Association of high disease activity and serum IL-6 levels with the incidence of inflammatory major organ events in Behçet disease: a prospective registry study

Background

Little is known about the relationship between the disease activity of Behçet disease (BD) and the incidence of inflammatory major organ events.

Objectives

In this prospective registry study, we investigated the association between the Behçet Disease Current Activity Form (BDCAF) and incidence of inflammatory major organ events, defined as the inflammation of the ocular, central nervous, intestinal, and vascular systems in BD.

Methods

We enrolled participants from Japanese multicenter prospective cohorts. The BDCAF was evaluated annually. BD-related symptoms, including inflammatory major organ events, were monitored. The association between BDCAF and inflammatory major organ events was analyzed by time-to-event analysis. An unsupervised clustering of the participants' BDCAF, therapeutic agents, and multiple serum cytokines was also performed to examine their association with inflammatory major organ events.

Results

A total of 260 patients were included. The patients had a median BDCAF score of 2 [Interquartile range, 1-3] at the enrolment and remained disease active at 1- and 2-year follow-ups, indicating residual disease activity in BD. Patients with a BDCAF score of 0 had a longer inflammatory major organ event-free survival at 52 weeks than those with a score of 1 or higher (p=2.2 x 10-4). Clustering analysis revealed that patients who did not achieve remission despite treatment with tumor necrosis factor inhibitors had high serum inflammatory cytokine levels and incidences of inflammatory major organ events. Among the elevated cytokines, IL-6 was associated with inflammatory major organ events.

Conclusion

This study suggests that treatment strategies targeting overall disease activity and monitoring residual serum IL-6 may help prevent inflammatory major organ events in BD.

Predictors of treatment switching in the Big Multiple Sclerosis Data Network

Background

Treatment switching is a common challenge and opportunity in real-world clinical practice. Increasing diversity in disease-modifying treatments (DMTs) has generated interest in the identification of reliable and robust predictors of treatment switching across different countries, DMTs, and time periods.

Objective

The objective of this retrospective, observational study was to identify independent predictors of treatment switching in a population of relapsing-remitting MS (RRMS) patients in the Big Multiple Sclerosis Data Network of national clinical registries, including the Italian MS registry, the OFSEP of France, the Danish MS registry, the Swedish national MS registry, and the international MSBase Registry.

Methods

In this cohort study, we merged information on 269,822 treatment episodes in 110,326 patients from 1997 to 2018 from five clinical registries. Patients were included in the final pooled analysis set if they had initiated at least one DMT during the relapsing-remitting MS (RRMS) stage. Patients not diagnosed with RRMS or RRMS patients not initiating DMT therapy during the RRMS phase were excluded from the analysis. The primary study outcome was treatment switching. A multilevel mixed-effects shared frailty time-to-event model was used to identify independent predictors of treatment switching. The contributing MS registry was included in the pooled analysis as a random effect.

Results

Every one-point increase in the Expanded Disability Status Scale (EDSS) score at treatment start was associated with 1.08 times the rate of subsequent switching, adjusting for age, sex, and calendar year (adjusted hazard ratio [aHR] 1.08; 95% CI 1.07-1.08). Women were associated with 1.11 times the rate of switching relative to men (95% CI 1.08-1.14), whilst older age was also associated with an increased rate of treatment switching. DMTs started between 2007 and 2012 were associated with 2.48 times the rate of switching relative to DMTs that began between 1996 and 2006 (aHR 2.48; 95% CI 2.48-2.56). DMTs started from 2013 onwards were more likely to switch relative to the earlier treatment epoch (aHR 8.09; 95% CI 7.79-8.41; reference = 1996-2006).

Conclusion

Switching between DMTs is associated with female sex, age, and disability at baseline and has increased in frequency considerably in recent years as more treatment options have become available. Consideration of a patient's individual risk and tolerance profile needs to be taken into account when selecting the most appropriate switch therapy from an expanding array of treatment choices.

Characterization of patients with psoriatic arthritis in dermatologic and rheumatologic care: analysis of two registries

BACKGROUND AND OBJECTIVE

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disease affecting the musculoskeletal system, skin and nails. The aim is to characterize sociodemographic and clinical patient profiles documented in dermatologic and rheumatologic care.

PATIENTS AND METHODS

Data of 704 patients with PsA from the dermatological Psoriasis Registry PsoBest (PB) and 1066 patients from the rheumatological disease registry RABBIT-SpA (RS) were analyzed. Comparable anamnestic and clinical variables were identified and descriptively analyzed.

