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Doumen M, Diricks L, Hermans J, Bertrand D, De Meyst E, Westhovens R, Verschueren P. Definitions of rheumatoid arthritis flare and how they relate to patients' perspectives: A scoping review of qualitative and quantitative evidence. Semin Arthritis Rheum 2024; 67:152481. [PMID: 38815403 DOI: 10.1016/j.semarthrit.2024.152481] [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] [Received: 12/05/2023] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is characterized by intermittent flares of disease activity with a significant impact on patients' lives. However, distinguishing flare from daily symptom variation may be approached differently by patients and healthcare providers, potentially hampering shared decision-making when treating RA. OBJECTIVES To provide a comprehensive overview of RA flare definitions reported in the published literature, and to compare these with patients' perceptions of the flare concept according to qualitative evidence. METHODS A systematic search was conducted on August 30th, 2022, and updated on September 30th, 2023, for both quantitative and qualitative studies reporting "flare" or related terms in the context of RA. We searched the following databases: Pubmed, EMBASE, Web of Science, Cochrane Library, and CINAHL. Definitions of RA flare reported in quantitative studies were summarized descriptively. In parallel, a thematic synthesis of qualitative studies was performed to outline patients' views on the concept of flare, and to compare these with the currently used definitions. RESULTS Among 32,864 potentially eligible records, 304 studies were included, 5 of which used qualitative/mixed methods to study patients' perceptions of flare. Remarkably, 62 different definitions for RA flare were reported, with many studies reporting more than one. The most commonly used definitions (54 %) were based on disease activity indices, with DAS28-based definitions the most widely applied (84 %). For each of the disease activity indices, several different cutoffs to define flares were used. Various definitions based on physician report were applied in 24 % of cases, while patient-reported criteria represented only 15 % of the applied definitions. Thematic synthesis of the qualitative/mixed-methods studies highlighted the multidimensional impact of flares on patients' lives, resulting in five sequential overarching themes: "Living with RA: a balancing act", "Flare: a disturbance of this balance", "The biopsychosocial impact of flares", "Self-management: the first line of defense", and "Medical help: the last resort". In turn, these five themes were underpinned by a central theme of "Uncertainty and variability". CONCLUSION We found a striking heterogeneity regarding the conceptualization and measurement of RA flare in the published literature. Although qualitative evidence highlighted the considerable impact of flares on patients' wellbeing, the majority of reported flare definitions were not based on patient report. There is a need to bridge this gap by aligning patients' and healthcare professionals' views on what distinguishes a flare from acceptable symptom variability when living with RA.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium.
| | - Lotte Diricks
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Joppe Hermans
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Elias De Meyst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Gandrup J, Selby DA, Dixon WG. Classifying Self-Reported Rheumatoid Arthritis Flares Using Daily Patient-Generated Data From a Smartphone App: Exploratory Analysis Applying Machine Learning Approaches. JMIR Form Res 2024; 8:e50679. [PMID: 38743480 PMCID: PMC11134244 DOI: 10.2196/50679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 02/04/2024] [Accepted: 02/26/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The ability to predict rheumatoid arthritis (RA) flares between clinic visits based on real-time, longitudinal patient-generated data could potentially allow for timely interventions to avoid disease worsening. OBJECTIVE This exploratory study aims to investigate the feasibility of using machine learning methods to classify self-reported RA flares based on a small data set of daily symptom data collected on a smartphone app. METHODS Daily symptoms and weekly flares reported on the Remote Monitoring of Rheumatoid Arthritis (REMORA) smartphone app from 20 patients with RA over 3 months were used. Predictors were several summary features of the daily symptom scores (eg, pain and fatigue) collected in the week leading up to the flare question. We fitted 3 binary classifiers: logistic regression with and without elastic net regularization, a random forest, and naive Bayes. Performance was evaluated according to the area under the curve (AUC) of the receiver operating characteristic curve. For the best-performing model, we considered sensitivity and specificity for different thresholds in order to illustrate different ways in which the predictive model could behave in a clinical setting. RESULTS The data comprised an average of 60.6 daily reports and 10.5 weekly reports per participant. Participants reported a median of 2 (IQR 0.75-4.25) flares each over a