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Williams HJ, Cannon GW, Clegg DO. John R. Ward, MD: Pioneer-Clinical Trials in Rheumatology. Rheum Dis Clin North Am 2024; 50:113-121. [PMID: 37973279 DOI: 10.1016/j.rdc.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
John Robert Ward was one of the early academic rheumatologists in the United States. He was the founding father of rheumatology in the Intermountain West, the first Chief of the Division of Rheumatology in the Department of Internal Medicine at the University of Utah. Dr Ward became a national leader in the understanding and treatment of rheumatic disease. His foundational work established gold-standard techniques for the successful investigation of anti-rheumatic drugs. His leadership and scientific contributions clearly qualify him as a "giant in rheumatology."
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Affiliation(s)
- H James Williams
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Grant W Cannon
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel O Clegg
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Sawitzke AD, Jackson CG, Carlson K, Bizien MD, Leiner M, Reda DJ, Sindowski T, Hanrahan C, Spencer RG, Kwoh CK, Lee SJ, Hose K, Robin L, Cain DW, Taylor MD, Bangerter N, Finco M, Clegg DO. Effect of Pulsed Low-Intensity Ultrasonography on Symptom Relief and Tibiofemoral Articular Cartilage Thickness Among Veterans Affairs Enrollees With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e220632. [PMID: 35258579 PMCID: PMC8905392 DOI: 10.1001/jamanetworkopen.2022.0632] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Osteoarthritis (OA) is a major cause of disability in the US, with no approved treatments to slow progression, but animal models suggest that pulsed low-intensity ultrasonography (PLIUS) may promote cartilage growth. OBJECTIVE To evaluate the efficacy of PLIUS in providing symptom reduction and decreased loss of tibiofemoral cartilage thickness in patients with knee OA. DESIGN, SETTING, AND PARTICIPANTS A phase 2A, sham-controlled, parallel, double-blind randomized clinical trial was conducted at 2 Veterans Affairs hospitals in Salt Lake City, Utah, and San Diego, California, from May 22, 2015, to January 31, 2019. Data were analyzed from June 27, 2020, to October 20, 2020. Participants recruited through the US Department of Veterans Affairs (N = 132) with clinical and radiographic evidence of early knee OA were randomly assigned to receive PLIUS or a sham device, self-administered for 20 minutes daily over the medial compartment of the knee. All enrollees participated in a 4-week prerandomization sham run-in period, followed by a 48-week treatment period. Randomization was stratified by study site and Kellgren-Lawrence grades 1 (n = 15), 2 (n = 51), and 3 (n = 66). INTERVENTION Participants either received 48 weeks of PLIUS or sham ultrasonography. MAIN OUTCOMES AND MEASURES The trial incorporated 2 coprimary outcomes: symptomatic improvement assessed by Outcome Measures in Rheumatology Clinical Trials-Osteoarthritis Research Society International Responder Criteria (ie, met if either >50% improvement in pain and function with at least a 20% absolute improvement of at least 2 of the following 3 factors: improvement by at least 20% [pain, function, and patient global assessment] with at least a 10-mm absolute improvement), and cartilage preservation assessed as change in central medial femoral condyle cartilage thickness by magnetic resonance imaging. Intention-to-treat analysis was used. RESULTS The mean (SD) participant age was 63.6 (10.7) years and 119 were men (90.2%). The mean (SD) duration of OA symptoms was 13.4 (12.3) years. In the PLIUS group, 70.4% (95% CI, 58.2%-82.6%) of the participants experienced symptomatic improvement, compared with 67.3% (95% CI, 54.9%-79.7%) of participants in the sham group (P = .84); there was no statistically significant difference in response rates between the treatment groups, and the between-group rate difference of 3.1% (95% CI, -14.3% to 20.5%) did not meet the predefined 10% threshold for clinically significant symptomatic improvement from application of PLIUS. At 48 weeks of treatment, central medial femoral condyle cartilage thickness decreased by a mean (SD) of 73.8 (168.1) μm in the PLIUS group and by 42.2 (297.0) μm in the sham group. This 48-week mean change between the 2 groups did not reach statistical significance (P = .44), and the between-group 48-week difference of -31.7 μm (95% CI, -129.0 μm to 65.7 μm) did not meet the predefined threshold. There were 99 nonserious adverse events in the PLIUS group and 89 in the sham group during the trial. No serious adverse events were deemed related to the study device. CONCLUSIONS AND RELEVANCE PLIUS, as implemented in this study, demonstrated neither symptomatic benefit nor a decrease in loss of tibiofemoral cartilage thickness in knee OA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02034409.
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Affiliation(s)
| | - Christopher G Jackson
- Department of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Kimberly Carlson
- Edward Hines Junior VA Hospital Cooperative Studies Program Coordinating Center, Hines, Illinois
| | - Marcel D Bizien
- VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
- School of Pharmacy, University of New Mexico, Albuquerque, New Mexico
| | - Mathew Leiner
- Edward Hines Junior VA Hospital Cooperative Studies Program Coordinating Center, Hines, Illinois
| | - Domenic J Reda
- Edward Hines Junior VA Hospital Cooperative Studies Program Coordinating Center, Hines, Illinois
| | - Tom Sindowski
- Edward Hines Junior VA Hospital Cooperative Studies Program Coordinating Center, Hines, Illinois
| | - Christopher Hanrahan
- Department of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Richard G Spencer
- National Institutes of Health/National Institute on Aging, Laboratory of Clinical Investigation, Baltimore, Maryland
| | - C Kent Kwoh
- University of Arizona Arthritis Center, University of Arizona, Tucson
| | - Susan J Lee
- VA San Diego Healthcare System, San Diego, California
| | - Kalli Hose
- Department of Medicine, San Diego VA Medical Center, San Diego, California
| | - Lisa Robin
- Edward Hines Junior VA Hospital Cooperative Studies Program Coordinating Center, Hines, Illinois
| | - Donna W Cain
- VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Meredith D Taylor
- Department of Electrical & Computer Engineering, Brigham Young University, Provo, Utah
| | - Neal Bangerter
- Department of Radiology, University of Utah, Salt Lake City
- Department of Orthopedics, University of Utah, Salt Lake City
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Martha Finco
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Daniel O Clegg
- Department of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
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Walsh JA, Pei S, Penmetsa GK, Overbury RS, Clegg DO, Sauer BC. Identifying Patients With Axial Spondyloarthritis in Large Datasets: Expanding Possibilities for Observational Research. J Rheumatol 2020; 48:685-692. [PMID: 33259327 DOI: 10.3899/jrheum.200570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Observational research of axial spondyloarthritis (axSpA) is limited by a lack of methods for identifying diverse axSpA phenotypes in large datasets. Algorithms were previously designed to identify a broad spectrum of patients with axSpA, including patients not identifiable with diagnosis codes. The study objective was to estimate the performance of axSpA identification methods in the general Veterans Affairs (VA) population. METHODS A patient sample with known axSpA status (n = 300) was established with chart review. For feasibility, this sample was enriched with veterans with axSpA risk factors. Algorithm performance outcomes included sensitivities, positive predictive values (PPV), and F1 scores (an overall performance metric combining sensitivity and PPV). Performance was estimated with unweighted outcomes for the axSpA-enriched sample and inverse probability weighted (IPW) outcomes for the general VA population. These outcomes were also assessed for traditional identification methods using diagnosis codes for the ankylosing spondylitis (AS) subtype of axSpA. RESULTS The mean age was 54.7 and 92% were male. Unweighted F1 scores (0.59-0.74) were higher than IPW F1 scores (0.48-0.65). The full algorithm had the best overall performance (F1IPW 0.65). The Early Algorithm was the most inclusive (sensitivityIPW 0.90, PPVIPW 0.38). The traditional method using ≥ 2 AS diagnosis codes from rheumatology had the highest PPV (PPVIPW 0.84, sensitivityIPW 0.34). CONCLUSION The axSpA identification methods demonstrated a range of performance attributes in the general VA population that may be appropriate for various types of studies. The novel identification algorithms may expand the scope of research by enabling identification of more diverse axSpA populations.
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Affiliation(s)
- Jessica A Walsh
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA.
| | - Shaobo Pei
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Gopi K Penmetsa
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Rebecca S Overbury
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Daniel O Clegg
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Brian C Sauer
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
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Walsh JA, Pei S, Penmetsa GK, Sauer BC, Patil V, Walker JH, Clewell J, Douglas KM, Clegg DO, Cannon GW, Halwani A. Treatment Patterns with Disease-Modifying Antirheumatic Drugs in U.S. Veterans with Newly Diagnosed Rheumatoid Arthritis, Psoriatic Arthritis, or Ankylosing Spondylitis. J Manag Care Spec Pharm 2019; 25:1218-1228. [PMID: 31663467 PMCID: PMC10398041 DOI: 10.18553/jmcp.2019.25.11.1218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/05/2022]
Abstract
BACKGROUND Delays in treatment for inflammatory arthritis (IA) are associated with unfavorable outcomes, including impaired quality of life, irreversible joint damage, and disability. OBJECTIVE To characterize treatment initiation patterns in veterans with newly diagnosed rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). METHODS ICD-9/10-CM codes and natural language processing were used to identify incident cases of RA, PsA, or AS between January 1, 2007, and December 31, 2015, in patients enrolled in the Veterans Health Administration. Patterns of treatment initiation and nontreatment with disease-modifying antirheumatic drugs (DMARDs) were assessed in the 12-month follow-up period after the incident diagnosis. Outcomes included the percentage of veterans treated with a DMARD, the mean time to the initial DMARD after diagnosis, and the percentage of veterans who accessed rheumatology care before DMARD initiation. To assess outcomes over time, veterans were grouped by year of initial IA diagnosis. Additionally, outcomes were compared between nonbiologic and biologic DMARDs and among IA subtypes (RA, PsA, and AS). Groups were statistically compared with 95% confidence intervals. RESULTS The population consisted of 12,118 IA veterans (9,711 RA, 1,472 PsA, and 935 AS), with 91.3% males and a mean age of 63.7 years. The percentage of veterans treated with ≥ 1 DMARD (nonbiologic or biologic) during the 12-month follow-up period increased from 48.8% in 2007 to 66.4% in 2015. In veterans diagnosed with IA in 2015, DMARD treatment was more common for PsA patients (72.9%) and RA patients (68.6%) than for AS patients (28.9%). In the subset treated with a DMARD within 12 months after diagnosis, the mean time to the initial DMARD after diagnosis did not change throughout the observation period (35.5 days for RA, 43.9 days for PsA, and 59.5 days for AS). Rheumatology specialty care was accessed by 87.4% of veterans treated with a nonbiologic DMARD and 92.2% of veterans treated with a biologic DMARD, in patients diagnosed in 2015. CONCLUSIONS DMARD treatment rates during the initial 12 months after diagnosis increased between 2007 and 2015, but nontreatment remained common, particularly in veterans with AS. The time to treatment after diagnosis was stable over time; it was shortest for RA, intermediate for PsA, and longest for AS. DMARD treatment was uncommon in veterans who did not access rheumatology specialty care. DISCLOSURES AbbVie Pharmaceuticals and Marriott Daughters Foundation funded this study via investigator-initiated grants. Data analyses were completed by investigators independent of AbbVie and Marriott Daughters Foundation. Walker, Clewell, and Douglas are employed by, and stockholders in, Abbvie. Halwani reports grants from BMS, Kyowa Hakko Kirin, Seattle Genetics, Roche-Genentech, Miragen, Immunedesign, Takeda, Amgen, Pharmacyclics, and Abbvie. The other authors have nothing to disclose.
