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Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line procedure for choledocholithiasis treatment. However, it is associated with a 10 % rate of adverse events. Spontaneous migration of common bile duct (CBD) stones occurs in 6-33 % of choledocholithiasis cases, making ERCP avoidable. This study aimed to identify predictors of spontaneous CBD stones' migration., Methods: Retrospective study including patients diagnosed with choledocholithiasis and submitted to ERCP. Patients were divided into 2 groups considering spontaneous stone migration (i.e.: the absence of CBD stones on ERCP). Data on patients' characteristics, imaging findings, biochemical analysis, and ERCP procedure were analyzed to identify predictors of spontaneous migration of CBD stones., Results: 334 patients with a mean age of 71.7 years were included in the study: 76.6 % without and 23.4 % with spontaneous migration of CBD stones. Although some patients' features (gender and clinical presentation), imaging findings (diameters of the largest stone and CBD), biochemical analysis (bilirubin levels at diagnosis and pre-ERCP), and ERCP procedure characteristics (time from diagnosis to ERCP) were different between groups, only three variables were defined as predictors: the absence of acute cholangitis, the largest stone diameter ≤5 mm, and the bilirubin levels pre-ERCP ≤ 2mg/dL. When using those variables together there was a chance of 81-86 % to correctly distinguishing patients with and without spontaneous CBD stone migration., Conclusion: The size of the largest stone at diagnosis was validated as a predictor of CBD stones' spontaneous migration. Furthermore, two new predictors were identified: bilirubin levels pre-ERCP ≤ 2 mg/dL, and no acute cholangitis at the clinical presentation of choledocholithiasis. EUS and ERCP in the same session should be considered in patients with factors predictive of stone migration, especially when combined, to minimize unnecessary ERCP and possible complications., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jorge Canena reports a relationship with Boston Scientific Corporation that includes: consulting or advisory. Jorge Canena reports a relationship with Micro-Tech that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Masson SAS.)

Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is an uncommon but significant hematological disorder characterized by the presence of lupus anticoagulant (LA) and reduced levels of prothrombin (factor II). This syndrome presents a unique clinical paradox where patients may experience both a bleeding tendency due to hypoprothrombinemia and a prothrombotic state associated with LA. This syndrome should be suspected in the presence of increased coagulation times (prothrombin time and activated partial thromboplastin time) in association with the presence of LA. The dual risk between bleeding and thrombosis poses significant diagnostic and therapeutic challenges, particularly in deciding whether to use anticoagulation therapy, which could exacerbate bleeding, or withhold it, which could increase the risk of thrombosis. The authors report a case of a woman with LAHPS treated with rituximab. This case reinforces the importance of establishing guidelines for this disease., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gago et al.)

Background: Axial Spondyloarthritis (axSpA) is a chronic inflammatory rheumatic condition affecting the axial skeleton, leading to pain, stiffness, and fatigue. While biologic therapies have improved clinical management, many patients experience partial or no responses, resulting in delays in disease control. Additionally, the risk of adverse events and increased costs remains a concern., Objectives: Our primary objectives are: 1. to identify reliable markers for treatment response to Tumor Necrosis Factor alpha inhibitors (TNFi), in particular Adalimumab, enabling the identification of individuals most likely to benefit; 2. to analyze the impact of TNFi on gene and protein expression., Methods: A multicenter, prospective 14-week study will be conducted with 36 participants aged 18-75 years, meeting the ASAS criteria for axSpA. Patient enrollment will follow the National Guidelines for the use of TNFi in axSpA treatment, with all included patients using TNFi (Adalimumab) as a first-line option. Epidemiological and clinical data will be collected, along with peripheral blood samples, for integrated transcriptome, using RNA Seq (whole genome sequencing) and proteome analysis at various time points (baseline, 3-5 days, weeks 2 and 14), corresponding to the initial administration of TNFi. Patients will be classified as responders and non-responders, primarily based on ASAS20 criteria and secondarily based on ASDAS-C Reactive Protein (CRP), at week 14., Discussion: This project's innovative approach lies in identifying potential biomarkers for TNFi (Adalimumab) response at baseline, paving the way for advancements in precision medicine in this field. Additionally, it seeks to establish evidence of the therapy's impact on gene and protein expression, offering deeper insights into the pathophysiological mechanisms underlying the therapeutic response.

