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Saygin D, Kim H, Douglas C, Erman B, Wilkerson J, McGrath JA, Oddis CV, Lundberg IE, Amato AA, García-De La Torre I, Chinoy H, Fiorentino D, Chung L, Song YW, Miller FW, Ruperto N, Vencovsky J, Aggarwal R, Rider LG. Performance of the 2016 ACR-EULAR Myositis Response Criteria in adult dermatomyositis/polymyositis therapeutic trials and consensus profiles. Rheumatology (Oxford) 2023; 62:3672-3679. [PMID: 36929923 PMCID: PMC10629785 DOI: 10.1093/rheumatology/kead110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE The ACR-EULAR Myositis Response Criteria (MRC) were developed as a composite measure using absolute percentage change in six core set measures (CSMs). We aimed to further validate the MRC by assessing the contribution of each CSM, frequency of strength vs extramuscular activity improvement, representation of patient-reported outcome measures (PROM), and frequency of CSM worsening. METHODS Data from adult dermatomyositis/polymyositis patients in the rituximab (n = 147), etanercept (n = 14), and abatacept (n = 19) trials, and consensus patient profiles (n = 232) were evaluated. The Total Improvement Score (TIS), number of improving vs worsening CSMs, frequency of improvement with and without muscle-related CSMs, and contribution of PROM were evaluated by MRC category. Regression analysis was performed to assess contribution of each CSM to the MRC. RESULTS Of 412 adults with dermatomyositis/polymyositis, there were 37%, 24%, 25%, and 14% with no, minimal, moderate, and major MRC improvement, respectively. The number of improving CSMs and absolute percentage change in all CSMs increased by improvement category. In minimal-moderate improvement, only physician-reported disease activity contributed significantly more than expected by MRC. Of patients with at least minimal improvement, 95% had improvement in muscle-related measures and a majority (84%) had improvement in PROM. Patients with minimal improvement had worsening in a median of 1 CSM, and most patients with moderate-major improvement had no worsening CSMs. Physician assessment of change generally agreed with MRC improvement categories. CONCLUSION The ACR-EULAR MRC performs consistently across multiple studies, further supporting its use as an efficacy end point in future myositis therapeutic trials.
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Affiliation(s)
- Didem Saygin
- Section of Rheumatology at University of Chicago and Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hanna Kim
- Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health (NIH), Bethesda, MD, USA
| | | | - Brian Erman
- Social & Scientific Systems, Inc, Durham, NC, USA
| | | | | | - Chester V Oddis
- Section of Rheumatology at University of Chicago and Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ingrid E Lundberg
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anthony A Amato
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ignacio García-De La Torre
- Hospital General de Occidente de la Secretaría de Salud and Universidad de Guadalajara, Department of Immunology and Rheumatology, Mexico
| | - Hector Chinoy
- National Institute for Health Research Manchester Biomedical Research Centre, Division of Musculoskeletal and Dermatological Sciences, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK
| | - David Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Lorinda Chung
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Yeong-Wook Song
- Medical Research Center, Institute of Human-Environment Interface Biology, Department of Internal Medicine, Seoul National University
| | - Frederick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, MD, USA
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOSID Centro Trial, Reumatologia, Pediatria II, PRINTO, Genoa, Italy
| | - Jiri Vencovsky
- Department of Rheumatology, 1st Medical Faculty, Institute of Rheumatology; Charles University, Prague, Czech Republic
| | - Rohit Aggarwal
- Section of Rheumatology at University of Chicago and Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, MD, USA
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Kim H, Saygin D, Douglas C, Wilkerson J, Erman B, Pistorio A, McGrath JA, Reed AM, Oddis CV, Bracaglia C, van Royen-Kerkhof A, Bica B, Dolezalova P, Ferriani VPL, Flato B, Bernard-Medina AG, Herlin T, Miller FW, Vencovsky J, Ruperto N, Aggarwal R, Rider LG. Performance of the 2016 ACR-EULAR myositis response criteria in juvenile dermatomyositis therapeutic trials and consensus profiles. Rheumatology (Oxford) 2023; 62:3680-3689. [PMID: 36929918 PMCID: PMC10629769 DOI: 10.1093/rheumatology/kead111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/11/2023] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES The 2016 ACR-EULAR Response Criteria for JDM was developed as a composite measure with differential weights of six core set measures (CSMs) to calculate a Total Improvement Score (TIS). We assessed the contribution of each CSM, representation of muscle-related and patient-reported CSMs towards improvement, and frequency of CSM worsening across myositis response criteria (MRC) categories in validation of MRC. METHODS Data from JDM patients in the Rituximab in Myositis trial (n = 48), PRINTO JDM trial (n = 139), and consensus patient profiles (n = 273) were included. Observed vs expected CSM contributions were compared using Sign test. Characteristics of MRC categories were compared by Wilcoxon tests with Bonferroni adjustment. Spearman correlation of changes in TIS and individual CSMs were examined. Agreement between physician-assessed change and MRC categories was evaluated by weighted Cohen's kappa. RESULTS Of 457 JDM patients with IMACS CSMs and 380 with PRINTO CSMs, 9-13% had minimal, 19-23% had moderate and 41-50% had major improvement. The number of improved and absolute percentage change of CSMs increased by MRC improvement level. Patients with minimal improvement by MRC had a median of 0-1 CSM worsened, and those with moderate/major improvement had a median of zero worsening CSMs. Of patients improved by MRC, 94-95% had improvement in muscle strength and 93-95% had improvement in ≥1 patient-reported CSM. IMACS and PRINTO CSMs performed similarly. Physician-rated change and MRC improvement categories had moderate-to-substantial agreement (Kappa 0.5-0.7). CONCLUSION The ACR-EULAR MRC perform consistently across multiple studies, supporting its further use as an efficacy end point in JDM trials.