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Affiliation(s)
- Jessica A. Walsh
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Shaobo Pei
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Gopi K. Penmetsa
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Brian C. Sauer
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Vikas Patil
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | | | | | | | - Daniel O. Clegg
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Grant W. Cannon
- Division of Rheumatology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
| | - Ahmad Halwani
- Division of Hematology, Department of Internal Medicine, Salt Lake City Veterans Affairs and University of Utah Medical Centers
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Walsh JA, Pei S, Penmetsa G, Hansen JL, Cannon GW, Clegg DO, Sauer BC. Identification of Axial Spondyloarthritis Patients in a Large Dataset: The Development and Validation of Novel Methods. J Rheumatol 2019; 47:42-49. [PMID: 30877217 DOI: 10.3899/jrheum.181005] [Citation(s) in RCA: 3] [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] [Accepted: 02/20/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Observational axial spondyloarthritis (axSpA) research in large datasets has been limited by a lack of adequate methods for identifying patients with axSpA, because there are no billing codes in the United States for most subtypes of axSpA. The objective of this study was to develop methods to accurately identify patients with axSpA in a large dataset. METHODS The study population included 600 chart-reviewed veterans, with and without axSpA, in the Veterans Health Administration between January 1, 2005, and June 30, 2015. AxSpA identification algorithms were developed with variables anticipated by clinical experts to be predictive of an axSpA diagnosis [demographics, billing codes, healthcare use, medications, laboratory results, and natural language processing (NLP) for key SpA features]. Random Forest and 5-fold cross validation were used for algorithm development and testing in the training subset (n = 451). The algorithms were additionally tested in an independent testing subset (n = 149). RESULTS Three algorithms were developed: Full algorithm, High Feasibility algorithm, and Spond NLP algorithm. In the testing subset, the areas under the curve with the receiver-operating characteristic analysis were 0.96, 0.94, and 0.86, for the Full algorithm, High Feasibility algorithm, and Spond NLP algorithm, respectively. Algorithm sensitivities ranged from 85.0% to 95.0%, specificities from 78.0% to 93.6%, and accuracies from 82.6% to 91.3%. CONCLUSION Novel axSpA identification algorithms performed well in classifying patients with axSpA. These algorithms offer a range of performance and feasibility attributes that may be appropriate for a broad array of axSpA studies. Additional research is required to validate the algorithms in other cohorts.
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Affiliation(s)
- Jessica A Walsh
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA. .,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center.
| | - Shaobo Pei
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Gopi Penmetsa
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Jared Lareno Hansen
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Grant W Cannon
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Daniel O Clegg
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
| | - Brian C Sauer
- From the Salt Lake City Veteran Affairs Medical Center; the University of Utah Medical Center, Salt Lake City, Utah, USA.,J.A. Walsh, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; S. Pei, PhD, Salt Lake City Veteran Affairs Medical Center; G. Penmetsa, MD, University of Utah Medical Center; J.L. Hansen, MStat, Salt Lake City Veteran Affairs Medical Center; G.W. Cannon, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; D.O. Clegg, MD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center; B.C. Sauer, PhD, Salt Lake City Veteran Affairs Medical Center, and University of Utah Medical Center
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Walsh JA, Jones H, Mallbris L, Duffin KC, Krueger GG, Clegg DO, Szumski A. The Physician Global Assessment and Body Surface Area composite tool is a simple alternative to the Psoriasis Area and Severity Index for assessment of psoriasis: post hoc analysis from PRISTINE and PRESTA. Psoriasis (Auckl) 2018; 8:65-74. [PMID: 30324088 PMCID: PMC6181091 DOI: 10.2147/ptt.s169333] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The product of Physician Global Assessment and Body Surface Area (PGA × BSA) is a new outcome measure for psoriasis severity and response to therapy. The objective of this study was to evaluate PGA × BSA as an alternative to Psoriasis Area and Severity Index (PASI) for psoriasis assessments. Methods The relationship between PASI and PGA × BSA was assessed in a post hoc analysis of pooled data from the PRISTINE (NCT00663052) and PRESTA (NCT00245960) trials in patients with moderate-to-severe psoriasis who received etanercept 50 mg/week. Data were analyzed using Spearman and intra-class correlation coefficients, effect sizes, scatterplots, Bland–Altman plots, and Kappa statistics. Results Spearman correlations at baseline, week 12, and week 24 were strong for PGA × BSA versus PASI (r=0.78, 0.87, and 0.90, respectively; all P<0.0001) as were intra-class correlations (0.76 [95% confidence interval 0.73–0.80], 0.80 [0.76–0.83], and 0.85 [0.82–0.87], respectively). The effect size was −1.53 for PASI and −0.94 for PGA × BSA (baseline to week 24). Scatterplots and Bland–Altman plots detected a trend across the range of measurement. Kappa statistics (at 12 and 24 weeks) between PASI50/75/90 and 50/75/90% improvement in PGA × BSA showed good agreement (0.58–0.69 at week 12 and 0.63–0.67, respectively; all P<0.0001). At baseline, the Spearman correlation coefficients were 0.96, 0.51, 0.19, and 0.17 for PGA × BSA versus BSA, PGA, Patient Global Assessment, and Dermatology Life Quality Index, respectively (all P<0.001). Conclusion PGA × BSA has advantages over PASI for measuring moderate-to-severe psoriasis; it is intuitive, sensitive, and easy to use.
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Affiliation(s)
- Jessica A Walsh
- Division of Rheumatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA,
| | - Heather Jones
- Inflammation and Immunology,Global Medical Affairs, Pfizer, Collegeville, PA, USA
| | - Lotus Mallbris
- Inflammation and Immunology,Global Medical Affairs, Pfizer, Collegeville, PA, USA
| | - Kristina Callis Duffin
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald G Krueger
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel O Clegg
- Division of Rheumatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA,
| | - Annette Szumski
- Pfizer Business Unit (PBU) Syneos Health, Princeton, NJ, United States
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Walsh JA, Pei S, Penmetsa GK, Leng J, Cannon GW, Clegg DO, Sauer BC. Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods. BMC Musculoskelet Disord 2018; 19:317. [PMID: 30185185 PMCID: PMC6123987 DOI: 10.1186/s12891-018-2211-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [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: 02/22/2018] [Accepted: 07/31/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Big data research is important for studying uncommon diseases in real-world settings. Most big data studies in axial spondyloarthritis (axSpA) have been limited to populations identified with billing codes for ankylosing spondylitis (AS). axSpA is a more inclusive concept, and reliance on AS codes does not produce a comprehensive axSpA study population. The first objective was to describe our process for establishing an appropriate sample of patients with and without axSpA for developing accurate axSpA identification methods. The second objective was to determine the classification performance of AS billing codes against the chart-reviewed axSpA reference standard. METHODS Veteran Health Affairs clinical and administrative data, between January 2005 and June 2015, were used to randomly select patients with clinical phenotypes that represented high, moderate, and low likelihoods of an axSpA diagnosis. With chart review, the sampled patients were classified as Yes axSpA, No axSpA or Uncertain axSpA, and these classification assignments were used as the reference standard for determining the positive predictive value (PPV) and sensitivity of AS ICD-9 codes for axSpA. RESULTS Six hundred patients were classified as Yes axSpA (26.8%), No axSpA (68.3%), or Uncertain axSpA (4.8%). The PPV and sensitivity of an AS ICD-9 code for axSpA were 83.3% and 57.3%, respectively. CONCLUSIONS Standard methods of identifying axSpA patients in a large dataset lacked sensitivity. An appropriate sample of patients with and without axSpA was established and characterized for developing novel axSpA identification methods that are anticipated to enable previously impractical big data research.