RESULTS

The mean age was 51.7 years in PB and 51.9 in RS. Disease duration of psoriasis was longer, mean cutaneous severity was higher in PB. However, more patients in RS vs. PB had tender joints and swollen joints. Mean Dermatology Life Quality Index was higher in PB and mean Health Assessment Questionnaire in RS. Patient reported global disease activity and pain were lower in PB. IL-23 inhibitors were used more frequently in PB, and TNF inhibitors in RS.

CONCLUSIONS

Clinical specialization was associated with different clinical and treatment patterns of PsA. This may indicate a selection by dominant manifestation of psoriatic disease and potentially by effects of health care access. Psoriatic arthritis should be treated in a multidisciplinary approach considering all facets of this complex disease.

Charakterisierung von Patienten mit Psoriasisarthritis in der dermatologischen und rheumatologischen Versorgung: Analyse von zwei Registern: Characterization of patients with psoriatic arthritis in dermatologic and rheumatologic care: analysis of two registries

Hintergrund und Zielsetzung

Die Psoriasisarthritis (PsA) ist eine chronische systemische Entzündungskrankheit, die den Bewegungsapparat, die Haut und die Nägel betrifft. Ziel ist es, soziodemografische und klinische Patientenprofile zu charakterisieren, die in der dermatologischen und rheumatologischen Versorgung dokumentiert werden.

Patienten und Methodik

Es wurden die Daten von 704 PsA‐Patienten aus dem dermatologischen Psoriasis‐Register PsoBest (PB) und 1066 Patienten aus dem rheumatologischen Krankheitsregister RABBIT‐SpA (RS) analysiert. Vergleichbare anamnestische und klinische Variablen wurden identifiziert und deskriptiv ausgewertet.

Ergebnisse

Das Durchschnittsalter betrug 51,7 Jahre bei PB und 51,9 Jahre bei RS. Die Krankheitsdauer der Psoriasis war länger und der mittlere Schweregrad der Hauterkrankung war bei den Patienten in PB höher, jedoch hatten mehr Patienten in RS schmerzende und geschwollene Gelenke. Der mittlere Dermatology Life Quality Index war bei den Patienten in PB höher und der mittlere Health Assessment Questionnaire bei den Patienten in RS. Die von den Patienten angegebene globale Krankheitsaktivität und die Schmerzen waren in PB geringer. IL‐23‐Inhibitoren wurden in PB häufiger eingesetzt, TNF‐Inhibitoren bei RS.

Schlussfolgerungen

Die klinische Spezialisierung wurde mit unterschiedlichen Krankheitsbildern und Behandlungsmustern der PsA in Verbindung gebracht. Dies könnte auf eine Selektion nach der vorherrschenden Manifestation der Psoriasis‐Erkrankung und möglicherweise auf Auswirkungen des Zugangs zur Gesundheitsversorgung hinweisen. Die PsA sollte in einem multidisziplinären Ansatz behandelt werden, der alle Facetten dieser komplexen Erkrankung berücksichtigt.

The suitability of government health information assets for secondary use in research: A fit-for-purpose analysis

BACKGROUND

Governments have responsibility for ensuring the quality and fitness-for-purpose of personal health data provided to them. While these health information assets are used widely for research, this secondary usage has received minimal research attention.

OBJECTIVE

This study aimed to investigate the secondary uses, in research, of population health and administrative datasets (information assets) of the Department of Health (DoH), Victoria, Australia. The objectives were to (i) identify research based on these datasets published between 2008 and 2020; (ii) describe the data quality studies published between 2008 and 2020 for each dataset and (iii) evaluate "fitness-for-purpose" of the published research.

METHOD

Using a modified scoping review, research publications from 2008 to 2020 based on information assets related to health service provision and containing person-level data were reviewed. Publications were summarised by data quality and purpose-categories based on a taxonomy of data use. Fitness-for-purpose was evaluated by comparing the publicly stated purpose(s) for which each information asset was collected, with the purpose(s) assigned to the published research.

RESULTS

Of the >1000 information assets, 28 were utilised in 756 publications: 54% were utilised for general research purposes, 14% for patient safety, 10% for quality of care and 39% included data quality-related publications. Almost 85% of publications used information assets that were fit-for-purpose.

CONCLUSION

The DoH information assets were used widely for secondary purposes, with the majority identified as fit-for-purpose. We recommend that data custodians, including governments, provide information on data quality and transparency on data use of their health information assets.

The Duke Myasthenia Gravis Clinic Registry: II. Analysis of outcomes

INTRODUCTION/AIMS

The Duke Myasthenia Gravis (MG) Clinic Registry contains comprehensive physician-derived data on patients with MG seen in the Duke MG Clinic since 1980. The aim of this study was to report outcomes in patients seen in the clinic and treated according to the International Consensus Guidance statements.

