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Ingrasciotta Y, Jin Y, Foti SS, Landon JE, Tari M, Mattace-Raso F, Kim SC, Trifirò G. Real-world patient characteristics and use of disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis: a cross-national study. Clin Rheumatol 2023; 42:1047-1059. [PMID: 36534353 PMCID: PMC10017582 DOI: 10.1007/s10067-022-06478-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is associated with significant morbidity and economic burden. This study aimed to compare baseline characteristics and patterns of anti-inflammatory drug use and disease-modifying anti-rheumatic drug (DMARD) use among patients with RA in Southern Italy versus the United States. METHOD Using Caserta Local Health Unit (Italy) and Optum's de-identified Clinformatics® Data Mart (United States) claims databases, patients with ≥ 2 diagnosis codes for RA during the study period (Caserta: 2010-2018; Optum: 2010-2019) were identified. Baseline patient characteristics, as well as proportion of RA patients untreated/treated with NSAIDs/glucocorticoids/conventional DMARDs (csDMARDs)/biological/targeted synthetic DMARDs (b/tsDMARDs) during the first year of follow-up, and the proportion of RA patients with ≥ 1 switch/add-on between the first and the second year of follow-up, were calculated. These analyses were then stratified by age group (< 65; ≥ 65). RESULTS A total of 9227 RA patients from Caserta and 195,951 from Optum databases were identified (two-thirds were females). During the first year of follow-up, 45.9% RA patients from Optum versus 79.9% from Caserta were exclusively treated with NSAIDs/glucocorticoids; 17.2% versus 11.3% from Optum and Caserta, respectively, were treated with csDMARDs, mostly methotrexate or hydroxychloroquine in both cohorts. Compared to 0.6% of RA patients from Caserta, 3.2% of the Optum cohort received ≥ 1 b/tsDMARD dispensing. Moreover, 61,655 (33.7%) patients from Optum cohort remained untreated compared to 748 (8.3%) patients from the Caserta cohort. The subgroup analyses stratified by age showed that 42,989 (39.8%) of elderly RA patients were untreated compared to 18,666 (24.9%) young adult RA patients in Optum during the first year of follow-up. Moreover, a higher proportion of young adult RA patients was treated with b/tsDMARDs, with and without csDMARDs, compared to elderly RA patients (Optum<65: 6.4%; Optum≥65: 1.0%; P-value < 0.001; Caserta<65: 0.8%; Caserta≥65: 0.1%; P-value < 0.001). Among RA patients untreated during the first year after ID, 41.2% and 48.4% RA patients from Caserta and Optum, respectively, received NSAIDs, glucocorticoids, and cs/b/tsDMARDs within the second year of follow-up. Stratifying the analysis by age groups, 50.6% of untreated young RA patients received study drug dispensing within the second year of follow-up, compared to only 36.7% of elderly RA patients in Optum. Interestingly, more young adult RA patients treated with csDMARDs during the first year after ID received a therapy escalation to b/tsDMARD within the second year after ID in both cohorts, compared to elderly RA patients (Optum<65: 7.8%; Optum≥65: 1.8%; Caserta<65: 3.2%; Caserta≥65: 0.6%). CONCLUSIONS Most of RA patients, with heterogeneous baseline characteristics in Optum and Caserta cohorts, were treated with anti-inflammatory/csDMARDs rather than bDMARDs/tsDMARDs during the first year post-diagnosis, especially in elderly RA patients, suggesting a need for better understanding and dealing with barriers in the use of these agents for RA patients. Key Points • Substantial heterogeneity in baseline characteristics and access to bDMARD or tsDMARD drugs between RA patients from the United States and Italy exists. • Most of RA patients seem to be treated with anti-inflammatory/csDMARD drugs rather than bDMARD/tsDMARD drugs during the first year post-diagnosis. • RA treatment escalation is less frequent in old RA patients than in young adult RA patients. • An appropriate use of DMARDs should be considered to achieve RA disease remission or low disease activity.
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Affiliation(s)
- Ylenia Ingrasciotta
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy. .,Academic Spin-Off "INSPIRE-Innovative Solutions For Medical Prediction And Big Data Integration In Real World Setting"-Azienda Ospedaliera Universitaria "G. Martino", Messina, Italy. .,Department of Internal Medicine, Erasmus MC University-Medical Center, Rotterdam, The Netherlands.