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Affiliation(s)
- Jessica A. Walsh
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Shaobo Pei
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Gopi K. Penmetsa
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Jianwei Leng
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Grant W. Cannon
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
| | - Daniel O. Clegg
- Division of Rheumatology School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Brian C. Sauer
- George E. Wahlen Veteran Affairs Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148 USA
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Velarde KE, Romesser JM, Johnson MR, Clegg DO, Efimova O, Oostema SJ, Scehnet JS, DuVall SL, Huang GD. An initiative using informatics to facilitate clinical research planning and recruitment in the VA health care system. Contemp Clin Trials Commun 2018; 11:107-112. [PMID: 30035242 PMCID: PMC6052195 DOI: 10.1016/j.conctc.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/21/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022] Open
Abstract
Background Randomized clinical trials are the gold standard for evaluating healthcare interventions and, more generally, add to the medical knowledge related to the treatment, diagnosis and prevention of diseases and conditions. Recent literature continues to identify health informatics methods that can help improve study efficiency throughout the life cycle of a clinical trial. Electronic medical record (EMR) data provides a mechanism to facilitate clinical trial research during the study planning and execution phases, and ultimately, can be utilized to enhance recruitment. The Department of Veterans Affairs (VA) has a strong history of clinical and epidemiological research with over four decades of data collected from Veterans it has served nationwide. The VA Informatics and Computing Infrastructure (VINCI) provides VA research investigators with a nationwide view of high-value VA patient data. Within VA, the Cooperative Studies Program (CSP) Network of Dedicated Enrollment Sites (NODES) is a consortium of nine sites that are part of an embedded clinical research infrastructure intended to provide systematic site-level solutions to issues that arise during the conduct of VA CSP clinical research. This paper describes the collaboration initiated by the Salt Lake City (SLC) node site to bring informatics and clinical trials together to enhance study planning and recruitment within the VA. Methods The SLC VA Medical Center physically houses both VINCI and a node site and the co-location of these two groups prompted a natural collaboration on both a local and national level. One of the functions of the SLC NODES is to enhance recruitment and promote the success of CSP projects. VINCI supports these efforts by providing VA researchers access to potential population pools. VINCI can provide 1) feasibility data during study planning, and 2) active patient lists during recruitment. The process for CSP study teams to utilize these services involves regulatory documentation, development of queries, revisions to the initial data request, and ongoing communications with several key study personnel including the requesting research team, study statisticians, and VINCI data managers. Results The early efforts of SLC NODES and VINCI aimed to provide patient lists exclusively to the SLC CSP study teams for the following purposes: 1) increasing recruitment for trials that were struggling to meet their respective enrollment goals, and 2) decreasing the time required by study coordinators to complete chart review activities. This effort was expanded to include multiple CSP sites and studies. To date, SLC NODES has facilitated the delivery of these VINCI services to nine active CSP studies. Conclusion The ability of clinical trial study teams to successfully plan and execute their respective trials is contingent upon their proficiency in obtaining data that will help them efficiently and effectively recruit and enroll eligible participants. This collaboration demonstrates that the utilization of a model that partners two distinct entities, with similar objectives, was effective in the provision of feasibility and patient lists to clinical trial study teams and facilitation of clinical trial research within a large, integrated healthcare system.
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Affiliation(s)
- Kandi E Velarde
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Jennifer M Romesser
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Marcus R Johnson
- Durham VA Health Care System, 508 Fulton Street (152), Durham, NC, 27705, USA
| | - Daniel O Clegg
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Olga Efimova
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Steven J Oostema
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Jeffrey S Scehnet
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Scott L DuVall
- VA Salt Lake City Health Care System, 500 Foothill Drive (151), Salt Lake City, UT, 84148, USA
| | - Grant D Huang
- Department of Veterans Affairs, Cooperative Studies Program (10P9CS), 810 Vermont Avenue, NW, Washington, DC, 20420, USA
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Affiliation(s)
- Tatjana S Bevans-Warren
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, Department of Pharmacy, University of Utah, Salt Lake City, Utah Department of Anesthesiology, University of Utah, Salt Lake City, Utah Department of Pharmacology/Toxicology, University of Utah, Salt Lake City, Utah
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Walsh JA, Pei S, Burningham Z, Penmetsa G, Cannon GW, Clegg DO, Sauer BC. Use of Disease-modifying Antirheumatic Drugs for Inflammatory Arthritis in US Veterans: Effect of Specialty Care and Geographic Distance. J Rheumatol 2017; 45:430-436. [DOI: 10.3899/jrheum.170554] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 01/27/2023]
Abstract
Objective.To evaluate the effect of access to and distance from rheumatology care on the use of disease-modifying antirheumatic drugs (DMARD) in US veterans with inflammatory arthritis (IA).Methods.Provider encounters and DMARD dispensations for IA (rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis) were evaluated in national Veterans Affairs (VA) datasets between January 1, 2015, and December 31, 2015.Results.Among 12,589 veterans with IA, 23.5% saw a rheumatology provider. In the general IA population, 25.3% and 13.6% of veterans were exposed to a synthetic DMARD (sDMARD) and biologic DMARD (bDMARD), respectively. DMARD exposure was 2.6- to 3.4-fold higher in the subpopulation using rheumatology providers, compared to the general IA population. The distance between veterans’ homes and the closest VA rheumatology site was < 40 miles (Near) for 55.9%, 40–99 miles (Intermediate) for 31.7%, and ≥ 100 miles (Far) for 12.4%. Veterans in the Intermediate and Far groups were less likely to see a rheumatology provider than veterans in the Near group (RR = 0.72 and RR = 0.49, respectively). Exposure to bDMARD was 34% less frequent in the Far group than the Near group. In the subpopulation who used rheumatology care, the bDMARD exposure discrepancy did not persist between distance groups.Conclusion.Use of rheumatology care and DMARD was low for veterans with IA. DMARD exposure was strongly associated with rheumatology care use. Veterans in the general IA population living far from rheumatology sites accessed rheumatology care and bDMARD less frequently than veterans living close to rheumatology sites.
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Walsh JA, Shao Y, Leng J, He T, Teng CC, Redd D, Treitler Zeng Q, Burningham Z, Clegg DO, Sauer BC. Identifying Axial Spondyloarthritis in Electronic Medical Records of US Veterans. Arthritis Care Res (Hoboken) 2017; 69:1414-1420. [PMID: 27813310 DOI: 10.1002/acr.23140] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/19/2016] [Accepted: 11/01/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Large database research in axial spondyloarthritis (SpA) is limited by a lack of methods for identifying most types of axial SpA. Our objective was to develop methods for identifying axial SpA concepts in the free text of documents from electronic medical records. METHODS Veterans with documents in the national Veterans Health Administration Corporate Data Warehouse between January 1, 2005 and June 30, 2015 were included. Methods were developed for exploring, selecting, and extracting meaningful terms that were likely to represent axial SpA concepts. With annotation, clinical experts reviewed sections of text containing the meaningful terms (snippets) and classified the snippets according to whether or not they represented the intended axial SpA concept. With natural language processing (NLP) tools, computers were trained to replicate the clinical experts' snippet classifications. RESULTS Three axial SpA concepts were selected by clinical experts, including sacroiliitis, terms including the prefix spond*, and HLA-B27 positivity (HLA-B27+). With supervised machine learning on annotated snippets, NLP models were developed with accuracies of 91.1% for sacroiliitis, 93.5% for spond*, and 97.2% for HLA-B27+. With independent validation, the accuracies were 92.0% for sacroiliitis, 91.0% for spond*, and 99.0% for HLA-B27+. CONCLUSION We developed feasible and accurate methods for identifying axial SpA concepts in the free text of clinical notes. Additional research is required to determine combinations of concepts that will accurately identify axial SpA phenotypes. These novel methods will facilitate previously impractical observational research in axial SpA and may be applied to research with other diseases.
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Affiliation(s)
- Jessica A Walsh
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
| | - Yijun Shao
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, and George Washington University, Washington, DC
| | - Jianwei Leng
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
| | - Tao He
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
| | - Chia-Chen Teng
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
| | - Doug Redd
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, and George Washington University, Washington, DC
| | - Qing Treitler Zeng
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, and George Washington University, Washington, DC
| | | | - Daniel O Clegg
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
| | - Brian C Sauer
- George E. Wahlen Veterans Affairs Medical Center and University of Utah, Salt Lake City
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Abstract
OBJECTIVE To compare survival in American veterans with and without the HLA-B27 (B27) gene. METHODS Mortality was evaluated in a national cohort of veterans with clinically available B27 test results between October 1, 1999, and December 31, 2011. The primary outcome was the mortality difference between B27-positive and B27-negative veterans, adjusted for age, sex, race, and diagnoses codes for diseases that may have influenced both B27 testing and mortality, including psoriasis, inflammatory bowel disease, spondyloarthritis (SpA), and other types of inflammatory arthritis. The secondary outcomes were the adjusted mortality HR for B27+ and B27- veterans, in subgroups with and without SpA. RESULTS Among veterans with available B27 test results, 27,652 (84.7%) were B27- and 4978 (15.3%) were B27+. The mean followup time was 4.6 years. Mortality was higher in the B27+ group than in the B27- group (HR 1.15, 95% CI 1.03-1.27). Mortality was also higher in the B27+ subgroups with SpA (HR 1.35, 95% CI 1.06-1.72) and without SpA (HR 1.11, 95% CI 0.99-1.24), but the difference was significant only in the subgroup with SpA. CONCLUSION B27 positivity was associated with an increased mortality rate in a cohort of veterans clinically selected for B27 testing, after adjustment for SpA. In the subgroup with SpA, the mortality rate was associated with B27 positivity, and in the subgroup without SpA, there was a nonsignificant association between B27+ and mortality.
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Affiliation(s)
- Jessica A Walsh
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center.
| | - Xi Zhou
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center
| | - Daniel O Clegg
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center
| | - Chiachen Teng
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center
| | - Grant W Cannon
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center
| | - Brian Sauer
- From the Division of Rheumatology, and the Division of Epidemiology, Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs (VA) Medical Center, and University of Utah Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; X. Zhou, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; C. Teng, MS, Biostatistician, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center; G.W. Cannon, MD, Professor of Rheumatology, Division of Rheumatology, Department of Internal Medicine, George E. Wahlen VA Medical Center and University of Utah Medical Center; B. Sauer, PhD, Assistant Professor of Epidemiology, Division of Epidemiology, Department of Internal Medicine, George E. Wahlen VA Medical Center
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Assassi S, Weisman MH, Lee M, Savage L, Diekman L, Graham TA, Rahbar MH, Schall JI, Gensler LS, Deodhar AA, Clegg DO, Colbert RA, Reveille JD. New population-based reference values for spinal mobility measures based on the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Rheumatol 2014; 66:2628-37. [PMID: 24782356 DOI: 10.1002/art.38692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/25/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To report population-based percentile reference values for selected spinal mobility measures in a nationally representative sample of 5,001 US adults ages 20-69 years who were examined in the 2009-2010 US National Health and Nutrition Examination Survey (NHANES). METHODS Occiput-to-wall distance (OWD), thoracic expansion (TE), and anterior lumbar flexion (ALF; by modified Schober test) were measured by trained examiners in a standardized manner. TE was measured at the xiphisternal level, while the lower reference point for ALF was a line marked at the level of the superior margin of the lateral iliac crests. We report reference values based on the 95th percentile for the OWD and the 5th percentile for TE and ALF, as well as other summary statistics for these measures, in the study population. RESULTS An OWD of >0 was present in 3.8% of the participants, while 8.8% of them had out-of-range values for TE based on the commonly used threshold of 2.5 cm. The 95th percentile of the OWD measurement was 0, while the 5th percentile for TE and ALF were 1.9 cm and 2 cm, respectively. The spinal measures were significantly associated with sex, age, ethnicity, height, and body mass index (BMI). Exclusion of individuals with severe obesity (BMI >35 kg/m(2) ) changed the proposed reference values for TE and ALF to 2.2 cm and 1.9 cm, respectively. CONCLUSION We verified a reference value of 0 for the OWD in the general population. Using the reported population-based percentile values, new reference values for TE and ALF can be derived.
