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Imam MS, Alshahrani SA, Alotaibi RMS, Almurayeh KN, Alshabab NA, Almutairi NK, Alomar H, Alomair L, Boules ME, Abdelrahim ME, Amin MA. A Meta-Analysis Examining the Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Medications on Postoperative Wound Complications in Various Orthopedic Surgeries. J Clin Med 2024; 13:5531. [PMID: 39337018 PMCID: PMC11432387 DOI: 10.3390/jcm13185531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/13/2024] [Accepted: 09/14/2024] [Indexed: 09/30/2024] Open
Abstract
This meta-analysis was designed to compare the risk of postoperative wound complications in various orthopedic surgeries (OSs) affected by the perioperative use of biologic disease-modifying anti-rheumatic drugs (bDMARDs). The odds ratio (OR) and mean difference (MD), with 95% confidence intervals (CIs), were calculated using dichotomous or continuous random or fixed-effect models, based on the meta-analysis data. This study incorporated 14 investigations conducted between 2005 and 2023, encompassing a total population of 19,021 individuals undergoing diverse OSs. Participants who continued their bDMARDs exhibited a substantially higher incidence of postoperative surgical site infections (OR, 1.39; 95% CI, 1.12-1.72, p = 0.002) compared to those who withheld bDMARDs. However, the study did not find any statistically significant difference between the continuation or withholding of bDMARDs regarding delayed wound healing (OR, 2.02; 95% CI, 1.00-4.06, p = 0.05) or disease flares (OR, 0.59; 95% CI, 0.28-1.25, p = 0.17). The results show that patients who continued their bDMARDs had a notably higher incidence of postoperative surgical site infections. However, no significant differences were observed in delayed wound healing or disease flares when compared to those who withheld bDMARDs. It is important to acknowledge the limitations of this analysis, such as the relatively small number of participants and the limited number of studies available for certain comparisons, which may impact the validity of the findings.
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Affiliation(s)
- Mohamed S Imam
- Department of Clinical Pharmacy, College of Pharmacy, Shaqra University, Shaqra 11961, Saudi Arabia
- Department of Clinical Pharmacy, National Cancer Institute, Cairo University, Fom El Khalig Square, Kasr Al-Aini Street, Cairo 11796, Egypt
| | | | | | | | | | - Nora Khaled Almutairi
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
| | - Hanin Alomar
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
| | - Leen Alomair
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
| | - Marina E Boules
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni Suef 65211, Egypt
| | - Mohamed E Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni Suef 65211, Egypt
| | - Mohammed A Amin
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni Suef 65211, Egypt
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2
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James WA, Rosenberg AL, Wu JJ, Hsu S, Armstrong A, Wallace EB, Lee LW, Merola J, Schwartzman S, Gladman D, Liu C, Koo J, Hawkes JE, Reddy S, Prussick R, Yamauchi P, Lewitt M, Soung J, Weinberg J, Lebwohl M, Glick B, Kircik L, Desai S, Feldman SR, Zaino ML. Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis. J Am Acad Dermatol 2024; 91:251.e1-251.e11. [PMID: 38499181 DOI: 10.1016/j.jaad.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/06/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication. OBJECTIVE To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery. METHODS We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery. RESULTS We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. CONCLUSION For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.