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Affiliation(s)
- Hanna Kim
- Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Didem Saygin
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
- School of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Brian Erman
- Social & Scientific Systems, Inc, Durham, NC, USA
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Direzione Scientifica, Genoa, Italy
| | | | - Ann M Reed
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Chester V Oddis
- School of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Claudia Bracaglia
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Annet van Royen-Kerkhof
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Blanca Bica
- Section of Rheumatology, Department of Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pavla Dolezalova
- General University Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Virginia P L Ferriani
- Department of Pediatrics; Division of Rheumatology, Ribeirao Preto Medical School- Sao Paulo University, Ribeirao Preto, Brazil
| | - Berit Flato
- Department of Rheumatology, Oslo University Hospital, Norway and Institute of clinical medicine, University of Oslo, Oslo, Norway
| | | | - Troels Herlin
- Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Frederick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, MD, USA
| | - Jiri Vencovsky
- Institute of Rheumatology, Department of Rheumatology, Charles University, Prague, Czech Republic
| | - Nicolino Ruperto
- UOSID Centro Trial, PRINTO, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Rohit Aggarwal
- School of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, MD, USA
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Gokturk B, Casanova JL, Picard C, Cagdas Ayvaz D, Erman B, Tezcan I, Ozdemir H, Ozel A, Reisli I. A Novel Homozygous Mutation With Different Clinical Presentations in 2 IRAK-4-Deficient Siblings: First Case With Recurrent Salmonellosis and Non-Hodgkin Lymphoma. J Investig Allergol Clin Immunol 2019; 28:271-273. [PMID: 30073964 DOI: 10.18176/jiaci.0261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- B Gokturk
- Baskent University Faculty of Medicine, Department of Pediatric Allergy and Immunology, Konya, Turkey
| | - J L Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM UMR1163, Paris, France.,St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, USA.,Paris Descartes University, Imagine Institute, Paris, France.,Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris AP-HP, Paris, France.,Howard Hughes Medical Institute, New York, USA
| | - C Picard
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM UMR1163, Paris, France.,St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, USA.,Paris Descartes University, Imagine Institute, Paris, France.,Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - D Cagdas Ayvaz
- Hacettepe University Ihsan Dogramacı Children's Hospital, Department of Pediatric Immunology, Ankara, Turkey
| | - B Erman
- Hacettepe University Ihsan Dogramacı Children's Hospital, Department of Pediatric Immunology, Ankara, Turkey
| | - I Tezcan
- Hacettepe University Ihsan Dogramacı Children's Hospital, Department of Pediatric Immunology, Ankara, Turkey
| | - H Ozdemir
- Ankara University Medical School, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - A Ozel
- Konya Training and Research Hospital, Department of Pediatric Nephrology, Konya, Turkey
| | - I Reisli
- Necmettin Erbakan University Meram Medical Faculty, Department of Pediatrics, Division of Pediatric Allergy and Immunology, Konya, Turkey
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4
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Rider LG, Ruperto N, Pistorio A, Erman B, Bayat N, Lachenbruch PA, Rockette H, Feldman BM, Huber AM, Hansen P, Oddis CV, Lundberg IE, Amato AA, Chinoy H, Cooper RG, Chung L, Danko K, Fiorentino D, García-De la Torre I, Reed AM, Wook Song Y, Cimaz R, Cuttica RJ, Pilkington CA, Martini A, van der Net J, Maillard S, Miller FW, Vencovsky J, Aggarwal R. 2016 ACR-EULAR adult dermatomyositis and polymyositis and juvenile dermatomyositis response criteria-methodological aspects. Rheumatology (Oxford) 2017; 56:1884-1893. [PMID: 28977549 DOI: 10.1093/rheumatology/kex226] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 11/12/2022] Open
Abstract
Objective The objective was to describe the methodology used to develop new response criteria for adult DM/PM and JDM. Methods Patient profiles from prospective natural history data and clinical trials were rated by myositis specialists to develop consensus gold-standard ratings of minimal, moderate and major improvement. Experts completed a survey regarding clinically meaningful improvement in the core set measures (CSM) and a conjoint-analysis survey (using 1000Minds software) to derive relative weights of CSM and candidate definitions. Six types of candidate definitions for response criteria were derived using survey results, logistic regression, conjoint analysis, application of conjoint-analysis weights to CSM and published definitions. Sensitivity, specificity and area under the curve were defined for candidate criteria using consensus patient profile data, and selected definitions were validated using clinical trial data. Results Myositis specialists defined the degree of clinically meaningful improvement in CSM for minimal, moderate and major improvement. The conjoint-analysis survey established the relative weights of CSM, with muscle strength and Physician Global Activity as most important. Many candidate definitions showed excellent sensitivity, specificity and area under the curve in the consensus profiles. Trial validation showed that a number of candidate criteria differentiated between treatment groups. Top candidate criteria definitions were presented at the consensus conference. Conclusion Consensus methodology, with definitions tested on patient profiles and validated using clinical trials, led to 18 definitions for adult PM/DM and 14 for JDM as excellent candidates for consideration in the final consensus on new response criteria for myositis.
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Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, NIEHS, National Institutes of Health, Bethesda, MD, USA
| | | | - Angela Pistorio
- Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | - Brian Erman
- Social and Scientific Systems, Inc., Durham, NC
| | - Nastaran Bayat
- Environmental Autoimmunity Group, NIEHS, National Institutes of Health, Bethesda, MD, USA
| | - Peter A Lachenbruch
- Environmental Autoimmunity Group, NIEHS, National Institutes of Health, Bethesda, MD, USA
| | - Howard Rockette
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian M Feldman
- Division of Rheumatology, Hospital for Sick Children, Toronto, Ontario
| | - Adam M Huber
- Rheumatology Department, Izaak Walton Killam Health Centre, Halifax, Nova Scotia, Canada
| | - Paul Hansen
- Department of Economics, University of Otago, Dunedin, New Zealand
| | - Chester V Oddis
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ingrid E Lundberg
- Rheumatology Unit, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hector Chinoy
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust.,Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Robert G Cooper
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Lorinda Chung
- Division of Rheumatology, Stanford University, Redwood City, CA, USA
| | - Katalin Danko
- 3rd Department of Internal Medicine, Division of Immunology, University of Debrecen, Debrecen, Hungary
| | - David Fiorentino
- Department of Dermatology, Stanford University, Redwood City, CA, USA
| | | | - Ann M Reed
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Yeong Wook Song