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Deodhar A, Reveille JD, van den Bosch F, Braun J, Burgos-Vargas R, Caplan L, Clegg DO, Colbert RA, Gensler LS, van der Heijde D, van der Horst-Bruinsma IE, Inman RD, Maksymowych WP, Mease PJ, Raychaudhuri S, Reimold A, Rudwaleit M, Sieper J, Weisman MH, Landewé RBM. The Concept of Axial Spondyloarthritis: Joint Statement of the Spondyloarthritis Research and Treatment Network and the Assessment of SpondyloArthritis international Society in Response to the US Food and Drug Administration's Comments and Concerns. Arthritis Rheumatol 2014; 66:2649-56. [DOI: 10.1002/art.38776] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 07/03/2014] [Indexed: 01/17/2023]
Affiliation(s)
| | | | | | | | - Ruben Burgos-Vargas
- Hospital General de México and Universidad Nacional Autónoma de México; Mexico City Mexico
| | - Liron Caplan
- University of Colorado and Denver VA Medical Center; Denver Colorado
| | | | - Robert A. Colbert
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH; Bethesda Maryland
| | | | - Désirée van der Heijde
- Leiden University Medical Centre; Leiden The Netherlands
- Diakonhjemmet Hospital; Olso Norway
| | | | - Robert D. Inman
- Toronto Western Hospital and University of Toronto; Toronto, Ontario Canada
| | - Walter P. Maksymowych
- Alberta Heritage Foundation for Medical Research and University of Alberta; Edmonton, Alberta Canada
| | | | | | | | - Martin Rudwaleit
- Charité Universitätsmedizin, Campus Benjamin Franklin; Berlin Germany
| | - Joachim Sieper
- Charité Universitätsmedizin, Campus Benjamin Franklin; Berlin Germany
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Bowers CA, Saad D, Clegg DO, Ng P, Clayton F, Haydoura S, Schmidt RH. Rapidly Fatal Internal Carotid Artery Mycotic Aneurysm Rupture in a Rheumatoid Patient Taking a TNF-α Inhibitor: Case Report and Literature Review. J Neurol Surg A Cent Eur Neurosurg 2014; 76:249-54. [PMID: 25045858 DOI: 10.1055/s-0034-1372435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECT Tumor necrosis factor (TNF)-α inhibitors are effective at treating certain inflammatory and autoimmune disorders. They are generally safe; potential adverse events include infections (bacterial, fungal, and viral), congestive heart failure exacerbations, and the potential for demyelinating diseases and possibly certain malignancies. We present the first documented case of fungal internal carotid artery (ICA) mycotic aneurysm in a patient being treated with a TNF-α inhibitor. We also review the literature on infections with TNF-α inhibition and the management of previously reported fungal ICA mycotic aneurysm cases. CASE DESCRIPTION A 76-year-old woman with rheumatoid arthritis, treated with etanercept and methotrexate, presented with a 2-week history of left temporal headaches. She was treated empirically for giant cell arteritis (GCA) with oral prednisone, which provided no symptom relief. She was subsequently hospitalized for a superficial temporal artery biopsy, which was negative for GCA. She returned 2 weeks later after experiencing a left thromboembolic ischemic stroke. She had an acute neurologic decline, and a head computed tomography scan showed diffuse subarachnoid hemorrhage from a ruptured left fusiform paraclinoid ICA aneurysm. She was taken emergently for a craniotomy for clip-wrapping of the aneurysm, but intraoperative ultrasound revealed poor flow in the left anterior cerebral circulation and a complete infarct of the left-sided anterior circulation. The family withdrew care and the patient died. Postmortem analysis demonstrated fungi consistent with Aspergillus invading the necrotic left ICA. CONCLUSIONS Although fungal mycotic aneurysms of the ICA are rare, their incidence may increase with the expanded use of immunosuppressive medications. Patients with rheumatoid arthritis who take potent immunosuppression regimens may be prime candidates for mycotic aneurysms because they often have two favoring conditions: atherosclerosis and immunosuppression. These ICA aneurysms carry a high mortality rate, so early diagnosis and aggressive therapy, potentially by endovascular trapping/vessel occlusion coupled with long-term antifungal therapy, is essential.
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Affiliation(s)
- Christian A Bowers
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States
| | - Dany Saad
- Department of Rheumatology, University of Utah, Salt Lake City, Utah, United States
| | - Daniel O Clegg
- Department of Rheumatology, University of Utah, Salt Lake City, Utah, United States
| | - Perry Ng
- Department of Radiology, University of Utah, Salt Lake City, Utah, United States
| | - Frederic Clayton
- Department of Pathology, University of Utah, Salt Lake City, Utah, United States
| | - Souha Haydoura
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Richard H Schmidt
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, United States
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Abstract
OBJECTIVE To explore the relationship between fatigue and work productivity loss (WPL) in people with psoriatic arthritis (PsA). METHODS Data were collected from participants in the Utah Psoriasis Initiative Arthritis registry between January 2010 and May 2013. WPL was measured with the 8-item Work Limitations Questionnaire. Fatigue was assessed with question 1 from the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI#1), "How would you describe the overall level of fatigue/tiredness you have experienced?" and with question 1 from the Psoriatic Arthritis Quality of Life Questionnaire (PsAQOL#1) "I feel tired whatever I do." Psoriatic activity was evaluated with tender joint count (TJC), swollen joint count (SJC), dactylitis count, enthesitis count, inflammatory back pain (IBP), physician global assessment, body surface area, and psoriasis pain and itch. RESULTS Among 107 participants, work productivity was reduced by 6.7%, compared to benchmark employees without limitations. Fatigue was reported by 54 patients (50.5%) on PsAQOL#1, and 64 (60.0%) were classified as high fatigue by BASDAI#1. TJC, SJC, enthesitis count, IBP, and depressed mood were highest or most frequent in participants reporting fatigue. After adjustments for psoriatic activity and depressed mood, WPL was associated with fatigue, as measured by PsAQOL#1 (p = 0.01) and BASDAI#1 (p = 0.002). CONCLUSION WPL was associated with fatigue, and the association was not entirely explained by the evaluated musculoskeletal, cutaneous, or psychiatric manifestations of PsA.
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Affiliation(s)
- Jessica A Walsh
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center.
| | - Molly L McFadden
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
| | - Michael D Morgan
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
| | - Allen D Sawitzke
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
| | - Kristina Callis Duffin
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
| | - Gerald G Krueger
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
| | - Daniel O Clegg
- From the Division of Rheumatology, Division of Epidemiology, Department of Dermatology, University of Utah; Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center, Salt Lake City, Utah, USA.J.A. Walsh, MD, Assistant Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; M.L. McFadden, MS, Biostatistician III, Division of Epidemiology, University of Utah; M.D. Morgan, MD, Fellow of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center; A.D. Sawitzke, MD, Professor of Rheumatology, Division of Rheumatology; K. Callis Duffin, MD, Assistant Professor of Dermatology; G.G. Krueger, MD, Professor of Dermatology, Department of Dermatology, University of Utah; D.O. Clegg, MD, Professor of Rheumatology, Division of Rheumatology, University of Utah, and Division of Rheumatology, George E. Wahlen Veteran Affairs Medical Center
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Walsh JA, McFadden M, Woodcock J, Clegg DO, Helliwell P, Dommasch E, Gelfand JM, Krueger GG, Duffin KC. Product of the Physician Global Assessment and body surface area: A simple static measure of psoriasis severity in a longitudinal cohort. J Am Acad Dermatol 2013; 69:931-7. [DOI: 10.1016/j.jaad.2013.07.040] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/29/2013] [Accepted: 07/30/2013] [Indexed: 11/15/2022]
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Abstract
The need for a rigorously developed longitudinal registry of patients with spondyloarthritis (SpA) is clear and urgent. Like randomized controlled trials, registries rely on a prospective, systematic protocol-driven approach to data acquisition to assess outcomes for a prescribed cohort of patients. Registries seek to capture large numbers of patients across large geographic zones and can serve as a valuable resource for patient advocacy, patient education and support, incidence and prevalence, and broad demographic profiles. Building on 3 existing registries--the Prospective Study of Outcomes in Ankylosing Spondylitis, the Program to Understand the Longterm Outcomes of Spondyloarthritis (PULSAR) and the University Health Network Spondyloarthritis Program--these registries and the Spondylitis Association of America propose to form a combined registry of North American SpA patients. The combined registry would, ideally, complement ongoing clinical goals and improve patient care.
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Affiliation(s)
- Liron Caplan
- Denver Veterans Affairs Medical Center, University of Colorado, Denver, Colorado, USA
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Tanner K, Roy N, Merrill RM, Kendall K, Miller KL, Clegg DO, Heller A, Houtz DR, Elstad M. Comparing nebulized water versus saline after laryngeal desiccation challenge in Sjögren's Syndrome. Laryngoscope 2013; 123:2787-92. [DOI: 10.1002/lary.24148] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/20/2013] [Accepted: 03/20/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Kristine Tanner
- Department of Communication Disorders; Brigham Young University; Salt Lake City Utah U.S.A
- Voice Disorders Center; Salt Lake City Utah U.S.A
| | - Nelson Roy
- Voice Disorders Center; Salt Lake City Utah U.S.A
- Department of Communication Sciences and Disorders; Salt Lake City Utah U.S.A
| | - Ray M. Merrill
- Department of Health Science (R.M.M.); Brigham Young University; Salt Lake City Utah U.S.A
| | - Katherine Kendall
- Voice Disorders Center; Salt Lake City Utah U.S.A
- Division of Otolaryngology-Head and Neck Surgery; Salt Lake City Utah U.S.A
| | | | | | - Amanda Heller
- Voice Disorders Center; Salt Lake City Utah U.S.A
- Department of Communication Sciences and Disorders; Salt Lake City Utah U.S.A
| | | | - Mark Elstad
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine (M.E.); The University of Utah; Salt Lake City Utah U.S.A
- George E. Wahlen Department of Veterans Affairs Medical Center; Salt Lake City Utah U.S.A
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Abstract
STUDY OBJECTIVES Sleep disturbances, including obstructive sleep apnea (OSA), commonly limit function and quality of life in people with spondyloarthritis (SpA). Systemic inflammation has been implicated in the pathophysiology of both OSA and SpA, and suppression of inflammation with tumor necrosis factor α (TNF) inhibitors may decrease OSA severity. In this study, we compared the frequency of OSA in patients receiving and not receiving TNF-inhibitor therapy. METHODS Data were collected from 63 consecutively screened veterans with SpA. Participant interviews, examinations, chart reviews, and referrals to the Salt Lake City Veteran Affairs (SLCVA) Sleep Center were used to obtain demographic data, comorbidities, SpA features, therapy data, and sleep study outcomes. RESULTS OSA occurred in 76% of SpA patients. OSA was less common in patients receiving TNF-inhibitor therapy (57%), compared to patients not receiving TNF-inhibitor therapy (91%) (p = 0.01). CONCLUSIONS OSA is underrecognized in veterans with SpA, and TNF-inhibition was associated with a lower frequency of OSA.