median follow-up time of 81 (IQR 79-82) days. AUCs were broadly similar between models, but logistic regression with elastic net regularization had the highest AUC of 0.82. At a cutoff requiring specificity to be 0.80, the corresponding sensitivity to detect flares was 0.60 for this model. The positive predictive value (PPV) in this population was 53%, and the negative predictive value (NPV) was 85%. Given the prevalence of flares, the best PPV achieved meant only around 2 of every 3 positive predictions were correct (PPV 0.65). By prioritizing a higher NPV, the model correctly predicted over 9 in every 10 non-flare weeks, but the accuracy of predicted flares fell to only 1 in 2 being correct (NPV and PPV of 0.92 and 0.51, respectively). CONCLUSIONS Predicting self-reported flares based on daily symptom scorings in the preceding week using machine learning methods was feasible. The observed predictive accuracy might improve as we obtain more data, and these exploratory results need to be validated in an external cohort. In the future, analysis of frequently collected patient-generated data may allow us to predict flares before they unfold, opening opportunities for just-in-time adaptative interventions. Depending on the nature and implication of an intervention, different cutoff values for an intervention decision need to be considered, as well as the level of predictive certainty required.
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Affiliation(s)
- Julie Gandrup
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, United Kingdom
| | - David A Selby
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, United Kingdom
- Department of Computer Science, Technische Universität Kaiserslautern, Kaiserslautern, Germany
| | - William G Dixon
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, United Kingdom
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
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Bozzalla-Cassione E, Grignaschi S, Xoxi B, Luvaro T, Greco MI, Mazzucchelli I, Bugatti S, Montecucco C, Manzo A. Insights Into the Concept of Rheumatoid Arthritis Flare. Front Med (Lausanne) 2022; 9:852220. [PMID: 35372374 PMCID: PMC8968115 DOI: 10.3389/fmed.2022.852220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/04/2022] [Indexed: 01/10/2023] Open
Abstract
Identification of a pathological change in the course of systemic chronic immune-inflammatory diseases is key to delivering effective treatment strategies. In this context, one of the most compelling issues is the concept of flare. The multifaceted expression of disease activity in rheumatoid arthritis (RA) makes it challenging to provide an omni-comprehensive definition of flare, encompassing the pathology's different objective and subjective domains. Our incomplete understanding of the pathophysiological mechanisms underlying this process contributes to the partial comprehension of its potential clinical expression. This review focuses on the proposed pathophysiological processes underlying disease recrudescence in RA and the variable definitions adopted to capture flare in clinical practice through its objective, subjective, and temporal domains. Overall, what emerges is a complex landscape far from being unraveled.
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Gandrup J, Selby D, van der Veer SN, McBeth J, Dixon WG. Using patient-reported data from a smartphone app to capture and characterise real-time patient-reported flares in rheumatoid arthritis. Rheumatol Adv Pract 2022; 6:rkac021. [PMID: 35392426 PMCID: PMC8982773 DOI: 10.1093/rap/rkac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objective We aimed to explore the frequency of self-reported flares and their association with preceding symptoms collected through a smartphone app by people with RA. Methods We used data from the Remote Monitoring of RA study, in which patients tracked their daily symptoms and weekly flares on an app. We summarized the number of self-reported flare weeks. For each week preceding a flare question, we calculated three summary features for daily symptoms: mean, variability and slope. Mixed effects logistic regression models quantified associations between flare weeks and symptom summary features. Pain was used as an example symptom for multivariate modelling. Results Twenty patients tracked their symptoms for a median of 81 days (interquartile range 80, 82). Fifteen of 20 participants reported at least one flare week, adding up to 54 flare weeks out of 198 participant weeks in total. Univariate mixed effects models showed that higher mean and steeper upward slopes in symptom scores in the week preceding the flare increased the likelihood of flare occurrence, but the association with variability was less strong. Multivariate modelling showed that for pain, mean scores and variability were associated with higher odds of flare, with odds ratios 1.83 (95% CI, 1.15, 2.97) and 3.12 (95% CI, 1.07, 9.13), respectively. Conclusion Our study suggests that patient-reported flares are common and are associated with higher daily RA symptom scores in the preceding week. Enabling patients to collect daily symptom data on their smartphones might, ultimately, facilitate prediction and more timely management of imminent flares.
