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DiIorio MA, Sobiesczcyk PS, Xu C, Huang W, Ford JA, Zhao SS, Solomon DH, Docken WP, Tedeschi SK. Associations among temporal and large artery abnormalities on vascular ultrasound in giant cell arteritis. Scand J Rheumatol 2021; 50:381-389. [PMID: 33655808 DOI: 10.1080/03009742.2020.1869302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: Giant cell arteritis (GCA) can manifest in cranial and/or extracranial arteries. We investigated the distribution of affected arteries on vascular ultrasound (VUS) among patients with new-onset or prior-onset GCA.Method: We retrospectively studied patients with either new-onset or prior-onset GCA and an abnormal VUS, from 2013 to 2017. Trained vascular technologists imaged the bilateral temporal arteries and carotid, axillary, and subclavian arteries. Vascular medicine physicians interpreted the images. Vasculitis-related abnormalities in individual vessels and their distribution (temporal artery, large artery, or both) were evaluated. Phi coefficients (φ) and Fisher's exact test were used to assess correlations among individual abnormal arteries.Results: Among 66 GCA patients, 28.8% had prior-onset GCA (median duration 17.8 months). Acute arteritis on VUS was observed in the majority of patients with both new-onset (72.3%) and prior-onset GCA (68.4%); the remainder had hyperechoic wall thickening without acute arteritis. Involvement of the temporal arteries only (45.5%) or large arteries only (34.8%) was more common than involvement of both (19.7%); this finding was similar in new-onset and prior-onset GCA. There were moderate positive correlations among temporal artery branches (φ = 0.51-0.58, p < 0.003) and among axillary and subclavian arteries (φ = 0.51-0.77, p < 0.003), and moderate negative correlations between abnormalities in the temporal and large arteries (φ = -0.46 to -0.58, p < 0.003).Conclusion: On VUS, vasculitis-related abnormalities in the temporal arteries only or large arteries only were more common than concurrent temporal and large artery abnormalities in patients with both new-onset GCA and prior-onset GCA.
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Affiliation(s)
- M A DiIorio
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - P S Sobiesczcyk
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - C Xu
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - W Huang
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - J A Ford
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - S S Zhao
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - D H Solomon
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - W P Docken
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - S K Tedeschi
- Harvard Medical Faculty, Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
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Duryea J, Gravallese EM, Wortman JR, Xu C, Lu B, Kay J, Solomon DH. Healing of erosions in rheumatoid arthritis remains elusive: results with 24 months of the anabolic agent teriparatide. Scand J Rheumatol 2020; 50:11-14. [PMID: 32757870 DOI: 10.1080/03009742.2020.1772362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Erosion healing in rheumatoid arthritis (RA) is difficult to demonstrate. This extension study aimed to determine whether 2 years of teriparatide (TPTD) produces erosion healing. Method: Subjects in a previous 12 month randomized controlled trial of TPTD in RA were invited to receive 12 additional months of open-label TPTD. Eleven of the 24 original subjects were enrolled in the extension study, six of whom received TPTD in the final 12 months only. Subjects receiving 24 months of TPTD were assessed for reduction in erosion volume from baseline using computed tomography. We also compared erosion volumes between 12 and 24 months of TPTD. Large erosions in subjects receiving TPTD for 24 months were examined for volume change. Results: In the six patients who received 24 months of TPTD, there was no significant change in erosion volume at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints compared with baseline. The six subjects who received 24 months of TPTD had similar changes in erosion volume to the five who received 12 months of TPTD, in MCP (p = 0.17) and PIP (p = 0.63) joints. Assessment of large erosions in those receiving TPTD for 24 months showed no evidence of erosion healing. Conclusion: While this extension study was too small to be conclusive, we observed no evidence of reduction in erosion volume with the addition of TPTD for 24 months in subjects with RA in whom disease activity was controlled on a tumour necrosis factor inhibitor. This is consistent with our negative findings at 12 months.
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Affiliation(s)
- J Duryea
- Department of Radiology, Brigham and Women's Hospital , Boston, MA, USA
| | - E M Gravallese
- Division of Rheumatology, University of Massachusetts Medical School , Worcester, MA, USA
| | - J R Wortman
- Department of Radiology, Brigham and Women's Hospital , Boston, MA, USA
| | - C Xu
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital , Boston, MA, USA
| | - B Lu
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital , Boston, MA, USA
| | - J Kay
- Division of Rheumatology, University of Massachusetts Medical School , Worcester, MA, USA
| | - D H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital , Boston, MA, USA
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Lyu H, Yoshida K, Tedeschi SK, Zhao S, Xu C, Nigwekar SU, Leder BZ, Solomon DH. Intervals between bone mineral density testing with dual-energy X-ray absorptiometry scans in clinical practice. Osteoporos Int 2019; 30:923-927. [PMID: 30680429 PMCID: PMC6499657 DOI: 10.1007/s00198-019-04847-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/06/2019] [Indexed: 11/28/2022]
Abstract
UNLABELLED Intervals between dual-energy X-ray absorptiometry (DXA) scans were evaluated in a large cohort of typical clinical practice. Intensive DXA scanning (intervals < 23 months) decreased substantially, from 16.7% in 2006 to 6.7% in 2015. INTRODUCTION Serial dual-energy X-ray absorptiometry (DXA) measurements are suggested for patients at high risk of fractures. However, little is known about how often DXA testing occurs in clinical practice. METHODS We examined time intervals between DXA testing for monitoring purpose at two academic medical centers in the US between 2004 and 2017. The primary outcome was the presence of testing intervals < 23 months (termed "intensive DXA testing"). A generalized linear mixed model was used to evaluate the association between selected patient-level clinical factors and intensive DXA testing. RESULTS Forty-nine thousand four hundred ninety-four DXA tests from 20,200 patients were analyzed. The mean time interval between scans was 36 ± 21 months. Only 11.1% of the repeated DXA testing met the criterion for intensive testing. The percentage of intensive DXA testing dropped from 16.7% in 2006 to 6.7% in 2015 (p for trend < 0.001). After adjusting for age, gender, number of outpatient visits, and calendar year, correlates of intensive DXA testing included a baseline T-score < -2.5 at any anatomic site (OR, 4.8; 95%CI, 4.0-5.7), active use of drugs for osteoporosis (OR, 1.6; 95%CI, 1.3-1.9), and active use of glucocorticoids (OR, 1.3; 95%CI, 1.2-1.4). CONCLUSIONS The predictors of intensive DXA testing suggest that this practice is used preferentially in patients with multiple risk factors and to monitor the response to pharmacotherapy. However, intensive DXA testing has become less common in real-world clinical practice over the last decade. Further studies are required to better define the optimal use of bone mineral density testing in this vulnerable population.
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Affiliation(s)
- H Lyu
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - K Yoshida
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - S K Tedeschi
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - S Zhao
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - C Xu
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - S U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - B Z Leder
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Yeomans ND, Graham DY, Husni ME, Solomon DH, Stevens T, Vargo J, Wang Q, Wisniewski LM, Wolski KE, Borer JS, Libby P, Lincoff AM, Lüscher TF, Bao W, Walker C, Nissen SE. Randomised clinical trial: gastrointestinal events in arthritis patients treated with celecoxib, ibuprofen or naproxen in the PRECISION trial. Aliment Pharmacol Ther 2018; 47:1453-1463. [PMID: 29667211 DOI: 10.1111/apt.14610] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/09/2017] [Accepted: 02/21/2018] [Indexed: 12/18/2022]
Abstract
AIM To evaluate GI safety of celecoxib compared with 2 nonselective (ns) NSAIDs, as a secondary objective of a large trial examining multiorgan safety. METHODS This randomised, double-blind controlled trial analysed 24 081 patients. Osteoarthritis or rheumatoid arthritis patients, needing ongoing NSAID treatment, were randomised to receive celecoxib 100-200 mg b.d., ibuprofen 600-800 mg t.d.s. or naproxen 375-500 mg b.d. plus esomeprazole, and low-dose aspirin or corticosteroids if already prescribed. Clinically significant GI events (CSGIE-bleeding, obstruction, perforation events from stomach downwards or symptomatic ulcers) and iron deficiency anaemia (IDA) were adjudicated blindly. RESULTS Mean treatment and follow-up durations were 20.3 and 34.1 months. While on treatment or 30 days after, CSGIE occurred in 0.34%, 0.74% and 0.66% taking celecoxib, ibuprofen and naproxen. Hazard ratios (HR) were 0.43 (95% CI 0.27-0.68, P = 0.0003) celecoxib vs ibuprofen and 0.51 (0.32-0.81, P = 0.004) vs naproxen. There was also less IDA on celecoxib: HR 0.43 (0.27-0.68, P = 0.0003) vs ibuprofen; 0.40 (0.25-0.62, P < 0.0001) vs naproxen. Even taken with low-dose aspirin, fewer CSGIE occurred on celecoxib than ibuprofen (HR 0.52 [0.29-0.94], P = 0.03), and less IDA vs naproxen (0.42 [0.23-0.77, P = 0.005]). Corticosteroid use increased total GI events and CSGIE. H. pylori serological status had no influence. CONCLUSIONS Arthritis patients taking NSAIDs plus esomeprazole have infrequent clinically significant gastrointestinal events. Co-prescribed with esomeprazole, celecoxib has better overall GI safety than ibuprofen or naproxen at these doses, despite treatment with low-dose aspirin or corticosteroids.