- Department of Molecular Medicine and Biopharmaceutical Sciences, Medical Research Center, Seoul National University, Seoul, Korea
| | - Rolando Cimaz
- Pediatric Rheumatology, Azienda Ospedaliero Universitaria Meyer, University of Florence, Florence, Italy
| | - Rubén J Cuttica
- Department of Pediatric Rheumatology, Hospital de Niños Pedro de Elizalde, University of Buenos Aires, Buenos Aires, Argentina
| | - Clarissa A Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alberto Martini
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO.,Università degli Studi di Genova, Dipartimento di Pediatria, Genoa, Italy
| | - Janjaap van der Net
- Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Susan Maillard
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Frederick W Miller
- Environmental Autoimmunity Group, NIEHS, National Institutes of Health, Bethesda, MD, USA
| | - Jiri Vencovsky
- Institute of Rheumatology and Department of Rheumatology, Charles University, Prague, Czech Republic
| | - Rohit Aggarwal
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
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5
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Rider LG, Aggarwal R, Pistorio A, Bayat N, Erman B, Feldman BM, Huber AM, Cimaz R, Cuttica RJ, de Oliveira SK, Lindsley CB, Pilkington CA, Punaro M, Ravelli A, Reed AM, Rouster-Stevens K, van Royen-Kerkhof A, Dressler F, Saad Magalhaes C, Constantin T, Davidson JE, Magnusson B, Russo R, Villa L, Rinaldi M, Rockette H, Lachenbruch PA, Miller FW, Vencovsky J, Ruperto N. 2016 American College of Rheumatology/European League Against Rheumatism Criteria for Minimal, Moderate, and Major Clinical Response in Juvenile Dermatomyositis: An International Myositis Assessment and Clinical Studies Group/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Ann Rheum Dis 2017; 76:782-791. [PMID: 28385804 DOI: 10.1136/annrheumdis-2017-211401] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 11/04/2022]
Abstract
To develop response criteria for juvenile dermatomyositis (DM). We analysed the performance of 312 definitions that used core set measures from either the International Myositis Assessment and Clinical Studies Group (IMACS) or the Paediatric Rheumatology International Trials Organisation (PRINTO) and were derived from natural history data and a conjoint analysis survey. They were further validated using data from the PRINTO trial of prednisone alone compared to prednisone with methotrexate or cyclosporine and the Rituximab in Myositis (RIM) trial. At a consensus conference, experts considered 14 top candidate criteria based on their performance characteristics and clinical face validity, using nominal group technique. Consensus was reached for a conjoint analysis-based continuous model with a total improvement score of 0-100, using absolute per cent change in core set measures of minimal (≥30), moderate (≥45), and major (≥70) improvement. The same criteria were chosen for adult DM/polymyositis, with differing thresholds for improvement. The sensitivity and specificity were 89% and 91-98% for minimal improvement, 92-94% and 94-99% for moderate improvement, and 91-98% and 85-86% for major improvement, respectively, in juvenile DM patient cohorts using the IMACS and PRINTO core set measures. These criteria were validated in the PRINTO trial for differentiating between treatment arms for minimal and moderate improvement (p=0.009-0.057) and in the RIM trial for significantly differentiating the physician's rating for improvement (p<0.006). The response criteria for juvenile DM consisted of a conjoint analysis-based model using a continuous improvement score based on absolute per cent change in core set measures, with thresholds for minimal, moderate, and major improvement.
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Affiliation(s)
| | | | - Angela Pistorio
- Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | | | - Brian Erman
- Social and Scientific Systems, Inc., Durham, North Carolina, USA
| | | | | | | | - Rubén J Cuttica
- Hospital de Niños Pedro de Elizalde, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Carol B Lindsley
- University of Kansas City Medical Center, Kansas City, Kansas, USA
| | | | - Marilynn Punaro
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Angelo Ravelli
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, and Università degli Studi di Genova, Genoa, Italy
| | - Ann M Reed
- Duke University, Durham, North Carolina, USA
| | | | | | | | | | | | - Joyce E Davidson
- Royal Hospital for Sick Children, Glasgow, UK.,Royal Hospital for Sick Children, Edinburgh, UK
| | - Bo Magnusson
- Karolinska University Hospital, Stockholm, Sweden
| | - Ricardo Russo
- Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Luca Villa
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | - Mariangela Rinaldi
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | | | | | | | | | - Nicolino Ruperto
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
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6
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Aggarwal R, Rider LG, Ruperto N, Bayat N, Erman B, Feldman BM, Oddis CV, Amato AA, Chinoy H, Cooper RG, Dastmalchi M, Fiorentino D, Isenberg D, Katz JD, Mammen A, de Visser M, Ytterberg SR, Lundberg IE, Chung L, Danko K, García-De la Torre I, Song YW, Villa L, Rinaldi M, Rockette H, Lachenbruch PA, Miller FW, Vencovsky J. 2016 American College of Rheumatology/European League Against Rheumatism criteria for minimal, moderate, and major clinical response in adult dermatomyositis and polymyositis: An International Myositis Assessment and Clinical Studies Group/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Ann Rheum Dis 2017; 76:792-801. [PMID: 28385805 DOI: 10.1136/annrheumdis-2017-211400] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 11/03/2022]
Abstract
To develop response criteria for adult dermatomyositis (DM) and polymyositis (PM). Expert surveys, logistic regression, and conjoint analysis were used to develop 287 definitions using core set measures. Myositis experts rated greater improvement among multiple pairwise scenarios in conjoint analysis surveys, where different levels of improvement in 2 core set measures were presented. The PAPRIKA (Potentially All Pairwise Rankings of All Possible Alternatives) method determined the relative weights of core set measures and conjoint analysis definitions. The performance characteristics of the definitions were evaluated on patient profiles using expert consensus (gold standard) and were validated using data from a clinical trial. The nominal group technique was used to reach consensus. Consensus was reached for a conjoint analysis-based continuous model using absolute per cent change in core set measures (physician, patient, and extramuscular global activity, muscle strength, Health Assessment Questionnaire, and muscle enzyme levels). A total improvement score (range 0-100), determined by summing scores for each core set measure, was based on improvement in and relative weight of each core set measure. Thresholds for minimal, moderate, and major improvement were ≥20, ≥40, and ≥60 points in the total improvement score. The same criteria were chosen for juvenile DM, with different improvement thresholds. Sensitivity and specificity in DM/PM patient cohorts were 85% and 92%, 90% and 96%, and 92% and 98% for minimal, moderate, and major improvement, respectively. Definitions were validated in the clinical trial analysis for differentiating the physician rating of improvement (p<0.001). The response criteria for adult DM/PM consisted of the conjoint analysis model based on absolute per cent change in 6 core set measures, with thresholds for minimal, moderate, and major improvement.