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Saveria S Foti
- Academic Spin-Off "INSPIRE-Innovative Solutions For Medical Prediction And Big Data Integration In Real World Setting"-Azienda Ospedaliera Universitaria "G. Martino", Messina, Italy
| | - Joan E Landon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Francesco Mattace-Raso
- Department of Internal Medicine, Erasmus MC University-Medical Center, Rotterdam, The Netherlands
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Academic Spin-Off "INSPIRE-Innovative Solutions For Medical Prediction And Big Data Integration In Real World Setting"-Azienda Ospedaliera Universitaria "G. Martino", Messina, Italy
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Cacciapaglia F, Spinelli FR, Bartoloni E, Bugatti S, Erre GL, Fornaro M, Manfredi A, Piga M, Sakellariou G, Viapiana O, Atzeni F, Gremese E. Clinical Features of Diabetes Mellitus on Rheumatoid Arthritis: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group. J Clin Med 2023; 12:jcm12062148. [PMID: 36983150 PMCID: PMC10058987 DOI: 10.3390/jcm12062148] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023] Open
Abstract
Rheumatoid arthritis (RA) and diabetes mellitus (DM) are linked by underlying inflammation influencing their development and progression. Nevertheless, the profile of diabetic RA patients and the impact of DM on RA need to be elucidated. This cross-sectional study includes 1523 patients with RA and no episodes of cardiovascular events, followed up in 10 Italian University Rheumatologic Centers between 1 January and 31 December 2019 belonging to the “Cardiovascular Obesity and Rheumatic DISease (CORDIS)” Study Group of the Italian Society of Rheumatology. The demographic and clinical features of DM RA patients were compared to non-diabetic ones evaluating factors associated with increased risk of DM. Overall, 9.3% of the RA patients had DM, and DM type 2 was more common (90.2%). DM patients were significantly older (p < 0.001), more frequently male (p = 0.017), with a significantly higher BMI and mean weight (p < 0.001) compared to non-diabetic patients. DM patients were less likely to be on glucocorticoids (p < 0.001), with a trend towards a more frequent use of b/ts DMARDs (p = 0.08), and demonstrated higher HAQ (p = 0.001). In around 42% of patients (n = 114), DM diagnosis preceded that of RA. Treatment lines were identical in diabetic and non-diabetic RA patients. DM is a comorbidity that may influence RA management and outcome. The association between DM and RA supports the theory of systemic inflammation as a condition underlying the development of both diseases. DM may not have a substantial impact on bDMARDs resistance, although further investigation is required to clarify the implications of biological therapy resistance in RA patients.
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Affiliation(s)
- Fabio Cacciapaglia
- Department of Precision and Regenerative Medicine and Jonian Area, Università Degli Studi di Bari Facoltà di Medicina e Chirurgia, 70124 Bari, Italy
- Correspondence:
| | - Francesca Romana Spinelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari—Reumatologia, Università Degli Studi di Roma La Sapienza, 00185 Roma, Italy
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, 06100 Perugia, Italy
| | - Serena Bugatti
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Gian Luca Erre
- Dipartimento di Medicina, Chirurgia e Farmacia, Università Degli Studi di Sassari, 07100 Sassari, Italy
| | - Marco Fornaro
- Department of Precision and Regenerative Medicine and Jonian Area, Università Degli Studi di Bari Facoltà di Medicina e Chirurgia, 70124 Bari, Italy
| | - Andreina Manfredi
- Rheumatology Unit, Azienda Ospedaliera Universitaria Policlinico of Modena, 41121 Modena, Italy
| | - Matteo Piga
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, 09042 Cagliari, Italy
| | - Garifallia Sakellariou
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, 37126 Verona, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, 98122 Messina, Italy
| | - Elisa Gremese
- Division of Clinical Immunology, Fondazione Policlinico Universitario A. Gemelli—IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Li J, Chen Y, Liu Q, Tian Z, Zhang Y. Mechanistic and therapeutic links between rheumatoid arthritis and diabetes mellitus. Clin Exp Med 2022; 23:287-299. [DOI: 10.1007/s10238-022-00816-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/24/2022] [Indexed: 02/07/2023]
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Cacciapaglia F, Spinelli FR, Piga M, Erre GL, Sakellariou G, Manfredi A, Viapiana O, Fornaro M, Colella S, Floris A, Mangoni AA, Castagna F, Vacchi C, Orsolini G, Bugatti S, Cafaro G, Cauli A, Gremese E, Atzeni F, Bartoloni E. Estimated 10-year cardiovascular risk in a large Italian cohort of rheumatoid arthritis patients: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group. Eur J Intern Med 2022; 96:60-65. [PMID: 34657778 DOI: 10.1016/j.ejim.2021.