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Affiliation(s)
- Jessica A Walsh
- George E. Wahlen Veteran Affairs Medical Center, University of Utah, Division of Rheumatology, Salt Lake City, UT, USA.
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Kunkel GA, Cannon GW, Clegg DO. Combined structural and synovial assessment for improved ultrasound discrimination of rheumatoid, osteoarthritic, and normal joints: a pilot study. Open Rheumatol J 2012; 6:199-206. [PMID: 22905071 PMCID: PMC3419873 DOI: 10.2174/1874312901206010199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/27/2012] [Accepted: 06/29/2012] [Indexed: 11/22/2022] Open
Abstract
Background: Current ultrasonographic scoring systems used to assess the degree of finger joint synovitis in rheumatoid arthritis (RA) are not designed for distinguishing healthy or osteoarthritis (OA) patients from those with RA in clinical settings. Objective: To explore a novel scoring approach using structural and synovial ultrasonographic features to distinguish between healthy and OA finger joints and those with RA. Methods: 22 patients with RA, 16 healthy controls, and 14 OA controls received a comprehensive ultrasound of one hand, with scores assigned using a modification of a previously reported RA scoring system (Semiquantitative Synovial Score), and using the novel approach (Combined Structural/Synovial Score). The number of joints classified as supporting the diagnosis of RA (“RA-supported”) with each approach was recorded. Sensitivity and specificity for each scoring system were calculated with respect to the clinical diagnosis. Results: The Semiquantitative Synovial Score was highly sensitive (100%), but without specificity (0%) for the diagnosis of RA, when RA was defined as having more than 1 joint classified as “RA-supported.” The Combined Structural/Synovial Score had high sensitivity (95%) and moderate specificity (77%) when RA was defined as having any joint classified as “RA-supported”. Moderate sensitivity (73%) and high specificity (97%) were found when having more than 1 joint classified as “RA-supported” was required to diagnose RA. Conclusion: A novel structural and synovial hand joint scoring system was capable of distinguishing OA and healthy controls from RA subjects in this pilot evaluation. Prospective validation of this approach is planned.
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Affiliation(s)
- Gary A Kunkel
- George E. Wahlen VA Medical Center, Division of Rheumatology, University of Utah School of Medicine, USA
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Hung M, Nickisch F, Beals TC, Greene T, Clegg DO, Saltzman CL. New paradigm for patient-reported outcomes assessment in foot & ankle research: computerized adaptive testing. Foot Ankle Int 2012; 33:621-6. [PMID: 22995227 DOI: 10.3113/fai.2012.0621] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [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: 02/01/2023]
Abstract
BACKGROUND Accurately measuring, reporting and comparing outcomes is essential for improving health care delivery. Current challenges with available health status scales include patient fatigue, floor/ceiling effects and validity/reliability. METHODS This study compared Patient Reported Outcomes Measurement Information System (PROMIS)-based Lower Extremity Physical Function Computerized Adaptive Test (LE CAT) and two legacy scales -the Foot and Function Index (FFI) and the sport module from the Foot and Ankle Ability Measure (spFAAM) -for 287 patients scheduled for elective foot and ankle surgery. We documented the time required by patients to complete the instrument, instrument precision, and the extent to which each instrument covered the full range of physical functioning across the patient sample. RESULTS Average time of test administration: 66 seconds for LE CAT, 130 seconds for spFAAM and 239 seconds for FFI. All three instruments were fairly precise at intermediate physical functioning levels (i.e., Standard Error of Measurement < 0.35), were relatively less precise at the higher trait levels and the LE CAT maintained precision in the lower range while the spFAAM and FFI's had decreased precision. The LE CAT had less floor/ceiling effects than the FFI and the spFAAM. CONCLUSION The LE CAT showed considerable advantage compared to legacy scales for measuring patient-reported outcomes in orthopaedic patients with foot and ankle problems. CLINICAL RELEVANCE A paradigm shift to broader use of PROMIS-based CATs should be considered to improve precision and reduce patient burden with patient-reported outcome measuremen foot and ankle patients.
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Affiliation(s)
- Man Hung
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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Deodhar A, Clegg DO. Management of Ankylosing Spondylitis: What Is Known; What Is Not Known? Am J Med Sci 2012. [DOI: 10.1016/s0002-9629(15)30959-9] [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: 11/29/2022]
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Hung M, Clegg DO, Greene T, Weir C, Saltzman CL. A lower extremity physical function computerized adaptive testing instrument for orthopaedic patients. Foot Ankle Int 2012; 33:326-35. [PMID: 22735205 DOI: 10.3113/fai.2012.0326] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [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: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to develop a lower extremity (LE) physical function computerized adaptive testing (CAT) instrument based on Patient Reported Outcomes Measurement Information System (PROMIS) physical function items. METHODS The PROMIS physical function item bank was administered to adult outpatient orthopaedic patients. Three hundred eighty-two patients presenting with LE disorders were analyzed using item response theory modeling. A LE physical function item bank was developed by distilling relevant and psychometrically sound items from the full PROMIS physical function bank. Real data CAT simulations were conducted to examine specifications for a live CAT. RESULTS The LE physical function item bank was sufficiently unidimensional and free of item bias. It demonstrated high reliability along with content and construct validity. The flexible length LE CAT was highly correlated with the full LE instrument and showed uniformly high precision across the entire measurement continuum. The average CAT length was 6 to 7 items when standard error of measurement was 0.3 or less. CONCLUSION This LE physical function CAT is a valid, reliable and feasible physical function assessment tool for orthopaedic patients with LE problems that has the potential to reduce patient burden as well as administrative costs associated with data collection.
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Gossec L, Paternotte S, Bingham CO, Clegg DO, Coste P, Conaghan PG, Davis AM, Giacovelli G, Gunther KP, Hawker G, Hochberg MC, Jordan JM, Katz JN, Kloppenburg M, Lanzarotti A, Lim K, Lohmander LS, Mahomed NN, Maillefert JF, Manno RL, March LM, Mazzuca SA, Pavelka K, Punzi L, Roos EM, Rovati LC, Shi H, Singh JA, Suarez-Almazor ME, Tajana-Messi E, Dougados M. OARSI/OMERACT initiative to define states of severity and indication for joint replacement in hip and knee osteoarthritis. An OMERACT 10 Special Interest Group. J Rheumatol 2012; 38:1765-9. [PMID: 21807799 DOI: 10.3899/jrheum.110403] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To define pain and physical function cutpoints that would, coupled with structural severity, define a surrogate measure of "need for joint replacement surgery," for use as an outcome measure for potential structure-modifying interventions for osteoarthritis (OA). METHODS New scores were developed for pain and physical function in knee and hip OA. A cross-sectional international study in 1909 patients was conducted to define data-driven cutpoints corresponding to the orthopedic surgeons' indication for joint replacement. A post hoc analysis of 8 randomized clinical trials (1379 patients) evaluated the prevalence and validity of cutpoints, among patients with symptomatic hip/knee OA. RESULTS In the international cross-sectional study, there was substantial overlap in symptom levels between patients with and patients without indication for joint replacement; indeed, it was not possible to determine cutpoints for pain and function defining this indication. The post hoc analysis of trial data showed that the prevalence of cases that combined radiological progression, high level of pain, and high degree of function impairment was low (2%-12%). The most discriminatory cutpoint to define an indication for joint replacement was found to be [pain (0-100) + physical function (0-100) > 80]. CONCLUSION These results do not support a specific level of pain or function that defines an indication for joint replacement. However, a tentative cutpoint for pain and physical function levels is proposed for further evaluation. Potentially, this symptom level, coupled with radiographic progression, could be used to define "nonresponders" to disease-modifying drugs in OA clinical trials.
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Affiliation(s)
- Laure Gossec
- Paris Descartes University, Medicine Faculty, Paris, France
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Hung M, Clegg DO, Greene T, Saltzman CL. Evaluation of the PROMIS physical function item bank in orthopaedic patients. J Orthop Res 2011; 29:947-53. [PMID: 21437962 DOI: 10.1002/jor.21308] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [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] [Received: 07/08/2010] [Accepted: 10/18/2010] [Indexed: 02/04/2023]
Abstract
The patient-reported outcomes measurement information system (PROMIS) physical function item bank v1 (PPFIB) contains 124 item response theory (IRT) calibrated items (Rose et al. 2008. J Clin Epidemiol 61:17–33).We report the psychometric properties of these items within an outpatient, orthopaedic patient population. In particular, we investigated whether a single unidimensional IRT scale can adequately define physical function of patients presenting with primarily upper or lower extremity orthopaedic complaints. We conducted a prospective study at an orthopaedic outpatient clinic to collect data from 865 adult patients with all 124 PROMIS physical function items and seven demographic items. Items were evaluated by a Rasch model. Total variance (60.6%) across the 124 items was explained by a single Rasch dimension. The variance explained by the second dimension was 7.7%, reflecting differential item functioning in the upper and lower extremity patients. The upper extremity physical function items had a pronounced ceiling effect. A single physical function dimension accounts for most of the item variance in the PPFIB, suggesting that the items are measuring predominantly one single construct. Separate subscales for lower versus upper extremities, especially with additional items at the upper trait level of the upper extremity subscale, may further enhance evaluation of physical function in orthopaedic patients.
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Affiliation(s)
- Man Hung
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA.