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Affiliation(s)
- Warren A James
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Angela L Rosenberg
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jashin J Wu
- Department of Dermatology, University of Miami Miller School of Medicine, Miami, Florida
| | - Sylvia Hsu
- Department of Dermatology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - April Armstrong
- Department of Dermatology, Keck School of Medicine at University of Southern California, Los Angeles, California
| | | | - Lara Wine Lee
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
| | - Joseph Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sergio Schwartzman
- Department of Dermatology, 72nd Street Medical Associates, New York, New York
| | - Dafna Gladman
- Department of Dermatology, University of Toronto, Toronto, Canada
| | - Clive Liu
- Department of Dermatology, Bellevue Dermatology, Bellevue, Washington
| | - John Koo
- Department of Dermatology, University of California, San Francisco Medical Center, San Francisco, California
| | - Jason E Hawkes
- Department of Dermatology, University of California, Davis, Rocklin, California
| | - Soumya Reddy
- Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Ron Prussick
- Department of Dermatology, Washington Dermatology Center, Frederick, Maryland
| | - Paul Yamauchi
- Department of Dermatology, Dermatology Institute & Skin Care Center, Santa Monica, California
| | - Michael Lewitt
- Department of Dermatology, Illinois Dermatology Institute, LLC, Chicago, Illinois
| | - Jennifer Soung
- Department of Dermatology, Southern California Dermatology, Santa Ana, California
| | - Jeffery Weinberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brad Glick
- Department of Dermatology, Glick Skin Institute, Margate, Florida
| | - Leon Kircik
- Department of Dermatology, Physicians Skin Care, Louisville, Kentucky
| | - Seemal Desai
- Department of Dermatology, Innovative Dermatology, Plano, Texas
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mallory L Zaino
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Baig MMFA, Wong LK, Zia AW, Wu H. Development of biomedical hydrogels for rheumatoid arthritis treatment. Asian J Pharm Sci 2024; 19:100887. [PMID: 38419762 PMCID: PMC10900807 DOI: 10.1016/j.ajps.2024.100887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/16/2023] [Accepted: 11/05/2023] [Indexed: 03/02/2024] Open
Abstract
Rheumatoid Arthritis (RA) is an autoimmune disorder that hinders the normal functioning of bones and joints and reduces the quality of human life. Every year, millions of people are diagnosed with RA worldwide, particularly among elderly individuals and women. Therefore, there is a global need to develop new biomaterials, medicines and therapeutic methods for treating RA. This will improve the Healthcare Access and Quality Index and also relieve administrative and financial burdens on healthcare service providers at a global scale. Hydrogels are soft and cross-linked polymeric materials that can store a chunk of fluids, drugs and biomolecules for hydration and therapeutic applications. Hydrogels are biocompatible and exhibit excellent mechanical properties, such as providing elastic cushions to articulating joints by mimicking the natural synovial fluid. Hence, hydrogels create a natural biological environment within the synovial cavity to reduce autoimmune reactions and friction. Hydrogels also lubricate the articulating joint surfaces to prevent degradation of synovial surfaces of bones and cartilage, thus exhibiting high potential for treating RA. This work reviews the progress in injectable and implantable hydrogels, synthesis methods, types of drugs, advantages and challenges. Additionally, it discusses the role of hydrogels in targeted drug delivery, mechanistic behaviour and tribological performance for RA treatment.
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Affiliation(s)
| | - Lee Ki Wong
- Department of Chemistry, Hong Kong University of Science and Technology, Hong Kong 999077, China
| | - Abdul Wasy Zia
- Institute of Mechanical, Process and Energy Engineering (IMPEE), School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, United Kingdom
| | - Hongkai Wu
- Department of Chemistry, Hong Kong University of Science and Technology, Hong Kong 999077, China
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Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology. Z Rheumatol 2023; 82:1-11. [PMID: 35235025 DOI: 10.1007/s00393-021-01150-9] [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: 12/08/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
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van Duren BH, Wignall A, Goodman S, Hewitt C, Mankia K, Pandit H. The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications: Surgical Site Infection, Delayed Wound Healing, and Disease Flares Following Orthopaedic Surgical Procedures. J Bone Joint Surg Am 2022; 104:1116-1126. [PMID: 35175994 DOI: 10.2106/jbjs.21.00811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are effective in treating inflammatory diseases and have been increasingly utilized over the past decade. Patients who receive bDMARDs have been shown to be at an increased risk for surgical site infection following surgical procedures. The severe consequences of infection following orthopaedic surgery have led to the practice of withholding bDMARDs perioperatively; however, there has been no definitive evidence showing a clear benefit of withholding the use of bDMARDs, and in doing so, patients may be at an increased risk for higher disease activity. As such, the purpose of the present study was to compare the risk of infection, delayed