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Gambrah-Lyles C, Kannan V, Lotze T, Abrams A, Schreiner T, Rodriguez M, Casper TC, Rose JW, Gorman MP, Chitnis T, Loud S, Wheeler Y, Mar S. Assessing Needs and Perceptions of Research Participation in Pediatric-Onset Multiple Sclerosis: A Multistakeholder Survey. Pediatr Neurol 2024; 151:115-120. [PMID: 38154238 DOI: 10.1016/j.pediatrneurol.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/30/2023] [Accepted: 11/29/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Patient-powered research networks (PPRNs) for autoimmune disease are widely used in the adult population to recruit patients and drive patient-centered research, but few have included pediatric patients. We aimed to characterize viewpoints regarding research needs and participation in pediatric-onset multiple sclerosis (POMS) via a PPRN-disseminated survey. METHODS This is an exploratory, cross-sectional study. The study period was February 1, 2022, to February 9, 2023. Three questionnaires were disseminated to (1) patients with POMS (PwPOMS), (2) caregivers of PwPOMS (C-PwPOMS), and (3) health care providers/researchers in POMS (HR-POMS). RESULTS A total of 88 participants were included for analysis; 44% (n = 39) were PwPOMS, 42% (n = 37) were C-PwPOMS, and 14% (n = 12) were HR-POMS. Some PwPOMS (18%) and C-PwPOMS (9%) expressed research hesitancy, but more, 69% of PwPOMS and 68% of C-PwPOMS, were interested in research participation. Nevertheless, less than half of PwPOMS (38%) and C-PwPOMS (38%) reported previous research involvement. HR-POMS reported difficulties in funding (100%) and recruiting participants (58%). PwPOMS (67%), C-PwPOMS (62%), and HR-POMS (67%) were open to future involvement in PPRNs. CONCLUSIONS Participants with POMS in this study expressed strong interest in research involvement but also expressed participation hesitancy, which may contribute to recruiting challenges expressed by researchers. Although the exploratory design limits generalizability to the larger POMS population, this study shows PPRNs are well-suited to soliciting attitudes and opinions of key stakeholders in POMS. Future studies utilizing PPRNs for POMS should prioritize diverse, representative cohorts and focus on understanding and mitigating issues hindering research participation.
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Affiliation(s)
- Claudia Gambrah-Lyles
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Varun Kannan
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Tim Lotze
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Aaron Abrams
- Cleveland Clinic, Center for Pediatric Neurosciences and Mellen Center for MS, Neurologic Institute, Cleveland, Ohio
| | - Teri Schreiner
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Moses Rodriguez
- Department of Pediatrics, Mayo Clinic Pediatric MS Center, Rochester, Minnesota
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - John W Rose
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Diseases Program, Boston, Massachusetts
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, Pediatric Multiple Sclerosis Center, Boston, Massachusetts
| | - Sara Loud
- Accelerated Cure Project, Inc. and iConquerMS, Waltham, Massachusetts
| | - Yolanda Wheeler
- Department of Pediatrics, Center for Pediatric Onset Demyelinating Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Soe Mar
- Department of Neurology, Washington University in Saint Louis, St. Louis, Missouri
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Nowell WB, Barnes EL, Venkatachalam S, Kappelman MD, Curtis JR, Merkel PA, Shaw DG, Larson K, Greisz J, George MD. Racial and Ethnic Distribution of Rheumatic Diseases in Health Systems of the National Patient-Centered Clinical Research Network. J Rheumatol 2023; 50:1503-1508. [PMID: 37657793 DOI: 10.3899/jrheum.2022-1300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To evaluate the relative prevalence of 8 rheumatic and musculoskeletal diseases (RMDs) across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet). METHODS Electronic health records from participating PCORnet institutions and systems from January 1, 2013, to December 31, 2018, were used to identify adult patients with ≥ 2 diagnosis codes for rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoporosis (OP), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), giant cell arteritis (GCA), and Takayasu arteritis (TAK). Among those with race and ethnicity data available, we compared prevalence of RMDs by race and ethnicity. RESULTS Data from 28,059,546 patients were available for analysis. RA was more common in patients who were American Indian or Alaska Native vs White, with a prevalence of 11.57 vs 10.11/1000 (odds ratio [OR] 1.15, 95% CI 1.09-1.22). SLE was more common in patients who were Black or African American (6.73/1000), American Indian or Alaska Native (3.82/1000), and Asian (3.39/1000) vs White (2.80/1000; OR 2.43, 95% CI 2.39-2.46; OR 1.39, 95% CI 1.25-1.53; OR 1.26, 95% CI 1.21-1.31, respectively). SLE was more common in patients who were Hispanic vs non-Hispanic (prevalence 3.93 vs 3.45/1000, OR 1.14, 95% CI 1.12-1.16). TAK was more common in patients who were Asian vs White (prevalence 0.05 vs 0.04/1000, OR 1.43, 95% CI 1.00-2.03). OP, RA, and the vasculitides were all more common in patients who were White vs Black or African American. CONCLUSION These data provide important information on the prevalence of RMDs by race and ethnicity in the United States. PCORnet can be used as a reliable data source to study RMDs within a large representative population.