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Weisman M, Learch TJ, Baraliakos X, Chandran V, Gladman DD, Raychaudhuri SP, Xu H, Collantes-Estévez E, Vázquez-Mellado J, Mease PJ, Sieper J, Deodhar AA, Colbert RA, Clegg DO. Current controversies in spondyloarthritis: SPARTAN. J Rheumatol 2011; 37:2617-23. [PMID: 21123334 DOI: 10.3899/jrheum.100890] [Citation(s) in RCA: 10] [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: 01/22/2023]
Abstract
The Spondyloarthritis Research and Therapy Network (SPARTAN), founded in 2003 to promote research, education, and treatment of ankylosing spondylitis (AS) and related forms of spondyloarthritis (SpA), held its 7th Annual Research and Education Meeting in July 2009 in Houston, Texas. Current controversies in SpA discussed during the meeting included an update on the epidemiology of AS, axial SpA, and inflammatory back pain; the adequacy of the mSASS to assess radiographic involvement; the helpfulness of magnetic resonance imaging in assessing disease progression; the reliability of metrology in assessing damage; and whether biologic agents alter the course of AS. Presentations also were made on psoriasis in the SCID mouse model; the challenges and opportunities of SpA in China; a discussion of the special needs in managing SpA in Ibero-America, and the SPARK Survey in Europe and North America.
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Reveille JD, Clegg DO. Prologue: 2009 Joint Meeting of Spondyloarthritis Research and Therapy Network (SPARTAN) and International Genetics of Ankylosing Spondylitis (IGAS). J Rheumatol 2011; 37:2604-5. [PMID: 21123332 DOI: 10.3899/jrheum.100888] [Citation(s) in RCA: 4] [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: 10/18/2022]
Abstract
In July 2009, a 3-day conference was held in Houston, Texas, USA, by members of several groups: the Spondyloarthritis Research and Therapy Network (SPARTAN); the International Genetics of Ankylosing Spondylitis (IGAS); and interested members of the Pan American League of Associations of Rheumatology (PANLAR). The purpose of this meeting was to bring together physician scientists, clinicians, and educators from around the world who are working together to improve their understanding of spondyloarthritis (SpA). In addition to the annual educational and Fellows sessions for SPARTAN members, the conference included a one-day international meeting dedicated to the role of HLA-B27, along with a series of sessions that summarized advances among various collaborative groups and defined opportunities for future genetic initiatives. This supplement provides a review of the SPARTAN and IGAS meetings.
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Sawitzke AD, Shi H, Finco MF, Dunlop DD, Harris CL, Singer NG, Bradley JD, Silver D, Jackson CG, Lane NE, Oddis CV, Wolfe F, Lisse J, Furst DE, Bingham CO, Reda DJ, Moskowitz RW, Williams HJ, Clegg DO. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis 2010; 69:1459-64. [PMID: 20525840 DOI: 10.1136/ard.2009.120469] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Knee osteoarthritis (OA) is a major cause of pain and functional limitation in older adults, yet longer-term studies of medical treatment of OA are limited. OBJECTIVE To evaluate the efficacy and safety of glucosamine and chondroitin sulphate (CS), alone or in combination, as well as celecoxib and placebo on painful knee OA over 2 years. METHODS A 24-month, double-blind, placebo-controlled study, conducted at nine sites in the US ancillary to the Glucosamine/chondroitin Arthritis Intervention Trial, enrolled 662 patients with knee OA who satisfied radiographic criteria (Kellgren/Lawrence grade 2 or 3 changes and baseline joint space width of at least 2 mm). This subset continued to receive their randomised treatment: glucosamine 500 mg three times daily, CS 400 mg three times daily, the combination of glucosamine and CS, celecoxib 200 mg daily, or placebo over 24 months. The primary outcome was a 20% reduction in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain over 24 months. Secondary outcomes included an Outcome Measures in Rheumatology/Osteoarthritis Research Society International response and change from baseline in WOMAC pain and function. RESULTS Compared with placebo, the odds of achieving a 20% reduction in WOMAC pain were celecoxib: 1.21, glucosamine: 1.16, combination glucosamine/CS: 0.83 and CS alone: 0.69, and were not statistically significant. CONCLUSIONS Over 2 years, no treatment achieved a clinically important difference in WOMAC pain or function as compared with placebo. However, glucosamine and celecoxib showed beneficial but not significant trends. Adverse reactions were similar among treatment groups and serious adverse events were rare for all treatments.
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Affiliation(s)
- Allen D Sawitzke
- University of Utah School of Medicine, 30E 1900 S SOM 4B200, Salt Lake City UT 84132, USA.
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Weisman MH, Chen L, Clegg DO, Davis JC, Dubois RW, Prete PE, Savage LM, Schafer L, Suarez-Almazor ME, Yu HT, Reveille JD. Development and validation of a case ascertainment tool for ankylosing spondylitis. Arthritis Care Res (Hoboken) 2010; 62:19-27. [PMID: 20191487 DOI: 10.1002/acr.20009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ankylosing spondylitis (AS) diagnosis is often delayed. The availability of effective biologic agents for treating AS has increased the importance of early diagnosis. We tested questions derived from a comprehensive literature review and an advisory board in a case-control study designed to identify patients with AS from among patients with chronic back pain (CBP). METHODS Question items were cognitively tested among patients with AS, and then in case-control studies for validation and creation of a scoring algorithm and question item reduction. AS cases were recruited from a known database, and CBP subjects (controls) were recruited from clinics, employers, and from the SpineUniverse Web site. We used individual question items in a multivariate framework to discriminate between people with and without AS. RESULTS Forty-three questions yielded 24 items for analyses; 12 of these were entered into a multivariate regression model. Individual items yielded odds ratios ranging from 0.07 to 30.31. Question items with a significant positive relationship to AS included male sex, neck or hip pain/stiffness, longer pain duration, decreased pain/stiffness with daily physical activity, pain relief within 48 hours of nonsteroidal antiinflammatory drugs, and diagnosis of iritis. The tool demonstrated a sensitivity of 67.4 and a specificity of 94.6. The tool was developed from clinically and radiologically diagnosed AS cases and therefore is designed to distinguish AS cases among CBP subjects. In addition, approximately 54% of the AS cases in the study were treated with biologic agents, which may impact questionnaire responses. CONCLUSION This tool can identify undiagnosed patients with AS and, potentially, those at an earlier stage in their disease course.
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Jackson CG, Plaas AH, Sandy JD, Hua C, Kim-Rolands S, Barnhill JG, Harris CL, Clegg DO. The human pharmacokinetics of oral ingestion of glucosamine and chondroitin sulfate taken separately or in combination. Osteoarthritis Cartilage 2010; 18:297-302. [PMID: 19912983 PMCID: PMC2826597 DOI: 10.1016/j.joca.2009.10.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [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: 06/19/2009] [Revised: 10/09/2009] [Accepted: 10/23/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVE As part of the National Institutes of Health (NIH)-sponsored Glucosamine/Chondroitin sulfate Arthritis Intervention Trial (GAIT) our objective here was to examine (1) the pharmacokinetics (PK) of glucosamine (GlcN) and chondroitin sulfate (CS) when taken separately or in combination as a single dose in normal individuals (n=29) and (2) the PK of GlcN and CS when taken as a single dose after 3 months daily dosing with GlcN, CS or GlcN+CS, in patients with symptomatic knee pain (n=28). METHODS The concentration of GlcN in the circulation was determined by established fluorophore-assisted carbohydrate electrophoresis (FACE) methods. The hydrodynamic size and disaccharide composition of CS chains in the circulation and dosage samples was determined by Superose 6 chromatography and FACE. RESULTS We show that circulating levels of CS in human plasma are about 20 microg/ml. Most significantly, the endogenous concentration and CS disaccharide composition were not detectably altered by ingestion of CS, when the CS was taken alone or in combination with GlcN. On the other hand, the Cmax (single-dose study) and AUC values (multiple-dose study) for ingested GlcN were significantly reduced by combination dosing with CS, relative to GlcN dosing alone. CONCLUSIONS We conclude that pain relief perceived following ingestion of CS probably does not depend on simultaneous or prior intake of GlcN. Further, such effects on joint pain, if present, probably do not result from ingested CS reaching the joint space but may result from changes in cellular activities in the gut lining or in the liver, where concentrations of ingested CS, or its breakdown products, could be substantially elevated following oral ingestion. Moreover, since combined dosing of GlcN with CS was found to reduce the plasma levels seen with GlcN dosing alone, any improved pain relief by combination dosing cannot be explained by higher circulating concentrations of GlcN.
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Affiliation(s)
- C G Jackson
- University of Utah School of Medicine, Salt Lake City, UT, USA
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Colbert RA, Deodhar AA, Fox D, Gravallese EM, Khan MA, McGonagle D, Reveille JD, Schett G, Weisman M, Clegg DO. Entheses and bones in spondyloarthritis: 2008 Annual Research and Education Meeting of the Spondyloarthritis Research and Therapy Network (SPARTAN). J Rheumatol 2009; 36:1527-31. [PMID: 19567633 DOI: 10.3899/jrheum.090122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The Spondyloarthritis Research and Therapy Network (SPARTAN), founded in 2003 to promote research, education, and treatment of ankylosing spondylitis (AS) and related forms of spondyloarthritis (SpA), held its 6th Annual Research and Education Meeting in July 2008 in Cleveland, Ohio, USA. The overall theme of the meeting was entheses and bones in SpA, which included presentations on the anatomy and physiology of the synovial-entheseal complex; bone formation and destruction, and the effect of inflammation on bone; the Th17 axis, HLA-B27, IL23R, and ARTS1; and breakout sessions on epidemiology and registries.