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Affiliation(s)
| | | | - Nicolino Ruperto
- Istituto Giannina Gaslini, Pediatria II - Rheumatologia, PRINTO, Genoa, Italy
| | | | - Brian Erman
- Social and Scientific Systems, Inc., Durham, North Carolina, USA
| | | | | | - Anthony A Amato
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hector Chinoy
- Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, UK
| | | | - Maryam Dastmalchi
- Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Andrew Mammen
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Ingrid E Lundberg
- Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | - Ignacio García-De la Torre
- Hospital General de Occidente de la Secretaría de Salud and University of Guadalajara, Guadalajara, México
| | - Yeong Wook Song
- Graduate School of Convergence Science and Technology and Seoul National University Hospital, Seoul, Korea
| | - Luca Villa
- Istituto Giannina Gaslini, Pediatria II - Rheumatologia, PRINTO, Genoa, Italy
| | - Mariangela Rinaldi
- Istituto Giannina Gaslini, Pediatria II - Rheumatologia, PRINTO, Genoa, Italy
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7
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Erman B, Bilic I, Hirschmugl T, Salzer E, Boztug H, Sanal Ö, Çağdaş Ayvaz D, Tezcan I, Boztug K. Investigation of Genetic Defects in Severe Combined Immunodeficiency Patients from Turkey by Targeted Sequencing. Scand J Immunol 2017; 85:227-234. [PMID: 28109013 DOI: 10.1111/sji.12523] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/13/2017] [Indexed: 12/30/2022]
Abstract
Primary immunodeficiencies (PIDs) represent a large group of disorders with an increased susceptibility to infections. Severe combined immunodeficiency (SCID) is the most severe form of primary immunodeficiencies (PIDs) with marked T-cell lymphopenia. Investigation of the genetic aetiology using classical Sanger sequencing is associated with considerable diagnostic delay. We here established a custom-designed, next-generation sequencing (NGS)-based panel to efficiently identify disease-causing genetic defects in PID patients and applied this method in SCID patients of Turkish origin with previously undefined genetic aetiology. We used HaloPlex enrichment technology, a targeted, NGS-based method which was designed to diagnose patients with SCID and other PIDs. Our HaloPlex panel included a total of 356 PID-related genes, and we searched disease-causing mutations in 19 Turkish SCID patients without a genetic diagnosis. The coverage of targeted regions ranged from 97.47% to 99.62% with an average of 98.31% for all patients. All known SCID genes were covered with a percentage of at least 97.3%. We made a genetic diagnosis in six of 19 (33%) patients, including four novel disease-causing mutations identified in RAG1, JAK3 and IL2RG, respectively. We showed that this NGS-based method can provide rapid genetic diagnosis for patients suffering from SCID, potentially facilitating clinical treatment decisions.
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Affiliation(s)
- B Erman
- Department of Immunology, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - I Bilic
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - T Hirschmugl
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - E Salzer
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - H Boztug
- Department of Paediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Ö Sanal
- Department of Immunology, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey
| | - D Çağdaş Ayvaz
- Department of Immunology, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey
| | - I Tezcan
- Department of Immunology, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey
| | - K Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Department of Paediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria.,Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
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Rider LG, Aggarwal R, Pistorio A, Bayat N, Erman B, Feldman BM, Huber AM, Cimaz R, Cuttica RJ, de Oliveira SK, Lindsley CB, Pilkington CA, Punaro M, Ravelli A, Reed AM, Rouster-Stevens K, van Royen-Kerkhof A, Dressler F, Magalhaes CS, Constantin T, Davidson JE, Magnusson B, Russo R, Villa L, Rinaldi M, Rockette H, Lachenbruch PA, Miller FW, Vencovsky J, Ruperto N. 2016 American College of Rheumatology/European League Against Rheumatism Criteria for Minimal, Moderate, and Major Clinical Response in Juvenile Dermatomyositis: An International Myositis Assessment and Clinical Studies Group/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Arthritis Rheumatol 2017; 69:911-923. [PMID: 28382778 DOI: 10.1002/art.40060] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 01/31/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop response criteria for juvenile dermatomyositis (DM). METHODS We analyzed the performance of 312 definitions that used core set measures from either the International Myositis Assessment and Clinical Studies Group (IMACS) or the Paediatric Rheumatology International Trials Organisation (PRINTO) and were derived from natural history data and a conjoint analysis survey. They were further validated using data from the PRINTO trial of prednisone alone compared to prednisone with methotrexate or cyclosporine and the Rituximab in Myositis (RIM) trial. At a consensus conference, experts considered 14 top candidate criteria based on their performance characteristics and clinical face validity, using nominal group technique. RESULTS Consensus was reached for a conjoint analysis-based continuous model with a total improvement score of 0-100, using absolute percent change in core set measures of minimal (≥30), moderate (≥45), and major (≥70) improvement. The same criteria were chosen for adult DM/polymyositis, with differing thresholds for improvement. The sensitivity and specificity were 89% and 91-98% for minimal improvement, 92-94% and 94-99% for moderate improvement, and 91-98% and 85-86% for major improvement, respectively, in juvenile DM patient cohorts using the IMACS and PRINTO core set measures. These criteria were validated in the PRINTO trial for differentiating between treatment arms for minimal and moderate improvement (P = 0.009-0.057) and in the RIM trial for significantly differentiating the physician's rating for improvement (P < 0.006). CONCLUSION The response criteria for juvenile DM consisted of a conjoint analysis-based model using a continuous improvement score based on absolute percent change in core set measures, with thresholds for minimal, moderate, and major improvement.
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Affiliation(s)
| | | | - Angela Pistorio
- Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | | | - Brian Erman
- Social and Scientific Systems, Inc., Durham, North Carolina
| | | | | | | | - Rubén J Cuttica
- Hospital de Niños Pedro de Elizalde, University of Buenos Aires, Buenos Aires, Argentina
| | | | | | | | | | - Angelo Ravelli
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, and Università degli Studi di Genova, Genoa, Italy
| | | | | | | | | | | | | | - Joyce E Davidson
- Royal Hospital for Sick Children, Glasgow, UK, and Royal Hospital for Sick Children, Edinburgh, UK
| | - Bo Magnusson
- Karolinska University Hospital, Stockholm, Sweden
| | - Ricardo Russo
- Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Luca Villa
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | - Mariangela Rinaldi
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | | | | | | | | | - Nicolino Ruperto
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
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Aggarwal R, Rider LG, Ruperto N, Bayat N, Erman B, Feldman BM, Oddis CV, Amato AA, Chinoy H, Cooper RG, Dastmalchi M, Fiorentino D, Isenberg D, Katz JD, Mammen A, de Visser M, Ytterberg SR, Lundberg IE, Chung L, Danko K, García-De la Torre I, Song YW, Villa L, Rinaldi M, Rockette H, Lachenbruch PA, Miller FW, Vencovsky J. 2016 American College of Rheumatology/European League Against Rheumatism Criteria for Minimal, Moderate, and Major Clinical Response in Adult Dermatomyositis and Polymyositis: An International Myositis Assessment and Clinical Studies Group/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Arthritis Rheumatol 2017; 69:898-910. [PMID: 28382787 DOI: 10.1002/art.40064] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 01/31/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To develop response criteria for adult dermatomyositis (DM) and polymyositis (PM). METHODS Expert surveys, logistic regression, and conjoint analysis were used to develop 287 definitions using core set measures. Myositis experts rated greater improvement among multiple pairwise scenarios in conjoint analysis surveys, where different levels of improvement in 2 core set measures were presented. The PAPRIKA (Potentially All Pairwise Rankings of All Possible Alternatives) method determined the relative weights of core set measures and conjoint analysis definitions. The performance characteristics of the definitions were evaluated on patient profiles using expert consensus (gold standard) and were validated using data from a clinical trial. The nominal group technique was used to reach consensus. RESULTS Consensus was reached for a conjoint analysis-based continuous model using absolute percent change in core set measures (physician, patient, and extramuscular global activity, muscle strength, Health Assessment Questionnaire, and muscle enzyme levels). A total improvement score (range 0-100), determined by summing scores for each core set measure, was based on improvement in and relative weight of each core set measure. Thresholds for minimal, moderate, and major improvement were ≥20, ≥40, and ≥60 points in the total improvement score. The same criteria were chosen for juvenile DM, with different improvement thresholds. Sensitivity and specificity in DM/PM patient cohorts were 85% and 92%, 90% and 96%, and 92% and 98% for minimal, moderate, and major improvement, respectively. Definitions were validated in the clinical trial analysis for differentiating the physician rating of improvement (P < 0.001). CONCLUSION The response criteria for adult DM/PM consisted of the conjoint analysis model based on absolute percent change in 6 core set measures, with thresholds for minimal, moderate, and major improvement.
