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Şahin ÖF, Tarıkçı Kılıç E, Aksoy Y, Kaydu A, Gökçek E. The importance of perfusion index monitoring in evaluating the efficacy of stellate ganglion blockage treatment in Raynaud's disease. Libyan J Med 2018; 13:1422666. [PMID: 29350104 PMCID: PMC5774394 DOI: 10.1080/19932820.2017.1422666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Stellate ganglion blockage (SGB) is a method used for treating Raynaud's phenomenon (RP). This study primarily aimed to determine whether the perfusion index (PI) can be used an alternative to Horner's signs in evaluating the efficacy of SGB in patients diagnosed with RP. In a total of 40 patients, aged 18-65 years and diagnosed with primary RP, SGB was applied for 5 days on the same side with the 2-finger method, using 6 mL of 5% levobupivacaine at the 7th cervical vertebra level. The PI values were recorded from the distal end of the 2nd finger of the upper extremity on the side applied with the block at baseline and at 5, 15, 30, 60 and 120 min. The onset time of Horner findings was recorded. The PI values and visual analogue scale (VAS) pain scores were recorded pre-treatment and after 2 weeks.When the PI values of the 40 patients were examined, a 62.7% increase was observed from baseline to the first session at 5 min (p < 0.05). When all sessions were evaluated, a statistically significant increase was determined in the PI values measured at 5, 15, 30, 60 and 120 min compared with the baseline PI values. There was a statistically significant decrease in the post-treatment VAS pain scores and a statistically significant increase in the post-treatment PI values (p < 0.05). By eliminating peripheral vasospasm with the application of SGB in patients with RP, the distal artery blood flow and PI are increased. PI measurement is a more objective method and therefore could be used as an alternative to Horner findings in evaluating the success of SGB. PI is a non-invasive and simple measurement and also an earlier indicator in evaluating the success of SGB than Horner's signs.
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Affiliation(s)
- Ömer Fatih Şahin
- a Department of Anesthesiology and Reanimation , Diyarbakır Bismil State Hospital , Bismil , Diyarbakır
| | - Ebru Tarıkçı Kılıç
- b Department of Anesthesiology and Reanimation , Ümraniye Training and Research Hospital , Istanbul
| | - Yakup Aksoy
- a Department of Anesthesiology and Reanimation , Diyarbakır Bismil State Hospital , Bismil , Diyarbakır
| | - Ayhan Kaydu
- c Department of Anesthesiology and Reanimation , Diyarbakır Selahaddin Eyyübi State Hospital , Diyarbakır
| | - Erhan Gökçek
- c Department of Anesthesiology and Reanimation , Diyarbakır Selahaddin Eyyübi State Hospital , Diyarbakır
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A randomized, single-blinded cross-over trial of ischemic preconditioning in Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction Ischemic preconditioning (IPC) is protective against future ischemia, with brief cycles of ischemia and reperfusion leading to the release of circulating endogenous compounds from ischemic cells. IPC may increase vasodilatory substances and improve Raynaud's phenomenon (RP). We hypothesized that IPC would be more effective than sham in RP treatment. Sample size required 18 participants to detect 5 fewer RP attacks per week. Methods This was a randomized single-blinded cross-over trial. The IPC intervention of inflating a standard blood pressure cuff on the upper arm (200 mmHg) and sham intervention (60 mmHg) were performed 3 times per week for 2 weeks, with a 2-week washout period between IPC and sham interventions. Cuff inflation was performed 4 times for 2.5 minutes, with 2.5 minutes between cuff inflation. Participants completed a daily diary on RP disease activity. Results Eighteen participants were enrolled (17 with secondary RP and 1 with primary RP); mean age 60.8 (SD 9.4) years, 89% female; and mean number of RP attacks/2 weeks in screen was 16.9 (SD 11.3). With IPC versus sham, results were not significant including an increase of 0.5 RP episodes/week (SD: 10.0; p = 0.84), decrease of 55.6 minutes per week (SD 516.4; p = 0.66), and a decrease in average severity of 0.4 points (on a scale of 0 to 10) (SD 12.9; p = 0.88). Secondary outcomes were also not significant. Conclusions No significant differences in RP disease activity were found between IPC and sham. This could be due to lack of effect of IPC on RP, too few treatments, or sham having a partial effect.