METHODS

This is a retrospective cohort study of patients initially seen after 2000 and followed for at least 2 years in the clinic. Treatment goal (TG) was defined as achieving MGFA post-intervention status of "minimal manifestations" or better; PIS was determined by the treating neurologist. Time-to-event analysis, including Cox proportional hazards modeling, was performed to assess the effect of sex, acetylcholine receptor antibody (AChR-Ab) status, age at disease onset, distribution (ocular vs generalized), thymectomy, and thymoma on the time to achieve TG.

RESULTS

Among the 367 cohort patients, 72% achieved TG (median time less than 2 years). A greater proportion of patients with AChR-Abs and thymectomy achieved TG and they did so sooner than patients without these antibodies or thymectomy. Otherwise, there were no significant differences in these findings within the tested subgroups. The disease duration at the first Duke Clinic visit was shorter in patients who achieved TG than in those who did not.

DISCUSSION

These results demonstrate outcomes that can be achieved in patients with MG treated according to the current Consensus Guidance statements. Among other things, they can be used to determine the added value and potential role of new treatment modalities developed since 2018.

Towards a validated definition of the clinical transition to secondary progressive multiple sclerosis: A study from the Italian MS Register

BACKGROUND

Definitions for reliable identification of transition from relapsing-remitting multiple sclerosis (MS) to secondary progressive (SP)MS in clinical cohorts are not available.

OBJECTIVES

To compare diagnostic performances of two different data-driven SPMS definitions.

METHODS

Data-driven SPMS definitions based on a version of Lorscheider's algorithm (DDA) and on the EXPAND trial inclusion criteria were compared, using the neurologist's definition (ND) as gold standard, in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Akaike information criterion (AIC) and area under the curve (AUC).

RESULTS

A cohort of 10,240 MS patients with ⩾5 years of follow-up was extracted from the Italian MS Registry; 880 (8.5%) patients were classified as SPMS according to the neurologist definition, 1806 (17.6%) applying the DDA and 1134 (11.0%) with the EXPAND definition. The DDA showed greater discrimination power (AUC: 0.8 vs 0.6) and a higher sensitivity (77.1% vs 38.0%) than the EXPAND definition, with similar specificity (88.0% vs 91.5%). PPV and NPV were higher using the DDA than considering EXPAND definition (37.5% vs 29.5%; 97.6% vs 94.0%).

CONCLUSION

Data-driven definitions demonstrated greater ability to capture SP transition than neurologist's definition and the global accuracy of DDA seems to be higher than the EXPAND definition.

Sample size calculation for the augmented logrank test in randomized clinical trials

In randomized clinical trials, incorporating baseline covariates can improve the power in hypothesis testing for treatment effects. For survival endpoints, the Cox proportional hazards model with baseline covariates as explanatory variables can improve the standard logrank test in power. Although this has long been recognized, this adjustment is not commonly used as the primary analysis and instead the logrank test followed by the estimation of the hazard ratio between treatment groups is often used. By projecting the score function for the Cox proportional hazards model onto a space of covariates, the logrank test can be more powerful. We derive a power formula for this augmented logrank test under the same setting as the widely used power formula for the logrank test and propose a simple strategy for sizing randomized clinical trials utilizing historical data of the control treatment. Through numerical studies, the proposed procedure was found to have the potential to reduce the sample size substantially as compared to the standard logrank test. A concern to utilize historical data is that those might not reflect well the data structure of the study to design and then the sample size calculated might not be accurate. Since our power formula is applicable to datasets pooled across the treatment arms, the validity of the power calculation at the design stage can be checked in blind reviews.

Barriers and facilitators for the implementation of health condition and outcome registry systems: a systematic literature review

OBJECTIVE

Health condition and outcome registry systems (registries) are used to collect data related to diseases and other health-related outcomes in specific populations. The implementation of these programs encounters various barriers and facilitators. Therefore, the present review aimed to identify and classify these barriers and facilitators.

MATERIALS AND METHODS

Some databases, including PubMed, Embase, ISI Web of Sciences, Cochrane Library, Scopus, Ovid, ProQuest, and Google Scholar, were searched using related keywords. Thereafter, based on the inclusion and exclusion criteria, the required data were collected using a data extraction form and then analyzed by the content analysis method. The obtained data were analyzed separately for research and review studies, and the developed and developing countries were compared.

