Systemic lupus erythematosus (SLE) affects predominantly women at reproductive age but may present at any age. Age at disease onset has a modulating effect on presentation and course of disease, but controversies persist regarding its impact on long-term outcome. Our aims were to characterize clinical features, co-morbidities and cumulative damage in childhood-onset, adult-onset and late-onset SLE. Patients with childhood-onset SLE fulfilling ACR 1997 criteria were identified in a nationwide register-Reuma.pt/SLE (N = 89) and compared with adult-onset and late-onset counterparts matched 1:1:1 for disease duration. 267 SLE patients with mean disease duration of 11.9 ± 9.3 years were analyzed. Skin (62 %), kidney (58 %), neurological (11 %) and hematologic involvement (76 %) were significantly more common in childhood-onset SLE and disease activity was higher in this subset than in adult- and late-onset disease (SLEDAI-2K 3.4 ± 3.8 vs. 2.2 ± 2.7 vs. 1.6 ± 2.8, respectively; p = 0.004). Also, more childhood-onset patients received cyclophosphamide (10 %) and mycophenolate mofetil (34 %). A greater proportion of women (96 %), prevalence of arthritis (89 %) and anti-SSA antibodies (34 %) were noted in the adult-onset group. There was a significant delay in the diagnosis of SLE in older ages. Co-morbidities such as hypertension, diabetes and thyroid disease were significantly more frequent in late-onset SLE, as well as the presence of irreversible damage evaluated by the SLICC/ACR damage index (20 vs. 26 vs. 40 %; p < 0.001). Greater organ involvement as well as the frequent need for immunosuppressants supports the concept of childhood-onset being a more severe disease. In contrast, disease onset is more indolent but co-morbidity burden and irreversible damage are greater in late-onset SLE, which may have implications for patients' management.

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.

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We report a case of a 46-year-old woman with a history of autoimmune atrophic gastritis and recurrent erythema nodosum (EN). Laboratory results showed iron-deficiency anaemia, positive antiparietal cell antibodies and marginal deficiency of vitamin B12. Although EN was refractory to general measures (rest and non-steroidal anti-inflammatory drugs) and corticosteroid therapy, it was successfully treated with vitamin B12 supplementation.

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A 45 year old white man presented to the emergency department with progressively worsening weakness and chest discomfort on moderate intensity physical activity over the past two months. He also reported paleness and "yellowish eyes" in the past month. He had a history of anxiety, treated with alprazolam as needed.At presentation, his vital signs were normal. On physical examination he had mild generalised pallor, scleral icterus, and tender non-painful hepatomegaly.He was admitted to the internal medicine ward for further evaluation.Laboratory studies showed haemoglobin 70 g/L (reference range 13-17), mean corpuscular volume 111.5 fL (83-101), haematocrit 19.4% (40-50%), leucocyte count 3. Antibodies against parietal cells were positive; Coombs test and anti-intrinsic factor antibodies were negative.Upper gastrointestinal endoscopy showed atrophic gastritis of the body and fundus. Staining for Helicobacter pylori was negative (fig 1). Biopsy confirmed the presence of type A atrophic gastritis with moderate intestinal metaplasia.