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Affiliation(s)
- William Benjamin Nowell
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York;
| | - Edward L Barnes
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Shilpa Venkatachalam
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York
| | - Michael D Kappelman
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Jeffrey R Curtis
- J.R. Curtis, MD, MS, MPH, Illumination Health, Hoover, and University of Alabama at Birmingham, Birmingham, Alabama
| | - Peter A Merkel
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dianne G Shaw
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Kalen Larson
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Justin Greisz
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael D George
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
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Hsiao B, Downs JS, Lanyon M, Blalock SJ, Curtis JR, Harrold LR, Nowell WB, Wiedmeyer C, Venkatachalam S, Patterson MT, Gavigan K, Stradford L, Ali D, Fraenkel L. Understanding Heterogeneity in Patients' Conceptualisation of Treatment for Rheumatoid Arthritis: A Cluster Analysis. BMJ Open 2023; 13:e070848. [PMID: 37666546 PMCID: PMC10481841 DOI: 10.1136/bmjopen-2022-070848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/10/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE Uptake of treat-to-target (TTT) strategies for rheumatoid arthritis (RA) management is low. Our objective was to understand the heterogeneity in patients' conceptualisation of RA treatment to inform interventions improving TTT uptake. DESIGN Eligible participants recruited from an online research registry rated 56 items (on 5-point scales) reflecting concepts raised from patient interviews. Using items describing adhering to physician recommendations to create a binary criterion variable for medication adherence, we conducted a principal components analysis on the remaining items using Varimax rotation, describing how these factors predict adherence over and above demographic characteristics. We further use optimal sets in regression to identify the individual concepts that are most predictive of medication adherence. RESULTS We found significant heterogeneity in patients' conceptualisation of RA treatment among 621 persons with RA. A scree plot revealed a four-factor solution explained 38.4% of the variance. The four factors expected to facilitate TTT uptake were (% variance explained): (1) Access to high quality care and support (11.3%); (2) low decisional conflict related to changing disease-modifying antirheumatic drugs (DMARDs) (10.1%); (3) endorsement of a favourable DMARD risk/benefit ratio (9.9%); and (4) confidence that testing reflects disease activity (7.2%). These factors account for 13.8% of the variance in full medication adherence, fully explaining the only significant demographic predictor, age of the patient. The individual items most predictive of poor adherence centre on the lack of effective patient-physician communication, specifically insufficient access to information from rheumatologists, along with the need to seek information elsewhere. CONCLUSION Patients' conceptualisation of RA treatment varies; however, almost all patients have difficulty escalating DMARDs, even with access to quality information and an understanding of the benefits of TTT. Tailored interventions are needed to address patient hesitancy to escalate DMARDs.
