1
|
Çay HF, Alkan Melikoğlu M, Yurdakul FG, Bodur H, Ataman Ş, Çapkın E, Gürer G, Sezer İ, Duruöz MT, Rezvani A, Yağcı İ, Göğüş F, Kamanli A, Çevik R, Akgül Ö. Real-life data on the comorbidities in spondyloarthritis from our multicenter nationwide registry: BioStar. Arch Rheumatol 2023; 38:333-346. [PMID: 38046248 PMCID: PMC10689009 DOI: 10.46497/archrheumatol.2023.9793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/08/2022] [Indexed: 12/05/2023] Open
Abstract
Objectives Considering that the comorbid situations during the management of Spondyloarthritis (SpA) have been underlined in several recommendations, the main objective of this study was to evaluate the comorbid conditions of Turkish patients with SpA. Patients and methods This cross-sectional observational study was conducted with 1,242 SpA patients (844 males, 398 females; mean age: 43.9±11.0 years; range, 19 to 81 years) diagnosed according to the modified New York criteria for ankylosing spondylitis or the Assessment of SpondyloArthritis International Society (ASAS) criteria. The patient data were collected from the Biologic and targeted Synthetic antirheumatic drugs Registry (BioStar) between February 1, 2019, and December 29, 2020. Clinical and demographic data, including, age, sex, disease duration, body mass index (BMI), pain, patient's global assessment, physician's global assessment, Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, and Maastricht Enthesitis Score, were recorded. Comorbid conditions were recorded by filling out a questionnaire according to the clinical history or medical records. Charlson Comorbidity Index and Rheumatic Disease Comorbidity Index scores were calculated from the gathered comorbidity information. Results Nine hundred thirteen patients had radiographic axial SpA, 153 had nonradiographic axial SpA, and 176 had peripheral SpA. The most common comorbidities were hypertension (HT) (n=167, 13.4%), diabetes mellitus (DM) (n=83, 6.7%), thyroid disorders (n=64, 5.6%), and depression (n=61, 4.9%). The comorbidities and the calculated comorbidity indices were significantly higher in females, in those with a BMI >25 kg/m2 , and those over 60 years of age. No relationship was found between smoking and alcohol use and comorbidities. A significantly higher prevalence of HT and DM in peripheral SpA patients and a lower prevalence of thyroid disorders in radiographic axial SpA patients were observed. Conclusion The most commonly reported comorbidities were HT, DM, thyroid disorders, and depression in SpA patients according to the BioStar database. The frequency of comorbidities and composite comorbidity scores were higher among females, older (>60 years) patients, and overweight (BMI >25 kg/m2 ) patients.
Collapse
Affiliation(s)
- H. Fatih Çay
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Türkiye
| | - Meltem Alkan Melikoğlu
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Atatürk University Faculty of Medicine, Erzurum, Türkiye
| | - Fatma Gül Yurdakul
- Department of Physical Medicine Rehabilitation, Ankara City Hospital, Ankara, Türkiye
| | - Hatice Bodur
- Department of Physical Medicine Rehabilitation, Ankara City Hospital, Ankara, Türkiye
| | - Şebnem Ataman
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Erhan Çapkın
- Department of Physical Medicine Rehabilitation, Karadeniz Technical University Faculty of Medicine, Trabzon, Türkiye
| | - Gülcan Gürer
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Adnan Menderes University Faculty of Medicine, Aydın, Türkiye
| | - İlhan Sezer
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Akdeniz University Faculty of Medicine, Antalya, Türkiye
| | - M. Tuncay Duruöz
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Marmara University Faculty of Medicine, Istanbul, Türkiye
| | - Aylin Rezvani
- Department of Physical Medicine Rehabilitation, Istanbul Medipol University, International Faculty of Medicine, Istanbul, Türkiye
| | - İlker Yağcı
- Department of Physical Medicine Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Türkiye
| | - Feride Göğüş
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Ayhan Kamanli
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Sakarya University Faculty of Medicine, Sakarya, Türkiye
| | - Remzi Çevik
- Department of Physical Medicine Rehabilitation, Dicle University Faculty of Medicine, Diyarbakır, Türkiye
| | - Özgür Akgül
- Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Manisa Celal Bayar University Faculty of Medicine, Manisa, Türkiye
| |
Collapse
|
2
|
Kagan P, Horesh N, Amital H, Tsur AM, Watad A, Cohen AD, Ben-Shabat N. The Risk and Predictors of Malignancies in Ankylosing Spondylitis Patients in Israel-A Retrospective Electronic Data-Based Study. J Clin Med 2023; 12:5153. [PMID: 37568555 PMCID: PMC10419948 DOI: 10.3390/jcm12155153] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Previous studies demonstrated unclear and vast variability in the association between Ankylosing Spondylitis (AS) and the risk of cancer. OBJECTIVES To assess the risk of overall and site-specific malignancies for AS patients in Israel, while examining the role of comorbidities and immunomodulatory therapy. METHODS We conducted a retrospective electronic data-based study including all AS patients diagnosed between 2002 and 2018, with no history of cancer prior to enrollment, with 5:1 ratio matched-control by age, gender, and place of residence. The odds Ratios (OR) for site-specific malignancies, comparing AS patients and controls, were calculated using logistic regression. Risk factors for malignancies within the AS cohort were evaluated in the same manner. RESULTS This study comprised 5825 AS patients and 28,356 matched controls. There was a higher overall risk of cancer in AS patients compared to controls (OR = 1.4, 95% CI 1.24-1.6), specifically for solid malignancies (OR = 1.5, 95% CI 1.3-1.7), CNS (OR = 3.72, 95% CI 1.29-10.7), kidney (OR = 2.06, 95% CI 1.12-3.8), and malignancy of unknown primary (OR = 3.06, 95% CI 2.35-3.98). Regarding predictors for malignancy within AS patients, older age at diagnosis (OR = 1.31, 95%,CI 1.25-2.36), diabetes (OR = 1.52, 95% CI 1.18-1.97), IBD (OR = 2.61, 95% CI 1.75-3.89), and treatment with DMARDs (OR = 2.17, 95% CI 1.65-2.83) were associated with a higher risk of solid malignancies, while NSAIDs treatment alone had a protective effect for solid malignancies (OR = 0.78, 95% CI 0.61-0.99). No significant association was found between anti-TNF therapy and the risk of solid or hematologic malignancies within the AS group. CONCLUSION AS is associated with an increased risk of overall and site-specific malignancies, with independently higher risk for older age, comorbidity of DM, IBD, and treatment with DMARDs.
Collapse
Affiliation(s)
- Polina Kagan
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
| | - Noy Horesh
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
| | - Howard Amital
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
| | - Avishai M. Tsur
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 9112102, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 7610001, Israel
| | - Abdulla Watad
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds LS7 4SA, UK
| | - Arnon D. Cohen
- Chief Physician’s Office, Clalit Health Services, Tel-Aviv 6209813, Israel;
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Niv Ben-Shabat
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 5262100, Israel; (P.K.); (N.H.); (H.A.); (A.W.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
| |
Collapse
|
3
|
Macfarlane GJ, Biallas R, Dean LE, Jones GT, Goodson NJ, Rotariu O. Inflammatory Bowel Disease Risk in Patients With Axial Spondyloarthritis Treated With Biologic Agents Determined Using the BSRBR-AS and a MetaAnalysis. J Rheumatol 2023; 50:175-184. [PMID: 35777821 DOI: 10.3899/jrheum.211034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine, among patients with axial spondyloarthritis (axSpA), whether the risk of inflammatory bowel disease (IBD) varies between patients treated with biologic therapies and those treated with other therapies and, specifically, whether the risk is higher in patients treated with etanercept (ETN). METHODS The British Society for Rheumatology Biologics Register in Ankylosing Spondylitis (BSRBR-AS) was used to determine the incidence of IBD during follow-up and to calculate the incidence rate difference (IRD) per 1000 person-years (PY), between biologic treatment and other treatment groups. We then conducted a systematic review, involving observational studies and randomized controlled trials (RCTs), to perform a metaanalysis to quantify the difference in incidence of IBD between treatment groups. RESULTS According to the BSRBR-AS, among people with axSpA, exposure to biologic therapy was associated with