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Affiliation(s)
| | | | - Nicolino Ruperto
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | | | - Brian Erman
- Social and Scientific Systems, Inc., Durham, North Carolina
| | | | | | - Anthony A Amato
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hector Chinoy
- Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, UK
| | | | - Maryam Dastmalchi
- Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Andrew Mammen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Ingrid E Lundberg
- Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | - Ignacio García-De la Torre
- Hospital General de Occidente de la Secretaría de Salud and University of Guadalajara, Guadalajara, México
| | - Yeong Wook Song
- Graduate School of Convergence Science and Technology and Seoul National University Hospital, Seoul, Korea
| | - Luca Villa
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
| | - Mariangela Rinaldi
- Istituto Giannina Gaslini, Pediatria II - Reumatologia, PRINTO, Genoa, Italy
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Çağdaş D, Erman B, Hanoğlu D, Tavil B, Kuşkonmaz B, Aydın B, Akyüz C, Uçkan D, Sanal Ö, Tezcan I. Course of IL-2-inducible T-cell kinase deficiency in a family: lymphomatoid granulomatosis, lymphoma and allogeneic bone marrow transplantation in one sibling; and death in the other. Bone Marrow Transplant 2016; 52:126-129. [PMID: 27454071 DOI: 10.1038/bmt.2016.185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- D Çağdaş
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Immunology, Ankara, Turkey
| | - B Erman
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Immunology, Ankara, Turkey
| | - D Hanoğlu
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatrics, Ankara, Turkey
| | - B Tavil
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Hematology, Ankara, Turkey
| | - B Kuşkonmaz
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Hematology, Ankara, Turkey
| | - B Aydın
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Oncology, Ankara, Turkey
| | - C Akyüz
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Oncology, Ankara, Turkey
| | - D Uçkan
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Hematology, Ankara, Turkey
| | - Ö Sanal
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Immunology, Ankara, Turkey
| | - I Tezcan
- Hacettepe University İhsan Doğramacı Children's Hospital, Section of Pediatric Immunology, Ankara, Turkey
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Jernigan RL, Bahar I, Covell DG, Atilgan AR, Erman B, Flatow DT. Relating the Structure of HIV-1 Reverse Transcriptase to Its Processing Step. J Biomol Struct Dyn 2016; 17 Suppl 1:49-55. [PMID: 22607406 DOI: 10.1080/07391102.2000.10506603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Abstract By treating an enzyme as a coarse-grained uniform block of material, utilizing only the α-Carbon positions, the normal modes of motion can be obtained. For reverse transcriptase the slower of these motions are suggestive of being involved in the processing step, where the RNA or DNA strand is copied onto a new DNA strand at a polymerase site, and the RNA strand is subsequently cut up at the distant Ribonuclease H site. The slowest mode of motion involves hinge bending about a site midway between the polymerase and Ribonuclease H sites, suggesting that it can push or pull the RNA strand between these two sites. Pulling the nucleic acid strand would require tight binding to the RNase H site. The next slowest mode involves a hinge that opens and closes the protein like a clamp, which could facilitate the release of the nucleic acids for their step-wise progression. The third mode could rotate the substrate. An overall description of the step-wise processing step would involve close coordination among these steps. Results suggest that the smaller p51 subunit serves only as ballast to support the various modes of motion involving the different parts of the p66 subunit.
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Affiliation(s)
- R L Jernigan
- a Molecular Structure Section, Laboratory of Experimental and Computational Biology, Division of Basic Sciences , National Cancer Institute, National Institutes of Health , MSC 5677 , Bethesda , MD , 20892-5677
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Gul A, Bozkurt Y, Demir A, Erman B. Unified modeling of Familial Mediterranean Fever and Cryopyrin Associated Periodic Syndromes. Pediatr Rheumatol Online J 2015. [PMCID: PMC4596958 DOI: 10.1186/1546-0096-13-s1-o43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Jones CD, Holmes GM, DeWalt DA, Erman B, Wu JR, Cene CW, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Macabasco-O'Connell A, Hawk V, Broucksou K, Pignone M. Self-reported recall and daily diary-recorded measures of weight monitoring adherence: associations with heart failure-related hospitalization. BMC Cardiovasc Disord 2014; 14:12. [PMID: 24483776 PMCID: PMC3912256 DOI: 10.1186/1471-2261-14-12] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 01/08/2014] [Indexed: 01/10/2023] Open
Abstract
Background Weight monitoring is an important element of HF self-care, yet the most clinically meaningful way to evaluate weight monitoring adherence is uncertain. We conducted this study to evaluate the association of (1) self-reported recall and (2) daily diary-recorded weight monitoring adherence with heart failure-related (HF-related) hospitalization. Methods We conducted a prospective cohort study among 216 patients within a randomized trial of HF self-care training. All patients had an initial self-care training session followed by 15 calls (median) to reinforce educational material; patients were also given digital scales, instructed to weigh daily, record weights in a diary, and mail diaries back monthly. Weight monitoring adherence was assessed with a self-reported recall question administered at 12 months and dichotomized into at least daily versus less frequent weighing. Diary-recorded weight monitoring was evaluated over 12 months and dichotomized into ≥80% and <80% adherence. HF-related hospitalizations were ascertained through patient report and confirmed through record review. Results Over 12 months in 216 patients, we identified 50 HF-related hospitalizations. Patients self-reporting daily or more frequent weight monitoring had an incidence rate ratio of 1.34 (95% CI 0.24-7.32) for HF-related hospitalizations compared to those reporting less frequent weight monitoring. Patients who completed ≥80% of weight diaries had an IRR of 0.37 (95% CI 0.18-0.75) for HF-related hospitalizations compared to patients who completed <80% of weight diaries. Conclusions Self-reported recall of weight monitoring adherence was not associated with fewer HF hospitalizations. In contrast, diary-recorded adherence ≥80% of days was associated with fewer HF-related hospitalizations. Incorporating diary-based measures of weight monitoring adherence into HF self-care training programs may help to identify patients at risk for HF-related hospitalizations.