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Affiliation(s)
- Julie Gandrup
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - David Selby
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | | | - John McBeth
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - William G Dixon
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
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Kuettel D, Terslev L, Weber U, Østergaard M, Primdahl J, Petersen R, Ammitzbøll-Danielsen M, Möller S, Hørslev-Petersen K. Flares in rheumatoid arthritis: do patient-reported swollen and tender joints match clinical and ultrasonography findings? Rheumatology (Oxford) 2020; 59:129-136. [PMID: 31382292 DOI: 10.1093/rheumatology/kez231] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/15/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To investigate how patient-reported flares in RA are related to clinical joint examination and inflammation detected by US. METHODS Eighty RA patients with DAS28-CRP <3.2 and no swollen joints at baseline were followed for 1 year. In case of patient-reported hand flare with swollen and tender joints (SJ and TJ, respectively), patients underwent clinical examination for SJ/TJ and US of bilateral wrists, MCP and PIP 1st-5th, six extensor tendon compartments and wrist flexor tendons for synovitis/tenosynovitis. Percentage agreement and kappa were calculated between patient-reported SJ and TJ, clinical examination for SJ/TJ and US findings indicative of inflammation. With US as reference, sensitivity, specificity, positive/negative predictive value and accuracy of patient-reported and clinically examined joints were determined. RESULTS Hand flare was reported by 36% (29/80) of patients. At time of flare, all clinical and ultrasonographic measures of disease activity deteriorated compared with baseline. Agreement between patient-reported SJ/TJ, clinically examined SJ/TJ and US was slight (kappa = 0.02-0.20). Patients and clinicians agreed in 79-93% of joints, more frequently on SJ than TJ. With US as reference, specificities were 86-100% and 88-100%, and sensitivities 12-34% and 4-32% for patient-reported SJ/TJ and clinically examined SJ/TJ, respectively. CONCLUSION Over 12 months of follow-up, hand flare was reported by every third RA patient. Self-reported flares were associated with increased disease activity as determined by clinical examination and US. Patient-reported joint assessment may aid in capturing flares between routine clinical visits.
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Affiliation(s)
- Dorota Kuettel
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lene Terslev
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup, Denmark
| | - Ulrich Weber
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup, Denmark
| | - Jette Primdahl
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Sygehus Sønderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Randi Petersen
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark
| | - Mads Ammitzbøll-Danielsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup, Denmark
| | - Sören Möller
- OPEN - Odense Patient data Explorative Network, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kim Hørslev-Petersen
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Kuettel D, Glinatsi D, Østergaard M, Terslev L, Primdahl J, Möller S, Pedersen A, Petersen R, Weber U, Hørslev-Petersen K. Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis. Arthritis Res Ther 2020; 22:19. [PMID: 32014018 PMCID: PMC6998154 DOI: 10.1186/s13075-020-2105-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA. METHODS Eighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements. RESULTS Synovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05). CONCLUSIONS Patient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.
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Affiliation(s)
- Dorota Kuettel
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Engelshøjgade 9A, DK-6400, Sønderborg, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, C 5000, Odense, Denmark.
