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Bernatsky S, Ramsey-Goldman R, Petri M, Urowitz MB, Gladman DD, Fortin PR, Yelin EH, Ginzler E, Hanly JG, Peschken C, Gordon C, Nived O, Aranow C, Bae SC, Isenberg D, Rahman A, Hansen JE, Pierre YS, Clarke AE. Smoking Is the Most Significant Modifiable Lung Cancer Risk Factor in Systemic Lupus Erythematosus. J Rheumatol 2018; 45:393-396. [PMID: 29335347 DOI: 10.3899/jrheum.170652] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess lung cancer risk in systemic lupus erythematosus (SLE), relative to demographics, drug exposures, smoking, and disease activity. METHODS We analyzed data from 14 SLE cohorts. We calculated adjusted HR estimates for lung cancer in SLE, relative to demographics, smoking, time-dependent medication exposures, and cumulative disease activity [mean adjusted SLE Disease Activity Index (SLEDAI) scores]. This project was approved by the ethics boards of all participating institutions, including the Institutional Review Board of the McGill University Health Centre. The ethics approval number for the Cancer Risk study is GEN-06-031. RESULTS Within these 14 SLE cohorts, 49 incident lung cancers occurred. Among lung cancer cases, 59.0% were in the highest SLEDAI quartile at baseline versus 40.8% of lung cancer-free SLE controls. The vast majority (84.2%) of SLE lung cancer cases were ever-smokers at baseline, versus 40.1% of those without lung cancer. In adjusted models, the principal factors associated with lung cancer were ever smoking (at cohort entry) and current age. Estimated adjusted effects of all drugs were relatively imprecise, but did not point toward any drug exposures as strong lung cancer risk factors. CONCLUSION We saw no clear evidence for drugs as a trigger for lung cancer risk in SLE, although drug risk estimates were relatively imprecise. Smoking may be the most significant modifiable lung cancer risk factor in SLE.
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Affiliation(s)
- Sasha Bernatsky
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea. .,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine.
| | - Rosalind Ramsey-Goldman
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Michelle Petri
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Murray B Urowitz
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Dafna D Gladman
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Paul R Fortin
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Edward H Yelin
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Ellen Ginzler
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - John G Hanly
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Christine Peschken
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Caroline Gordon
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Ola Nived
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Cynthia Aranow
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Sang-Cheol Bae
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - David Isenberg
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Anisur Rahman
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - James E Hansen
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Yvan St Pierre
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
| | - Ann E Clarke
- From The Research Institute of the McGill University Health Centre, Montreal; Université de Laval, Service de rheumatologie, Quebec City, Quebec; Toronto Western Hospital, Toronto, Ontario; Dalhousie University and Capital Health, Halifax, Nova Scotia; University of Manitoba, Winnipeg, Manitoba; Division of Rheumatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of California at San Francisco, Department of Medicine, San Francisco, California; State University of New York-Downstate Medical Center, Brooklyn; The Feinstein Institute for Medical Research, Manhasset, New York; Therapeutic Radiology, Yale University, New Haven, Connecticut, USA; University of Birmingham, College of Medical and Dental Sciences, Birmingham; University College London, Faculty of Medicine, Department of Rheumatology, London, UK; Lund University Hospital, Lund, Sweden; The Hospital for Rheumatic Diseases, Hanyang University, Seoul, Korea.,S. Bernatsky, MD, PhD, The Research Institute of the McGill University Health Centre; R. Ramsey-Goldman, MD, MPH, Northwestern University Feinberg School of Medicine; M. Petri, MD, MPH, Johns Hopkins University School of Medicine; M.B. Urowitz, MD, Toronto Western Hospital; D.D. Gladman, MD, Toronto Western Hospital; P.R. Fortin, MD, MPH, Université de Laval, Service de rheumatologie; E.H. Yelin, PhD, MCP, University of California, Department of Medicine; E. Ginzler, MD, MPH, State University of New York-Downstate Medical Center; J.G. Hanly, MD, Dalhousie University and Capital Health; C. Peschken, MD, MSc, University of Manitoba; C. Gordon, MD, University of Birmingham, College of Medical and Dental Sciences; O. Nived, MD, PhD, Lund University Hospital; C. Aranow, MD, The Feinstein Institute for Medical Research; S.C. Bae, MD, PhD, MPH, The Hospital for Rheumatic Diseases, Hanyang University; D. Isenberg, MD, University College, Faculty of Medicine, Department of Rheumatology; A. Rahman, MB, ChB, PhD, University College, Faculty of Medicine, Department of Rheumatology; J.E. Hansen, MD, MS, Therapeutic Radiology, Yale University; Y. St. Pierre, MSc, The Research Institute of the McGill University Health Centre; A.E. Clarke, MD, MSc, Division of Rheumatology, Cumming School of Medicine
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