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Affiliation(s)
- Betty Hsiao
- Yale University, New Haven, Connecticut, USA
| | - Julie S Downs
- Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Mandy Lanyon
- Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Susan J Blalock
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeffrey R Curtis
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | | | | | | | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, New York, USA
| | - Laura Stradford
- Global Healthy Living Foundation, Upper Nyack, New York, USA
| | - Danielle Ali
- Global Healthy Living Foundation, Upper Nyack, New York, USA
| | - Liana Fraenkel
- Yale University, New Haven, Connecticut, USA
- Berkshire Medical Center, Pittsfield, Massachusetts, USA
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Nowell WB, Curtis JR. Remote Therapeutic Monitoring in Rheumatic and Musculoskeletal Diseases: Opportunities and Implementation. MEDICAL RESEARCH ARCHIVES 2023; 11:3957. [PMID: 38550526 PMCID: PMC10972608 DOI: 10.18103/mra.v11i7.2.3957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2024]
Abstract
Therapeutic Monitoring (RTM) is a new program in the United States that began in 2022 allowing electronic patient-reported outcomes (ePRO) and other patient-generated data to be reviewed by clinical staff between visits so that patients can receive clinical attention as needed. Remote Therapeutic Monitoring simultaneously enhances the capacity to generate prospective longitudinal data that may be useful for secondary research purposes. As many governmental and private insurance programs in the United States now provide reimbursement for Remote Therapeutic Monitoring, increasing numbers of rheumatologists may be incentivized to provide this service for their patient populations. Launched in 2015, the ArthritisPower® Research Registry and associated mobile and desktop application, registered with the Food & Drug Administration (FDA) as a Class I medical device, enables patients to track their disease across dozens of domains and to securely participate in voluntary research studies. ArthritisPower, in partnership with Illumination Health, has developed infrastructure and a clinical workflow for Remote Therapeutic Monitoring that will help rheumatologists more closely track their patients' disease activity and flares, identify primary non-adherence, record changes in key health domains (e.g. fatigue, pain, physical function, mental health) and meet the needs for other data elements important for clinical care identified by individual providers. Ultimately, the approach to use digital health tools between visits seeks to improve clinical outcomes for patients with rheumatic and musculoskeletal diseases. This editorial review discusses the evolution of remote monitoring in rheumatologic care, describes the opportunities for physician reimbursement as of 2023, and provides a suggested workflow in order to establish Remote Therapeutic Monitoring within rheumatology practices.
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Affiliation(s)
| | - Jeffrey R Curtis
- Illumination Health, Hoover, AL, USA
- University of Alabama at Birmingham, Birmingham, AL, USA
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Nowell WB, Venkatachalam S, Gavigan K, George MD, Withers JB, Stradford L, Rivera E, Curtis JR. Patient Perceptions of Rheumatoid Arthritis Blood Work: A Cross-Sectional Survey in the ArthritisPower Registry. Arthritis Care Res (Hoboken) 2023. [PMID: 37386276 DOI: 10.1002/acr.25187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To examine how patients with rheumatoid arthritis (RA) perceive RA-related laboratory testing and the potential utility of a blood test to predict treatment response to a new RA medication. METHODS ArthritisPower members with RA were invited to participate in a cross-sectional survey on reasons for laboratory testing plus a choice-based conjoint analysis exercise to determine how patients value different attributes of a biomarker-based test to predict treatment response. RESULTS Most patients perceived that their doctors ordered laboratory tests to check for active inflammation (85.9%) or assess medication side effects (81.2%). The most commonly ordered blood tests used to monitor RA were complete blood counts, liver function tests, and those measuring C-reactive protein (CRP) and erythrocyte sedimentation rate. Patients felt CRP was most helpful in understanding their disease activity. Most worried their current RA medication would eventually stop working (91.4%) and they would waste time trying a new RA medication that may not work for them (81.7%). For patients who would require a future change in RA treatment, a majority (89.2%) reported that they would be very/extremely interested in a blood test that could help predict whether such new medication would be effective. Highly accurate test results (improving the chance RA medication will work from 50% to 85-95%) were more important to patients than low out-of-pocket cost (<$20) or minimal wait time (<7 days). CONCLUSIONS Patients consider RA-related blood work important for monitoring of inflammation and medication side effects. They worry about treatment effectiveness and would undergo testing to accurately predict treatment response.