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Affiliation(s)
- N D Yeomans
- Department of Medicine, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Western Sydney University, Campbelltown, NSW, Australia
| | - D Y Graham
- Baylor College of Medicine, Veterans Affairs Medical Center, Houston, TX, USA
| | - M E Husni
- Cleveland Clinic, Cleveland, OH, USA
| | - D H Solomon
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - T Stevens
- Cleveland Clinic, Cleveland, OH, USA
| | - J Vargo
- Cleveland Clinic, Cleveland, OH, USA
| | - Q Wang
- Cleveland Clinic, Cleveland, OH, USA
| | | | | | - J S Borer
- Downstate College of Medicine, State University of New York, New York, NY, USA
| | - P Libby
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - T F Lüscher
- Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - W Bao
- Pfizer, New York, NY, USA
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Ruppert K, Cauley J, Lian Y, Zgibor JC, Derby C, Solomon DH. The effect of insulin on bone mineral density among women with type 2 diabetes: a SWAN Pharmacoepidemiology study. Osteoporos Int 2018; 29:347-354. [PMID: 29075805 PMCID: PMC5818624 DOI: 10.1007/s00198-017-4276-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/13/2017] [Indexed: 12/12/2022]
Abstract
UNLABELLED This was a longitudinal study examining the effects of insulin use on bone mineral density loss. Insulin use was found to be associated with greater bone mineral density loss at the femoral neck among women with diabetes mellitus. INTRODUCTION Women with diabetes mellitus (DM) have higher bone mineral density (BMD) and experience slower BMD loss but have an increased risk of fracture. The data regarding the effect of insulin treatment on BMD remains conflicted. We examined the impact of insulin initiation on BMD. METHODS We investigated the annual changes in BMD associated with the new use of insulin among women with DM in the Study of Women's Health Across the Nation (SWAN). Propensity score (PS) matching, which is a statistical method that helps balance the baseline characteristics of women who did and did not initiate insulin, was used. Covariates with a potential impact on bone health were included in all models. Mixed model regression was used to test the change in BMD between the two groups. Median follow-up time was 5.4 years. RESULTS The cohort consisted of 110 women, mean age, 53.6 years; 49% white and 51% black. Women using insulin (n = 55) were similar on most relevant characteristics to the 55 not using insulin. Median diabetes duration for the user group was 10 vs. 5.0 years for the non-user group. There was a greater loss of BMD at the femoral neck among insulin users (- 1.1%) vs non-users (- 0.77%) (p = 0.04). There were no differences in BMD loss at the spine - 0.30% vs - 0.32% (p = 0.85) or at the total hip - 0.31% vs - 0.25 (p = 0.71), respectively. CONCLUSIONS Women with T2DM who initiated insulin experienced a more rapid BMD loss at the femoral neck as compared to women who did use insulin.
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Affiliation(s)
- K Ruppert
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 4420 Bayard St Suite 600, Pittsburgh, PA, 15260, USA.
| | - J Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 4420 Bayard St Suite 600, Pittsburgh, PA, 15260, USA
| | - Y Lian
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 4420 Bayard St Suite 600, Pittsburgh, PA, 15260, USA
| | - J C Zgibor
- Department of Epidemiology and Biostatistics, University of South Florida, Tampa, FL, USA
| | - C Derby
- Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
| | - D H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Solomon DH, Kay J, Duryea J, Lu B, Bolster MB, Yood RA, Han R, Ball S, Coleman C, Lo E, Wohlfahrt A, Sury M, Yin M, Yu Z, Zak A, Gravallese EM. Effects of Teriparatide on Joint Erosions in Rheumatoid Arthritis: A Randomized Controlled Trial. Arthritis Rheumatol 2017; 69:1741-1750. [PMID: 28544807 DOI: 10.1002/art.40156] [Citation(s) in RCA: 25] [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: 01/23/2017] [Accepted: 05/16/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Articular erosions correlate with disability in rheumatoid arthritis (RA). Biologic agents reduce erosion progression in RA, but erosion healing occurs infrequently. This study was undertaken to assess the effects of the anabolic agent teriparatide on joint erosion volume in RA patients treated with a tumor necrosis factor inhibitor (TNFi). METHODS We conducted a randomized controlled trial in 24 patients with erosive RA, osteopenia, and disease activity controlled by TNFi treatment for at least 3 months. Half were randomized to receive teriparatide for 1 year and the others constituted a wait-list control group. Subjects and primary rheumatologists were not blinded with regard to treatment assignment, but all outcomes were assessed in a blinded manner. The primary outcome measure was change in erosion volume determined by computed tomography at 6 anatomic sites. Significance within each hand and anatomic site was based on a 2-tailed test, with P values less than 0.05 considered significant. RESULTS Baseline characteristics of the treatment groups were well balanced. After 52 weeks, the median change in erosion volume in the teriparatide group was -0.4 mm3 (interquartile range [IQR] -34.5, 29.6) and did not differ significantly from that in controls (median change +9.1 mm3 [IQR -29.6, 26.4]) (P = 0.28). No significant difference in change in erosion volume was noted at the radius, ulna, or metacarpophalangeal joints. Bone mineral density improved at the femoral neck and lumbar spine in the teriparatide group. CONCLUSION Our findings indicate that teriparatide treatment for 1 year does not significantly reduce erosion volume in the hands or wrists of patients with established RA with disease activity controlled by TNFi treatment.
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Affiliation(s)
- D H Solomon
- Brigham and Women's Hospital, Boston, Massachusetts
| | - J Kay
- University of Massachusetts Memorial Medical Center, Worcester
| | - J Duryea
- Brigham and Women's Hospital, Boston, Massachusetts
| | - B Lu
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - R A Yood
- Reliant Medical Group, Worcester, Massachusetts
| | - R Han
- Brigham and Women's Hospital, Boston, Massachusetts
| | - S Ball
- University of Massachusetts Memorial Medical Center, Worcester
| | - C Coleman
- Brigham and Women's Hospital, Boston, Massachusetts
| | - E Lo
- Brigham and Women's Hospital, Boston, Massachusetts
| | - A Wohlfahrt
- Brigham and Women's Hospital, Boston, Massachusetts
| | - M Sury
- Brigham and Women's Hospital, Boston, Massachusetts
| | - M Yin
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Z Yu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - A Zak
- Brigham and Women's Hospital, Boston, Massachusetts
| | - E M Gravallese
- University of Massachusetts Memorial Medical Center, Worcester
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Gedmintas L, Wright EA, Dong Y, Lehmann E, Katz JN, Solomon DH, Losina E. Factors associated with fractures in HIV-infected persons: which factors matter? Osteoporos Int 2017; 28:239-244. [PMID: 27421978 PMCID: PMC5480613 DOI: 10.1007/s00198-016-3704-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED This study aims to determine what factors are associated with increased risk of fracture among patients with HIV, in particular whether an important medication used to treat HIV, tenofovir, is associated with fracture. Our study found that while co-infection with hepatitis C and markers of HIV severity were associated with fracture, tenofovir was not. INTRODUCTION Growing evidence suggests that tenofovir disoproxil fumarate decreases bone density among patients with HIV, but there are conflicting reports as to whether this decrease in bone density translates to higher fracture risk. We aimed to determine what factors were associated with an increased risk of fracture for patients with HIV, in particular whether tenofovir is associated with elevated fracture risk. METHODS We conducted a retrospective cohort study at two tertiary care hospitals in Boston, MA, between 2001 and 2012 to determine whether tenofovir use is associated with elevated all-site fracture risk, as compared to other antiretroviral medications. We also examined other potential factors associated with fracture among patients with HIV. RESULTS We identified 1981 HIV-infected patients who had at some point used tenofovir and 682 patients who had not. The mean age was 43 years, and 72 % were male. The hepatitis C co-infection rate was 28 %, about 40 % had nadir CD4 count <200, and about 40 % had a history of an AIDS-defining illness. We did not find an association between risk of fracture and tenofovir disoproxil fumarate (TDF) (adjusted RR (aRR) 0.8, 95 % CI 0.6-1.1). However, co-infection with hepatitis C did increase risk of fracture (aRR 1.6, 95 % CI 1.1-2.3), as did nadir CD4 count <200 (aRR 3.1, 95 % CI 1.9-5.0) and history of AIDS-defining illness (aRR 1.6, 95 % CI 1.1-2.2). CONCLUSION There was no association found between fracture and tenofovir use, but there were associations between co-infection with hepatitis C and markers of advanced HIV disease and fracture.