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Affiliation(s)
- Christine D Jones
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Wu JR, DeWalt DA, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Macabasco-O'Connell A, Holmes GM, Broucksou KA, Erman B, Hawk V, Cene CW, Jones CD, Pignone M. A single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure. J Clin Nurs 2013; 23:2554-64. [PMID: 24355060 DOI: 10.1111/jocn.12471] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2013] [Indexed: 10/25/2022]
Abstract
AIMS AND OBJECTIVES To determine whether a single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure. BACKGROUND Poor medication adherence is associated with increased morbidity and mortality. Having a simple means of identifying suboptimal medication adherence could help identify at-risk patients for interventions. DESIGN We performed a prospective cohort study in 592 participants with heart failure within a four-site randomised trial. METHODS Self-report medication adherence was assessed at baseline using a single-item question: 'Over the past seven days, how many times did you miss a dose of any of your heart medication?' Participants who reported no missing doses were defined as fully adherent, and those missing more than one dose were considered less than fully adherent. The primary outcome was combined all-cause hospitalisation or death over one year and the secondary endpoint was heart failure hospitalisation. Outcomes were assessed with blinded chart reviews, and heart failure outcomes were determined by a blinded adjudication committee. We used negative binomial regression to examine the relationship between medication adherence and outcomes. RESULTS Fifty-two percent of participants were 52% male, mean age was 61 years, and 31% were of New York Heart Association class III/IV at enrolment; 72% of participants reported full adherence to their heart medicine at baseline. Participants with full medication adherence had a lower rate of all-cause hospitalisation and death (0·71 events/year) compared with those with any nonadherence (0·86 events/year): adjusted-for-site incidence rate ratio was 0·83, fully adjusted incidence rate ratio 0·68. Incidence rate ratios were similar for heart failure hospitalisations. CONCLUSION A single medication adherence question at baseline predicts hospitalisation and death over one year in heart failure patients. RELEVANCE TO CLINICAL PRACTICE Medication adherence is associated with all-cause and heart failure-related hospitalisation and death in heart failure. It is important for clinicians to assess patients' medication adherence on a regular basis at their clinical follow-ups.
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Affiliation(s)
- Jia-Rong Wu
- The School of Nursing, University of North Carolina, Chapel Hill, NC, USA
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Wu JR, Holmes GM, DeWalt DA, Macabasco-O'Connell A, Bibbins-Domingo K, Ruo B, Baker DW, Schillinger D, Weinberger M, Broucksou KA, Erman B, Jones CD, Cene CW, Pignone M. Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure. J Gen Intern Med 2013; 28:1174-80. [PMID: 23478997 PMCID: PMC3744307 DOI: 10.1007/s11606-013-2394-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 10/31/2012] [Accepted: 02/14/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied. METHODS We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy. RESULTS Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization. CONCLUSIONS Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.
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Affiliation(s)
- Jia-Rong Wu
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460, USA.
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Gul A, Erman B. AB0002 Structural analysis of the SPRY domain of pyrin protein by bioinformatics and thermodynamics methods: Implications for the pathogenesis of familial mediterranean fever. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2012-eular.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Leone LA, Reuland DS, Lewis CL, Ingle M, Erman B, Summers TJ, Dubard CA, Pignone MP. Reach, usage, and effectiveness of a Medicaid patient navigator intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011. Prev Chronic Dis 2013; 10:E82. [PMID: 23701719 PMCID: PMC3670641 DOI: 10.5888/pcd10.120221] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Screening for colorectal cancer can reduce incidence and death, but screening is underused, especially among vulnerable groups such as Medicaid patients. Effective interventions are needed to increase screening frequency. Our study consisted of a controlled trial of an intervention designed to improve colorectal cancer screening among Medicaid patients in North Carolina. Methods The intervention included a mailed screening reminder letter and decision aid followed by telephone support from an offsite, Medicaid-based, patient navigator. The study included 12 clinical practices, 6 as intervention practices and 6 as matched controls. Eligible patients were aged 50 years or older, covered by Medicaid, and identified from Medicaid claims data as not current with colorectal cancer screening recommendations. We reviewed Medicaid claims data at 6 months and conducted multivariate logistic regression to compare participant screening in intervention practices with participants in control practices. We controlled for sociodemographic characteristics. Results Most of the sample was black (53.1%) and female (57.2%); the average age was 56.5 years. On the basis of Medicaid claims, 9.2% of intervention participants (n = 22/240) had had a colorectal cancer screening at the 6-month review, compared with 7.5% of control patients (n = 13/174). The adjusted odds ratio when controlling for age, comorbidities, race, sex, and continuous Medicaid eligibility was 1.44 (95% confidence interval, 0.68–3.06). The patient navigator reached 44 participants (27.6%). Conclusion The intervention had limited reach and little effect after 6 months on the number of participants screened. Higher-intensity interventions, such as use of practice-based navigators, may be needed to reach and improve screening rates in vulnerable populations.
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Affiliation(s)
- Lucia A Leone
- Cecil G. Sheps Center for Health Services Research, 725 Martin Luther King Jr Blvd, CB# 7590, Chapel Hill, NC 27599-7590, USA.
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Jones CD, Holmes GM, Dewalt DA, Erman B, Broucksou K, Hawk V, Cene CW, Wu JR, Pignone M. Is adherence to weight monitoring or weight-based diuretic self-adjustment associated with fewer heart failure-related emergency department visits or hospitalizations? J Card Fail 2012; 18:576-84. [PMID: 22748492 DOI: 10.1016/j.cardfail.2012.05.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 05/07/2012] [Accepted: 05/08/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. METHODS AND RESULTS We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23-0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19-0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. CONCLUSIONS Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity.
