical analysis a p<0,05 was considered statistical significant.Results101 RA patients (82% females, mean disease duration 13,0±8,6 years, mean age 58,8±12,41 years old) were included. The mean difference of Disease Activity assessment between patients and physicians was 37,89 (±28,6), with patients generally rating their disease activity higher than their physician. This difference was strongly and positively correlated with Pain (r=0,737, p<0,001), Fatigue (r=0,646, p<0,001), mobility (r=0,639; p<0,001), Function (r=0,472, p<0,001) and deformity (r=0,459, p<0,001) and also with anxiety (r=0,551, p<0,001) and depression (r=0,464, p<0,001). A weak negative correlation was observed with Happiness (r=-0,269, p=0,008). The discrepancy was also negatively correlated with 28 tender joint count (TJC28) (r=-0,246, p=0,047), but not with SJC or CRP. In the multivariate analysis only pain (β=0,7, 95%CI: 0,526-0,876, p<0,001), anxiety (β=1,807, 95%CI: 0,688-2,926, p<0,002) and TJC (β=-1,1169; 95%CI: -2,34,-0,15, p<0,002) remained as independent predictors, explaining around 62%, of the discordance (R=0,624, p<0,001).ConclusionsPatients rate disease activity higher than their physicians. Higher scores in pain and anxiety were associated with higher degrees of discordance. Recognizing this difference and its predictors can guide interventions to improve care of RA patients.Disclosure of InterestNone declared

BackgroundThe physician's assessment of disease activity has been shown to be a determinant factor for therapeutic interventions in Rheumatoid Arthritis. The adequacy of this assessment is, therefore, crucial to assure that the best options are taken in the perspective of the patient's interest.ObjectivesWith this study we aim to evaluate the determinants of Physicians' Global Assessment of Disease Activity.MethodsConsecutive RA patients followed in a Tertiary Rheumatology Department were included in this cross-sectional study. Patient demographics and clinical assessments were collected through a standardized protocol which includes age, gender, disease duration, DAS284v-PCR (and its individuals measures), Hospital Anxiety and Depression Scale (HADS), Happiness Scale (HS), Health Assessment Questionnaire (HAQ), Pain (VAS 0-100mm), Fatigue (VAS 0-100mm), Mobility and deformity in the physicians perspective (VAS 0-100mm), Sleep, Physical and emotional wellbeing in the patients' perspective, using RAID questions. The Physician's Global Assessment of Disease Activity (PhGA-VAS 0-100 mm) was registered at the same time. Correlations between PhGA and other variables were evaluated through Pearson's Correlation Coefficient. Variables identified as correlated in the univariate analysis (p<0,05) were included in linear regression stepwise model to identify independent predictors of PhGA. p<0,05 was considered statistical significant in all statistical analysis.Results101 RA patients (82% females, mean disease duration of 13,0±8,6 years, mean age of 58,8±12,4 years old) were included. PhGA was strongly associated only with swollen joint 44 (r=0,826, p<0,001) and 28 count (r=0,812, p<0,001). Moderate correlation was observed with ESR (r=0,355, p<0,001) and Pain-VAS (r=0,326, p=0,001). PhGA showed a weak correlation with 44 tender joint count (r=0,287, p<0,05), Physicians' assessment of patient deformity (r=0,207, p=0,04) and function (r=0,213, p<0,036). No correlation was found with the most other important outcomes as sleep, fatigue, wellbeing or psychological aspects. In the multivariate analysis, swollen joint count (in 44) was the most important predictor of PhGA-VAS (β=4,620, 95%CI:3,96;5,28], p<0,001). Other significant predictors were ESR ((β=0,176, 95%CI: [0,07;0,281], p<0,002) and Patient Pain-VAS (β=0,07; 95%CI:[0,1;0,31], p<0,002). This model explains around 77% of the PhGA (R2:0,777; p<0,001).ConclusionsPhysicians consider mainly objective measures when assessing disease activity, apparently disregarding the patient's perspective. Although this is in line with current treat-to-target strategies, it may lead to sub-optimal management approaches in the perspective of diminishing the overall impact of the disease in the patient's life.Disclosure of InterestNone declared