an increased incidence of IBD compared to those who were not exposed to biologic therapy (IRD 11.9, 95% CI 4.3-19.6). This finding was replicated across observational studies but was not seen in placebo-controlled RCTs (IRD 2.2, 95% CI -4.1 to 8.5). Data from the BSRBR-AS do not suggest that excess incidence of IBD is associated with exposure to ETN compared to other anti-tumor necrosis factor (TNF) therapies (IRD -6.5, 95% CI -21.3 to 8.5). RCTs and their extensions suggest a small-yet not statistically significant-absolute increased incidence associated with ETN of between 2.1 and 5.8 per 1000 PY compared to other anti-TNF therapies. CONCLUSION There was an excess risk of IBD among persons treated with biologics in observational studies. Only evidence from RCTs suggested that ETN was associated with an increased risk compared to other anti-TNF therapies, albeit with considerable uncertainty.
Collapse
Affiliation(s)
- Gary J Macfarlane
- G.J. Macfarlane, MD (Hons), R. Biallas, MPH, L.E. Dean, PhD, G.T. Jones, PhD, O. Rotariu, PhD, Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen;
| | - Renke Biallas
- G.J. Macfarlane, MD (Hons), R. Biallas, MPH, L.E. Dean, PhD, G.T. Jones, PhD, O. Rotariu, PhD, Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen
| | - Linda E Dean
- G.J. Macfarlane, MD (Hons), R. Biallas, MPH, L.E. Dean, PhD, G.T. Jones, PhD, O. Rotariu, PhD, Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen
| | - Gareth T Jones
- G.J. Macfarlane, MD (Hons), R. Biallas, MPH, L.E. Dean, PhD, G.T. Jones, PhD, O. Rotariu, PhD, Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen
| | - Nicola J Goodson
- N.J. Goodson, PhD, Rheumatology Department, Liverpool University Foundation Trust, Liverpool, UK
| | - Ovidiu Rotariu
- G.J. Macfarlane, MD (Hons), R. Biallas, MPH, L.E. Dean, PhD, G.T. Jones, PhD, O. Rotariu, PhD, Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen
| |
Collapse
|
4
|
Webers C, Ortolan A, Sepriano A, Falzon L, Baraliakos X, Landewé RBM, Ramiro S, van der Heijde D, Nikiphorou E. Efficacy and safety of biological DMARDs: a systematic literature review informing the 2022 update of the ASAS-EULAR recommendations for the management of axial spondyloarthritis. Ann Rheum Dis 2023; 82:130-141. [PMID: 36270657 DOI: 10.1136/ard-2022-223298] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/03/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To update the evidence on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with axial spondyloarthritis (axSpA) to inform the 2022 update of the Assessment of SpondyloArthritis international Society/European Alliance of Associations for Rheumatology (ASAS-EULAR) recommendations for the management of axSpA. METHODS Systematic literature review (2016-2021) on efficacy and safety of bDMARDs in axSpA (radiographic axSpA (r-axSpA)/non-radiographic axSpA (nr-axSpA)). Eligible study designs included randomised controlled trials (RCTs), strategy trials and observational studies (the latter only for safety and extra-musculoskeletal manifestations). All relevant efficacy/safety outcomes were included. RESULTS In total, 148 publications were included. Efficacy of golimumab and certolizumab was confirmed. Tumour necrosis factor inhibitor (TNFi) biosimilar-originator equivalence was demonstrated. RCT (n=15) data on efficacy of interleukin-17 inhibitors (IL-17i) demonstrated clinically relevant effects (risk ratio vs placebo to achieve ASAS40 response 1.3-15.3 (r-axSpA, n=9), 1.4-2.1 (nr-axSpA, n=2)). Efficacy of secukinumab/ixekizumab was demonstrated in TNFi-naïve and TNFi-inadequate responders. IL-23 and IL-12/23 inhibitors (risankizumab/ustekinumab) failed to show relevant benefits. Tapering of TNFi by spacing was non-inferior to standard-dose treatment. The first axSpA treat-to-target trial did not meet its primary endpoint, but showed improvements in secondary outcomes. No new risks were identified with TNFi use in observational studies (data lacking for IL-17i). Secukinumab (n=1) and etanercept (n=2) were associated with increased risk of uveitis in observational studies compared to monoclonal TNFi. CONCLUSIONS New evidence supports the efficacy and safety of TNFi (originators/biosimilars) and IL-17i in r-axSpA and nr-axSpA, while IL-23i failed to show relevant effects. Observational studies are needed to confirm long-term IL-17i safety. PROSPERO REGISTRATION NUMBER CRD42021257588.