| | - Daniel Glinatsi
- Department of Rheumatology, Skaraborg Hospital, Lövängsvägen, 541 42, Skövde, Sweden.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Internal Medicine, University of Copenhagen, Nordre Ringvej 57, 2600, Glostrup, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Internal Medicine, University of Copenhagen, Nordre Ringvej 57, 2600, Glostrup, Denmark
| | - Lene Terslev
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Internal Medicine, University of Copenhagen, Nordre Ringvej 57, 2600, Glostrup, Denmark
| | - Jette Primdahl
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Engelshøjgade 9A, DK-6400, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, C 5000, Odense, Denmark.,Hospital of Southern Denmark, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark
| | - Sören Möller
- OPEN - Open Patient data Explorative Network, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 9 A, C 5000, Odense, Denmark
| | - Andreas Pedersen
- Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, C 5000, Odense, Denmark
| | - Randi Petersen
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Engelshøjgade 9A, DK-6400, Sønderborg, Denmark
| | - Ulrich Weber
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Engelshøjgade 9A, DK-6400, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, C 5000, Odense, Denmark
| | - Kim Hørslev-Petersen
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Engelshøjgade 9A, DK-6400, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, C 5000, Odense, Denmark
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Kuettel D, Primdahl J, Weber U, Terslev L, Østergaard M, Petersen R, Pedersen AK, Möller S, Hørslev-Petersen K. Pain and Self-reported Swollen Joints Are Main Drivers of Patient-reported Flares in Rheumatoid Arthritis: Results from a 12-month Observational Study. J Rheumatol 2019; 47:1305-1313. [PMID: 31787604 DOI: 10.3899/jrheum.190760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine prospectively self-reported flare characteristics and their longitudinal association with disease activity and patient-reported outcomes (PRO) in patients with rheumatoid arthritis (RA). METHODS Consecutive RA patients with 28-joint count Disease Activity Score based on C-reactive protein (DAS28-CRP) < 3.2 and no swollen joints were examined at baseline, Month 6, and Month 12. Assessments included joint counts, DAS28-CRP, visual analog scale-evaluator's global assessment (EGA), and PRO. Every third month, patients completed the Flare Assessment in Rheumatoid Arthritis and RA Flare Questionnaire, and disclosed self-management strategies. Flaring and non-flaring patients were compared and longitudinal associations between self-reported flare status (yes/no) and disease activity, PRO, and treatment escalation were explored. RESULTS Among 80 patients with RA [74% females, mean (SD) age 63 (10) yrs, disease duration 11 (7) yrs, and baseline DAS28-CRP 1.9 (0.6)], 64 (80%) reported flare at least once during 12 months. Fifty-five percent of flares lasted less than 1 week. Common self-management strategies were analgesics (50%) and restricted activities (38%). Patients who reported being in flare had consistently higher disease activity measures and PRO compared to patients without flare. In a partly adjusted model, all flare domains, patient-reported swollen and tender joint counts and disease activity measures were associated with flares. In fully adjusted analyses, present flare was independently associated with pain (OR 1.85, 95% CI 1.34-2.60), patient-reported swollen joints (OR 1.18, 95% CI 1.03-1.36), and higher EGA (OR 1.15, 95% CI 1.04-1.28). Treatment escalation was associated with present flare (p ≤ 0.001). CONCLUSION In RA, self-reported flares were frequent, mainly managed by analgesics, substantiated by higher disease activity measures, independently associated with pain and patient-reported swollen joints, and related to treatment escalation.
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Affiliation(s)
- Dorota Kuettel
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark.