RESULTS

Forty-five studies were reviewed and 175 unique codes were identified, among which 93 barriers and 82 facilitators were identified. Afterward, these factors were classified into the following 7 categories: barriers/facilitators to management and data management, poor/improved collaborations, technological constraints/appropriateness, barriers/facilitators to legal and regulatory factors, considerations/facilitators related to diseases, and poor/improved patients' participation. Although many of these factors have been more cited in the literature related to the developing countries, they were found to be common in both developed and developing countries.

CONCLUSION

Lack of budget, poor performance of managers, low data quality, and low stakeholders' interest/motivation on one hand, and financing, providing adequate training, ensuring data quality, and appropriate data collection on the other hand were found as the most common barriers or facilitators for the success of the registry implementation.

Opportunities and Challenges for Machine Learning in Rare Diseases

Rare diseases (RDs) are complicated health conditions that are difficult to be managed at several levels. The scarcity of available data chiefly determines an intricate scenario even for experts and specialized clinicians, which in turn leads to the so called “diagnostic odyssey” for the patient. This situation calls for innovative solutions to support the decision process via quantitative and automated tools. Machine learning brings to the stage a wealth of powerful inference methods; however, matching the health conditions with advanced statistical techniques raises methodological, technological, and even ethical issues. In this contribution, we critically point to the specificities of the dialog of rare diseases with machine learning techniques concentrating on the key steps and challenges that may hamper or create actionable knowledge and value for the patient together with some on-field methodological suggestions and considerations.

Long-term disability trajectories in relapsing multiple sclerosis patients treated with early intensive or escalation treatment strategies

Background and aims:

No consensus exists on how aggressively to treat relapsing–remitting multiple sclerosis (RRMS) nor on the timing of the treatment. The objective of this study was to evaluate disability trajectories in RRMS patients treated with an early intensive treatment (EIT) or with a moderate-efficacy treatment followed by escalation to higher-efficacy disease modifying therapy (ESC).

Methods:

RRMS patients with ⩾5-year follow-up and ⩾3 visits after disease modifying therapy (DMT) start were selected from the Italian MS Registry. EIT group included patients who received as first DMT fingolimod, natalizumab, mitoxantrone, alemtuzumab, ocrelizumab, cladribine. ESC group patients received the high efficacy DMT after ⩾1 year of glatiramer acetate, interferons, azathioprine, teriflunomide or dimethylfumarate treatment. Patients were 1:1 propensity score (PS) matched for characteristics at the first DMT. The disability trajectories were evaluated by applying a longitudinal model for repeated measures. The effect of early versus late start of high-efficacy DMT was assessed by the mean annual Expanded Disability Status Scale (EDSS) changes compared with baseline values (delta-EDSS) in EIT and ESC groups.

Results:

The study cohort included 2702 RRMS patients. The PS matching procedure produced 363 pairs, followed for a median (interquartile range) of 8.5 (6.5–11.7) years. Mean annual delta-EDSS values were all significantly (p < 0.02) higher in the ESC group compared with the EIT group. In particular, the mean delta-EDSS differences between the two groups tended to increase from 0.1 (0.01–0.19, p = 0.03) at 1 year to 0.30 (0.07–0.53, p = 0.009) at 5 years and to 0.67 (0.31–1.03, p = 0.0003) at 10 years.

Conclusion:

Our results indicate that EIT strategy is more effective than ESC strategy in controlling disability progression over time.

Neovascular age-related macular degeneration: A review of findings from the real-world Fight Retinal Blindness! registry

The use of vascular endothelial growth factor (VEGF) inhibitors has revolutionised the treatment of neovascular age‐related macular degeneration (nAMD) since the pivotal Phase III studies demonstrated their efficacy more than 10 years ago. The Fight Retinal Blindness! project was developed to track the treatment outcomes of patients with nAMD in real‐world practice. Data from this registry have been used to answer several clinically relevant questions related to the treatment of nAMD including the effect of under‐treatment, the comparative effectiveness of different anti‐vascular endothelial growth factor agents, long‐term treatment outcomes, identifying optimal treatment regimens and the rate and outcomes of rare adverse events. Observational studies are a valuable complement to the shortcomings of clinical trials and a combination of data from real‐world settings and clinical trials are necessary to provide evidence on how to achieve the best outcomes for individual patients with nAMD.

Creation and validation of a citywide pediatric asthma registry for the District of Columbia

OBJECTIVE

To create and validate a citywide pediatric Asthma Registry to improve the care and outcomes of children and adolescents in Washington, DC through data-driven quality improvement (QI).