Collapse
Affiliation(s)
- Casper Webers
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre+, Maastricht, The Netherlands .,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padua, Italy.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Louise Falzon
- Health Economics and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Robert B M Landewé
- Department of Clinical Immunology and Rheumatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.,Department of Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | | | - Elena Nikiphorou
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, King's College Hospital, London, UK.,Centre for Rheumatic Diseases, King's College London, London, UK
| |
Collapse
|
5
|
Schwartzman S, Ruderman EM. A Road Map of the Axial Spondyloarthritis Continuum. Mayo Clin Proc 2022; 97:134-145. [PMID: 34801248 DOI: 10.1016/j.mayocp.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 12/17/2022]
Abstract
Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.
Collapse
Affiliation(s)
| | - Eric M Ruderman
- Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
6
|
Truong SL, Chin J, Liew DFL, Zahir SF, Ryan EG, Rubel D, Radford-Smith G, Robinson PC. Systematic Review and Meta-Analysis of Inflammatory Bowel Disease Adverse Events with Anti-Interleukin 17A Agents and Tumor Necrosis Factor Inhibitors in Rheumatic Disease and Skin Psoriasis. Rheumatol Ther 2021; 8:1603-1616. [PMID: 34449067 PMCID: PMC8572260 DOI: 10.1007/s40744-021-00360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/11/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The aim of this work is to perform a systematic review and meta-analysis of anti-tumor necrosis factor (anti-TNF) and anti-interleukin-17 (anti-IL-17) trials for spondyloarthritis, psoriatic arthritis, and psoriasis comparing rates of inflammatory bowel disease (IBD) events compared to placebo. METHODS MEDLINE, EMBASE, and The Cochrane Library were searched for double-blind, randomized placebo-controlled anti-TNF and anti-IL-17 trials of included diseases. Inflammatory bowel disease events from the RCT period were pooled and meta-analyzed using statistical methods suitable for low-event-rate meta-analysis (Peto's, Mantel-Haenszel, hypergeometric-normal model, and Shuster-Guo-Skyler). When observed data were insufficient, we performed an exploratory sensitivity analysis to compare methods. RESULTS We identified 9551 original papers, and included 96 publications: 65 anti-TNF and 31 anti-IL-17 trials, containing 21 new and 12 flare IBD events in 28,209 participants. New IBD on anti-IL-17 occurred 0.23/100 patient-years (PY) in psoriasis, 0.61/100 PY in PsA and 1.63/100 PY in spondyloarthritis, rates similar to observational cohorts, and less commonly on anti-TNF (0/100 PY, 0/100 PY, 0.32/100 PY, respectively). No evidence of difference between groups was found, with wide CI from many pooled counts of zero, especially in placebo arms. CONCLUSIONS IBD events were rare, occurring at rates similar to biologic-naive groups. We could not find statistically significant differences in risk of new or recurrent IBD between treatment and control groups using selected meta-analytical methods for low event rate scenarios. Meta-analyses of this topic require more IBD events, ideally without pooling heterogeneous groups. Larger, thoroughly reported trials with systematic and detailed safety reporting are required to improve risk estimation and to make accurate inferences.