Purpose: To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care., Methods: We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points)., Results: We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC., Conclusions: Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC., (© 2024 Annals of Family Medicine, Inc.)

This study aims at identifying molecular biomarkers differentiating responders and non-responders to treatment with Tumor Necrosis Factor inhibitors (TNFi) among patients with axial spondyloarthritis (axSpA). Whole blood mRNA and plasma proteins were measured in a cohort of biologic-naïve axSpA patients ( n = 35), pre and post (14 weeks) TNFi treatment with adalimumab. Differential expression analysis was used to identify the most enriched pathways and in predictive models to distinguish responses to TNFi. A treatment-associated signature suggests a reduction in inflammatory activity. We found transcripts and proteins robustly differentially expressed between baseline and week 14 in responders. C-reactive protein (CRP) and Haptoglobin (HP) proteins showed strong and early decrease in the plasma of axSpA patients, while a cluster of apolipoproteins (APOD, APOA2, APOA1) showed increased expression at week 14. Responders to TNFi treatment present higher levels of markers of innate immunity at baseline, and lower levels of adaptive immunity markers, particularly B-cells. A logistic regression model incorporating ASDAS-CRP, gender, and AFF3 , the top differentially expressed gene at baseline, enabled an accurate prediction of response to adalimumab in our cohort (AUC = 0.97). In conclusion, innate and adaptive immune cell type composition at baseline may be a major contributor to response to adalimumab in axSpA patients. A model including clinical and gene expression variables should also be considered.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder which may affect the gastrointestinal system. Half of the patients with SLE experience gastrointestinal symptoms, with the most common being nausea, vomiting, anorexia, and abdominal pain. Mesenteric vasculitis is a severe and rare complication of SLE and one of the most frequent causes of severe acute abdominal pain. The authors present a case of a 57-year-old woman with SLE who was diagnosed with necrotizing mesenteric vasculitis following a urinary septic shock. The patient was treated with high-dose corticosteroid therapy and cyclophosphamide, with resolution of the clinical picture.

Hypereosinophilia is unusual in rheumatoid arthritis (RA), but can occur in severe long-lasting disease, especially in patients with extra-articular manifestations and high titers of rheumatoid factor (RF). The association of RA and hypereosinophilic syndrome (HES) remains yet poorly known. We present a case of a 46 years old woman with long-standing untreated RA, that presented to emergency department with severe symptoms of constrictive pericarditis with cardiac tamponade and bilateral pleural effusion, that progressed to cardiac arrest, associated to symmetrical polyarthritis and pruritic erythematous skin papules. She was submitted to urgent pericardial drainage and partial pericardiotomy. Laboratory analyses revealed hypereosinophilia, and elevated inflammatory parameters and immunoglobulin E. The histological study of the pericardium showed results consistent with inflammatory fibrinous pericarditis. Taking into account the presence of some characteristics that are usually present in cases of reactive HES instead of idiopathic HES, and after an intensive diagnostic study, that could rule out other potential causes of secondary HES, the diagnosis of HES associated with RA was made. She started glucocorticoids during hospitalization and methotrexate 15mg per week at the first outpatient rheumatology visit. After 12 weeks of treatment, we considered that she was in clinical and analytical remission, consistently maintaining that after a complete tapering of glucocorticoids. This case illustrates that clinicians should be aware that HES (including severe life-threatening cases) can occur in patients with RA, especially in cases of long-lasting disease with high titters of RF and without treatment, even in the absence of extra-articular features.