| | - Jette Primdahl
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Ulrich Weber
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Lene Terslev
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Mikkel Østergaard
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Randi Petersen
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Andreas Kristian Pedersen
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Sören Möller
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
| | - Kim Hørslev-Petersen
- From the Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg; Institute of Regional Health Research, University of Southern Denmark, Odense; Hospital of Southern Jutland, University Hospital of Southern Denmark, Aabenraa; Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup, Glostrup; Open Patient data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,D. Kuettel, MD, PhD, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark; J. Primdahl, MSN, PhD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; U. Weber, MD, Associate Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark, and Hospital of Southern Jutland, University Hospital of Southern Denmark; L. Terslev, MD, PhD, Associate Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; M. Østergaard, MD, PhD, DMSc, Professor, COPECARE, Center for Rheumatology and Spine Diseases, Rigshospitalet - Glostrup; R. Petersen, MSN, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark; A.K. Pedersen, MS, Hospital of Southern Jutland, University Hospital of Southern Denmark; S. Möller, MS, PhD, Associate Professor, OPEN, Odense University Hospital and Department of Clinical Research, University of Southern Denmark; K. Hørslev-Petersen, MD, DMSc, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, and Institute of Regional Health Research, University of Southern Denmark
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8
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McWilliams DF, Rahman S, James RJE, Ferguson E, Kiely PDW, Young A, Walsh DA. Disease activity flares and pain flares in an early rheumatoid arthritis inception cohort; characteristics, antecedents and sequelae. BMC Rheumatol 2019; 3:49. [PMID: 31832600 PMCID: PMC6859633 DOI: 10.1186/s41927-019-0100-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background RA flares are common and disabling. They are described in terms of worsening inflammation but pain and inflammation are often discordant. To inform treatment decisions, we investigated whether inflammatory and pain flares are discrete entities. Methods People from the Early RA Network (ERAN) cohort were assessed annually up to 11 years after presentation (n = 719, 3703 person-years of follow up). Flare events were defined in 2 different ways that were analysed in parallel; DAS28 or Pain Flares. DAS28 Flares satisfied OMERACT flare criteria of increases in DAS28 since the previous assessment (≥1.2 points if active RA or ≥ 0.6 points if inactive RA). A ≥ 4.8-point worsening of SF36-Bodily Pain score defined Pain Flares. The first documented episode of each of DAS28 and Pain Flare in each person was analysed. Subgroups within DAS28 and Pain Flares were determined using Latent Class Analysis. Clinical course was compared between flare subgroups. Results DAS28 (45%) and Pain Flares (52%) were each common but usually discordant, with 60% of participants in DAS28 Flare not concurrently in Pain Flare, and 64% of those in Pain Flare not concurrently in DAS28 Flare. Three discrete DAS28 Flare subgroups were identified. One was characterised by increases in tender/swollen joint counts (14.4%), a second by increases in symptoms (13.1%), and a third displayed lower flare severity (72.5%). Two discrete Pain Flare subgroups were identified. One occurred following low disease activity and symptoms (88.6%), and the other occurred on the background of ongoing active disease and pain (11.4%). Despite the observed differences between DAS28 and Pain Flares, each was associated with increased disability which persisted beyond the flare episode. Conclusion Flares are both common and heterogeneous in people with RA. Furthermore our findings indicate that for some patients there is a discordance between inflammation and pain in flare events. This discrete flare subgroups might reflect different underlying inflammation and pain mechanisms. Treatments addressing different mechanisms might be required to reduce persistent disability after DAS28 and Pain Flares.
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Affiliation(s)
- Daniel F McWilliams
- 1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,2Division of ROD, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,3NIHR Biomedical Research Centre, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK
| | - Shimin Rahman
- 1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,2Division of ROD, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,3NIHR Biomedical Research Centre, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK
| | - Richard J E James
- 1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,4School of Psychology, University of Nottingham, Nottingham, UK
| | - Eamonn Ferguson
- 1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,3NIHR Biomedical Research Centre, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,4School of Psychology, University of Nottingham, Nottingham, UK
| | - Patrick D W Kiely
- 5Department of Rheumatology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Adam Young
- 6University of Hertfordshire, Hatfield, UK