We present the case of a 73-year-old man, with a history of SARS-CoV2 infection (January 2021), who came to the emergency department three months post infection, with complaints of left hip and knee pain, that turned out to be a substantial thigh hematoma. Analysis showed a normocytic/ normochromic anaemia (9,0 g/dL), prolonged aPTT (63.2 seconds; normal range 24.7-39.0 sec.), with normal prothrombin time. We arrived at a diagnosis of Acquired Haemophilia A. Treatment was promptly started, with clinical and laboratory improvement. After the vaccination to SARS-CoV2, a relapse was observed. Acquired Haemophilia A is a rare, autoimmune disease, distinguished by the presence of inhibitors against factor VIII. It's characterised by subcutaneous hematomas and muscle bleeding, with prolonged aPTT. SARS-CoV2 infection has already been mentioned as a possible cause.

BackgroundPatient global assessment (PGA) of disease activity is included in a large number of composite indices of disease activity and definitions of remission in Rheumatoid Arthritis (RA). However, the actual question is formulated in a variety of different ways according to the instrument considered.ObjectivesTo evaluate how 6 different formulations of PGA affect patient estimates and impact upon disease activity and remission rates as assessed by 4 Disease Activity Indices.MethodsConsecutive RA patients followed in a Rheumatology outpatient department were included in this cross-sectional study. Data collection comprised: 28 joint counts (tender and swollen), C-reactive protein (CRP) and 6 different PGA formulations. The chosen formulations were the ones stated in the: v1) Portuguese National Registry Reuma.pt, the locally used formulation; v2) ACR/EULAR provisional definition of remission (considered in this study as the “standard”); v3) CDAI and SDAI; v4) Disease Activity Score (DAS28) assessment of general health; v5) DAS28 assessment of disease activity (the currently used); v6) one, exploratory, developed by the investigators, including idiomatic cultural expressions. ACR/EULAR Boolean criteria, CDAI, SDAI, and DAS28-CRP (4v) were used to test how these 6 PGA formulations change the rates of remission. PGA differences were assessed by descriptive analyses (including patients with PGA ≤10 and ≤20mm) and Bland-Altman test.ResultsIn total, 193 patients were included (82% female, mean (SD) age of 59 (13) years, mean disease duration of 12 (9) years and 31% under biologics). The average PGA ranged from 42.3 (25.3) to 48.1 (26.7)mm as measured in different formulations. The ACR/EULAR (v2) formulation yielded the largest proportion of patients scoring ≤10mm (16.1%), corresponding to a difference of up to 4.7% versus other PGAs. Similar results were found for the ≤20 cut-off (Table 1).By using different PGA's formulations the rates of remission calculated with different indices can vary between 4.7% and 6.7% (Table 2).Bland-Altman chart confirmed the low agreement between ACR/EULAR formulation and the other PGA formulations (p<.05), except for the DAS “general health” (p=.054).Table 1.Descriptive statistics of the 6 PGA's formulations (n=193)PGA FormulationMean (SD)PGA below cut-off n (%) ≤10 mm≤20mm v1 Reuma.pt47.5 (28.0)26 (13.5)43 (22.3)v2 ACR/EULAR43.5 (27.9)31 (16.1)48 (24.9)v3 CDAI/SDAI47.2 (25.9)23 (11.9)34 (17.6)v4 DAS28-GH42.9 (25.3)27 (14.0)42 (21.8)v5 DAS28-DA42.3 (25.3)28 (14.5)44 (22.8)v6 Investigators48.1 (26.7)22 (11.4)35 (18.1)Table 2.Remission rates according to four composite indexes with the 6 PGA's formulations (n=193)PGA FormulationDefinition – n (%) ACR/EULAR BooleanSDAICDAIDAS28 4vCRP v1 Reuma.pt19 (9.8)32 (16.8)33 (17.1)97 (50.5)v2 ACR/EULAR25 (13.0)36 (19.1)39 (20.0)100 (51.7)v3 CDAI/SDAI16 (8.3)27 (14.1)26 (13.5)91 (47.3)v4 DAS28-GH20 (10.4)29 (15.2)33 (17.1)99 (51.4)v5 DAS28-DA19 (9.8)29 (15.2)30 (15.5)100 (51.7)v6 Investigators17 (8.8)27 (14.1)27 (14.0)97 (50.0)Max. dif. within de...

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