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Affiliation(s)
- L Gedmintas
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E A Wright
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Harvard School of Public Health, Boston, MA, USA
| | - Y Dong
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
| | - E Lehmann
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - J N Katz
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Harvard School of Public Health, Boston, MA, USA
| | - D H Solomon
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, MA, USA
| | - E Losina
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Feldman CH, Liu J, Feldman S, Solomon DH, Kim SC. Risk of high-grade cervical dysplasia and cervical cancer in women with systemic lupus erythematosus receiving immunosuppressive drugs. Lupus 2016; 26:682-689. [PMID: 27799438 DOI: 10.1177/0961203316672928] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Prior studies suggest an increased risk of cervical cancer among women with systemic lupus erythematosus. However, the relationship with immunosuppressive drugs is not well studied in US nationwide cohorts. We compared the risk of high-grade cervical dysplasia and cervical cancer among women with systemic lupus erythematosus who started immunosuppressive drugs versus hydroxychloroquine. Methods We identified systemic lupus erythematosus patients initiating immunosuppressive drugs or hydroxychloroquine using claims data from two US commercial health plans and Medicaid (2000-2012). We used a validated claims-based algorithm to identify high-grade cervical dysplasia or cervical cancer. To account for potential confounders, including demographic factors, comorbidities, medication use, HPV vaccination status, and health care utilization, immunosuppressive drugs and hydroxychloroquine initiators were 1:1 matched on the propensity score. We used inverse variance-weighted, fixed effect models to pool hazard ratios from the propensity score-matched Medicaid and commercial cohorts. Results We included 2451 matched pairs of immunosuppressive drugs and hydroxychloroquine new users in the commercial cohort and 7690 matched pairs in Medicaid. In the commercial cohort, there were 14 cases of cervical dysplasia or cervical cancer among immunosuppressive drugs users and five cases among hydroxychloroquine users (hazard ratio 2.47, 95% CI 0.89-6.85, hydroxychloroquine = ref). In Medicaid, there were 46 cases among immunosuppressive drugs users and 29 cases in hydroxychloroquine users (hazard ratio 1.24, 95% CI 0.78-1.98, hydroxychloroquine = ref). The pooled hazard ratio of immunosuppressive drugs was 1.40 (95% CI 0.92-2.12). Conclusion Among women with systemic lupus erythematosus, immunosuppressive drugs may be associated with a greater, albeit not statistically significant, risk of high-grade cervical dysplasia and cervical cancer compared to patients receiving hydroxychloroquine alone.
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Affiliation(s)
- C H Feldman
- 1 Brigham and Women's Hospital, Division of Rheumatology, Immunology and Allergy, Boston, USA
| | - J Liu
- 2 Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, USA
| | - S Feldman
- 3 Brigham and Women's Hospital, Department of Obstetrics, Gynecology and Reproductive Biology, Boston, USA
| | - D H Solomon
- 1 Brigham and Women's Hospital, Division of Rheumatology, Immunology and Allergy, Boston, USA.,2 Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, USA
| | - S C Kim
- 1 Brigham and Women's Hospital, Division of Rheumatology, Immunology and Allergy, Boston, USA.,2 Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, USA
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Solomon DH, Greenberg J, Kremer JM, Etzel CJ. Reply. Arthritis Rheumatol 2015; 67:3327-8. [DOI: 10.1002/art.39413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/25/2015] [Indexed: 11/10/2022]
Affiliation(s)
| | - J. Greenberg
- Albany Medical Center, and Center for Rheumatology; Albany NY
- Consortium of Rheumatology Researchers of North America; Southborough MA
| | - J. M. Kremer
- Albany Medical Center, and Center for Rheumatology; Albany NY
- Consortium of Rheumatology Researchers of North America; Southborough MA
| | - C. J. Etzel
- Consortium of Rheumatology Researchers of North America; Southborough MA
- University of Texas MD Anderson Cancer Center; Houston TX
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Solomon DH, Reed GW, Kremer JM, Curtis JR, Farkouh ME, Harrold LR, Hochberg MC, Tsao P, Greenberg JD. Disease activity in rheumatoid arthritis and the risk of cardiovascular events. Arthritis Rheumatol 2015; 67:1449-55. [PMID: 25776112 DOI: 10.1002/art.39098] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/26/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Use of several immunomodulatory agents has been associated with reduced numbers of cardiovascular (CV) events in epidemiologic studies of rheumatoid arthritis (RA). However, it is unknown whether time-averaged disease activity in RA correlates with CV events. METHODS We studied patients with RA whose cases were followed in a longitudinal US-based registry. Time-averaged disease activity was assessed during followup using the area under the curve of the Clinical Disease Activity Index (CDAI), a validated measure of RA disease activity. Age, sex, presence of diabetes mellitus, hypertension, or hyperlipidemia, body mass index, family history of myocardial infarction (MI), use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), presence of CV disease, and baseline use of an immunomodulator were assessed at baseline. Cox proportional hazards regression models were examined to determine the risk of a composite CV end point that included MI, stroke, and death from CV causes. RESULTS A total of 24,989 patients who had been followed up for a median of 2.7 years were included in these analyses. During followup, we observed 534 confirmed CV end points, for an incidence rate of 7.8 per 1,000 person-years (95% confidence interval [95% CI] 6.7-8.9). In models adjusted for variables noted above, a 10-point reduction in the time-averaged CDAI was associated with a 21% reduction in CV risk (95% CI 13-29). These results were robust in subgroup analyses stratified by the presence of CV disease, use of corticosteroids, use of NSAIDs or selective cyclooxygenase 2 inhibitors, and change in RA treatment, as well as when restricted to events adjudicated as definite or probable. CONCLUSION Our findings showed that reduced time-averaged disease activity in RA is associated with fewer CV events.
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Affiliation(s)
- D H Solomon
- Brigham and Women's Hospital, Boston, Massachusetts
| | - G W Reed
- University of Massachusetts Medical School, Worcester and the Consortium of Rheumatology Researchers of North America (CORRONA), Southborough, Massachusetts
| | - J M Kremer
- Albany Medical College and Center for Rheumatology, Albany, New York and CORRONA, Southborough, Massachusetts
| | | | - M E Farkouh
- Mount Sinai School of Medicine, New York, New York
| | - L R Harrold
- University of Massachusetts Medical School, Worcester and the Consortium of Rheumatology Researchers of North America (CORRONA), Southborough, Massachusetts
| | - M C Hochberg
- University of Maryland School of Medicine, Baltimore
| | - P Tsao
- Brigham and Women's Hospital, Boston, Massachusetts
| | - J D Greenberg
- New York University School of Medicine and New York University Hospital for Joint Diseases, New York, New York, and CORRONA, Southborough, Massachusetts
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Solomon DH, Greenberg J, Curtis JR, Liu M, Farkouh ME, Tsao P, Kremer JM, Etzel CJ. Derivation and Internal Validation of an Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis: A Consortium of Rheumatology Researchers of North America Registry Study. Arthritis Rheumatol 2015; 67:1995-2003. [DOI: 10.1002/art.39195] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/12/2015] [Indexed: 12/19/2022]
Affiliation(s)
| | - J. Greenberg
- New York University School of Medicine and New York University Hospital for Joint Diseases, New York, New York, and CORRONA; Southborough Massachusetts
| | | | - M. Liu
- CORRONA; Southborough Massachusetts
| | - M. E. Farkouh
- Mount Sinai School of Medicine, New York, New York, and University of Toronto; Toronto Ontario Canada
| | - P. Tsao
- Brigham and Women's Hospital; Boston Massachusetts
| | - J. M. Kremer
- Albany Medical College and Center for Rheumatology, Albany, New York, and CORRONA; Southborough Massachusetts
| | - C. J. Etzel
- University of Texas MD Anderson Cancer Center, Houston, and CORRONA; Southborough Massachusetts
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Solomon DH, Brown EM, Chandler D, Bower A, Barron R, Mogun H, Franklin JM. Patterns of treatment among a cohort of older low-income adults starting new medications for osteoporosis. Osteoporos Int 2014; 25:2255-62. [PMID: 24899104 DOI: 10.1007/s00198-014-2757-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/20/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED Among 125,954 new users of osteoporosis (OP) medications, 77 % of subjects stopped OP medications, and 23 % of subjects added or started a new OP medication during follow-up, with the first addition or start of a new OP medication occurring in a mean of 739 days after original OP treatment. INTRODUCTION We described patterns and predictors of OP medication use, focusing on treatment changes over time. METHODS We analyzed health and pharmacy insurance claims for a large cohort of low-income Medicare beneficiaries with a drug benefit for the years 1998-2008. Study subjects had documented Medicare claims and no receipt of OP medications (i.e., bisphosphonate, raloxifene, calcitonin, teriparatide, or hormonal therapy) during a baseline of 180 days. Subjects were then required to start an OP medication. Baseline patient and prescriber characteristics were assessed in multivariable Cox regression models to identify correlates of adding or starting a new OP medication. Fractures, bone mineral density testing, and visits with endocrinologists or rheumatologists occurring after baseline were also examined as correlates. RESULTS We included 125,954 new users of OP medications with a mean age of 78 years, 97 % female, and 92 % white. OP medication prescribers included specialists (i.e., endocrinologists or rheumatologists) (6.2 %), orthopedic surgeons (1.0 %), primary care providers (64.9 %), other physicians (3.7 %), and missing (24.1 %). Seventy-seven percent of subjects stopped OP medications, and 23 % of subjects added or started a new OP medication during follow-up, with the first addition or start of a new OP medication occurring in a mean of 739 days after original OP treatment; 4 % added or started a new OP medication more than once. In fully adjusted models, many baseline variables correlated with starting a second OP medication. Post-baseline fractures [hazard ratio (HR) 1.76, 95 % confidence interval (CI) 1.71-1.82] and bone mineral density testing (HR 2.94, 95 % CI 2.86-3.03) were strong predictors. CONCLUSION Approximately one quarter of patients starting an OP medication added or started a new OP medication during follow-up. Long-term sequential treatment strategy trials would inform optimal medication treatment for OP.