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Affiliation(s)
| | | | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, New York
| | | | | | | | | | - Jeffrey R Curtis
- University of Alabama at Birmingham and the Foundation for Advancing Science, Technology, Education and Research, Birmingham
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Beukelman T, Long MD, Rhee RL, Kappelman MD, Merkel PA, Nowell WB, Clinton C, Ringold S, Del Gaizo V, Price B, Shaw DG, Venkatachalam S, Cuthbertson D, Xie F, Zhang X, Curtis JR. Assessment of Real-World Patient-Reported Outcomes in Patients Initiating Biologic Agents for the Treatment of Autoimmune Diseases: An Observational Study in Four Patient-Powered Research Networks. Patient Relat Outcome Meas 2023; 14:171-180. [PMID: 37333063 PMCID: PMC10276583 DOI: 10.2147/prom.s392174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/23/2023] [Indexed: 06/20/2023] Open
Abstract
Background The most reliable and meaningful approach for inclusion of patient-reported outcomes (PROs) in the evaluation of real-world clinical effectiveness of biologics in the treatment of autoimmune diseases is u ncertain. This study aimed to assess and compare the proportions of patients who had abnormalities in PROs measuring important general health domains at the initiation of treatment with biologics, as well as the effects of baseline abnormalities on subsequent improvement. Methods PROs were collected for patient participants with inflammatory arthritis, inflammatory bowel disease, and vasculitis using Patient-Reported Outcomes Measurement Information System instruments. Scores were reported as T-scores normalized to the general population in the United States. Baseline PROs scores were collected near the time of biologic initiation, and follow-up scores were collected 3 to 8 months later. In addition to summary statistics, the proportion of patients with PROs abnormalities (scores ≥5 units worse than the population norm) was determined. Baseline and follow-up scores were compared, and an improvement of ≥5 units was considered significant. Results There was wide variation across autoimmune diseases in baseline PROs scores for all domains. For example, the proportion of participants with abnormal baseline pain interference scores ranged from 52% to 93%. When restricted to participants with baseline PROs abnormalities, the proportion of participants experiencing an improvement of ≥5 units was substantially higher. Conclusion As expected, many patients experienced improvement in PROs following initiation of treatment with biologics for autoimmune diseases. Nevertheless, a substantial proportion of participants did not exhibit abnormalities in all PROs domains at baseline, and these participants appear less likely to experience improvement. For PROs to be reliably and meaningfully included in the evaluation of real-world medication effectiveness, more knowledge and careful consideration are needed to select the most appropriate patient populations and subgroups for inclusion and evaluation in studies measuring change in PROs.
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Affiliation(s)
- Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rennie L Rhee
- Department of Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peter A Merkel
- Department of Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics; Division of Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Cassie Clinton
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah Ringold
- Department of Pediatrics, Division of Rheumatology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Vincent Del Gaizo
- Childhood Arthritis and Rheumatology Research Alliance (CARRA) and PARTNERS PPRN, Milwaukee, WI, USA
| | - Brian Price
- Crohn’s and Colitis Foundation and IBD-Partners, New York, NY, USA
| | - Dianne G Shaw
- Vasculitis Patient Powered Research Network, Kansas City, MO, USA
| | | | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Fenglong Xie
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xian Zhang
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Venkatachalam S, Gavigan K, Banerjee S, Gordon J, Emrich L, Sullivan H, Blazer A, Banbury B, Weaver KN, Stradford L, Dronadula V, Degrassi A, Merkel PA, Shaw DG, Larsen K, Curtis JR, McBurney RN, Kappelman MD, George MD, Nowell WB. Engaging Multistakeholder Perspectives to Identify Patient-Centered Research Priorities Regarding Vaccine Uptake Among Adults With Autoimmune Conditions. ACR Open Rheumatol 2023; 5:290-297. [PMID: 37127530 PMCID: PMC10267803 DOI: 10.1002/acr2.11546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/12/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE The study objective was to prioritize topics for future patient-centered research to increase uptake of common vaccines, such as for pneumococcal pneumonia, influenza, herpes zoster, human papillomavirus, and severe acute respiratory syndrome coronavirus 2, among adults living with autoimmune conditions. METHODS A steering committee (SC) was formed that included clinicians, patients, patient advocates, and researchers associated with rheumatic diseases (psoriatic arthritis, rheumatoid arthritis, vasculitis), inflammatory bowel disease, and multiple sclerosis. Through a scoping review and discussions, SC members identified research topics regarding vaccine uptake and/or hesitancy for prioritization. A larger multistakeholder alliance that included patients and patient advocates, clinicians, researchers, policy makers, regulators, and vaccine manufacturers conducted a modified Delphi exercise online with three rating rounds and one ranking round. Frequency analysis and comparisons across stakeholder groups were conducted. A weighted ranking score was generated for each item in the ranking round for final prioritization. RESULTS Through the Delphi process, 33 research topics were identified, of which 13 topics were rated as critical by more than 70% of all stakeholders (n = 31). The two highest ranked critical topics per the full stakeholder group were "How well a vaccine works for adults with autoimmune conditions" and "How beliefs about vaccine safety affect vaccine uptake." CONCLUSION A multistakeholder group identified key topics as critically important priorities for future research to decrease vaccine hesitancy and improve uptake of vaccines for adults with autoimmune conditions.