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Affiliation(s)
- Christine D Jones
- Department of Social Medicine, University of North Carolina-Chapel Hill, NC, USA
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DeWalt DA, Schillinger D, Ruo B, Bibbins-Domingo K, Baker DW, Holmes GM, Weinberger M, Macabasco-O'Connell A, Broucksou K, Hawk V, Grady KL, Erman B, Sueta CA, Chang PP, Cene CW, Wu JR, Jones CD, Pignone M. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation 2012; 125:2854-62. [PMID: 22572916 DOI: 10.1161/circulationaha.111.081745] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Self-care training can reduce hospitalization for heart failure (HF), and more intensive intervention may benefit more vulnerable patients, including those with low literacy. METHODS AND RESULTS A 1-year, multisite, randomized, controlled comparative effectiveness trial with 605 patients with HF was conducted. Those randomized to a single session received a 40-minute in-person, literacy-sensitive training; the multisession group received the same initial training and then ongoing telephone-based support. The primary outcome was combined incidence of all-cause hospitalization or death; secondary outcomes included HF-related hospitalization and HF-related quality of life, with prespecified stratification by literacy. Overall, the incidence of all-cause hospitalization and death did not differ between intervention groups (incidence rate ratio, 1.01; 95% confidence interval, 0.83-1.22). The effect of multisession training compared with single-session training differed by literacy group: Among those with low literacy, the multisession training yielded a lower incidence of all-cause hospitalization and death (incidence rate ratio, 0.75; 95% confidence interval, 0.45-1.25), and among those with higher literacy, the multisession intervention yielded a higher incidence (incidence rate ratio, 1.22; 95% confidence interval, 0.99-1.50; interaction P=0.048). For HF-related hospitalization, among those with low literacy, multisession training yielded a lower incidence (incidence rate ratio, 0.53; 95% confidence interval, 0.25-1.12), and among those with higher literacy, it yielded a higher incidence (incidence rate ratio, 1.32; 95% confidence interval, 0.92-1.88; interaction P=0.005). HF-related quality of life improved more for patients receiving multisession than for those receiving single-session interventions at 1 and 6 months, but the difference at 12 months was smaller. Effects on HF-related quality of life did not differ by literacy. CONCLUSIONS Overall, an intensive multisession intervention did not change clinical outcomes compared with a single-session intervention. People with low literacy appear to benefit more from multisession interventions than people with higher literacy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00378950.
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Affiliation(s)
- Darren A DeWalt
- Division of General Internal Medicine, University of North Carolina School of Medicine, 5041 Old Clinic Bldg, CB#7110, Chapel Hill, NC 27599, USA.
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Macabasco-O'Connell A, DeWalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes GM, Erman B, Weinberger M, Pignone M. Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure. J Gen Intern Med 2011; 26:979-86. [PMID: 21369770 PMCID: PMC3157534 DOI: 10.1007/s11606-011-1668-y] [Citation(s) in RCA: 173] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 11/22/2010] [Accepted: 02/10/2011] [Indexed: 10/26/2022]
Abstract
BACKGROUND We sought to examine the relationship between literacy and heart failure-related quality of life (HFQOL), and to explore whether literacy-related differences in knowledge, self-efficacy and/or self-care behavior explained the relationship. METHODS We recruited patients with symptomatic heart failure (HF) from four academic medical centers. Patients completed the short version of the Test of Functional Health Literacy in Adults (TOFHLA) and questions on HF-related knowledge, HF-related self-efficacy, and self-care behaviors. We assessed HFQOL with the Heart Failure Symptom Scale (HFSS) (range 0-100), with higher scores denoting better quality of life. We used bivariate (t-tests and chi-square) and multivariate linear regression analyses to estimate the associations between literacy and HF knowledge, self-efficacy, self-care behaviors, and HFQOL, controlling for demographic characteristics. Structural equation modeling was conducted to assess whether general HF knowledge, salt knowledge, self-care behaviors, and self-efficacy mediated the relationship between literacy and HFQOL. RESULTS We enrolled 605 patients with mean age of 60.7 years; 52% were male; 38% were African-American and 16% Latino; 26% had less than a high school education; and 67% had annual incomes under $25,000. Overall, 37% had low literacy (marginal or inadequate on TOFHLA). Patients with adequate literacy had higher general HF knowledge than those with low literacy (mean 6.6 vs. 5.5, adjusted difference 0.63, p < 0.01), higher self-efficacy (5.0 vs. 4.1, adjusted difference 0.99, p < 0.01), and higher prevalence of key self-care behaviors (p < 0.001). Those with adequate literacy had better HFQOL scores compared to those with low literacy (63.9 vs. 55.4, adjusted difference 7.20, p < 0.01), but differences in knowledge, self-efficacy, and self-care did not mediate this difference in HFQOL. CONCLUSION Low literacy was associated with worse HFQOL and lower HF-related knowledge, self-efficacy, and self-care behaviors, but differences in knowledge, self-efficacy and self-care did not explain the relationship between low literacy and worse HFQOL.
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Affiliation(s)
- Aurelia Macabasco-O'Connell
- UCLA School of Nursing, University of California, Olive View-UCLA Medical Center Los Angeles, 700 Tiverton Ave., 4-242 Factor Blvd., Los Angeles, CA 90095, USA.
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Baker DW, Dewalt DA, Schillinger D, Hawk V, Ruo B, Bibbins-Domingo K, Weinberger M, Macabasco-O'Connell A, Grady KL, Holmes GM, Erman B, Broucksou KA, Pignone M. The effect of progressive, reinforcing telephone education and counseling versus brief educational intervention on knowledge, self-care behaviors and heart failure symptoms. J Card Fail 2011; 17:789-96. [PMID: 21962415 DOI: 10.1016/j.cardfail.2011.06.374] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/07/2011] [Accepted: 06/08/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The optimal strategy for promoting self-care for heart failure (HF) is unclear. METHODS AND RESULTS We conducted a randomized trial to determine whether a "teach to goal" (TTG) educational and behavioral support program provided incremental benefits to a brief (1 hour) educational intervention (BEI) for knowledge, self-care behaviors, and HF-related quality of life (HFQOL). The TTG program taught use of adjusted-dose diuretics and then reinforced learning goals and behaviors with 5 to 8 telephone counseling sessions over 1 month. Participants' (n = 605) mean age was 61 years; 37% had marginal or inadequate literacy; 69% had ejection fraction <0.45; and 31% had Class III or IV symptoms. The TTG group had greater improvements in general and salt knowledge (P < .001) and greater increases in self-care behaviors (from mean 4.8 to 7.6 for TTG vs. 5.2 to 6.7 for BEI; P < .001). HFQOL improved from 58.5 to 64.6 for the TTG group but did not change for the BEI group (64.7 to 63.9; P < .001 for the difference in change scores). Improvements were similar regardless of participants' literacy level. CONCLUSIONS Telephone reinforcement of learning goals and self-care behaviors improved knowledge, health behaviors, and HF-related QOL compared to a single education session.