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Fardoun MM, Nassif J, Issa K, Baydoun E, Eid AH. Raynaud's Phenomenon: A Brief Review of the Underlying Mechanisms. Front Pharmacol 2016; 7:438. [PMID: 27899893 PMCID: PMC5110514 DOI: 10.3389/fphar.2016.00438] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/03/2016] [Indexed: 11/28/2022] Open
Abstract
Raynaud’s phenomenon (RP) is characterized by exaggerated cold-induced vasoconstriction. This augmented vasoconstriction occurs by virtue of a reflex response to cooling via the sympathetic nervous system as well as by local activation of α2C adrenoceptors (α2C-AR). In a cold-initiated, mitochondrion-mediated mechanism involving reactive oxygen species and the Rho/ROCK pathway, cytoskeletal rearrangement in vascular smooth muscle cells orchestrates the translocation of α2C-AR to the cell membrane, where this receptor readily interacts with its ligand. Different parameters are involved in this spatial and functional rescue of α2C-AR. Of notable relevance is the female hormone, 17β-estradiol, or estrogen. This is consistent with the high prevalence of RP in premenopausal women compared to age-matched males. In addition to dissecting the role of these various players, the contribution of pollution as well as genetic background to the onset and prevalence of RP are also discussed. Different therapeutic approaches employed as treatment modalities for this disease are also highlighted and analyzed. The lack of an appropriate animal model for RP mandates that more efforts be undertaken in order to better understand and eventually treat this disease. Although several lines of treatment are utilized, it is important to note that precaution is often effective in reducing severity or frequency of RP attacks.
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Affiliation(s)
- Manal M Fardoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Joseph Nassif
- Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Khodr Issa
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Elias Baydoun
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut Beirut, Lebanon
| | - Ali H Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
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Cruz JE, Ward A, Anthony S, Chang S, Bae HB, Hermes-DeSantis ER. Evidence for the Use of Epoprostenol to Treat Raynaud's Phenomenon With or Without Digital Ulcers. Ann Pharmacother 2016; 50:1060-1067. [PMID: 27465880 DOI: 10.1177/1060028016660324] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To review the evidence for using intravenous (IV) epoprostenol to treat Raynaud's phenomenon (RP). DATA SOURCES The databases MEDLINE (1946 to March 2016), PubMed, and International Pharmaceutical Abstracts were searched using the terms epoprostenol, Flolan, Raynaud's disease, and CREST syndrome. Further literature sources were identified by reviewing article citations. STUDY SELECTION AND DATA EXTRACTION All English-language, clinical trials and case series evaluating IV epoprostenol for the management or treatment of RP were included. Lower-quality evidence were incorporated due to limited information. DATA SYNTHESIS Seven small uncontrolled studies/case series, 1 small placebo controlled study, and 1 larger randomized trial were identified and included. There was no consistent measurement of efficacy utilized, but improvements in hand temperature, RP attack duration and frequency were commonly associated with IV epoprostenol treatment (5 trials). There were conflicting data regarding effect sustainability, with 5 trials showing long-term effects and 3 showing immediate effects. Fewer ischemic ulcers developed during treatment with IV epoprostenol in 1 trial compared to conventional treatment. Ulcer healing ocurred in 2 trials. Common adverse effects included hypotension, headache, flushing, gastrointestinal symptoms, and jaw pain. CONCLUSIONS Available evidence supports the use of IV epoprostenol for treatment of severe RP in patients refractory or intolerant to standard therapies. The dose, titration schedule, and duration of IV epoprostenol utilized in studies varied, but a conservative approach to initiation should be considered. Patients who do not respond to intermittent infusions and have severe digital ischemia may require more aggressive regimens.