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Affiliation(s)
| | | | | | | | - Lisa Emrich
- Accelerated Cure ProjectWalthamMassachusetts
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Wicks P, Wahlstrom-Edwards L, Fillingham S, Downing A, Davies EH. So You Want to Build Your Disease's First Online Patient Registry: An Educational Guide for Patient Organizations Based on US and European Experience. THE PATIENT 2023; 16:183-199. [PMID: 36947286 PMCID: PMC10031688 DOI: 10.1007/s40271-023-00619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/23/2023]
Abstract
Patient registries fulfill a number of key roles for clinicians, researchers, non-profit organizations, payers, and policy makers. They can help the field understand the natural history of a condition, determine the effectiveness of interventions, measure safety, and audit the quality of care provided. Successful registries in cystic fibrosis, Duchenne's muscular dystrophy, and other rare diseases have become a model for accelerating progress. However, the complex tasks required to develop a modern registry can seem overwhelming, particularly for those who are not from a technical background. In this Education article, a team of co-authors from across patient advocacy, technology, privacy, and commercial perspectives who have worked on a number of such projects offer a "Registry 101" primer to help get started. We will outline the promise and potential of patient registries with worked case examples, identify some of the key technical considerations you will need to consider, describe the type of data you might want to collect, consider privacy risks to protect your users, sketch out some of the paths towards long-term financial sustainability we have observed, and conclude with plans to mitigate some of the challenges that can occur and signpost interested readers to further resources. While rapid growth in the digital health market has presented numerous opportunities to those at the beginning of their journey, it is important to start with the long-term goals in mind and to benefit from the learnings of those who have walked this path before.
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Affiliation(s)
- Paul Wicks
- Wicks Digital Health Ltd, Lichfield, UK.
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Hsiao B, Downs J, Lanyon M, Blalock SJ, Curtis JR, Harrold LR, Nowell WB, Wiedmeyer C, Venkatachalam S, Fraenkel L. Rheumatologist and Patient Mental Models for Treatment of Rheumatoid Arthritis Help Explain Low Treat-to-Target Rates. ACR Open Rheumatol 2022; 4:700-710. [PMID: 35665497 PMCID: PMC9374053 DOI: 10.1002/acr2.11443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Despite proven benefits, less than half of patients with rheumatoid arthritis (RA) are treated using a treat-to-target (TTT) strategy. Our objective was to identify critical discrepancies between rheumatologist and patient mental models related to the treatment of RA to inform interventions designed to increase implementation of TTT. METHODS We developed rheumatologist and patient mental models using the Mental Models Approach to Risk Communication. We conducted semistructured interviews to elicit views related to RA treatment decisions with 14 rheumatologists and 30 patients with RA. We also included responses (n = 284) to an open-ended question on a survey fielded to augment qualitative descriptions from the interviews. Interviews were transcribed and coded independently by two members of the research team. RESULTS Rheumatologist and patient mental models for RA treatment are significantly more complex than the TTT model. Both consider domains (system factors and patient readiness) outside of disease activity measurement, target setting, and risk versus benefit assessment in their decision-making. Furthermore, specific factors were found to be unique to each model. For example, the physician model stresses the importance of evaluating disease activity over time and patient adherence. In contrast, patients discussed the impact of chronic disease weariness, medication-related fatigue, the importance of feeling adequately informed, and stress associated with changing medications. CONCLUSION We found several discrepancies primarily related to information gaps and differences in how patients and physicians value trade-offs that can serve as specific targets to improve patient-physician communication and ultimately inform interventions to improve uptake of TTT.