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Affiliation(s)
- D H Solomon
- Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA,
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13
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Losina E, Burbine SA, Suter LG, Hunter DJ, Solomon DH, Daigle ME, Dervan EE, Jordan JM, Katz JN. Pharmacologic regimens for knee osteoarthritis prevention: can they be cost-effective? Osteoarthritis Cartilage 2014; 22:415-30. [PMID: 24487044 PMCID: PMC4006219 DOI: 10.1016/j.joca.2014.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/20/2013] [Accepted: 01/17/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We sought to determine the target populations and drug efficacy, toxicity, cost, and initiation age thresholds under which a pharmacologic regimen for knee osteoarthritis (OA) prevention could be cost-effective. DESIGN We used the Osteoarthritis Policy (OAPol) Model, a validated state-transition simulation model of knee OA, to evaluate the cost-effectiveness of using disease-modifying OA drugs (DMOADs) as prophylaxis for the disease. We assessed four cohorts at varying risk for developing OA: (1) no risk factors, (2) obese, (3) history of knee injury, and (4) high-risk (obese with history of knee injury). The base case DMOAD was initiated at age 50 with 40% efficacy in the first year, 5% failure per subsequent year, 0.22% major toxicity, and annual cost of $1,000. Outcomes included costs, quality-adjusted life expectancy (QALE), and incremental cost-effectiveness ratios (ICERs). Key parameters were varied in sensitivity analyses. RESULTS For the high-risk cohort, base case prophylaxis increased quality-adjusted life-years (QALYs) by 0.04 and lifetime costs by $4,600, and produced an ICER of $118,000 per QALY gained. ICERs >$150,000/QALY were observed when comparing the base case DMOAD to the standard of care in the knee injury only cohort; for the obese only and no risk factors cohorts, the base case DMOAD was less cost-effective than the standard of care. Regimens priced at $3,000 per year and higher demonstrated ICERs above cost-effectiveness thresholds consistent with current US standards. CONCLUSIONS The cost-effectiveness of DMOADs for OA prevention for persons at high risk for incident OA may be comparable to other accepted preventive therapies.
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Affiliation(s)
- E Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Boston University School of Public Health, Boston, MA, USA.
| | - S A Burbine
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - L G Suter
- Yale University, New Haven, CT, USA.
| | - D J Hunter
- University of Sydney and Royal North Shore Hospital, Sydney, Australia.
| | - D H Solomon
- Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - M E Daigle
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - E E Dervan
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - J M Jordan
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA.
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Lillegraven S, Greenberg JD, Reed GW, Saunders K, Curtis JR, Harrold L, Hochberg MC, Pappas D, Kremer JM, Solomon DH. OP0161 Use of TNF Inhibitors is Associated with a Reduced Risk of Diabetes in RA Patients. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2013-eular.366] [Citation(s) in RCA: 2] [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: 11/04/2022]
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Mercer E, Norton T, Woo S, Treister N, Dodson TB, Solomon DH. Ninety-one osteoporosis patients affected with bisphosphonate-related osteonecrosis of the jaw: a case series. Calcif Tissue Int 2013; 93:241-8. [PMID: 23756612 PMCID: PMC3744621 DOI: 10.1007/s00223-013-9747-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/19/2013] [Indexed: 11/26/2022]
Abstract
Bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ) presents with necrotic bone in the mouth in the setting of BP exposure. It has been studied in cancer patients taking high-dose BP, but BRONJ has also been noted in patients taking lower-dose BP for osteoporosis. The purpose of this study was to characterize the phenotypes and outcomes in a large series of patients with osteoporosis and BRONJ in the setting of BP exposure. We conducted a retrospective case series. The sample was composed of subjects with BRONJ and osteoporosis. Subjects with a history of BP treatment for myeloma or metastatic cancer to the bones were excluded. Descriptive statistics were computed for the study variables. Ninety-one cases of BRONJ met the inclusion criteria. Subjects had a median age of 71 years and were predominantly female (94.5 %). The median time of BP exposure was 60 months (range 2-120). Most subjects were treated with alendronate (82.4 %). The mandible was involved more frequently (58.2 %) than the maxilla (37.3 %). Subjects commonly (65.9 %), but not universally, reported pain. For subjects with treatment outcome data (n = 0), most reported improvement (80.0 %). Although BRONJ is an uncommon condition, the absolute number of cases is fairly large due to the very large number of patients taking BPs for osteoporosis. The findings of this study confirm that BRONJ primarily affects the mandible, a substantial minority present without pain, and patients typically improve with treatment.
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Affiliation(s)
- E Mercer
- Division of Rheumatology, Brigham and Women's Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA
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Pappas DA, John A, Kremer J, Reed G, Greenberg J, Shewade A, Solomon DH, Curtis JR. OP0005 Effect of Biologic Agents on Lipids and Cardiovascular Risk in Rheumatoid Arthritis Patients. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.210] [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: 11/03/2022]
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17
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Sung YK, Yoshida K, Prince FH, Frits ML, Choe JY, Lee HS, Lee J, Lee S, Yoo DH, Helfgott SM, Shadick NA, Weinblatt ME, Bae SC, Solomon DH. SAT0040 Prevalence and Predictors for Sustained Remission in Rheumatoid Arthritis. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1766] [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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18
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Najm MS, Solomon DH, Woo SB, Treister NS. Resource utilization in cancer patients with bisphosphonate-associated osteonecrosis of the jaw. Oral Dis 2013; 20:94-9. [PMID: 23419136 DOI: 10.1111/odi.12080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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: 11/01/2012] [Revised: 01/18/2013] [Accepted: 01/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Bisphosphonate-associated osteonecrosis of the jaw (BONJ) is an emerging oral complication that occurs most commonly in the setting of high-dose bisphosphonate therapy for cancer. The purpose of this study was to estimate the health care-related costs associated with a diagnosis of BONJ in patients with cancer evaluated and managed at one tertiary oral medicine practice. METHODS This was a retrospective electronic medical record review of cancer patients with BONJ. All health care-related resources were abstracted using a structured chart abstraction tool; data captured included medications, imaging studies, laboratory investigations, procedures, and visits. Standardized references were used to assign costs in 2010 US dollars. RESULTS Ninety-two cancer patients with BONJ were identified who were followed for a median of 12 months. The median cost of a case of BONJ was $1667 (interquartile range from $976 to $3350). Medication costs comprised the majority (42%) of the total costs, followed by procedural interventions (22%), clinic visits (19.5%), and imaging studies (13.8%). Patient factors associated with higher median costs included a greater number of involved oral quadrants and more advanced BONJ stage. CONCLUSION There are considerable costs associated with the diagnosis and management of BONJ in patients with cancer, with medications accounting for nearly half of resource expenditures.