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Affiliation(s)
- Joseph E Cruz
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA .,Department of Pharmacy, Englewood Hospital Medical Center, Englewood, NJ, USA
| | - Ashley Ward
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Shannon Anthony
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | | | | | - Evelyn R Hermes-DeSantis
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Abstract
Raynaud phenomenon may be a primary disorder or associated with a variety of other autoimmune processes. Raynaud phenomenon produces digital vasospasm, which can lead to ischemia and ulceration. The treatment of Raynaud phenomenon has been difficult because multiple medical treatments have not provided uniform resolution of symptoms. Many patients have turned to surgery and sympathectomies for the treatment of unrelenting vasospasm. Botulinum toxin has been shown to be an effective alternative to surgery, with a single treatment being capable of resolving pain and healing ulcer. This article reviews the use of botulinum toxin for the treatment of Raynaud phenomenon.
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Seo JC, Lee HJ, Kwak MA, Park SH, Shin I, Yun WS, Park K. Acupuncture in subjects with cold hands sensation: study protocol for a randomized controlled trial. Trials 2014; 15:348. [PMID: 25185456 PMCID: PMC4167502 DOI: 10.1186/1745-6215-15-348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 08/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cold hands sensation is a common disorder within the Korean population. Many Korean family physicians believe that it is a mild early manifestation of Raynaud's phenomenon (RP), or may be related to RP. RP is characterized by reversible digital vasospasm provoked by cold temperatures and/or emotional stress, and doctors often prescribe medications that are used in treatment of RP for subjects with cold hands. However, this has not shown a clear benefit, and these medications can cause unwanted side effects. It is also reported that traditional Korean medicine, including acupuncture, is widely used to treat cold hands, although the current level of evidence for this approach is also poor and to date, there have been no published randomized controlled clinical trials (RCTs) evaluating the efficacy and safety of acupuncture for cold hands. We have therefore designed a pilot RCT to obtain information for the design of a further full-scale trial. METHODS/DESIGN The proposed study is a five-week pilot RCT. A total of 14 subjects will be recruited and randomly allocated to two groups: an acupuncture plus medication group (experimental group) and a medication-only group (control group). All subjects will take nifedipine (5 mg once daily) and beraprost (20 mg three times daily) for three weeks. The experimental group will receive additional treatment with three acupuncture sessions per week for three weeks (nine sessions total). The primary outcome will be measured using a visual analogue scale. Secondary outcomes will be measured by blood perfusion in laser Doppler perfusion imaging of the hands, frequency and duration of episodes of cold hands, and heart rate variability. Assessments will be made at baseline and at one, three, and five weeks thereafter. DISCUSSION This study will provide an indication of the feasibility and a clinical foundation for a future large-scale trial. TRIAL REGISTRATION This study was registered at Korean Clinical Research Information Service (CRIS) registry on 5 August 2013 with the registration number #KCT0000817.
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Affiliation(s)
| | | | | | | | | | | | - Kihyuk Park
- Division of Vascular Surgery, Department of sugery, School of Medicine, Catholic University of Daegu, 3056-6 Daemyeong 4-dong, Nam-gu, Daegu 705-718, Republic of Korea.