Introduction: The association of hepatitis delta virus (HDV) infection with positive autoantibodies and autoimmune features has been known for decades. However, to date, very few cases of clinical autoimmune hepatitis (AIH) have been reported in association with HDV infection, most of them being in the context of treatment with peginterferon., Case Report: This case refers to a 46-year-old woman born in Guinea-Bissau who moved to Portugal in 2018 to investigate complaints of diffuse abdominal discomfort and nausea. Her initial work-up, including laboratory and liver histology, was consistent with type 1 AIH. She had HBe antigen-negative chronic hepatitis B virus infection with negative DNA and also a positive total anti-HDV antibody, with negative IgM and undetectable RNA. Therefore, after initiating prophylactic tenofovir difumarate, she was started on prednisolone followed by azathioprine, which was later stopped due to presumed hepatotoxicity. Repeated histology showed signs of viral superinfection, and she was treated with acyclovir due to a positive herpes simplex IgM, with HDV RNA remaining negative. A third flare in transaminases prompted the introduction of mycophenolate mofetil (MMF) after a thorough exclusion of additional causes of liver disease. About 6 months later, during another bout of hepatitis, HDV RNA was finally positive and classified as genotype 5. MMF was stopped, and, considering a contraindication to interferon, the patient was offered therapy with bulevirtide, which she refused for personal reasons as she is currently living in her home country., Discussion: This is a challenging case of autoimmune or "autoimmune-like" hepatitis, probably induced by chronic HDV infection. High suspicion of HDV was essential because, had the case been interpreted as refractory AIH, with escalation of immunosuppression, a more severe course of the viral infection might have ensued. Recently, HDV suppression with bulevirtide was shown to reverse autoimmune liver disease. We hypothesize that the same could have happened to our patient, had she accepted this treatment., Competing Interests: The authors have no conflicts of interest to declare., (© 2023 The Author(s).Published by S. Karger AG, Basel.)

Cytomegalovirus (CMV) infection is a common and typically benign disease in immunocompetent individuals. However, immunocompromised patients are at a greater risk of reactivation, leading to more severe outcomes. Patients with rheumatic diseases have a particularly high risk of opportunistic infections due to both the inherent immunosuppressive state conveyed by the disease itself and the use of potent immunosuppressant drugs, such as glucocorticoids, cyclophosphamide, and rituximab. Limited data are available regarding prophylactic or preemptive treatment of CMV infection in patients with rheumatic diseases. In this article the authors present two cases of rheumatic conditions complicated by CMV infection. The first case describes a patient with eosinophilic granulomatosis with polyangiitis, previously treated with glucocorticoids and cyclophosphamide, who developed CMV colitis with bowel perforation. The second case involves a woman with systemic lupus erythematosus who was diagnosed with CMV meningitis. Both cases reinforce the importance of establishing guidelines for surveillance and prophylaxis of CMV infection in these patients.

Objectives: Chronic low back pain (CLBP) is a common health problem and in most patients it is not possible to identify a specific cause (non-specific CLBP). Spondyloarthritis is a musculoskeletal disorder characterized by (often inflammatory) back pain and spinal stiffness. The impact of CLBP and spondyloarthritis on patients' physical function may be different. This study aims to compare physical disability in patients with spondyloarthritis and CLBP, in a population-based setting. Furthermore, we aim to identify modifiable risk factors for physical disability among these two populations., Methods: Data from EpiReumaPt, a national health cohort with 10 661 individuals, conducted from September 2011 to December 2013, was used. Physical function was accessed by the Health Assessment Questionnaire Disability Index (HAQ-DI) and by the physical function dimension of the 36-Item Short Form Survey (SF-36). Univariable and multivariable linear regression analyses were used to assess the differences between groups. Factors associated with physical disability were explored for both diseases., Results: We evaluated 92 patients with spondyloarthritis, 1376 patients with CLBP and 679 subjects without rheumatic and musculoskeletal diseases (RMDs). Spondyloarthritis and CLBP patients reported significantly higher levels of disability in HAQ-DI (ß=0.33; p < 0.001 and ß=0.20; p < 0.001, respectively) than subjects without RMDs. In comparison to CLBP patients, spondyloarthritis patients reported higher disability (ß=0.14; p=0.03). The physical domains of SF-36, bodily pain and general health, where more affected in spondyloarthritis patients than in CLBP patients (ß=-6.61; p=0.02 and ß=-5.94; p=0.001, respectively). Spondyloarthritis and CLBP patients had a worse physical summary score (PCS) than mental summary score (MCS), and only PCS was significantly worse in comparison to subjects without RMDs. Factors associated with physical disability in CLBP were low back pain intensity, older age, obesity, multimorbidity, and retirement. Similarly, in spondyloarthritis physical disability was associated with retirement and multimorbidity. Factors associated with lower disability were alcohol consumption and male gender in CLBP, and regular physical exercise was associated with lower disability in both disorders., Conclusions: In this nationwide cohort, spondyloarthritis and CLBP patients reported significant physical disability. Regular physical exercise was associated with lower disability in both diseases.