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several cardiovascular (CV) risk algorithms are available to predict CV events in the general population. However, their performance in patients with rheumatoid arthritis (RA) might differ from the general population. This cross-sectional multicentre study aimed to estimate the 10-year CV risk using two different algorithms in a large RA cohort and in patients with osteoarthritis (OA). METHODS In a consecutive series of RA patients and matched OA controls without prior CV events, clinical and serologic data and traditional CV risk factors were recorded. The 10-year CV risk was assessed with the Systematic COronary Risk Evaluation (SCORE) and the "Progetto Cuore" algorithms. RESULTS 1,467 RA patients and 342 OA subjects were included. RA patients were more frequently diabetic (9.9% vs 6.4%; p=0.04) and smokers (20.4% vs 12.5%; p=0.002) but had lower prevalence of obesity (15% vs 21%; p=0.003). Dyslipidaemia was more prevalent in OA (32.5% vs 21.7%; p<0.0001). The 10-year estimated CV risk was 1.6% (95%CI 1.3-1.9) in RA and 1.4% (95%CI 1.3-1.6) in OA (p=0.002) according to SCORE and 6.5% (95%CI 6.1-6.9) in RA and 4.4% (95%CI 3.9-5.1) in OA (p<0.001) according to "Progetto Cuore". Regardless of the score used, RA patients had a 3- to-4-fold increased 10-year risk of CV events compared to OA subjects. CONCLUSION RA patients have a significantly higher 10-year risk of CV events than OA subjects. In addition to effective disease control and joint damage prevention, specific protective measures targeting modifiable traditional CV risk factors should be implemented in RA.
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Affiliation(s)
- Fabio Cacciapaglia
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy.
| | - Francesca Romana Spinelli
- Dipartimento di Medicina Interna e Specialità Mediche - Reumatologia, Università degli Studi di Roma La Sapienza, Roma, Italy
| | - Matteo Piga
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Gian Luca Erre
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Garifallia Sakellariou
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Andreina Manfredi
- Rheumatology Unit, Azienda Ospedaliera Universitaria Policlinico of Modena, Modena, Italy
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Marco Fornaro
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy
| | - Sergio Colella
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy
| | - Alberto Floris
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Arduino Aleksander Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Floriana Castagna
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Caterina Vacchi
- Rheumatology Unit, Azienda Ospedaliera Universitaria Policlinico of Modena, Modena, Italy
| | - Giovanni Orsolini
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Serena Bugatti
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giacomo Cafaro
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alberto Cauli
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Elisa Gremese
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Abstract
PURPOSE OF REVIEW Patients with chronic inflammatory disease have an increased risk of cardiovascular disease. This article reviews the current evidence of cardiovascular prevention in three common systemic inflammatory disorders (SIDs): psoriasis, rheumatoid arthritis, and systemic lupus erythematosus. RECENT FINDINGS General population cardiovascular risk assessment tools currently underestimate cardiovascular risk and disease-specific risk assessment tools are an area of active investigation. A disease-specific cardiovascular risk estimator has not been shown to more accurately predict risk compared with the current guidelines. Rheumatoid arthritis-specific risk estimators have been shown to better predict cardiovascular risk in some cohorts and not others. Systemic lupus erythematosus-specific scores have also been proposed and require further validation, whereas psoriasis is an open area of active investigation. The current role of universal prevention treatment with statin therapy in patients with SID remains unclear. Aggressive risk factor modification and control of disease activity are important interventions to reduce cardiovascular risk. SUMMARY A comprehensive approach that includes cardiovascular risk factor modification, control of systemic inflammation, and increased patient and physician awareness is needed in cardiovascular prevention of chronic inflammation. Clinical trials are currently underway to test whether disease-specific anti-inflammatory therapies will reduce cardiovascular risk.
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Lurati A, Laria A, Mazzocchi D, Re KA, Marrazza MG, Faggioli PM, Mazzone A. Improvement of HbA1c in Patients with Type 2 Diabetes Mellitus and Rheumatoid Arthritis Treated with bDMARDs. Open Access Rheumatol 2021; 13:73-78. [PMID: 33953620 PMCID: PMC8092350 DOI: 10.2147/oarrr.s302679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Objective The aim of our study was to evaluate the possible role of biological treatments for rheumatoid arthritis (RA) in improving the glycemic profile in patients affected not only by RA but also by type 2 diabetes mellitus (2TDM). Methods An observational retrospective study was conducted using data from patients referred to our Rheumatology Unit. Patients with active RA despite standard DMARDs therapy and concomitant 2TDM were selected into one of five exposure groups to first-line bDMARDs (adalimumab, golimumab, etanercept, tocilizumab, sarilumab) and observed for the outcome of CRP, ESR, DAS28CRP and glycated hemoglobin (HbA1c) variations. Results After the start of treatment, there was a significant reduction in the values of acute phase reactants ESR and CRP (p<0.01), DAS28-CRP (p<0.01) and HbA1C (p<0.05), in the absence of any confounding factors such as a reduction in BMI or a change in steroid doses. There was no statistically significant difference between the various treatments. Anti-IL6 drugs appear to be associated with a slightly greater reduction in HbA1c values, bordering on statistical significance (p=0.047). Conclusion Initiation of a bDMARD appears to be associated with an improvement in concomitant 2TDM in patients with active RA, which, in the first hypothesis, is linked with a reduction of the inflammatory milieu.