| | - David A Walsh
- 1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,2Division of ROD, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,3NIHR Biomedical Research Centre, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.,7Department of Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
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9
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Radawski C, Genovese MC, Hauber B, Nowell WB, Hollis K, Gaich CL, DeLozier AM, Gavigan K, Reynolds M, Cardoso A, Curtis JR. Patient Perceptions of Unmet Medical Need in Rheumatoid Arthritis: A Cross-Sectional Survey in the USA. Rheumatol Ther 2019; 6:461-471. [PMID: 31385264 PMCID: PMC6702617 DOI: 10.1007/s40744-019-00168-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Many rheumatoid arthritis (RA) patients do not achieve their treatment goals and experience symptoms that affect psychosocial outcomes and daily activities. This study aimed to identify and quantify the unmet needs perceived by US patients with RA currently taking a disease-modifying antirheumatic drug (DMARD). METHODS A cross-sectional, web-based survey was conducted with RA patients recruited through CreakyJoints, an online patient support community, and ArthritisPower®, an online patient research registry, from December 2017 to January 2018. Participant patients were aged ≥ 21 years, failed ≥ 1 DMARDs, and were receiving their current DMARD(s) for ≥ 6 months; they answered 50 questions about treatment history, RA symptoms, and flares and completed the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire and the Treatment Satisfaction Questionnaire for Medication (TSQM). Treatment satisfaction was defined by a TSQM global satisfaction score ≥ 80. RESULTS Of 415 patients screened, 258 (62%) were eligible and completed the survey; 87% were women, and 87% white, with mean (SD) age of 54.5 (11.4) years. A total of 232 patients (90%) had current or past biologic DMARD (bDMARD) use, with 67% currently on a bDMARD, 65% on ≥ 1 conventional synthetic DMARD, and 40% on methotrexate. Forty-three percent of patients reported daily/almost daily use of prescription pain medications, and 44% reported a current flare. Mean (SD) TSQM scores were 59 [20] for effectiveness, 59 [26] for side effects, 72 [18] for convenience, and 65 [21] for global satisfaction. The mean (SD) RAID overall score was 5.1 (2.0) on a 0-10 scale. Only 26% (67 patients) were satisfied with their RA treatment. Patients not satisfied with treatment reported higher RAID scores overall and by domain, and approximately half reported a current flare. CONCLUSIONS Results from this real-world survey suggest that three-fourths of RA patients are not satisfied with treatments, which include bDMARDs. Patients continued to experience bothersome symptoms that impacted their daily activities and life. There remains a need for improved disease management among currently treated RA patients. FUNDING Eli Lilly and Company (Indianapolis, IN, USA).
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Affiliation(s)
| | | | - Brett Hauber
- RTI Health Solutions, Research Triangle Park, NC, USA
| | | | - Kelly Hollis
- RTI Health Solutions, Research Triangle Park, NC, USA
| | | | | | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, NY, USA
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10
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Smolen JS, Pedersen R, Jones H, Mahgoub E, Marshall L. Impact of flare on radiographic progression after etanercept continuation, tapering or withdrawal in patients with rheumatoid arthritis. Rheumatology (Oxford) 2019; 59:153-164. [DOI: 10.1093/rheumatology/kez224] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
The structural consequences of flare after dose reduction/discontinuation of biologic DMARDs in patients with RA who achieve remission are unclear. We compared the incidence of radiographic progression in patients with RA who did and did not experience flare after etanercept (ETN) reduction/withdrawal.
Methods
Eligible adults with moderately active RA despite MTX received ETN 50 mg plus MTX weekly in a 36-week, open-label induction period; patients achieving sustained low disease activity by week 36 were randomized to ETN 50 mg plus MTX, ETN 25 mg plus MTX, or placebo plus MTX in a 52-week, double-blind maintenance period. In post hoc analyses, radiographic progression (Δ modified total Sharp score ⩾0.5 units/year) was compared in patients with and without flare [based on DAS28 relapse (main analysis), and clinical disease activity index and simplified disease activity index relapse (sensitivity analyses)]. Findings from patients receiving full- and reduced-dose combination therapy were pooled for comparison with those from patients receiving MTX only.
Results
Significantly more patients receiving MTX monotherapy experienced flare, defined as DAS28 relapse (62% vs 21%; P < 0.0001) and radiographic progression (17% vs 9%; P < 0.001), than patients receiving full-/reduced-dose combination therapy in the double-blind period. Patients with flare defined as clinical disease activity index and simplified disease activity index relapse had higher rates of radiographic progression than those without flare in the full-/reduced-dose combination therapy group (P < 0.01).
Conclusion
Radiographic progression may be a consequence of flare after biologic DMARD dose reduction/withdrawal in patients with RA. If these approaches are taken, careful monitoring for signs/symptoms of relapse is needed.