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Affiliation(s)
- M S Najm
- Division of Oral Medicine, College of Dentistry, Al-Mustansiriya University, Baghdad, Iraq
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19
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Solomon DH, Mercer E, Woo SB, Avorn J, Schneeweiss S, Treister N. Defining the epidemiology of bisphosphonate-associated osteonecrosis of the jaw: prior work and current challenges. Osteoporos Int 2013; 24:237-44. [PMID: 22707065 DOI: 10.1007/s00198-012-2042-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Bisphosphonate-related osteonecrosis of the jaw (BONJ) is an adverse effect of bisphosphonate use with a poorly described epidemiology in osteoporosis patients. We examined the literature and two new cohorts for BONJ. The literature suggests an incidence rate of 0.028 % to 4.3 %. Our cohort studies found an incidence of 0.02 % (95 % CI 0.004 %-0.11 %). INTRODUCTION We examined the epidemiology of BONJ associated with osteoporosis dosing of bisphosphonates. METHODS First, we systematically searched the literature about osteoporosis BONJ. Identified studies were abstracted by two authors. Second, we attempted to estimate the relative risk of BONJ among bisphosphonate users with osteoporosis. Two different large insurance databases, one from 2005-2007 and another from 2007-2010, combined with medical record review, were searched. The older dataset did not include the International Classification of Diagnoses (ICD) diagnosis code for osteonecrosis of the jaw (ONJ; ICD 733.45). Incidence rates and relative risks were estimated using Cox regression. RESULTS The literature review produced nine studies of varying quality. The incidence rates for BONJ among osteoporosis patients varied from 0.028 % to 4.3 %. Two prior studies estimated the relative risk of ONJ related to bisphosphonates and found odds ratios of 7.2 and 9.2. Our attempts to estimate the incidence rate of BONJ encompassed 41,957 in the dataset from 2005-2007 and 466,645 in a separate dataset from 2007-2010. From the older dataset, we found 51 potential cases of BONJ using a broad definition of possible ONJ. One case was confirmed by a dentist for a prevalence of 0.02 % (95 % CI 0.004 %-0.11 %) among bisphosphonate users. From the newer dataset, we found 13 possible cases, but none could be confirmed. Most subjects with the ONJ diagnosis code appeared to have had an osteoporosis-related fracture and not ONJ. CONCLUSIONS The literature suggests a broad range of possible values for the prevalence of BONJ; our estimate fell within the range from prior literature.
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Affiliation(s)
- D H Solomon
- Division of Pharmacoepidemiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
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Burden AM, Paterson JM, Solomon DH, Mamdani M, Juurlink DN, Cadarette SM. Bisphosphonate prescribing, persistence and cumulative exposure in Ontario, Canada. Osteoporos Int 2012; 23:1075-82. [PMID: 21604008 PMCID: PMC3277689 DOI: 10.1007/s00198-011-1645-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 03/15/2011] [Indexed: 11/02/2022]
Abstract
UNLABELLED We studied new users of oral bisphosphonates and found that less than half persisted with therapy for 2 years, and interruptions in use were common. During a median observation period of 4.7 years, 10% of patients filled only a single prescription, 37% switched therapies and median cumulative exposure was 2.2 years. INTRODUCTION We sought to describe bisphosphonate prescribing, persistence and cumulative exposure among seniors in Ontario, Canada. METHODS We used Ontario Drug Benefit pharmacy claims to identify residents aged ≥ 66 years who initiated oral bisphosphonate therapy between April 1996 and March 2009. The first date of bisphosphonate dispensing was considered the index date. Persistence with therapy was defined as continuous treatment with no interruption exceeding 60 days. We examined persistence with therapy and the number of extended gaps (>60 days) between prescriptions over time periods ranging from 1 to 9 years. We also identified the proportion of patients filling only a single prescription and switching to a different bisphosphonate, and calculated the median days of exposure irrespective of gaps in therapy. RESULTS A total of 451,113 eligible new bisphosphonate users were identified: mean age = 75.6 years (SD = 6.9), 84% female, and median follow-up length = 4.7 years. Persistence with therapy declined from 63% at 1 year to 46% at 2 years and 12% at 9 years. Among those with at least 5 years of follow-up (n = 213,029), 61% had one or more extended gaps in bisphosphonate therapy. Overall, 10% of patients filled only a single prescription, 37% switched to a different bisphosphonate and the median exposure was 2.2 years. CONCLUSION Less than half of patients persisted with bisphosphonate therapy for 2 years and interruptions in therapy were common, with most patients experiencing two or more >60-day gaps in therapy. Interventions are needed to improve persistence with bisphosphonate therapy and reduce the frequency of gaps in treatment.
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Affiliation(s)
- A. M. Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
| | - J. M. Paterson
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Department of Family Medicine, McMaster University, Hamilton, ON Canada
- Centre for Evaluation of Medicines, St. Joseph’s Healthcare, Hamilton, ON Canada
| | - D. H. Solomon
- Division of Rheumatology, Immunology and Allergy and Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - M. Mamdani
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON Canada
| | | | - S. M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
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Solomon DH, Mercer E, Kavanaugh A. Observational studies on the risk of cancer associated with tumor necrosis factor inhibitors in rheumatoid arthritis: a review of their methodologies and results. ACTA ACUST UNITED AC 2012; 64:21-32. [PMID: 21898354 DOI: 10.1002/art.30653] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- D H Solomon
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Patel AM, Amity CL, Frydrych LM, Jones DM, Goudeau D, Eng HF, Kyle D, Saul M, Solomon DH, Wisniewski SR, Moreland LW, Levesque MC. Does ACR/EULAR remission mean improved functional ability, quality of life and work productivity?: Table 1. Ann Rheum Dis 2012. [DOI: 10.1136/annrheumdis-2011-201230.36] [Citation(s) in RCA: 1] [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: 11/04/2022]
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Solomon DH. Postfracture interventions disseminated through health care and drug insurers: attempting to integrate fragmented health care delivery. Osteoporos Int 2011; 22 Suppl 3:465-9. [PMID: 21847767 DOI: 10.1007/s00198-011-1698-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 06/17/2011] [Indexed: 10/17/2022]
Abstract
Osteoporosis care after a fracture is often suboptimal. Suboptimal treatment seems to be most common in fragmented health care systems. We examined the literature to assess possible causes for suboptimal postfracture osteoporosis care within fragmented health care systems. The review of the literature did not attempt to meta-analyze prior studies. We found several possible methods for improving postfracture osteoporosis care in a fragmented health care system. These include changes in health care financing, application of information technology, incorporation of case management, the use of system champions, and dissemination of performance measures. The strengths and weaknesses of each of these potential levers for improvement were explored. Postfracture osteoporosis care is sub-optimal and challenging to improve in fragmented health care delivery systems.
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Affiliation(s)
- D H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA.
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Adler RA, Bates DW, Dell RM, LeBoff MS, Majumdar SR, Saag KG, Solomon DH, Suarez-Almazor ME. Systems-based approaches to osteoporosis and fracture care: policy and research recommendations from the workgroups. Osteoporos Int 2011; 22 Suppl 3:495-500. [PMID: 21847772 DOI: 10.1007/s00198-011-1708-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/22/2011] [Indexed: 10/17/2022]
Abstract
Participants in the conference selected to attend two different working group sessions. The working groups discussed different perspectives of system-based approaches to osteoporosis and fracture care. The group on postfracture case management recommended that nurse case managers be used to improve communication among patients, orthopaedic surgeons, and those providing ongoing clinical care. The hospital working group discussed the impact of and barriers to improved postfracture management in the hospital setting. The health systems group emphasized the difference between a closed system in which long-term benefits of interventions were more likely to be appreciated than in fee for service systems. The health information technology group discussed the advantages and challenges of electronic health records. The working group on consumer and provider education discussed interventions for both primary and secondary prevention of fractures. Recommendations were produced by most groups for improving postfracture care.
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Affiliation(s)
- R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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Cadarette SM, Solomon DH, Katz JN, Patrick AR, Brookhart MA. Adherence to osteoporosis drugs and fracture prevention: no evidence of healthy adherer bias in a frail cohort of seniors. Osteoporos Int 2011; 22:943-54. [PMID: 20532481 PMCID: PMC3277855 DOI: 10.1007/s00198-010-1309-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 05/03/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED We examined new users of osteoporosis drugs among seniors in Pennsylvania and found no evidence of healthy adherer bias on observed associations between adherence to treatment and non-vertebral fracture risk; we document fracture reduction with better adherence to bisphosphonates, yet no fracture reduction with better adherence to calcitonin or raloxifene. INTRODUCTION We examined the potential for "healthy adherer bias" when studying the effects of adherence to osteoporosis pharmacotherapy on fracture risk. Based on clinical trial evidence, bisphosphonates, calcitonin, and raloxifene reduce vertebral fracture risk; yet only bisphosphonates are documented to reduce non-vertebral fracture risk. METHODS This is a cohort study of older women in Pennsylvania who initiated osteoporosis drugs between 1995 and 2005. We included new users of bisphosphonates, calcitonin, and raloxifene. Adherence was categorized based on a measure of compliance as high [proportion of days covered (PDC) ≥ 80%], intermediate (50% < PDC < 80%), or low (PDC ≤ 50%) according to a 180-day ascertainment period. Non-vertebral fracture rates within 365 days after the ascertainment period were compared between adherence categories (reference = low) using Cox proportional hazard models and adjusting for fracture risk factors. Primary and secondary prevention cohorts were examined separately. Adherence to calcitonin and raloxifene were control analyses. RESULTS We found little difference in fracture rates between levels of adherence to calcitonin, bisphosphonates for primary prevention, or raloxifene for secondary prevention. We document lower fracture rates among high versus low adherent bisphosphonate users for secondary prevention (HR = 0.53, 95%CI = 0.38-0.74) and higher fracture rates among high versus low adherent raloxifene users for primary prevention (HR = 2.01, 95%CI = 1.04-3.87). CONCLUSIONS We document little evidence of healthy adherer bias when studying the association between better adherence to osteoporosis drugs and fracture risk reduction, with only better adherence to bisphosphonates reducing fracture risk. The higher fracture risk among highly adherent raloxifene users for primary prevention is likely due to residual confounding.