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Affiliation(s)
| | - Antonella Laria
- Rheumatology Unit, Fornaroli Hospital Magenta Italy, Milan, Italy
| | | | - Katia Angela Re
- Rheumatology Unit, Fornaroli Hospital Magenta Italy, Milan, Italy
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Rheumatoide Arthritis und Diabetes Typ 2. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1265-3883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Ob Patienten mit einer rheumatoiden Arthritis (RA)
überproportional häufig an einem Diabetes mellitus Typ 2
erkranken, wird in der wissenschaftlichen Literatur kontrovers
diskutiert. US-Forscher untersuchten diese Fragestellung nun im Rahmen
einer retrospektiven Kohortenstudie. Sie bildeten dabei die
Diabetesinzidenz in 4 verschiedenen Vergleichsgruppen ab.
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Baker JF, England BR, George M, Cannon G, Sauer B, Ogdie A, Hamilton BC, Hunter C, Duryee MJ, Thiele G, Mikuls TR. Disease activity, cytokines, chemokines and the risk of incident diabetes in rheumatoid arthritis. Ann Rheum Dis 2021; 80:566-572. [PMID: 33397733 PMCID: PMC8928597 DOI: 10.1136/annrheumdis-2020-219140] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Rheumatoid arthritis (RA) is associated with a higher risk of diabetes mellitus (DM). Our aim was to determine associations between inflammatory disease activity (including evaluation of specific cytokines and chemokines) and incident DM. METHODS Participants were adults with physician-confirmed RA from Veteran's Affairs Rheumatoid Arthritis Registry. Disease activity and clinical assessments occur longitudinally as part of clinical care. Thirty cytokines and chemokines were measured in banked serum obtained at the time of enrolment. Cytokine/chemokine values were log-adjusted and standardised (per SD). Incident DM was defined based on validated algorithms using diagnostic codes and medications. Multivariable Cox proportional hazard models evaluated associations between clinical factors and incident DM. Independent associations between cytokines/chemokines and incident DM were assessed adjusting for age, sex, race, smoking, body mass index (BMI) and medication use at baseline. RESULTS Among 1866 patients with RA without prevalent DM at enrolment, there were 130 incident cases over 9223 person-years of follow-up. High Disease Activity Score (DAS28)-C reactive protein (CRP), obese BMI, older age and male sex were associated with greater risk for incident DM while current smoking and methotrexate use were protective. Patients using methotrexate were at lower risk. Several cytokines/chemokines evaluated were independently associated (per 1 SD) with DM incidence including interleukin(IL)-1, IL-6 and select macrophage-derived cytokines/chemokines (HR range 1.11-1.26). These associations were independent of the DAS28-CRP. CONCLUSIONS Higher disease activity and elevated levels of cytokines/chemokines are associated with a higher risk of incident DM in patients with RA. Future study may help to determine if targeted treatments in at-risk individuals could prevent the development of DM.
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Affiliation(s)
- Joshua F Baker
- Rheumatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA .,Departments of Medicine/Rheumatology and Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Bryant R England
- Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Rheumatology, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
| | - Michael George
- Departments of Medicine/Rheumatology and Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Grant Cannon
- Rheumatology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Brian Sauer
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alexis Ogdie
- Departments of Medicine/Rheumatology and Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Bartlett C Hamilton
- University of Nebraska Medical Center and Omaha VA Medical Center, University of Nebraska, Omaha, Nebraska, USA
| | - Carlos Hunter
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael J Duryee
- Internal Medicine Division of Rheumatology, University of Nebraska System, Lincoln, Nebraska, USA
| | - Geoffrey Thiele
- Internal Medicine, University of Nebraska System, Lincoln, Nebraska, USA.,Research Service, 151, VAMC Omaha, Omaha, Nebraska, USA
| | - Ted R Mikuls
- Department of Medicine, University of Nebraska System, Lincoln, Nebraska, USA
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