Trial registration
ClinicalTrials.gov, https://clinicaltrials.gov, NCT00565409.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Heather Jones
- Global Medical Affairs, Pfizer, Collegeville, PA, USA
| | - Ehab Mahgoub
- Global Medical Affairs, Pfizer, Collegeville, PA, USA
| | - Lisa Marshall
- Global Medical Affairs, Pfizer, Collegeville, PA, USA
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11
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Mahmoud TG, Huang J, Frits M, Iannaccone C, Bykerk V, Bingham CO, Weinblatt M, Shadick NA. Correlates of Successful Rheumatoid Arthritis Flare Management: Clinician-driven Treatment, Home-based Strategies, and Medication Change. J Rheumatol 2019; 47:333-340. [PMID: 31203222 DOI: 10.3899/jrheum.181160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Describe strategies used to manage rheumatoid arthritis (RA) flares that contribute to a successful postflare outcome. METHODS Data were collected from the BRASS registry, including clinical and patient-reported outcomes, and a survey with a Likert scale assessing postflare symptoms (better, unchanged, or worse). A logistic regression analysis adjusting for age, sex, flare number in the past 6 months, flare pain severity, home management, clinical consultation, and medication change was performed to evaluate factors influencing flare outcome. RESULTS Of 503 participants, 185 reported at least 1 flare that had resolved in the past 6 months, with median (interquartile range) 28-joint count Disease Activity Score based on C-reactive protein 3 score 2.1 (1.7-2.8). Compared with RA symptoms before the flare, 22 (12%) patients felt worse, 125 (68%) were unchanged, and 38 (20%) felt better. To manage flares, 72% of patients used home-based remedies, 23% sought clinical consultation, and 56% made medication change. Of 103 patients who changed medication, 70% did so without seeking clinical advice. Making a medication change (OR 3.48, 95% CI 1.68-7.21) and having lower flare pain (OR 0.83, 95% CI 0.71-0.97) were associated with better flare outcome. CONCLUSION Flares occur frequently even in patients with low disease activity. Independent of home-based or clinically guided care, making a medication change and having less severe pain during a flare were associated with better flare outcomes. Of interest, the decision to change medications was frequently made without clinical advice. Future studies might address how best to intervene when patients experience flares and whether patient-initiated medication changes have adverse outcomes.
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Affiliation(s)
- Taysir G Mahmoud
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. .,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School.
| | - Jie Huang
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Michelle Frits
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Christine Iannaccone
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Vivian Bykerk
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Clifton O Bingham
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Michael Weinblatt
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
| | - Nancy A Shadick
- From the Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Hospital for Special Surgery, New York, New York; Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,T.G. Mahmoud, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; J. Huang, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; M. Frits, BA, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; C. Iannaccone, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; V. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery; C.O. Bingham III, MD, Division of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine; M. Weinblatt, MD, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School; N.A. Shadick, MD, MPH, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School
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Møller-Bisgaard S, Hørslev-Petersen K, Ejbjerg B, Hetland ML, Ørnbjerg LM, Glinatsi D, Møller J, Boesen M, Christensen R, Stengaard-Pedersen K, Madsen OR, Jensen B, Villadsen JA, Hauge EM, Bennett P, Hendricks O, Asmussen K, Kowalski M, Lindegaard H, Nielsen SM, Bliddal H, Krogh NS, Ellingsen T, Nielsen AH, Balding L, Jurik AG, Thomsen HS, Østergaard M. Effect of Magnetic Resonance Imaging vs Conventional Treat-to-Target Strategies on Disease Activity Remission and Radiographic Progression in Rheumatoid Arthritis: The IMAGINE-RA Randomized Clinical Trial. JAMA 2019; 321:461-472. [PMID: 30721294 PMCID: PMC6440221 DOI: 10.1001/jama.2018.21362] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Whether using magnetic resonance imaging (MRI) to guide treatment in patients with rheumatoid