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Sawitzke AD, Shi H, Finco MF, Dunlop DD, Bingham CO, Harris CL, Singer NG, Bradley JD, Silver D, Jackson CG, Lane NE, Oddis CV, Wolfe F, Lisse J, Furst DE, Reda DJ, Moskowitz RW, Williams HJ, Clegg DO. The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial. ACTA ACUST UNITED AC 2008; 58:3183-91. [PMID: 18821708 DOI: 10.1002/art.23973] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Osteoarthritis (OA) of the knee causes significant morbidity and current medical treatment is limited to symptom relief, while therapies able to slow structural damage remain elusive. This study was undertaken to evaluate the effect of glucosamine and chondroitin sulfate (CS), alone or in combination, as well as celecoxib and placebo on progressive loss of joint space width (JSW) in patients with knee OA. METHODS A 24-month, double-blind, placebo-controlled study, conducted at 9 sites in the United States as part of the Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), enrolled 572 patients with knee OA who satisfied radiographic criteria (Kellgren/Lawrence [K/L] grade 2 or grade 3 changes and JSW of at least 2 mm at baseline). Patients with primarily lateral compartment narrowing at any time point were excluded. Patients who had been randomized to 1 of the 5 groups in the GAIT continued to receive glucosamine 500 mg 3 times daily, CS 400 mg 3 times daily, the combination of glucosamine and CS, celecoxib 200 mg daily, or placebo over 24 months. The minimum medial tibiofemoral JSW was measured at baseline, 12 months, and 24 months. The primary outcome measure was the mean change in JSW from baseline. RESULTS The mean JSW loss at 2 years in knees with OA in the placebo group, adjusted for design and clinical factors, was 0.166 mm. No statistically significant difference in mean JSW loss was observed in any treatment group compared with the placebo group. Treatment effects on K/L grade 2 knees, but not on K/L grade 3 knees, showed a trend toward improvement relative to the placebo group. The power of the study was diminished by the limited sample size, variance of JSW measurement, and a smaller than expected loss in JSW. CONCLUSION At 2 years, no treatment achieved a predefined threshold of clinically important difference in JSW loss as compared with placebo. However, knees with K/L grade 2 radiographic OA appeared to have the greatest potential for modification by these treatments.
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Affiliation(s)
- Allen D Sawitzke
- University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Colbert RA, Deodhar AA, Khan MA, Lories RJ, Maksymowych WP, Reveille JD, Ritchlin CT, Rosenbaum JT, Targan SR, Weisman M, Clegg DO. 2007 annual research and education meeting of the Spondyloarthritis Research and Therapy Network (SPARTAN). J Rheumatol 2008; 35:1398-1402. [PMID: 18484685] [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: 05/26/2023]
Abstract
The Spondyloarthritis Research and Therapy Network (SPARTAN; www.spartangroup.org) was founded in 2003 by a group of North American clinicians and researchers to promote research, education, and treatment of spondyloarthritis (SpA). In past years, it has produced and disseminated United States-specific modifications of the ASsessments in Ankylosing Spondylitis (ASAS) guidelines for the use of anti-tumor necrosis factor (TNF) therapy in AS1,2. SPARTAN held its fifth annual research meeting in September 2007 in Cleveland, Ohio. Highlights of the meeting included updates on current research in SpA, including epidemiology and genetics, bone formation and inflammation, biomarkers, activation of the IL-23/IL-17 axis, and animal models. A presentation was made on basic and clinical science of inflammatory bowel disease, and an educational pre-meeting conference was specifically designed for rheumatology fellows.
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Affiliation(s)
- Robert A Colbert
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
The Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) was a randomized double-blind placebo and active comparator (celecoxib) controlled trial of 1583 persons with symptomatic osteoarthritis (OA) of the knee(1). Patients randomized to celecoxib had significant improvement in knee pain compared to those randomized to placebo. No statistically significant improvement in knee pain compared to placebo was seen among patients randomized to the dietary supplements, although a subset of patients with moderate-to-severe knee pain at entry who were assigned to the combination of glucosamine and chondroitin sulfate did seem to experience some improvement. Additionally, patients taking chondroitin sulfate were noted to have a statistically significant improvement in knee joint swelling. An exploratory post hoc analysis of GAIT patients suggested the effect of chondroitin sulfate on joint swelling occurred more often in patients with milder pain and lower Kellgren-Lawrence Grade at entry.
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Davis JC, van der Heijde DM, Braun J, Dougados M, Clegg DO, Kivitz AJ, Fleischmann RM, Inman RD, Ni L, Lin SL, Tsuji WH. Efficacy and safety of up to 192 weeks of etanercept therapy in patients with ankylosing spondylitis. Ann Rheum Dis 2007; 67:346-52. [DOI: 10.1136/ard.2007.078139] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [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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Khan MA, Clegg DO, Deodhar AA, Gabriel S, Gaston JSH, Hirsch R, Ostergaard M, Reveille JD, Turkiewicz AM, Weisman MH, Davis JC. 2006 annual research and education meeting of the Spondyloarthritis Research and Therapy Network (SPARTAN). J Rheumatol 2007; 34:1118-24. [PMID: 17444582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Muhammad Asim Khan
- Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio 44109-1998, USA.
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Abstract
Osteoarthritis (OA) treatment is limited by the inability of prescribed medications to alter disease outcome. As a result, patients with OA often take food substances called nutraceuticals in an attempt to affect the structural changes that occur within a degenerating joint. The role of nutraceuticals in OA management can be defined only by an evidence-based approach to support their use. This paper reviews the clinical trials studying glucosamine, chondroitin sulfate, vitamin C, vitamin E, and avocado-soybean unsaponifiables. It highlights the need for additional randomized, placebo-controlled trials to further define the utility of nutraceuticals in OA treatment.
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Affiliation(s)
- Tracy M Frech
- Division of Rheumatology, University of Utah School of Medicine, George E. Wahlen Veterans Affairs Medical Center, 4B200 School of Medicine, 50 North Medical Drive, Salt Lake, UT 84132, USA
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Clegg DO. Treatment of ankylosing spondylitis. J Rheumatol Suppl 2006; 78:24-31. [PMID: 17042057] [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: 05/12/2023]
Abstract
Ankylosing spondylitis (AS) is a condition characterized by inflammatory back pain and associated with considerable disability and diminished quality of life in affected individuals. The condition is undertreated in part due to a delay in diagnosis and limited therapeutic interventions. Although traditional treatment approaches (physical therapy, exercise, patient education, nonsteroidal antiinflammatory drugs) remain important components of the management of AS, the demonstrated efficacy of tumor necrosis factor-a (TNF-a) antagonists such as etanercept and infliximab have allowed clinicians to more effectively manage this condition. These targeted therapies have demonstrated rapid and consistent effectiveness in reducing the axial and peripheral symptoms of AS, slowing disease progression, and improving patient function and quality of life. Appropriate and timely use of TNF-a antagonists offers additional options for patients with active AS who are inadequately controlled with conventional treatment.
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Affiliation(s)
- Daniel O Clegg
- Rheumatology Section, Salt Lake City Veterans Health Care System, University of Utah School of Medicine, USA.
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Inman RD, Clegg DO, Davis JC, Whitmore JB, Solinger A. Etanercept in adult patients with early onset ankylosing spondylitis. J Rheumatol 2006; 33:1634-6. [PMID: 16881118] [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: 05/11/2023]
Abstract
OBJECTIVE To determine whether twice-weekly subcutaneous etanercept improves the signs and symptoms of adult patients with early onset ankylosing spondylitis (AS). METHODS A retrospective analysis was performed on a subgroup of patients with AS with onset < 18 years of age from a multicenter, double-blind, placebo-controlled, randomized study of etanercept in the treatment of patients with AS. Twenty patients met criteria and are presented. RESULTS As early as week four, 5/9 (56%) patients who received etanercept achieved an Assessments in Ankylosing Spondylitis 20% response (ASAS 20) versus only 1/11 (9%) of those who received placebo (p = 0.032). The observed ASAS 20 response continued through week 24, with 6/9 (66%) patients receiving etanercept responding, versus 2/11 of patients receiving placebo (p = 0.025). CONCLUSION Etanercept improves signs and symptoms of early onset AS in adult patients for at least 24 weeks.
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Barnhill JG, Fye CL, Williams DW, Reda DJ, Harris CL, Clegg DO. Chondroitin product selection for the glucosamine/chondroitin arthritis intervention trial. J Am Pharm Assoc (2003) 2006; 46:14-24. [PMID: 16529337 DOI: 10.1331/154434506775268616] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [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: 11/23/2022]
Abstract
OBJECTIVE To select a high-quality chondroitin dosage form and/or an appropriate source of sodium chondroitin for the National Institutes of Health's Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). DESIGN Controlled experimental trials. SETTING Laboratory. PATIENTS OR PARTICIPANTS Not applicable. INTERVENTIONS Commercially available chondroitin products were reviewed, and purified sodium chondroitin from two suppliers was evaluated through tests (infrared and near-infrared identification, moisture content, pH, optical rotation, color and clarity of aqueous solutions prepared from the powders, protein contamination, total residue following ignition and nitrogen content, determination of sodium chondroitin molecular weight, disaccharide analysis, and measurement of chondroitin, sodium, and total glycosaminoglycan content) and an onsite supplier audit. MAIN OUTCOME MEASURES Purity, potency, and quality of sodium chondroitin powders. RESULTS No commercially available chondroitin product was deemed appropriate for use in GAIT. Samples of sodium chondroitin powder from two suppliers exhibited similar disaccharide and glycosaminoglycan content. Each contained approximately 2% hyaluronic acid and 8%-9% unsulfated disaccharide. Potency was inconsistent across groups, which might have resulted from different analytical methods and choice of reference standard. Mean potency obtained by five separate methods ranged from 82.2% to 95.5% for one supplier, 92.5% to 110.1% for another, and 95.1% to 112.5% for a commercially obtained reference standard. Critical issues raised by the results include choice of reference standard, selection of assay method, and the consistent appearance of an unidentifiable contaminant present in all three lots from one supplier. CONCLUSION This blinded study determined methods to identify acceptable agents and provided results, which, in addition to regulatory compliance supplier audits, formed the basis for chondroitin product selection in GAIT.
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Affiliation(s)
- Jamie G Barnhill
- Biopharmaceutics/Pharmacokinetics Laboratory, VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, 2401 Centre Ave., SE, Albuquerque, NM 87106, USA.