Collapse
Affiliation(s)
- Steven L Truong
- Department of Medicine, Griffith University, Brisbane, QLD, Australia
- Coast Joint Care, Maroochydore, QLD, Australia
| | - Jasmine Chin
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - David F L Liew
- Department of Medicine, University of Melbourne, Parkville, Australia
- Department of Clinical Pharmacology and Therapeutics, Austin Health, Heidelberg, VIC, Australia
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia
| | - Syeda Farah Zahir
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth G Ryan
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Diana Rubel
- Australian National University and Woden Dermatology, Canberra, Australia
| | | | - Philip C Robinson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
- School of Clinical Medicine, University of Queensland, Royal Brisbane and Women's Hospital, Bowen Bridge Road, Herston, QLD, 4006, Australia.
| |
Collapse
|
7
|
Wiginder A, Sahlin-Ingridsson C, Geijer M, Blomberg A, Franklin KA, Forsblad-d'Elia H. Prevalence and factors related to sleep apnoea in ankylosing spondylitis. Clin Rheumatol 2021; 41:491-498. [PMID: 34581892 PMCID: PMC8782774 DOI: 10.1007/s10067-021-05924-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022]
Abstract
An increased prevalence of obstructive sleep apnoea (OSA) has been suggested in patients with ankylosing spondylitis (AS) in a few controlled studies. We aimed to study the prevalence of OSA compared to controls and to investigate if disease-related and non-disease-related factors were determinants of OSA in AS patients. One hundred and fifty-five patients with AS were included in the Backbone study, a cross-sectional study that investigates severity and comorbidities in AS. Controls were recruited from the Swedish CArdioPulmonary bioImage Study. To evaluate OSA, the participants were asked to undergo home sleep-monitoring during one night’s sleep. For each AS patient 45–70 years old, four controls were matched for sex, age, weight, and height. OSA was defined as an apnoea-hypopnoea index (AHI) ≥ 5 events/hour. Sixty-three patients with AS were examined with home sleep-monitoring, and 179 controls were matched with 46 patients, 45–70 years. Twenty-two out of 46 (47.8%) patients with AS vs. 91/179 (50.8%) controls had OSA (AHI ≥ 5 events/hour), P = 0.72. No differences in the sleep measurements were noted in AS patients vs. controls. In logistic regression analysis adjusted for age and sex, higher age, higher BMI, and lesser chest expansion were associated with the presence of OSA in the 63 AS patients. In the current study, patients with AS did not have a higher prevalence of OSA compared to matched controls. AS patients with OSA had higher BMI, were older, and had lesser chest expansion because of more severe AS compared to patients without OSA.
Key points |
---|
• Patients with ankylosing spondylitis did not have a higher prevalence of obstructive sleep apnoea versus matched controls. | • Patients with ankylosing spondylitis and obstructive sleep apnoea were older and had higher body mass index versus patients without obstructive sleep apnoea. | • Patients with ankylosing spondylitis and obstructive sleep apnoea had lesser chest expansion versus patients without obstructive sleep apnoea. |
Collapse
Affiliation(s)
- Adrian Wiginder
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Carin Sahlin-Ingridsson
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Mats Geijer
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Faculty of Medicine, Lund University, Lund, Sweden
| | - Anders Blomberg
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Karl A Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Helena Forsblad-d'Elia
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden.