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Affiliation(s)
| | - Julie Downs
- Carnegie Mellon UniversityPittsburghPennsylvania
| | - Mandy Lanyon
- Carnegie Mellon UniversityPittsburghPennsylvania
| | | | | | | | | | | | | | - Liana Fraenkel
- Yale University, New Haven Connecticut, and Berkshire Medical CenterPittsfieldMassachusetts
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10
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Global Regulatory and Public Health Initiatives to Advance Pediatric Drug Development for Rare Diseases. Ther Innov Regul Sci 2022; 56:964-975. [PMID: 35471559 PMCID: PMC9040360 DOI: 10.1007/s43441-022-00409-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/07/2022] [Indexed: 12/17/2022]
Abstract
The literature thoroughly describes the challenges of pediatric drug development for rare diseases. This includes (1) generating interest from sponsors, (2) small numbers of children affected by a particular disease, (3) difficulties with study design, (4) lack of definitive outcome measures and assessment tools, (5) the need for additional safeguards for children as a vulnerable population, and (6) logistical hurdles to completing trials, especially with the need for longer term follow-up to establish safety and efficacy. There has also been an increasing awareness of the need to engage patients and their families in drug development processes and to address inequities in access to pediatric clinical trials. The year 2020 ushered in yet another challenge—the COVID-19 pandemic. The pediatric drug development ecosystem continues to evolve to meet these challenges. This article will focus on several key factors including recent regulatory approaches and public health policies to facilitate pediatric rare disease drug development, emerging trends in product development (biologics, molecularly targeted therapies), innovations in trial design/endpoints and data collection, and current efforts to increase patient engagement and promote equity. Finally, lessons learned from COVID-19 about building adaptable pediatric rare disease drug development processes will be discussed.
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Weiner J, Lui G, Brown M, Páez YD, Fritz S, Sydnor-Campbell T, Allen A, Jabri A, Venkatachalam S, Gavigan K, Nowell WB, Curtis JR, Fraenkel L, Safford M, Navarro-Millán I. Protocol for the pilot randomized trial of the CArdiovascular Risk assEssment for Rheumatoid Arthritis (CARE RA) intervention: a peer coach behavioral intervention. Pilot Feasibility Stud 2022; 8:84. [PMID: 35428359 PMCID: PMC9011938 DOI: 10.1186/s40814-022-01041-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/02/2022] [Indexed: 11/21/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the most common cause of death among people with rheumatoid arthritis (RA), with an estimated increased risk of 50–60% compared to the general population. Lipid-lowering strategies have been shown to lower CVD risk significantly in people with RA and hyperlipidemia. Thus, CVD risk assessment has an important role to play in reducing CVD among people with RA. Yet currently only 37 to 45% of this population are receiving primary lipids screening. This paper describes the CArdiovascular Risk assEssment for RA (CARE RA) intervention, which is designed to address this issue. CARE RA is a peer coach intervention, that is, an intervention in which a person with RA coaches another person with RA, which is designed to educate people with RA about the relation between RA and CVD risk and to help them obtain evidence-based CVD risk assessment and treatment. Methods This is an open-label pilot study that will test if the participants assigned to complete the CARE RA curriculum with a peer coach will receive a cardiovascular risk assessment more frequently compared to those that complete the CARE RA curriculum by themselves. The CARE RA intervention is guided by Social Cognitive Theory. Participants in the peer coach intervention arm will receive the assistance of a peer coach who will call the participants once a week for 5 weeks to go over the CARE RA curriculum and train them on how to obtain CVD risk assessment. The control arm will complete the CARE RA curriculum without any assistance. Participants will be randomized 1:1 either to the control arm or to the peer coach intervention arm. The primary outcome is a participant’s having a CVD risk assessment or initiating a statin, if indicated. Secondary outcomes include patient activation and RA medication adherence. The RE-AIM implementation framework guides the implementation and evaluation of the intervention. Discussion This pilot study will test the feasibility of the peer coach intervention in anticipation of a larger trial. CARE RA pioneers the use of peer coaches to facilitate the implementation of evidence-based treatment guidelines among people with RA. Trial registration ClinicalTrials.gov NCT04488497. Registered on July 28, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01041-z.