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Affiliation(s)
- S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada M5S3M2.
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Solomon DH, Gleeson T, Iversen M, Avorn J, Brookhart MA, Lii J, Losina E, May F, Patrick A, Shrank WH, Katz JN. A blinded randomized controlled trial of motivational interviewing to improve adherence with osteoporosis medications: design of the OPTIMA trial. Osteoporos Int 2010; 21:137-44. [PMID: 19436935 PMCID: PMC2922963 DOI: 10.1007/s00198-009-0951-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 03/27/2009] [Indexed: 01/17/2023]
Abstract
UNLABELLED We have designed an innovative randomized controlled trial for improving adherence with osteoporosis medications. Recruitment and randomization have been successful. Also, the counseling intervention has been well accepted by subjects randomized to this treatment arm. INTRODUCTION While many effective treatments exist for osteoporosis, most people do not adhere to such treatments long term. No proven interventions exist to improve osteoporosis medication adherence. We report here on the design and initial enrollment in an innovative randomized controlled trial aimed at improving adherence to osteoporosis treatments. METHODS The trial represents a collaboration between academic researchers and a state-run pharmacy benefits program for low-income older adults. Beneficiaries beginning treatment with a medication for osteoporosis are targeted for recruitment. We randomize consenting individuals to receive 12 months of mailed education (control arm) or an intervention consisting of one-on-one telephone-based counseling and the mailed education. Motivational interviewing forms the basis for the counseling program which is delivered by seven trained and supervised health counselors over ten telephone calls. The counseling sessions include scripted dialog and open-ended questions about medication adherence and its barriers, as well as structured questions. The primary end point of the trial is medication adherence measured over the 12-month intervention period. Secondary end points include fractures, nursing home admissions, health care resource utilization, and mortality. RESULTS During the first 7 months of recruitment, we have screened 3,638 potentially eligible subjects. After an initial mailing, 1,115 (30.6%) opted out of telephone recruitment and 1,019 (28.0%) could not be successfully contacted. Of the remaining, 879 (24.2%) consented to participate and were randomized. Women comprise over 90% of all groups; mean ages range from 77 to 80 years old, and the majority in all groups was white. The distribution of osteoporosis medications was comparable across groups and the median number of different prescription drugs used in the prior year was eight to ten. CONCLUSIONS We have developed a novel intervention for improving osteoporosis medication adherence. The intervention is currently being tested in a large-scale randomized controlled trial. If successful, the intervention may represent a useful model for improving adherence to other chronic treatments.
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Affiliation(s)
- D H Solomon
- Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Gleeson T, Iversen MD, Avorn J, Brookhart AM, Katz JN, Losina E, May F, Patrick AR, Shrank WH, Solomon DH. Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review. Osteoporos Int 2009; 20:2127-34. [PMID: 19499273 PMCID: PMC3257053 DOI: 10.1007/s00198-009-0976-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 04/02/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
Abstract
SUMMARY Adherence and persistence with osteoporosis medications are poor. We conducted a systematic literature review of interventions to improve adherence and persistence with osteoporosis medications. Seven studies met eligibility requirements and were included in the review. Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial. INTRODUCTION Adherence and persistence with pharmacologic therapy for osteoporosis are suboptimal. Our goal was to examine the design and efficacy of published interventions to improve adherence and persistence. METHODS We searched medical literature databases for English-language papers published between January 1990 and July 2008. We selected papers that described interventions and provided results for control and intervention subjects. We assessed the design and methods of each study, including randomization, blinding, and reporting of drop-outs. We summarized the results and calculated effect sizes for each trial. RESULTS Seven studies met eligibility requirements and were included in the review. Five of the seven studies provided adherence data. Of those five studies, three showed a statistically significant (p < or = 0.05) improvement in adherence by the intervention group, with effect sizes from 0.17 to 0.58. Five of the seven studies provided persistence data. Of those five, one reported statistically significant improvement in persistence by the intervention group, with an effect size of 0.36. CONCLUSIONS Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified in this small sample of studies. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.
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Affiliation(s)
- T. Gleeson
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA
| | - M. D. Iversen
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA. MGH Institute of Health Professions, Boston, MA, USA
| | - J. Avorn
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - A. M. Brookhart
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - J. N. Katz
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA. Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - E. Losina
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA. Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - F. May
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - A. R. Patrick
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - W. H. Shrank
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - D. H. Solomon
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA. Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Cadarette SM, Katz JN, Brookhart MA, Stürmer T, Stedman MR, Levin R, Solomon DH. Comparative gastrointestinal safety of weekly oral bisphosphonates. Osteoporos Int 2009; 20:1735-47. [PMID: 19266138 PMCID: PMC3257315 DOI: 10.1007/s00198-009-0871-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 01/09/2009] [Indexed: 01/11/2023]
Abstract
SUMMARY Weekly bisphosphonates are the primary agents used to treat osteoporosis. Although these agents are generally well tolerated, serious gastrointestinal adverse events, including hospitalization for gastrointestinal bleed, may arise. We compared the gastrointestinal safety between weekly alendronate and weekly risedronate and found no important difference between new users of these agents. INTRODUCTION Weekly bisphosphonates are the primary agents prescribed for osteoporosis. We examined the comparative gastrointestinal safety between weekly bisphosphonates. METHODS We studied new users of weekly alendronate and weekly risedronate from June 2002 to August 2005 among enrollees in a state-wide pharmaceutical benefit program for seniors. Our primary outcome was hospitalization for upper gastrointestinal bleed. Secondary outcomes included outpatient diagnoses for upper gastrointestinal disease, symptoms, endoscopic procedures, use of gastroprotective agents, and switching between therapies. We used Cox proportional hazard models to compare outcomes between agents within 120 days of treatment initiation, adjusting for propensity score quintiles. We also examined composite safety outcomes and stratified results by age and prior gastrointestinal history. RESULTS A total of 10,420 new users were studied, mean age = 79 years (SD, 6.9), and 95% women. We observed 31 hospitalizations for upper gastrointestinal bleed (0.91 per 100 person-years) within 120 days of treatment initiation. Adjusting for covariates, there was no difference in hospitalization for upper gastrointestinal bleed among those treated with risedronate compared with alendronate (HR, 1.12; 95%CI, 0.55 to 2.28). Risedronate switching rates were lower; otherwise, no differences were observed for secondary or composite outcomes. CONCLUSIONS We found no important difference in gastrointestinal safety between weekly oral bisphosphonates.
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Affiliation(s)
- S M Cadarette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Schneeweiss S, Korzenik J, Solomon DH, Canning C, Lee J, Bressler B. Infliximab and other immunomodulating drugs in patients with inflammatory bowel disease and the risk of serious bacterial infections. Aliment Pharmacol Ther 2009; 30:253-64. [PMID: 19438424 DOI: 10.1111/j.1365-2036.2009.04037.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [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: 12/12/2022]
Abstract
BACKGROUND There remain concerns about the safety of infliximab therapy in patients with inflammatory bowel disease (IBD). AIM To assess the association between the initiation of infliximab and other immunomodulating drugs and the risk of serious bacterial infection in the treatment of IBD. METHODS We assembled a cohort study of patients with IBD, including Crohn's disease (CD) and ulcerative colitis (UC). All patients initiating an immunomodulating drug between January 2001 and April 2006 were identified in British Columbia from linked health care utilization databases. Exposure of interest was initiation of infliximab or corticosteroids compared with initiation of other immunosuppressive agents, including azathioprine, mercaptopurine (MP) and methotrexate (MTX). Outcome of interest was serious bacterial infections requiring hospitalization, including Clostridium difficile. RESULTS Among 10 662 IBD patients, the incidence rate of bacteriaemia ranged from 3.8 per 1000 person-years (95% confidence interval 2.1-6.2) for other immunosuppressive agents to 7.4 (3.3-19.3) for infliximab with slightly higher rate for serious bacterial infections resulting in an adjusted relative risk 1.4 (0.47-4.24). Clostridium difficile infections occurred in 0/1000 (0-5.4) among 521 infliximab initiations and 14/1000 (10.6-18.2) for corticosteroids. Corticosteroid initiation tripled the risk of C. difficile infections (RR = 3.4; 1.9-6.1) compared with other immunosuppressant agents. This corticosteroid effect was neither dose-dependent nor duration-dependent. Bacteriaemia and other serious bacterial infections were not increased by corticosteroids or infliximab (5 events). CONCLUSIONS In a population-based cohort of patients with IBD, we found no meaningful association between infliximab and serious bacterial infections, although some subgroups had few events. Corticosteroid initiation increased the risk for C. difficile infections in these patients.