Background: Low back pain (LBP) is a long-term health condition with distinct clinical courses. Its characterization together with the identification of prognostic factors for a persistent LBP course may trigger the development of personalized interventions. This study aimed to investigate the courses of chronic LBP (CLBP), its cumulative impact, and the indicators for the persistence of pain., Material and Methods: Patients with active CLBP from the EpiDoC, a population-based cohort study of a randomly recruited sample of 10.661 adults with prolonged follow-up, were considered. Pain, disability, and health-related quality of life (HRQoL) were assessed at three time-points over five years. According to their pain symptoms over time, participants were classified as having a persistent (pain at the baseline and at all the subsequent time-points) or a relapsing pain course (pain at the baseline and no pain at least in one of the subsequent time-points). A mixed ANOVA was used to compare mean differences within and between patients of distinct courses. Prognostic indicators for the persistent LBP course were modulated through logistic regression., Results: Among the 1.201 adults with active CLBP at baseline, 634 (52.8%) completed the three time-points of data collection: 400 (63.1%) had a persistent and 234 (36.9%) a relapsing course. Statistically significant interactions were found between the group and time on disability (F (2,1258) = 23.779, p<0.001) and HRQoL (F (2,1252) = 82.779, p<0.001). In the adjusted model, the persistent course was associated with the disability level (OR 1.86, CI95% 1.40-2.40, p<0.001), depressive symptoms (OR 1.96, CI95% 1.21-3.18, p = 0.007), female gender (OR 1.90, CI95% 1.26-2.87, p = 0.002) and having a manual job (OR 1.46, CI95% 1.02-2.10, p = 0.040)., Conclusion: In the long-term, patients with CLBP may follow a persistent or relapsing course of pain. Being female, presenting depressive symptoms, having a manual job and higher disability at baseline predicts a persistent course of LBP., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Gomes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Accelerated nodulosis, the rapid progression/extension of preexisting nodules, is a recognized complication of immunomodulatory therapy, occurring mostly in patients with rheumatoid arthritis treated with methotrexate. As of today, its physiopathology remains incompletely understood, and there are no standardized guidelines regarding its management. Here, we conduct a literature review of the reported cases of drug-induced accelerated nodulosis and add our case of a 79-year-old female with an atypical clinical presentation., (© 2022 the International Society of Dermatology.)

Arthritis in the paediatric population is the hallmark of many rheumatic inflammatory diseases, as well as other cutaneous, infectious, or neoplastic conditions. It can be quite devastating, whereby prompt recognition and treatment of these disorders are essential. However, arthritis can sometimes be mistaken for other cutaneous or genetic conditions leading to misdiagnosis and overtreatment. Pachydermodactyly is a rare and benign form of digital fibromatosis, usually manifested by swelling of the proximal interphalangeal joints of both hands, mimicking arthritis. The authors report a case of a 12-year-old boy with a one-year history of painless swelling of the proximal interphalangeal joints of both hands that was referred to the Paediatric Rheumatology department due to the suspicion of juvenile idiopathic arthritis. The diagnostic work-up was unremarkable, and the patient remained asymptomatic over an 18-month follow-up period. A diagnosis of pachydermodactyly was assumed and no treatment was introduced, given the benign nature of the disorder and absence of symptoms. Therefore, it was possible to safely discharge the patient from the Paediatric Rheumatology clinic.