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| |
Collapse
|
8
|
Walsh JA, Pei S, Penmetsa GK, Overbury RS, Clegg DO, Sauer BC. Identifying Patients With Axial Spondyloarthritis in Large Datasets: Expanding Possibilities for Observational Research. J Rheumatol 2020; 48:685-692. [PMID: 33259327 DOI: 10.3899/jrheum.200570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Observational research of axial spondyloarthritis (axSpA) is limited by a lack of methods for identifying diverse axSpA phenotypes in large datasets. Algorithms were previously designed to identify a broad spectrum of patients with axSpA, including patients not identifiable with diagnosis codes. The study objective was to estimate the performance of axSpA identification methods in the general Veterans Affairs (VA) population. METHODS A patient sample with known axSpA status (n = 300) was established with chart review. For feasibility, this sample was enriched with veterans with axSpA risk factors. Algorithm performance outcomes included sensitivities, positive predictive values (PPV), and F1 scores (an overall performance metric combining sensitivity and PPV). Performance was estimated with unweighted outcomes for the axSpA-enriched sample and inverse probability weighted (IPW) outcomes for the general VA population. These outcomes were also assessed for traditional identification methods using diagnosis codes for the ankylosing spondylitis (AS) subtype of axSpA. RESULTS The mean age was 54.7 and 92% were male. Unweighted F1 scores (0.59-0.74) were higher than IPW F1 scores (0.48-0.65). The full algorithm had the best overall performance (F1IPW 0.65). The Early Algorithm was the most inclusive (sensitivityIPW 0.90, PPVIPW 0.38). The traditional method using ≥ 2 AS diagnosis codes from rheumatology had the highest PPV (PPVIPW 0.84, sensitivityIPW 0.34). CONCLUSION The axSpA identification methods demonstrated a range of performance attributes in the general VA population that may be appropriate for various types of studies. The novel identification algorithms may expand the scope of research by enabling identification of more diverse axSpA populations.
Collapse
Affiliation(s)
- Jessica A Walsh
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA.
| | - Shaobo Pei
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Gopi K Penmetsa
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Rebecca S Overbury
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Daniel O Clegg
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Brian C Sauer
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| |
Collapse
|
9
|
Parkinson JT, Foley ÉM, Jadon DR, Khandaker GM. Depression in patients with spondyloarthritis: prevalence, incidence, risk factors, mechanisms and management. Ther Adv Musculoskelet Dis 2020; 12:1759720X20970028. [PMID: 33224281 PMCID: PMC7649919 DOI: 10.1177/1759720x20970028] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/12/2020] [Indexed: 12/27/2022] Open
Abstract
Depression is a major neuropsychiatric disorder common in patients with rheumatological conditions including spondyloarthritis (SpA). It is associated with higher disease activity, functional impairment, poor treatment response and quality of life in patients with musculoskeletal disorders. Using ankylosing spondylitis (AS) and psoriatic arthritis (PsA) as examples, we have reviewed the evidence regarding the burden, risk factors, potential mechanisms and clinical management of depression in spondyloarthritis. The prevalence of depression is higher in patients with AS and PsA compared with the general population, with evidence of moderate/severe depression in about 15% of patients with AS or PsA. Mild depression is even more common and estimated to be present in about 40% of patients with AS. In addition to conventional risk factors such as stressful life events and socioeconomic deprivation, increased risk of depression in SpA may be associated with disease-related factors, such as disease activity, poor quality of life, fatigue, and sleep disturbances. Emerging evidence implicates inflammation in the aetiology of depression, which could also be a shared mechanism for depression and chronic inflammatory conditions such as AS and PsA. It is imperative for clinicians to actively assess and treat depression in SpA, as this could improve treatment adherence, quality of life, and overall long-term clinical and occupational outcomes. The use of validated tools can aid recognition and management of depression in rheumatology clinics. Management of depression in SpA, especially when to refer to specialist mental health services, are discussed.
Collapse
Affiliation(s)
- Joel T. Parkinson
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Herchel Smith Building for Brain and Mind Sciences, Cambridge Biomedical Campus, Robinson Way, Cambridge, Cambridgeshire CB2 0SZ, UK
| | - Éimear M. Foley
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Deepak R. Jadon
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, UK
| | - Golam M. Khandaker
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
10
|
Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing Axial Spondyloarthritis: A Guide for Primary Care. Mayo Clin Proc 2020; 95:2499-2508. [PMID: 32736944 DOI: 10.1016/j.mayocp.2020.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/30/2020] [Accepted: 02/07/2020] [Indexed: 01/18/2023]
Abstract
Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.