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Kuryliszyn-Moskal A, Kita J, Dakowicz A, Chwieśko-Minarowska S, Moskal D, Kosztyła-Hojna B, Jabłońska E, Klimiuk PA. The influence of Multiwave Locked System (MLS) laser therapy on clinical features, microcirculatory abnormalities and selected modulators of angiogenesis in patients with Raynaud's phenomenon. Clin Rheumatol 2014; 34:489-96. [PMID: 24820143 PMCID: PMC4348551 DOI: 10.1007/s10067-014-2637-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/20/2014] [Accepted: 04/15/2014] [Indexed: 11/25/2022]
Abstract
The aim of this study was to investigate the influence of the Multiwave Locked System (MLS) laser therapy on clinical features, microvascular changes in nailfold videocapillaroscopy (NVC) and circulating modulators releasing as a consequence of vascular endothelium injury such as vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang-2) in patients with primary and secondary Raynaud’s phenomenon. Seventy-eight RP patients and 30 healthy volunteers were recruited into the study. All patients with RP received MLS laser irradiation for 3 weeks. Clinical, NVC and laboratory investigations were performed before and after the MLS laser therapy. The serum concentration of VEGF and Ang-2 were determined by an enzyme-linked immunosorbent assay (ELISA). After 3 weeks of MLS laser therapy, the clinical improvement manifested by decreasing of the number of RP attacks, mean duration of Raynaud’s attack and pain intensity in RP patients was observed. After MLS laser therapy in 65 % of patients with primary and in 35 % with secondary RP, an increase in the loop number and/or a reduction in avascular areas in NVC were observed. In comparison with a control group, higher serum concentration of VEGF and Ang-2 in RP patients was demonstrated. After MLS laser therapy, a reduction of Ang-2 in both groups of RP patients was found. Our results suggest that NVC may reflect microvascular changes associated with clinical improvement after MLS laser therapy in patients with primary and secondary RP. Ang-2 serum levels may be a useful marker of microvascular abnormalities in RP patients treated with MLS laser therapy.
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Affiliation(s)
- Anna Kuryliszyn-Moskal
- Department of Rehabilitation, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276, Bialystok, Poland,
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Cutolo M, Ruaro B, Pizzorni C, Ravera F, Smith V, Zampogna G, Paolino S, Seriolo B, Cimmino M, Sulli A. Longterm treatment with endothelin receptor antagonist bosentan and iloprost improves fingertip blood perfusion in systemic sclerosis. J Rheumatol 2014; 41:881-6. [PMID: 24692525 DOI: 10.3899/jrheum.131284] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the longterm effects of endothelin-1 (ET-1) antagonism on peripheral blood perfusion (PBP) in patients with systemic sclerosis (SSc). METHODS Twenty-six patients with SSc already receiving cyclic intravenous iloprost (ILO) for severe Raynaud phenomenon were enrolled. Thirteen patients continued the treatment for a further 3 years (ILO group) and 13 patients, because of the appearance of digital ulcers, received in addition bosentan (BOS; 125 mg twice/day) for 3 years (ILO + BOS group). Both PBP at fingertips and nailfold microangiopathy were evaluated yearly by laser Doppler flowmetry and nailfold videocapillaroscopy, respectively. RESULTS A progressive significant increase of PBP was observed in the ILO + BOS group during the 3 followup years (p = 0.0007, p = 0.0002, p = 0.01, respectively). In contrast, an insignificant progressive decrease of PBP was observed in the ILO group. Difference of perfusion between the PBP evaluations at basal temperature and at 36 °C (to test capillary dilation capacity), was found progressively decreased during the 3-year followup only in the ILO group (p = 0.05, p = 0.26, p = 0.09, respectively). A progressive increase of nailfold capillary number was observed only in the ILO + BOS group after 2 and 3 years of followup (p = 0.05). CONCLUSION Longterm treatment of SSc patients with ET-1 antagonism, in combination with ILO, seems to increase fingertip blood perfusion, as well as both capillary dilation capacity and number.