Aim: To estimate the disease specific prevalence of undiagnosed rheumatic and musculoskeletal diseases (RMDs) in Portugal and determine if people with undiagnosed RMDs have worse quality of life, physical function and higher health resources consumption, than people without RMDs., Methods: A subgroup analysis of EpiReumaPt was made that included all participants≥18 years evaluated by a rheumatologist. Participants were stratified into three groups: undiagnosed RMDs; previously diagnosed RMDs; non-RMDs. A descriptive analysis of the three groups was performed. To estimate the prevalence of undiagnosed RMDs, weighted proportion were computed considering the sample design. The three groups were compared (Undiagnosed RMDs vs non-RMDs; Previously diagnosed RMDs vs non-RMDs) for health related quality of life (HRQoL) (EQ5D), physical function (HAQ), mental health (HADS) and health resources consumption. The effect of being undiagnosed for these outcomes was assessed in multivariable models adjusted for age, gender, geographical region and years of education (reference: non-RMD)., Results: A total of 3877 participants were included. The prevalence of undiagnosed RMDs was 29%. Compared to participants without RMDs, undiagnosed participants had lower HRQoL (EQ-5D: β (95% CI)=-0.07 (-0.103,-0.043)) and physical function (HAQ: β (95% CI)=0.10 (0.05, 0.15)), more anxiety (OR (95% CI)=2.3 (1.4, 3.7)) and depression symptoms (OR (95% CI)=1.4 (0.8, 2.4)). Undiagnosed RMDs participants were more likely to visit an orthopedist (OR (95% CI)=2.0 (1.1, 3.5)) and had a higher number of orthopedic appointments (IRR (95% CI)=2.5 (1.3, 4.9)) than participants without RMDs., Conclusion: Patients with undiagnosed RMDs are frequent in Portugal, have worse HRQoL, physical function and mental health than people without RMDs. Undiagnosed patients are nonetheless consumers of health resources and tend to seek help from specialties other than rheumatology. Increasing the awareness of RMDs might promote their early identification and treatment leading to both personal and societal benefits.

Erythema nodosum (EN) is a type of panniculitis often benign and self-limited. It may, however, be associated with numerous causes, the most common being infections (namely streptococcal infections), of which tuberculosis (TB) is also one. We report the case of a 43-year-old woman who was referred to our outpatient department with signs of a recurrent EN along with an asymmetrical oligoarthritis of the lower limbs. The investigation excluded all etiological causes of EN, except the interferon gamma release assay (IGRA) which was positive. It was assumed a latent TB infection was the cause of EN. Treatment with isoniazid was started, besides prednisolone and colchicine, with maintained clinical remission. There are just a few cases published about this subject and this intends to emphasize the importance of medical history and of an exhaustive search for a cause, as it may slip away due to the absence of symptoms., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Lourenço et al.)

Background: Methotrexate (MTX) is an anti-folate drug with anti-proliferative and anti-inflammatory effects. MTX proved to be the most highly effective, fast-acting disease modifying anti-rheumatic drug (DMARD), being widely used for the treatment of rheumatoid arthritis (RA). This review aims to describe the main genetic variants identified concerning proteins that play a role in methotrexate's kinetics and efficiency profile., Methods: A literature review was conducted since January of 2000 until December 2020, by searching the PubMed and Embase bibliographic databases, employing the following MeSH terms: methotrexate, pharmacogenetics, pharmacokinetics, and rheumatoid arthritis. The search was limited to articles in English language. Two independent reviewers screened the titles and abstracts followed by a full-text review to assess papers regarding their eligibility. A total of 48 articles matched the research criteria and were analyzed., Results: Reduced folate carrier 1 (RFC1), a constitutively expressed folate transport protein that has high affinity for MTX is responsible, almost exclusively, for the transport of folate and MTX into the cell. The most studied variant of the gene is the 80G&gt;A variant, mapped within exon 2, on chromosome 21. It seems to improve RA responses to MTX, clinical efficacy with long disease remission. ABC transporters are involved in the efflux of MTX from cells. An increased expression and function of these transporters should decrease MTX concentrations in target cells, resulting in lack of therapeutic response. ABCB1 3435 C/T is a high frequency polymorphism, significantly associated with RA good responses, symptom remission and reduced adverse events, due to MTX treatment. Thymidylate synthase (TYMS) is involved in thymidine synthesis. MTX decreases TYMS activity by inhibition and decreasing the access to tetrahydrofolate (THF) cofactors. The most common genetic variant of the TYMS gene consists of a 28 bp tandem repeat, with double and triple number of repeats (2R and 3R). The 3R allele genotype was associated with decreased efficacy and increased toxicity. The 5,10-methylenetetrahydrofolate reductase (MTHFR) enzyme is indirectly inhibited by MTX. The most common SNPs of the MTHFR gene are C677T and A1298C. Both are associated with a decreased efficacy and an increased toxicity of MTX., Conclusion: MTX response is affected by many gene variants; the effect of each variant separately is likely to be small. Additionally, gene-gene interaction seems to enhance the potential role of linkage disequilibrium. This shows the emerging need for a better gene characterization and to improve the knowledge about variants distribution according to ethnicity, to explain different responses to MTX at an individual level.