Collapse
Affiliation(s)
- Marina N Magrey
- MetroHealth System and School of Medicine, Division of Rheumatology, Case Western Reserve University, Cleveland, OH.
| | | | - Joerg Ermann
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Jessica A Walsh
- University of Utah and Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT
| |
Collapse
|
11
|
Zhao SS, Robertson S, Reich T, Harrison NL, Moots RJ, Goodson NJ. Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis. Rheumatology (Oxford) 2020; 59:iv47-iv57. [PMID: 33053193 PMCID: PMC7566561 DOI: 10.1093/rheumatology/keaa246] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Comorbidities are common in people with axial spondyloarthritis (axSpA). In this systematic review and meta-analysis, we aimed to: (i) describe the prevalence of commonly reported comorbidities, (ii) compare comorbidities between axSpA and control populations, and (iii) examine the impact of comorbidity burden on axSpA outcomes. METHODS We systematically searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We excluded studies of only one comorbid condition or a few closely related diseases within one organ system. Where possible, meta-analysis was performed using random-effects models. RESULTS A total of 40 studies were included for analysis. 36 studies reported prevalence of comorbidities, amounting to a combined sample size of 119 427 patients. The number of comorbidities studied ranged from 3 to 43. The most prevalent individual comorbidities were hypertension (pooled prevalence 23%), hyperlipidaemia (17%) and obesity (14%). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls, particularly large differences were seen for depression [pooled odds ratio (OR) 1.80] and heart failure (OR 1.84). Comorbidities (total number of and individual conditions) were also associated with axSpA disease activity, functional impairment, quality of life, work productivity and mortality. CONCLUSIONS Comorbidities are common in axSpA, particularly cardiovascular diseases and risk factors. Most comorbidities were more prevalent in axSpA patients than in control populations. Overall comorbidity burden, and many individual conditions, were associated with axSpA outcomes including worse disease severity, work productivity and mortality.
Collapse
Affiliation(s)
- Sizheng Steven Zhao
- Musculoskeletal Biology, Institute of Lifecourse and Medical Sciences, University of Liverpool
- Department of Academic Rheumatology, Liverpool University Hospitals
| | | | - Tzvi Reich
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Robert J Moots
- Musculoskeletal Biology, Institute of Lifecourse and Medical Sciences, University of Liverpool
- Department of Academic Rheumatology, Liverpool University Hospitals
| | - Nicola J Goodson
- Musculoskeletal Biology, Institute of Lifecourse and Medical Sciences, University of Liverpool
- Department of Academic Rheumatology, Liverpool University Hospitals
| |
Collapse
|
12
|
Tsao CH, Huang JY, Huang HH, Hung YM, Wei JCC, Hung YT. Ankylosing Spondylitis Is Associated With Risk of New-Onset Obstructive Sleep Apnea: A Nationwide Population-Based Cohort Study. Front Med (Lausanne) 2019; 6:285. [PMID: 31867336 PMCID: PMC6908486 DOI: 10.3389/fmed.2019.00285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022] Open
Abstract
Objectives: Investigating the risk of obstructive sleep apnea(OSA) among ankylosing spondylitis (AS) patients based on administrative healthcare databases. Methods: We conducted a nationwide cohort study by using the Taiwan National Health Insurance Research Database with 1997–2013 claim records. The AS cohort included 2,210 patients who were newly diagnosed between 2003 and 2013. Randomly selected non-AS controls were matched at a 1:4 ratio. The endpoint was set as OSA occurrence or the end of 2013. Cumulative incidences, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, comorbidities, and co-medication. Multivariate analyses were performed using the Cox proportional hazards model. Due to the violation of the proportionality assumption, landmark analysis was conducted to explore the risk of OSA during specific follow-up periods. Results: The adjusted HR (aHR) of OSA in the AS group was 2.826 (95% C.I. = 1.727–4.625) compared to the control group. On landmark analysis, aHR was 7.919 (95% C.I. = 3.169–19.792) for the AS group 0–24 months from the index date and decreased to 1.816 (95% C.I. = 0.944–3.494) at ≥ 24 months from the index date. The increased risks of OSA in the AS group compared to the control group were found for both males and females (aHRs were 4.533 and 2.672). On age-stratified analysis, a significant risk only for the 40–59 age group with aHR of 3.913 (95% C.I. = 1.890–8.102). Conclusions: A higher risk of developing OSA was found among newly diagnosed AS cohort during the maximum 11-year follow-up period, especially within 2 years after newly diagnosed AS and in the 40–59 age group.