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Affiliation(s)
- Maurizio Cutolo
- From the Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy; Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
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Münster T, Tiebel N, Seyer H, Maihöfner C. Modulation of somatosensory profiles by spinal cord stimulation in primary Raynaud's syndrome. Pain Pract 2012; 12:469-75. [PMID: 22304658 DOI: 10.1111/j.1533-2500.2012.00531.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND GOAL Spinal cord stimulation (SCS) is an effective antinociceptive treatment for various neuropathic pain syndromes. Apart from antinociceptive action, it may modulate overall somatosensory perception. This case report targets the question of whether SCS may alter quantitative sensory testing (QST) in a patient with primary Raynaud's syndrome. MATERIALS AND METHODS We report on a 44-year-old female patient with primary Raynaud's syndrome who had SCS via cervical and lumbar electrodes. QST was performed in a standardized manner assessing cold detection threshold (CDT) and warm detection threshold (WDT), cold pain threshold (CPT) and heat pain threshold (HPT), mechanical detection threshold (MDT) and mechanical pain threshold (MPT) thresholds, and vibration detection threshold (VDT) and pressure pain thresholds (PPT). We tested at the dorsum of the right/left hand of the patient with engaged and disengaged SCS. Test results were compared with a control group of 80 subjects. RESULTS Without SCS, the patient showed a sensory decrease in CDT, MDT, MPT, and VDT. SCS influenced the perception of cold, warm, and tactile detection thresholds, whereby CDT, WDT, and VDT were impaired and MDT was improved. CONCLUSION SCS significantly modulated the somatosensory profile in a patient with primary Raynaud's syndrome. These effects were pronounced in qualities involving Aβ, C, and A∂ nerve fibers. Further investigations may help to understand the mechanisms of action of SCS.
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Affiliation(s)
- Tino Münster
- Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
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Malenfant D, Summers K, Seney S, McBain D, Petrlich L, Watson S, Vanderhoek L, Samadi N, Bonner A, Pope J. Results of a Pilot Randomized Placebo-Controlled Trial in Primary and Secondary Raynaud's Phenomenon with St. John's Wort: Detecting Changes in Angiogenic Cytokines When RP Improves. ISRN RHEUMATOLOGY 2011; 2011:580704. [PMID: 22389797 PMCID: PMC3263747 DOI: 10.5402/2011/580704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/27/2011] [Indexed: 11/23/2022]
Abstract
Objectives.To perform a 6-week double-blind RCT in Raynaud's phenomenon (RP) comparing the plant extract St. John's Wort (SJW) to placebo. Methods. RP patients having at least 7 attacks per week were stratified by primary and secondary RP and within secondary by systemic sclerosis or other connective tissue disease. Subjects completed a daily standardized diary recording all RP attacks (frequency, duration and severity). Serum levels of 18 inflammatory and angiogenic cytokines were measured pre- and post-treatment. Results. Eighteen patients completed the study; 8 received SJW and 10 placebo. The decrease in mean number of attacks per day was 0.75 with SJW and 1.01 with placebo, P = 0.06. Attack duration and severity were not different between groups. Cytokine analyses demonstrated no between-groups differences. Combining treatment groups, those with >50% improvement in frequency of attacks yielded a significant increase in E-selectin (P = 0.049), MMP-9 (P = 0.011), G-CSF (P = 0.02), and VEGF (P = 0.012) pre- versus post-treatment. A ≥50% improvement in severity of attacks corresponded to a significant increase in levels of sVCAM-1 (P = 0.003), sICAM-1 (P = 0.007), and MCP-1 (P = 0.004). Conclusions. There were no clinical or biomarker benefit of SJW versus placebo in RP. However, combining all patients, there were changes in some cytokines that may be further investigated.
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Affiliation(s)
- Déanne Malenfant
- Department of Medicine, University of Western Ontario, London, ON, Canada N6A 5C1
| | - Kelly Summers
- Screening Laboratory for Immune Disorders, Lawson Health Research Institute, London, ON, Canada N6A 4V2
- Department of Microbiology & Immunology, University of Western Ontario, London, ON, Canada N6A 5C1
| | - Shannon Seney
- Screening Laboratory for Immune Disorders, Lawson Health Research Institute, London, ON, Canada N6A 4V2
| | - Donna McBain
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
| | - Lisa Petrlich
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
| | - Sharon Watson
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
| | - Louise Vanderhoek
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
| | - Nooshin Samadi
- Department of Medicine, University of Western Ontario, London, ON, Canada N6A 5C1
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
| | - Ashley Bonner
- Department of Mathematics and Statistics, McMaster University, Hamilton, ON, Canada L8S 4K1
| | - Janet Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada N6A 5C1
- Rheumatology, St. Joseph's Health Care London, London, ON, Canada N6A 4V2
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