wound healing, and disease flares associated with the use of bDMARDs in patients undergoing orthopaedic surgical procedures. METHODS We performed a systematic literature search of MEDLINE, Embase, and PubMed CENTRAL databases for studies comparing continuing and withholding the use of bDMARDs in patients undergoing orthopaedic procedures. Inclusion criteria were established following the PICO (Population, Intervention, Comparison, and Outcomes) approach: Population = patients who underwent orthopaedic surgical procedures and who were taking bDMARDs. Intervention = withholding the use of bDMARDs. Comparator = continuing the use of bDMARDs. Outcomes = surgical site infection, delayed wound healing, and disease flares. Article titles and abstracts were screened prior to review of the full text. Overall odds ratios (ORs) and associated 95% confidence intervals (CIs) for pooled effects were calculated. RESULTS Eleven studies met the inclusion criteria, providing data for 7,344 patients, including 2,385 patients who continued and 4,959 who withheld their bDMARDs perioperatively. Continuing bDMARDs was associated with a significantly lower risk of disease flares (OR, 0.22; 95% CI, 0.05 to 0.95; p = 0.04) and nonsignificant increases in surgical site infections (OR, 1.11; 95% CI, 0.82 to 1.49; p = 0.49) and wound complications (OR, 2.16; 95% CI, 0.48 to 9.85; p = 0.32). CONCLUSIONS The present systematic review highlights the limited evidence supporting the current practice of stopping bDMARDs perioperatively. These findings suggest that patients may not be at an increased risk for developing infection or wound complications if bDMARDs are continued but are at an increased risk for disease flare if bDMARDs are withheld. However, our conclusions are limited by the retrospective and heterogenous nature of the data, and possibly by a lack of study power. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bernard H van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Alice Wignall
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Susan Goodman
- Weill Cornell Medicine, New York, NY.,Integrative Rheumatology and Orthopedics Center of Excellence, Combined Arthritis Program, Hospital for Special Surgery, New York, NY
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, United Kingdom
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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Ito H, Murata K, Sobue Y, Kojima T, Nishida K, Matsushita I, Kawahito Y, Kojima M, Hirata S, Kaneko Y, Kishimoto M, Kohno M, Mori M, Morinobu A, Murashima A, Seto Y, Sugihara T, Tanaka E, Nakayama T, Harigai M. Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis. Mod Rheumatol 2022; 32:296-306. [PMID: 33855932 DOI: 10.1080/14397595.2021.1913824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/01/2019] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To examine the risk factors of surgical site infection (SSI), delayed wound healing, and death after orthopedic surgery in patients with rheumatoid arthritis (RA). METHODS We identified articles indexed in the Cochrane Library, PubMed, and Japan Centra Revuo Medicina Web published from 2013 to 2019 and other articles. Articles fulfilling the predefined inclusion criteria were reviewed systematically and their quality was appraised according to the Grading of Recommendations Assessment, Development, and Evaluation system with some modifications. RESULTS After inclusion and exclusion by full-text review, 29 articles were analyzed. Use of biological disease modifying antirheumatic drugs was a risk factor of SSI (risk ratio 1.66, 95% confidence interval 1.25-2.19), but not of delayed wound healing. RA itself was a risk factor of SSI, and oral glucocorticoid use was a risk factor of SSI in three of the four studies analyzed and of postoperative death. Age, male sex, comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease, surgical factors such as foot/ankle and spine surgery and longer operative time were risk factors of those postoperative complications. CONCLUSION Patients with those factors should be dealt with appropriate cautions to strike a risk-benefit balance of orthopedic surgeries.
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Affiliation(s)
- Hiromu Ito
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Matsushita
- Department of Rehabilitation Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayo Kojima
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine/Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Yohei Seto
- Department of Rheumatology, Yachiyo Medical Center, Tokyo Women's Medical University, Chiba, Japan
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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7
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Albrecht K, Poddubnyy D, Leipe J, Sewerin P, Iking-Konert C, Scholz R, Krüger K. [Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]. Z Rheumatol 2021; 81:212-224. [PMID: 34928422 DOI: 10.1007/s00393-021-01140-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
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Affiliation(s)
| | - Denis Poddubnyy
- Rheumatologie am Campus Benjamin Franklin - Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Philipp Sewerin
- Uniklinik Düsseldorf Poliklinik, Funktionsbereich & Hiller Forschungszentrum für Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Christof Iking-Konert
- Sektion Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Roger Scholz
- Orthopädie und Unfallchirurgie, Collm Klinik Oschatz, Oschatz, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, St.-Bonifatius-Str. 5, 81541, München, Deutschland.
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