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Affiliation(s)
- David W Baker
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Abstract
Statistical averages and correlations for backbone torsion angles of chymotrypsin inhibitor 2 are calculated by using the Rotational Isomeric States model of chain statistics. Statistical weights of torsional states of phipsi pairs, needed for the statistics of the full chain, are obtained in two different ways: 1) by using knowledge-based pairwise dependent phipsi energy maps from Protein Data Bank (PDB) and 2) by collecting torsion angle data from a large number of random coil configurations of an all-atom protein model with volume exclusion. Results obtained by using PDB data show strong correlations between adjacent torsion angle pairs belonging to both the same and different residues. These correlations favor the choice of the native-state torsion angles, and they are strongly context dependent, determined by the specific amino acid sequence of the protein. Excluded volume or steric clashes, only, do not introduce context-dependent phipsi correlations into the chain that would affect the choice of native-state torsional angles.
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Affiliation(s)
- O Keskin
- College of Engineering and Center for Computational Biology and Bioinformatics, Koc University, Istanbul, Turkey
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Bahar I, Erman B, Kremer F, Fischer EW. Segmental motions of cis-polyisoprene in the bulk state: interpretation of dielectric relaxation data. Macromolecules 2002. [DOI: 10.1021/ma00028a048] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Besbes S, Bokobza L, Monnerie L, Bahar I, Erman B. Molecular Orientation in Deformed Bimodal Networks. 2. Fourier Transform Infrared Measurements on Poly(dimethylsiloxane) Networks and Comparison with Theory. Macromolecules 2002. [DOI: 10.1021/ma00105a030] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Besbes S, Cermelli I, Bokobza L, Monnerie L, Bahar I, Erman B, Herz J. Segmental orientation in model networks of poly(dimethylsiloxane): Fourier-transform infrared dichroism measurements and theoretical interpretation. Macromolecules 2002. [DOI: 10.1021/ma00033a018] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Erman B, Mark JE. Stress-strain isotherms for elastomers cross-linked in solution. 2. Interpretation in terms of the constrained-chain model. Macromolecules 2002. [DOI: 10.1021/ma00033a013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yang Y, Kloczkowski A, Mark JE, Erman B, Bahar I. Theoretical Analysis of the Elastomeric and Optical Properties of Networks of Semirigid Chains in the Swollen State. Macromolecules 2002. [DOI: 10.1021/ma00118a020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jarry JP, Erman B, Monnerie L. Segmental mobility in deformed amorphous polymeric networks. 2. Experimental study of polyisoprene using the fluorescence polarization technique. Macromolecules 2002. [DOI: 10.1021/ma00165a015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kloczkowski A, Mark JE, Erman B. Chain dimensions and fluctuations in random elastomeric networks. 1. Phantom Gaussian networks in the undeformed state. Macromolecules 2002. [DOI: 10.1021/ma00193a070] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yang Y, Kloczkowski A, Mark JE, Erman B, Bahar I. Experimental Studies of Elastomeric and Optical Properties, and Strain-Induced Liquid-Crystalline Phase Transitions, in Deformed (Hydroxypropyl)cellulose Networks in the Swollen State. Macromolecules 2002. [DOI: 10.1021/ma00118a021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bahar I, Erman B, Monnerie L. Kinematics of polymer chains with freely rotating bonds in a restrictive environment. 2. Conformational and orientational correlations. Macromolecules 2002. [DOI: 10.1021/ma00049a031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bahar I, Baysal N, Erman B, Monnerie L. Kinematics of Polymer Chains in Dense Media. 3. Influence of Intramolecular Conformational Potentials. Macromolecules 2002. [DOI: 10.1021/ma00108a035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Erman B, Kloczkowski A, Mark JE. Chain dimensions and fluctuations in random elastomeric networks. 2. Dependence of chain dimensions and fluctuations on macroscopic strain. Macromolecules 2002. [DOI: 10.1021/ma00193a071] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bahar I, Erman B, Monnerie L. Kinematics of polymer chains with freely rotating bonds in a restrictive environment. 1. Theory. Macromolecules 2002. [DOI: 10.1021/ma00049a030] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kloczkowski A, Mark JE, Erman B. Small-angle neutron scattering from elastomeric networks. 1. Calculated scattering from a path containing several junctions in the James-Guth model. Macromolecules 2002. [DOI: 10.1021/ma00202a021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kloczkowski A, Mark JE, Erman B. Correlations among chains along a crosslinked path in a phantom network and their characterization by SANS. Macromolecules 2002. [DOI: 10.1021/ma00035a025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kloczkowski A, Mark JE, Erman B. Fluctuations, correlations, and small-angle neutron scattering from endlinked Gaussian chains in regular bimodal networks. Macromolecules 2002. [DOI: 10.1021/ma00011a035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Langevin dynamics of a protein molecule with Go-type potentials is developed and used to analyze long time-scale events in the folding of cytochrome c. Several trajectories are generated, starting from random coil configurations and going to the native state, that are a few angstroms root mean square deviation (RMSD) from the native structure. The dynamics is controlled, to a large scale, by the two terminal helices that are in contact in the native state. These two helices form very early during folding, and depending on the trajectory, they either stabilize rapidly or break and re-form in going over steric barriers. The extended initial chain exhibits a rapid folding transition into a relatively compact shape, after which the helices are reorganized in a highly correlated manner. The time of formation of residue pair contacts strongly points to the hierarchical nature of folding; i.e., secondary structure forms first, followed by rearrangements of larger length scales at longer times. The kinetics of formation of native contacts is also analyzed, and the onset of a stable globular configuration, referred to as the molten globule in the literature, is identified. Predictions of the model are compared with extensive experimental data on cytochrome c.
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Affiliation(s)
- B Erman
- Laboratory of Computational Biology, Sabanci University, Faculty of Engineering and Natural Sciences, Tuzla 81474 Istanbul, Turkey.
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