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Affiliation(s)
- S Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 021205, USA.
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Solomon DH, Hochberg MC, Mogun H, Schneeweiss S. The relation between bisphosphonate use and non-union of fractures of the humerus in older adults. Osteoporos Int 2009; 20:895-901. [PMID: 18843515 PMCID: PMC2886010 DOI: 10.1007/s00198-008-0759-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 08/18/2008] [Indexed: 10/21/2022]
Abstract
SUMMARY While nitrogen-containing bisphosphonates have been shown to reduce fracture risk in postmenopausal women and men, their safety in the period after a fracture is unclear. In fully adjusted multivariable regression models, bisphosphonate use in the post-fracture period was associated with an increased probability of non-union [odds ratio (OR) 2.37, 95% confidence interval (CI) 1.13-4.96]. Clinicians might consider waiting for several months before introduction of a bisphosphonate after a fracture. INTRODUCTION While nitrogen-containing bisphosphonates have been shown to reduce fracture risk in postmenopausal women and men, their safety in the period after a fracture is unclear. We examined the risk of non-union associated with post-fracture bisphosphonate use among a group of older adults who had experienced a humerus fracture. METHODS We conducted a nested case-control study among subjects who had experienced a humerus fracture. From this cohort, cases of non-union were defined as those with an orthopedic procedure related to non-union 91-365 days after the initial humerus fracture. Bisphosphonate exposure was assessed during the 365 days prior to the non-union among cases or the matched date for controls. Multivariable logistic regression models were examined to calculate the OR and 95% CI for the association of post-fracture bisphosphonate use with non-union. RESULTS From the cohort of 19,731 patients with humerus fractures, 81 (0.4%) experienced a non-union. Among the 81 cases, 13 (16.0%) were exposed to bisphosphonates post-fracture, while 69 of the 810 controls (8.5%) were exposed in the post-fracture interval. In fully adjusted multivariable regression models, bisphosphonate use in the post-fracture period was associated with an increased odds of non-union (OR 2.37, 95% CI 1.13-4.96). Albeit limited by small sample sizes, the increased risk associated with bisphosphonate use persisted in the subgroup of patients without a history of osteoporosis or prior fractures (OR 1.91, 95% CI 0.75-4.83). CONCLUSIONS In this study of older adults, non-union after a humerus fracture was rare. Bisphosphonate use after the fracture was associated with an approximate doubling of the risk of non-union.
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Affiliation(s)
- D H Solomon
- Division of Pharmacoepidemiology, Harvard Medical School, Boston, MA, USA.
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Agnew-Blais JC, Coblyn JS, Katz JN, Anderson RJ, Mehta J, Solomon DH. Measuring quality of care for rheumatic diseases using an electronic medical record. Ann Rheum Dis 2008; 68:680-4. [PMID: 18511547 DOI: 10.1136/ard.2008.089318] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The objective of this study was twofold: (1) to determine how best to measure adherence with time-dependent quality indicators (QIs) related to laboratory monitoring, and (2) to assess the accuracy and efficiency of gathering QI adherence information from an electronic medical record (EMR). METHODS A random sample of 100 patients were selected who had at least three visits with the diagnosis of rheumatoid arthritis (RA) at Brigham and Women's Hospital Arthritis Center in 2005. Using the EMR, it was determined whether patients had been prescribed a disease-modifying antirheumatic drug (DMARD) (QI #1) and if patients starting therapy received appropriate baseline laboratory testing (QI #2). For patients consistently prescribed a DMARD, adherence with follow-up testing (QI #3) was calculated using three different methods, the Calendar, Interval and Rolling Interval METHOD . RESULTS It was found that 97% of patients were prescribed a DMARD (QI #1) and baseline tests were completed in 50% of patients (QI #2). For follow-up testing (QI #3), mean adherence was 60% for the Calendar Method, 35% for the Interval Method, and 48% for the Rolling Interval Method. Using the Rolling Interval Method, adherence rates were similar across drug and laboratory testing type. CONCLUSIONS Results for adherence with laboratory testing QIs for DMARD use differed depending on how the QIs were measured, suggesting that care must be taken in clearly defining methods. While EMRs will provide important opportunities for measuring adherence with QIs, they also present challenges that must be examined before widespread adoption of these data collection methods.
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Affiliation(s)
- J C Agnew-Blais
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Goodson NJ, Brookhart AM, Symmons DPM, Silman AJ, Solomon DH. Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients. Ann Rheum Dis 2008; 68:367-72. [PMID: 18408253 PMCID: PMC2633631 DOI: 10.1136/ard.2007.076760] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [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] [Indexed: 11/05/2022]
Abstract
Objectives: There is controversy about the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on cardiovascular disease (CVD) mortality. The aim of this study was to explore associations between NSAID use and mortality in patients with inflammatory polyarthritis (IP). Subjects and methods: A total of 923 patients with new onset (IP), recruited to the UK Norfolk Arthritis Register (NOAR) between 1990–1994, were followed up to the end of 2004. Current medication was recorded annually for the first 6 years and then every 2–3 years. Rheumatoid factor (RF) and C-reactive protein (CRP) were measured. Logistic regression was used to calculate all cause and CVD mortality odds ratios (OR) for NSAID use at baseline and during follow-up, adjusting for gender and time-varying covariates: RF, CRP, joint counts, smoking, steroid use, DMARD use and other medication use. Results: By 2004 there were 203 deaths, 85 due to CVD. At baseline, NSAIDs were used by 66% of patients. In final multivariate models, baseline NSAID use was inversely associated with all cause mortality (adjusted OR 0.62, 95% CI 0.45 to 0.84) and CVD mortality (adjusted OR 0.54, 95% CI 0.34 to 0.86). Interval NSAID use had weaker mortality associations: all cause mortality (adjusted OR 0.72, 95% CI 0.52 to 1.00), CVD mortality (adjusted hazard ratio (HR) 0.66, 95% CI 0.40 to 1.08). Conclusion: No excess CVD or all cause mortality was observed in NSAID users in this cohort of patients with IP. This is at variance with the literature relating to NSAID use in the general population. It is unclear whether this represents unmeasured confounders influencing a doctor’s decision to avoid NSAIDs in the treatment of IP.
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Affiliation(s)
- N J Goodson
- Academic Rheumatology Unit, University Hospital Aintree, Liverpool University, Lower Lane, Liverpool, L9 7AL, UK.
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Geso M, Ackerly T, Brown S, Chua Z, He C, Wong CJ, Powell CE, Ho A, Qiao G, Solomon DH, Patterson W, Droege JM. Determination of dosimetric perturbations caused by aneurysm clip in stereotactic radiosurgery using gel phantoms and EBT-Gafchromic films. Med Phys 2008; 35:744-52. [DOI: 10.1118/1.2828200] [Citation(s) in RCA: 7] [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: 11/07/2022] Open
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Solomon DH, Gabriel SE. Quality Measures 101: what every rheumatologist should know. Clin Exp Rheumatol 2007; 25:18-21. [PMID: 18021502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In this paper, we review the essentials of quality measurement for rheumatologists. We will focus on four specific issues: why should rheumatology focus on quality measures now? how can rheumatology construct and assess quality measures? what can rheumatologists expect to achieve with quality measures? will quality measures be used for reimbursement?
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Affiliation(s)
- D H Solomon
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Abstract
BACKGROUND Uric acid lowering therapy (UALT) is considered a chronic treatment for gout. Relatively little is known about adherence to UALT. METHODS We assessed adherence with UALT over a 1-year study period among 9823 older adults enrolled in a pharmacy benefit program. Two adherence measures were calculated, the percentage of days covered (PDC) and the time until an extended break (at least 60 days) in treatment. A PDC <80% was considered poor adherence and its predictors were examined in multivariable logistic models. RESULTS The mean (SD) PDC was 54% (36%) with 64% of patients considered poorly compliant over the study period. A total of 56% had experienced an extended break in UALT. Predictors of poor adherence included younger age (odds ratio (OR) 1.50, 95% CI 1.33-1.69 for ages 65-74 compared with 85 and above) and African-American race (OR 1.86, 95% CI 1.52-2.27 compared with Caucasian race). Most patients (93%) received their initial UALT prescription from a non-specialist and this also predicted poor adherence (OR 1.15, 95% CI 0.96-1.38 compared with rheumatologists or nephrologists). CONCLUSION Adherence with UALT is poor. While uric acid levels were not measured in this study, poor adherence with UALT is likely to reduce attainment of goal uric acid levels.
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Affiliation(s)
- D H Solomon
- Division of Pharmacoepidemiology, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA.