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Danila MI, Gavigan K, Rivera E, Nowell WB, George MD, Curtis JR, Cristopher-Stine L, Banerjee S, Merkel PA, Young K, Shaw DG, Gordon J, Venkatachalam S. Patient Perceptions and Preferences Regarding Telemedicine for Rheumatologic Care during the COVID-19 Pandemic. Arthritis Care Res (Hoboken) 2022; 74:1049-1057. [PMID: 35040274 PMCID: PMC9011874 DOI: 10.1002/acr.24860] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 11/22/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022]
Abstract
Objective To assess the perceptions and preferences of telemedicine among patients with autoimmune rheumatic diseases during the COVID‐19 pandemic. Methods We conducted an online survey among patients with autoimmune rheumatic diseases. Attitudes about telemedicine (i.e., telemedicine acceptability), evaluated using the validated Telemedicine Perception Questionnaire (TMPQ), and visit satisfaction were assessed for different telemedicine experiences and types of autoimmune rheumatic disease. Results Of 3,369 invitations, 819 responses were received. Participants had a mean ± SD age of 58.6 ± 11.6 years and were mostly White (n = 759, or 92.7%) and female (n = 702, or 85.7%). Of the 618 participants who said that telemedicine was available to them, 449 (72.7%) reported having a telemedicine visit, with 303 (67.5%) reporting attending a telemedicine video visit. On a 0 to 10 scale, the mean ± SD visit satisfaction score was 7.3 ± 1.8, with 25.8% of respondents being very satisfied (scores of 9 or 10). Video visits and higher TMPQ scores were associated with higher satisfaction. Compared to those who did not experience a telemedicine visit, patients who did were more likely to prefer telemedicine (video or phone) for routine visits (73.7% versus 44.3%; P < 0.001), reviewing test results (64.8% versus 53.8%; P < 0.001), when considering changing medications (40.5% versus 26.8%; P < 0.001), and when starting a new injectable medication (18.9% versus 12.7%; P = 0.02). Conclusion During the COVID‐19 pandemic, patients with autoimmune rheumatic diseases frequently had telemedicine visits, with the majority held via video, and were satisfied with these visits. These results suggest that because patients prefer telemedicine for certain visit reasons, maximizing effective use of telemedicine will require personalized patient scheduling.
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Briggs FBS, Mateen FJ, Schmidt H, Currie KM, Siefers HM, Crouthamel S, Bebo BF, Fiol J, Racke MK, O'Connor KC, Kolaczkowski LG, Klein P, Loud S, McBurney RN. COVID-19 Vaccination Reactogenicity in Persons With Multiple Sclerosis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 9:9/1/e1104. [PMID: 34753828 PMCID: PMC8579248 DOI: 10.1212/nxi.0000000000001104] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES There are limited data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine reactogenicity in persons with multiple sclerosis (PwMS) and how reactogenicity is affected by disease-modifying therapies (DMTs). The objective of this retrospective cross-sectional study was to generate real-world multiple sclerosis-specific vaccine safety information, particularly in the context of specific DMTs, and provide information to mitigate specific concerns in vaccine hesitant PwMS. METHODS Between 3/2021 and 6/2021, participants in iConquerMS, an online people-powered research network, reported SARS-CoV-2 vaccines, experiences of local (itch, pain, redness, swelling, or warmth at injection site) and systemic (fever, chills, fatigue, headache, joint pain, malaise, muscle ache, nausea, allergic, and other) reactions within 24 hours (none, mild, moderate, and severe), DMT use, and other attributes. Multivariable models characterized associations between clinical factors and reactogenicity. RESULTS In 719 PwMS, 64% reported experiencing a reaction after their first vaccination shot, and 17% reported a severe reaction. The most common reactions were pain at injection site (54%), fatigue (34%), headache (28%), and malaise (21%). Younger age, being female, prior SARS-CoV-2 infection, and receiving the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vs BNT162b2 (Pfizer-BioNTech) vaccine were associated with experiencing a reaction after the first vaccine dose. Similar relationships were observed for a severe reaction, including higher odds of reactions among PwMS with more physical impairment and lower odds of reactions for PwMS on an alpha4-integrin blocker or sphingosine-1-phosphate receptor modulator. In 442 PwMS who received their second vaccination shot, 74% reported experiencing a reaction, whereas 22% reported a severe reaction. Reaction profiles after the second shot were similar to those reported after the first shot. Younger PwMS and those who received the mRNA-1273 (Moderna) vs BNT162b2 vaccine reported higher reactogenicity after the second shot, whereas those on a sphingosine-1-phosphate receptor modulator or fumarate were significantly less likely to report a reaction. DISCUSSION SARS-CoV-2 vaccine reactogenicity profiles and the associated factors in this convenience sample of PwMS appear similar to those reported in the general population. PwMS on specific DMTs were less likely to report vaccine reactions. Overall, the short-term vaccine reactions experienced in the study population were mostly self-limiting, including pain at the injection site, fatigue, headache, and fever.
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Affiliation(s)
- Farren Basil Shaw Briggs
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA.
| | - Farrah J Mateen
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Hollie Schmidt
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Keisha M Currie
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Heather M Siefers
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Slavka Crouthamel
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Bruce F Bebo
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Julie Fiol
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Michael K Racke
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Kevin C O'Connor
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Laura G Kolaczkowski
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Phyllis Klein
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Sara Loud
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Robert Nicholas McBurney
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
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