Collapse
Affiliation(s)
- Chien-Han Tsao
- Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hsin-Hsin Huang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yao-Min Hung
- Yuh-Ing Junior College of Health Care and Management, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - James Cheng-Chung Wei
- Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Yin-Tsan Hung
- Department of Otolaryngology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW This review will describe the available large-scale data sources to study spondyloarthritis (SpA), enumerate approaches to identify SpA and its disease-related manifestations and outcomes, and will outline existing and future methods to collect novel data types [e.g. patient-reported outcomes (PRO), passive data from wearables and biosensors]. RECENT FINDINGS In addition to traditional clinic visit-based SpA registries, newer data sources, such as health plan claims data, single and multispecialty electronic health record (EHR) based registries, patient registries and linkages between data sources, have catalyzed the breadth and depth of SpA research. Health activity tracker devices and PRO collected via PROMIS instruments have been shown to have good validity when assessed in SpA patients as compared to legacy disease-specific instruments. In certain cases, machine learning outperforms traditional methods to identify SpA and its associated manifestations in EHR and claims data, and may predict disease flare. SUMMARY Although caution remains in the application of newer data sources and methods including the important need for replication, the availability of new data sources, health tracker devices and analytic methods holds great promise to catalyze SpA research.
Collapse
|
14
|
Walsh JA, Pei S, Penmetsa GK, Leng J, Cannon GW, Clegg DO, Sauer BC. Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods. BMC Musculoskelet Disord 2018; 19:317. [PMID: 30185185 PMCID: PMC6123987 DOI: 10.1186/s12891-018-2211-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/31/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Big data research is important for studying uncommon diseases in real-world settings. Most big data studies in axial spondyloarthritis (axSpA) have been limited to populations identified with billing codes for ankylosing spondylitis (AS). axSpA is a more inclusive concept, and reliance on AS codes does not produce a comprehensive axSpA study population. The first objective was to describe our process for establishing an appropriate sample of patients with and without axSpA for developing accurate axSpA identification methods. The second objective was to determine the classification performance of AS billing codes against the chart-reviewed axSpA reference standard. METHODS Veteran Health Affairs clinical and administrative data, between January 2005 and June 2015, were used to randomly select patients with clinical phenotypes that represented high, moderate, and low likelihoods of an axSpA diagnosis. With chart review, the sampled patients were classified as Yes axSpA, No axSpA or Uncertain axSpA, and these classification assignments were used as the reference standard for determining the positive predictive value (PPV) and sensitivity of AS ICD-9 codes for axSpA. RESULTS Six hundred patients were classified as Yes axSpA (26.8%), No axSpA (68.3%), or Uncertain axSpA (4.8%). The PPV and sensitivity of an AS ICD-9 code for axSpA were 83.3% and 57.3%, respectively. CONCLUSIONS Standard methods of identifying axSpA patients in a large dataset lacked sensitivity. An appropriate sample of patients with and without axSpA was established and characterized for developing novel axSpA identification methods that are anticipated to enable previously impractical big data research.
Collapse
Affiliation(s)
- Jessica A. Walsh
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Shaobo Pei
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Gopi K. Penmetsa
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Jianwei Leng
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Grant W. Cannon
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Daniel O. Clegg
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Brian C. Sauer
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| |
Collapse
|