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Abstract
AIMS In mineralizing tissues such as growth plate cartilage extracellular organelles derived from the chondrocyte membrane are present. These matrix vesicles (MV), possess membrane transporters that accumulate Ca(2+) and inorganic phosphate (P(i)), and initiate the formation of hydroxyapatite crystals. MV are also present in articular cartilage, and hydroxyapatite crystals are believed to promote cartilage degradation in osteoarthritic joints. This study characterizes P(i) transport in MV derived from articular cartilage. METHODS Matrix vesicles were harvested from collagenase digests of bovine articular cartilage by serial centrifugation. P(i) uptake by MV was measured using radioactive phosphate ((33)[P]HPO(4)(2-)). The Na(+) dependence, pH sensitivity and effects of P(i) analogues that inhibit P(i) transport were determined. RESULTS P(i) uptake was temperature-sensitive and comprised Na(+)-dependent and Na(+)-independent components. The Na(+)-dependent component saturated at high extracellular P(i) concentrations, with a K(m) of 0.16 mM. In Na(+)-free solutions, uptake did not fully saturate implying that carrier-mediated uptake is supplemented by a diffusive pathway. Uptake was inhibited by phosphonoacetate and arsenate, although a fraction of Na(+)-independent P(i) uptake persisted. Total P(i) uptake was maximal at pH 6.5, and reduced at more acidic or alkaline values, representing inhibition of both components. CONCLUSION These properties are highly similar to those of P(i) uptake by chondrocytes, suggesting that MV inherit P(i) transporters of the chondrocyte membrane from which they are derived. Na(+)-independent P(i) uptake has not previously been described in MV from growth plate cartilage and is relatively uncharacterized, but warrants further attention in articular cartilage, given its likely role in initiating inappropriate mineral formation.
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Affiliation(s)
- D H Solomon
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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Shadick NA, Heller JE, Weinblatt ME, Maher NE, Cui J, Ginsburg G, Coblyn J, Anderson R, Solomon DH, Roubenoff R, Parker A. Opposing effects of the D70 mutation and the shared epitope in HLA-DR4 on disease activity and certain disease phenotypes in rheumatoid arthritis. Ann Rheum Dis 2007; 66:1497-502. [PMID: 17491100 PMCID: PMC2111627 DOI: 10.1136/ard.2006.067603] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Certain sequences present in the hypervariable region of human leucocyte antigen (HLA)-DRB1 known as the shared epitope (SE) are hypothesised to increase the risk of rheumatoid arthritis (RA), whereas alleles encoding aspartic acid at position 70 (D70 alleles) may have a protective effect. METHODS Patient HLA-DRB1 serotypes were assessed and the genotypes encoding the SE motif or the putatively protective D70 motif identified in a large RA cohort. Logistic regression was used to analyse associations of genotype with presence of disease, comorbidities and disease severity, and association between genotype and change in disease activity over time. RESULTS The 689 patients enrolled had a mean (SD) age of 57.9 (13.7) years and mean (SD) disease duration of 15.3 (12.7) years. In a comparison with 482 ethnicity matched population-based controls, the D70 sequence exerted a strong protective effect (OR = 0.52, p<0.001) that remained significant when the SE at the same locus was accounted for (OR = 0.72, 95% CI 0.60 to 0.86, p<0.001). The SE assessed on all HLA-DRB1 serotypic backgrounds except DR1 was associated with RA susceptibility (additive OR = 2.43, p<0.001). Associations were found between SE and serum levels of rheumatoid factor (p<0.001, with correlation of 0.18) and anti-cyclic citrullinated peptide antibodies (p<0.001, with correlation of 0.25) but not with serum C-reactive protein. CONCLUSION The D70 allele has a significant protective effect that is mitigated but still significant when the risk effect of the SE at the same locus is taken into account. The presence of the SE on DR4 is associated with greater RA susceptibility and certain disease-activity measures.
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Affiliation(s)
- N A Shadick
- Division of Rheumatology, Immunology, Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Charytan DM, Setoguchi S, Solomon DH, Avorn J, Winkelmayer WC. Clinical presentation of myocardial infarction contributes to lower use of coronary angiography in patients with chronic kidney disease. Kidney Int 2007; 71:938-45. [PMID: 17342183 DOI: 10.1038/sj.ki.5002159] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with chronic kidney disease (CKD) have high mortality following myocardial infarction (MI), but are less likely to undergo coronary angiography than those without CKD. Whether this phenomenon is explained by differences in the presentation of MI or by bias against performing coronary angiography in patients with CKD is unclear. We examined the clinical presentation of 1876 elderly patients who presented with MI and categorized them by estimated glomerular filtration rate: >60 ml/min (no/mild CKD), 30-60 ml/min (CKD Stage 3) or <30 ml/min (CKD Stage 4/5). Compared with patients with no/mild CKD, patients with CKD Stage 3 or Stage 4/5 had more comorbidity, greater prior nursing home use, and higher frequency of conduction abnormalities or anterior infarction. By contrast, peak creatinine kinase-MB fraction (CK-MB) concentrations were lower and ST-elevation MI was less common in patients with CKD Stage 3 or Stage 4/5. In univariate analyses, patients with CKD Stage 4/5 (odds ratio (OR)=0.34, 95% confidence interval (CI): 0.23-0.50) or Stage 3 (OR=0.57, 95% CI: 0.45-0.73) were markedly less likely to undergo angiography than subjects with no/mild CKD. After multivariable adjustment, the association of CKD Stage 3 with the use of coronary angiography was attenuated (OR=0.78, 95% CI: 0.60-1.03), but CKD Stage 4/5 remained strongly associated with lower use (OR=0.52, 95% CI: 0.34-0.80). Clinical features of MI are different in patients with and without CKD and may partly explain the low use of angiography in patients with CKD Stage 3. However, the clinical features of MI do not account for its underuse in MI patients with CKD Stages 4/5. Whether reduced use of angiography in patients with advanced CKD is justified must be evaluated in formal risk-benefit analyses.
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Affiliation(s)
- D M Charytan
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120, USA
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Wong CJ, Ackerly T, He C, Patterson W, Powell CE, Ho A, Qiao G, Solomon DH, Meder R, Geso M. High-resolution measurements of small field beams using polymer gels. Appl Radiat Isot 2007; 65:1160-4. [PMID: 17574428 DOI: 10.1016/j.apradiso.2007.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 04/02/2007] [Accepted: 04/03/2007] [Indexed: 01/27/2023]
Abstract
Small field sizes are increasingly becoming important in radiotherapy particularly since the introduction of intensity-modulated radiation therapy (IMRT) techniques. It is normally a challenging task to reliably measure the delivered dose and to determine its distribution in a medium for such small fields using conventional-type dosimeters such as gas ionisation chambers. Recently, attempts have been made to use films, but they are not tissue equivalent, they measure the dose only in two dimensions and they are not as responsive to radiations. In the present work, polyacrylamide gel (PAG) dosimeters are employed to measure the dose and its distribution in three dimensions for very small field sizes, such as those typically used in stereotactic radiosurgery. Field sizes of 6 x 6 and 18 x 18 mm in width are investigated. The results show an agreement with radiochromic film and ionisation diode measurements, with some variation in measured doses near the edge of the field, where the gel data decreases more rapidly than the other methods.
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Affiliation(s)
- C J Wong
- School of Medical Sciences, RMIT University, Bundoora, Vic. 3083, Australia
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Solomon DH, Browning JA, Wilkins RJ. Inorganic phosphate transport in matrix vesicles from bovine articular cartilage. Acta Physiol (Oxf) 2007. [DOI: 10.1111/j.1748-1761.2007.01670.x] [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: 11/27/2022]
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Rizzardo E, Solomon DH. Acid-Induced Free-Radical Decomposition of Hydroperoxides and Peroxides: New Low-Temperature Initiator Systems for Vinyl Polymerization. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222337708063086] [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: 10/23/2022]
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Quint G, Rizzardo E, Solomon DH, Spurling TH. Acid-Induced Free-Radical Decomposition of Hydroperoxides: Quantal Calculations. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222338108056747] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Moad G, Rizzardo E, Solomon DH. The Reaction of Benzoyloxy Radicals with Styrene—Implications Concerning the Structure of Polystyrene. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222338208056465] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rizzardo E, Solomon DH. Acid-Induced Free-Radical Decomposition of Hydroperoxides: Polymerization of Methyl Methacrylate with Tert-Butyl Hydroperoxide and Sulfuric Acid. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222338008063207] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Griffiths PG, Rizzardo E, Solomon DH. Initiation Pathways in the Polymerization of Alkyl Methacrylates with tert-Butoxy Radicals. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222338208056464] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Francis AP, Solomon DH, Spurling TH. A Numerical Approach to the Estimation of Reactivity Ratios: Application to the Styrene-DMAEMA System. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222337408065844] [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: 10/23/2022]
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Hawthorne DG, Hodgkin JH, Loft BC, Solomon DH. Polymerization of Vinyl Monomers on Mineral Surfaces; A Novel Method of Preparing Reinforcing Fillers. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/00222337408065856] [Citation(s) in RCA: 9] [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: 10/23/2022]
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