Objectives: To estimate the prevalence of medical care-seeking among adults with low back pain (LBP) and to characterise and compare use of diagnostic procedures and medical management between primary and secondary care., Design: Cross-sectional study., Setting: Data from the EpiReumaPt, a nationwide population-based study conducted in Portugal including a representative sample of non-institutionalised adults (n=10 661) stratified by administrative territorial units was analysed., Participants: Individuals who self-reported history of LBP within the previous 12 months (n=6434) and sought medical care for this problem in the same period (n=2618)., Outcome Measures: Patients' self-reported diagnostic workup and management procedures performed by medical care for LBP collected through a structured questionnaire. Medical care procedures were stratified by level of care., Results: The prevalence of medical care-seeking for LBP was 38.0% (95% CI 35.9% to 40.1%). Primary care in isolation (45.3%) was the most sought level of care. Emergency departments (25.9%) and orthopaedics (19.4%) were the most sought secondary medical specialties. Several pathoanatomical diagnoses were used, supported by laboratory or imaging tests (91.1%). Disc herniation (20.4%) and osteoarthritis (19.7%) were the most frequent diagnoses, and X-ray (63.7%) was the most frequent diagnostic procedure self-reported by individuals. Most (75.1%) reported being treated for LBP: 80.4% with oral medication and 49.9% with injectables. The mean duration of pharmacological treatment was 104.24 (SD, 266.80) days. The use of pathoanatomical diagnoses, laboratory or imaging tests, and pharmacological treatments were generally more frequent for secondary care (p<0.05). Approximately one-quarter of individuals (24.5%) reported seeking care from additional healthcare providers, physiotherapists (66.9%) were the most frequent., Conclusions: Medical care for LBP is frequent and associated with high levels of pathoanatomical diagnoses, imaging and laboratory tests and pharmacological therapy in both primary and secondary care settings. Funding and delivery actions should be prioritised to assure appropriate care for LBP., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Platelet-rich plasma injections have been a therapeutic option with exponential growth in several pathologies in the last decades, particularly musculoskeletal for their effect on improving pain and functionality. Rheumatoid arthritis is a chronic joint disease, which involves inflammation of the synovial membrane with cartilage and juxta-articular bone destruction. Conventional and biological disease-modifying anti-rheumatoid drugs are the cornerstone of the treatment of this disease. However, the use of intra-articular glucocorticoids is often necessary and the role of platelet-rich plasma injections in these patients remains uncertain. A literature review was carried out through the PubMed database, Cochrane and Google Scholar for the search terms "rheumatoid arthritis" and "platelet-rich plasma". Eleven studies have been included in this review: two of these are in vitro studies, five are animal studies, one case report, two case series and one randomized controlled trial. Most of the studies demonstrated a decrease in pain and inflammatory mediators and improvement of functional outcomes, with no severe adverse effects reported. However, the quantity and quality of literature about the effects and safety of plasma-rich plasma injections in rheumatoid arthritis patients are still scarce. It is essential that well-designed randomized controlled trials are made on this topic to understand if platelet-rich plasma may be useful as a coadjuvant therapy in rheumatoid arthritis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Moeda et al.)