arthritis (RA) improves disease activity and slows joint damage progression is unknown. OBJECTIVE To determine whether an MRI-guided treat-to-target strategy vs a conventional clinical treat-to-target strategy improves outcomes in patients with RA in clinical remission. DESIGN, SETTING, AND PARTICIPANTS Two-year, randomized, multicenter trial conducted at 9 hospitals in Denmark. Two hundred patients with RA in clinical remission (disease activity score in 28 joints-C-reactive protein [DAS28-CRP] <3.2 and no swollen joints) were enrolled between April 2012 and June 2015. The final follow-up visit was April 2017. INTERVENTIONS Patients were randomly allocated (1:1) to an MRI-guided vs a conventional treat-to-target strategy. In the MRI-guided group, the treatment goal was absence of MRI bone marrow edema combined with clinical remission, defined as DAS28-CRP of 3.2 or less and no swollen joints. In the conventional group, the treatment goal was clinical remission. MAIN OUTCOMES AND MEASURES Co-primary outcomes were proportions of patients achieving DAS28-CRP remission (DAS28-CRP <2.6) and with no radiographic progression (no increase in total van der Heijde-modified Sharp score) at 24 months. Significance testing for the primary outcome was based on 1-sided testing. Secondary outcomes were clinical and MRI measures of disease activity, physical function, and quality of life. RESULTS Of 200 patients randomized (133 women [67%]; mean [SD] age, 61.6 [10.5] years; median baseline DAS28-CRP, 1.9 [interquartile range, 1.7-2.2]; van der Heijde-modified Sharp score, 18.0 [interquartile range, 7.0-42.5]), 76 patients (76%) in the MRI-guided group and 95 (95%) in the conventional group completed the study. Of these, 64 (85%) vs 83 (88%), respectively, reached the primary clinical end point (risk difference, -4.8% [1-sided 95% CI, -13.6% to + ∞; 1-sided P = .19]) and 49 (66%) vs 58 (62%), respectively, reached the primary radiographic end point (risk difference, 4.7% [1-sided 95% CI, -7.0% to + ∞; 1-sided P = .25). Of 10 key secondary end points, 8 were null and 2 showed statistically significant benefit for the MRI treat-to-target group. Seventeen patients (17%) in the MRI-guided treat-to-target group and 6 patients (6%) in the conventional treat-to-target group experienced serious adverse events. CONCLUSIONS AND RELEVANCE Among patients with RA in clinical remission, an MRI-guided treat-to-target strategy compared with a conventional treat-to-target strategy did not result in improved disease activity remission rates or reduce radiographic progression. These findings do not support the use of an MRI-guided strategy for treating patients with RA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01656278.
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Affiliation(s)
- Signe Møller-Bisgaard
- Department of Rheumatology, Slagelse Hospital, Slagelse, Denmark
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Kim Hørslev-Petersen
- Department of Rheumatology, King Christian X’s Hospital for Rheumatic Diseases, Graasten, Denmark
| | - Bo Ejbjerg
- Department of Rheumatology, Slagelse Hospital, Slagelse, Denmark
- Department of Rheumatology, Zealand University Hospital, Køge, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lykke Midtbøll Ørnbjerg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Daniel Glinatsi
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Jakob Møller
- Department of Radiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Mikael Boesen
- Department of Radiology, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Kristian Stengaard-Pedersen
- Department of Rheumatology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Ole Rintek Madsen
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Bente Jensen
- Department of Rheumatology, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
| | | | - Ellen-Margrethe Hauge
- Department of Rheumatology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Philip Bennett
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Oliver Hendricks
- Department of Rheumatology, King Christian X’s Hospital for Rheumatic Diseases, Graasten, Denmark
| | - Karsten Asmussen
- Department of Rheumatology, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark
| | - Marcin Kowalski
- Department of Rheumatology, Hjørring Hospital, Hjørring, Denmark
| | - Hanne Lindegaard
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Sabrina Mai Nielsen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Henning Bliddal
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Lone Balding
- Department of Radiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik S. Thomsen
- Department of Radiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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