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Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, Bradley JD, Bingham CO, Weisman MH, Jackson CG, Lane NE, Cush JJ, Moreland LW, Schumacher HR, Oddis CV, Wolfe F, Molitor JA, Yocum DE, Schnitzer TJ, Furst DE, Sawitzke AD, Shi H, Brandt KD, Moskowitz RW, Williams HJ. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006; 354:795-808. [PMID: 16495392 DOI: 10.1056/nejmoa052771] [Citation(s) in RCA: 725] [Impact Index Per Article: 40.3] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Glucosamine and chondroitin sulfate are used to treat osteoarthritis. The multicenter, double-blind, placebo- and celecoxib-controlled Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) evaluated their efficacy and safety as a treatment for knee pain from osteoarthritis. METHODS We randomly assigned 1583 patients with symptomatic knee osteoarthritis to receive 1500 mg of glucosamine daily, 1200 mg of chondroitin sulfate daily, both glucosamine and chondroitin sulfate, 200 mg of celecoxib daily, or placebo for 24 weeks. Up to 4000 mg of acetaminophen daily was allowed as rescue analgesia. Assignment was stratified according to the severity of knee pain (mild [N=1229] vs. moderate to severe [N=354]). The primary outcome measure was a 20 percent decrease in knee pain from baseline to week 24. RESULTS The mean age of the patients was 59 years, and 64 percent were women. Overall, glucosamine and chondroitin sulfate were not significantly better than placebo in reducing knee pain by 20 percent. As compared with the rate of response to placebo (60.1 percent), the rate of response to glucosamine was 3.9 percentage points higher (P=0.30), the rate of response to chondroitin sulfate was 5.3 percentage points higher (P=0.17), and the rate of response to combined treatment was 6.5 percentage points higher (P=0.09). The rate of response in the celecoxib control group was 10.0 percentage points higher than that in the placebo control group (P=0.008). For patients with moderate-to-severe pain at baseline, the rate of response was significantly higher with combined therapy than with placebo (79.2 percent vs. 54.3 percent, P=0.002). Adverse events were mild, infrequent, and evenly distributed among the groups. CONCLUSIONS Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain. (ClinicalTrials.gov number, NCT00032890.).
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Affiliation(s)
- Daniel O Clegg
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Davis JC, Van der Heijde DMFM, Dougados M, Braun J, Cush JJ, Clegg DO, Inman RD, de Vries T, Tsuji WH. Baseline factors that influence ASAS 20 response in patients with ankylosing spondylitis treated with etanercept. J Rheumatol 2005; 32:1751-4. [PMID: 16142873] [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: 05/04/2023]
Abstract
OBJECTIVE To examine the baseline demographic and disease characteristics that might influence improvement as measured by the Assessment in Ankylosing Spondylitis Response Criteria (ASAS 20) in patients with ankylosing spondylitis (AS). METHODS A multicenter Phase 3 study was performed to compare the safety and efficacy of 24 weeks of etanercept 25 mg subcutaneous injection twice weekly (n = 138) and placebo (n = 139) in patients with AS. The ASAS 20 was measured at multiple time points. Using a significance level of 0.05, a repeated measures logistic regression model was used to determine which baseline factors influenced response in the etanercept-treated patients during the 24-week double blind portion of the trial. The following baseline factors were used in the model: demographic and disease severity variables, concomitant medications, extra-articular manifestations, and HLA-B27 status. The predictive capability of the model was then tested on the patients receiving placebo after they had received open-label etanercept treatment. RESULTS Baseline factors that were significant predictors of an ASAS 20 response in etanercept-treated patients were C-reactive protein (CRP), back pain score, and Bath Ankylosing Spondylitis Functional Index (BASFI) score. Although clinical response to etanercept was seen at all levels of baseline disease activity, responses were consistently more likely with higher CRP levels or back pain scores and less likely with increased BASFI scores at baseline. CONCLUSIONS Higher CRP values and back pain scores and lower BASFI scores at baseline were significant predictors of a higher ASAS 20 response in patients with AS receiving etanercept but predictive value was of insufficient magnitude to determine treatment in individual patients.
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Affiliation(s)
- John C Davis
- Division of Rheumatology, University of California, San Francisco 94143-0633, USA.
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Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) and traditional disease modifying antirheumatic drugs (DMARDs) are widely used in the treatment of psoriatic arthritis (PsA), but this is based more upon clinical experience than adequate evidence from clinical trials. This report summarises the results from available trials highlighting evidence of efficacy and deficiencies with respect to effect on joints and to a lesser degree cutaneous disease. The available published data on efficacy of NSAIDs, glucocorticoids, antimalarials, sulfasalazine, gold, methotrexate, azathioprine, and ciclosporin are detailed, as well as new data on leflunomide and other novel agents. The conclusions of this review are that evidence supports marginal efficacy of sulfasalazine and perhaps gold in the treatment of peripheral psoriatic arthropathy, and methotrexate and ciclosporin are effective for treating the skin disease although evidence for improvement of the arthropathy is empirical at best. New trials with standardised and validated outcome measures are required to better assess efficacy. Evaluating newer agents, against and in combination with traditional DMARDS, may further clarify the latter's role in the future management of this condition.
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Affiliation(s)
- P Nash
- Rheumatology Research Unit, Nambour Hospital, Sunshine Coast, University of Queensland, Australia.
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Davis JC, Van Der Heijde D, Braun J, Dougados M, Cush J, Clegg DO, Kivitz A, Fleischmann R, Inman R, Tsuji W. Recombinant human tumor necrosis factor receptor (etanercept) for treating ankylosing spondylitis: a randomized, controlled trial. ACTA ACUST UNITED AC 2003; 48:3230-6. [PMID: 14613288 DOI: 10.1002/art.11325] [Citation(s) in RCA: 505] [Impact Index Per Article: 24.0] [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: 02/06/2023]
Abstract
OBJECTIVE To determine the safety and efficacy of etanercept in a multicenter, randomized, placebo-controlled, double-blind trial of adults with moderate to severe active ankylosing spondylitis (AS). METHODS Patients (n = 277) were treated with either etanercept 25 mg (n = 138) or placebo (n = 139) subcutaneously twice weekly for 24 weeks. The primary outcome measures were the percentages of patients achieving the Assessments in Ankylosing Spondylitis 20% response (ASAS20) at weeks 12 and 24. Other outcome measures included the percentage of patients achieving higher ASAS responses, and the safety of etanercept in patients with AS. All outcome measures were assessed at 2, 4, 8, 12, and 24 weeks. RESULTS Treatment with etanercept resulted in dramatic improvement. The ASAS20 was achieved by 59% of patients in the etanercept group and by 28% of patients in the placebo group (P < 0.0001) at week 12, and by 57% and 22% of patients, respectively, at week 24 (P < 0.0001). All individual ASAS components, acute-phase reactant levels, and spinal mobility measures were also significantly improved. The safety profile of etanercept was similar to that reported in studies of patients with rheumatoid arthritis or psoriatic arthritis. The only adverse events that occurred significantly more often in the etanercept group were injection-site reactions, accidental injuries, and upper respiratory tract infections. CONCLUSION Etanercept is a highly effective and well tolerated treatment in patients with active AS.
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Affiliation(s)
- John C Davis
- University of California, San Francisco, CA 94143, USA.
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Sawitzke A, Clegg DO. Tumor necrosis factor inhibitors "SPARCC" an interest in consensus. J Rheumatol 2003; 30:1127-9. [PMID: 12784378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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Jawaheer D, Seldin MF, Amos CI, Chen WV, Shigeta R, Etzel C, Damle A, Xiao X, Chen D, Lum RF, Monteiro J, Kern M, Criswell LA, Albani S, Nelson JL, Clegg DO, Pope R, Schroeder HW, Bridges SL, Pisetsky DS, Ward R, Kastner DL, Wilder RL, Pincus T, Callahan LF, Flemming D, Wener MH, Gregersen PK. Screening the genome for rheumatoid arthritis susceptibility genes: a replication study and combined analysis of 512 multicase families. Arthritis Rheum 2003; 48:906-16. [PMID: 12687532 DOI: 10.1002/art.10989] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A number of non-HLA loci that have shown evidence (P < 0.05) for linkage with rheumatoid arthritis (RA) have been previously identified. The present study attempts to confirm these findings. METHODS We performed a second genome-wide screen of 256 new multicase RA families recruited from across the United States by the North American Rheumatoid Arthritis Consortium. Affected sibling pair analysis on the new data set was performed using SIBPAL. We subsequently combined our first and second data sets in an attempt to enhance the evidence for linkages in a larger sample size. We also evaluated the impact of covariates on the support for linkage, using LODPAL. RESULTS Evidence of linkage at 1p13 (D1S1631), 6p21.3 (the HLA complex), and 18q21 (D18S858) (P < 0.05) was replicated in this independent data set. In addition, there was new evidence for linkage at 9p22 (D9S1121 [P = 0.001]) and 10q21 (D10S1221 [P = 0.0002] and D10S1225 [P = 0.0038]) in the current data set. The combined analysis of both data sets (512 families) showed evidence for linkage at the level of P < 0.005 at 1p13 (D1S1631), 1q43 (D1S235), 6q21 (D6S2410), 10q21 (D10S1221), 12q12 (D12S398), 17p13 (D17S1298), and 18q21 (D18S858). Linkage at HLA was also confirmed (P < 5 x 10(-12)). Inclusion of DRB1*04 as a covariate significantly increased the probability of linkage on chromosome 6. In addition, some linkages on chromosome 1 showed improved significance when modeling DRB1*04 or rheumatoid factor positivity as covariates. CONCLUSION These results provide a rational basis for pursuing high-density linkage and association studies of RA in several regions outside of the HLA region, particularly on chromosomes 1p, 1q, and 18q.
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Affiliation(s)
- Damini Jawaheer
- Center for Genomics and Human Genetics, Manhasset, New York 11030, USA
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van der Horst-Bruinsma IE, Clegg DO, Dijkmans BAC. Treatment of ankylosing spondylitis with disease modifying antirheumatic drugs. Clin Exp Rheumatol 2002; 20:S67-70. [PMID: 12463451] [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: 02/27/2023]
Abstract
Ankylosing spondylitis (AS) is a common (prevalence 0.2-0.9%) chronic inflammatory disease that mainly affects young males and is characterised by inflammatory back pain with sacroiliitis and often arthritis of the peripheral joints. The disease can lead to deformities of the vertebral column, joints and extra-spinal structures, e.g. the eye (uveitis). Non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy seem to improve the long-term outcome of AS. However, the effect of disease modifying antirheumatic drugs (DMARDs) is less impressive compared with other rheumatic diseases, such as rheumatoid arthritis (RA). In placebo controlled trials, sulfasalazine showed some improvement of disease activity, especially in spondyloarthropathy patients with peripheral arthritis. Altogether the number of therapeutic options for AS is limited and other drugs, such as leflunomide or thalidomide, should be explored further in placebo-controlled trials.
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Silas S, Clegg DO. Selective COX-2 inhibition. Bull Rheum Dis 2002; 48:1-4. [PMID: 12024416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Affiliation(s)
- S Silas
- University of Utah School of Medicine, Salt Lake City, UT, USA
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