METHODS

All available electronic health record data from inpatient and outpatient domains of Children's National Hospital were aggregated from an existing enterprise data warehouse. Inclusion criteria included asthma relevant ICD-10 codes over the prior 24 months. Available Asthma Registry measures include patient demographics, ambulatory visits, hospital admissions, persistent asthma diagnoses, and prescription of controller medications. Data capture was validated using US Census data and current asthma prevalence estimate of the Behavioral Risk Factor Surveillance System (BRFSS).

RESULTS

The registry identified 15,991 DC children and adolescents with asthma aged 0-17 years, inclusive, at the end of 2020. This was 14.2% higher than the estimate of 14,001 children derived from BRFSS. Characteristics of those in the registry included: mean age of 9.5 (1.4) years, 57.9% male, 72.3% Black, and 66.7% publicly insured. Over the prior 24 months, 30.3% had ≥1 emergency department visit, and 10.5% had ≥1 hospital admission. Controller medications were prescribed for 59.6% of children with persistent asthma. Rates varied by sampled primary care practice sites.

CONCLUSIONS

A population-level pediatric asthma registry captures more children and adolescents with asthma in DC then a BRFSS-derived estimate, and provides city-wide measures of asthma-related utilization. The registry allows for stratification by primary care practice locations and asthma characteristics, supporting the design, implementation, and evaluation of QI projects at the practice, health system, and population levels.

Supplemental data for this article can be accessed at publisher's website.

Asbestos in High-Risk Communities: Public Health Implications

Asbestos-related diseases (ARDs)-mesothelioma, lung cancer, and asbestosis-are well known as occupational diseases. As industrial asbestos use is eliminated, ARDs within the general community from para-occupational, environmental, and natural exposures are more prominent. ARD clusters have been studied in communities including Broni, Italy; Libby, Montana; Wittenoom, Western Australia; Karain, Turkey; Ambler, Pennsylvania; and elsewhere. Community ARDs pose specific public health issues and challenges. Community exposure results in higher proportions of mesothelioma in women and a younger age distribution than occupational exposures. Exposure amount, age at exposure, fiber type, and genetic predisposition influence ARD expression; vulnerable groups include those with social and behavioral risk, exposure to extreme events, and genetic predispositions. To address community exposure, regulations should address all carcinogenic elongated mineral fibers. Banning asbestos mining, use, and importation will not reduce risks from asbestos already in place. Residents of high-risk communities are characteristically exposed through several pathways differing among communities. Administrative responsibility for controlling environmental exposures is more diffuse than for workplaces, complicated by diverse community attitudes to risk and prevention and legal complexity. The National Mesothelioma Registries help track the identification of communities at risk. High-risk communities need enhanced services for screening, diagnosis, treatment, and social and psychological support, including for retired asbestos workers. Legal settlements could help fund community programs. A focus on prevention, public health programs, particularization to specific community needs, and participation is recommended.

Transition to secondary progression in relapsing-onset multiple sclerosis: Definitions and risk factors

BACKGROUND

No uniform criteria for a sensitive identification of the transition from relapsing-remitting multiple sclerosis (MS) to secondary-progressive multiple sclerosis (SPMS) are available.

OBJECTIVE

To compare risk factors of SPMS using two definitions: one based on the neurologist judgment (ND) and an objective data-driven algorithm (DDA).

METHODS

Relapsing-onset MS patients (n = 19,318) were extracted from the Italian MS Registry. Risk factors for SPMS and for reaching irreversible Expanded Disability Status Scale (EDSS) 6.0, after SP transition, were estimated using multivariable Cox regression models.

RESULTS

SPMS identified by the DDA (n = 2343, 12.1%) were older, more disabled and with a faster progression to severe disability (p < 0.0001), than those identified by the ND (n = 3868, 20.0%). In both groups, the most consistent risk factors (p < 0.05) for SPMS were a multifocal onset, an age at onset >40 years, higher baseline EDSS score and a higher number of relapses; the most consistent protective factor was the disease-modifying therapy (DMT) exposure. DMT exposure during SP did not impact the risk of reaching irreversible EDSS 6.0.

CONCLUSION

A DDA definition of SPMS identifies more aggressive progressive patients. DMT exposure reduces the risk of SPMS conversion, but it does not prevent the disability accumulation after the SP transition.

Embedding "Smart" Disease Coding Within Routine Electronic Medical Record Workflow: Prospective Single-Arm Trial

BACKGROUND

Electronic medical record (EMR) chronic disease measurement can help direct primary care prevention and treatment strategies and plan health services resource management. Incomplete data and poor consistency of coded disease values within EMR problem lists are widespread issues that limit primary and secondary uses of these data. These issues were shared by the McMaster University Sentinel and Information Collaboration (MUSIC), a primary care practice-based research network (PBRN) located in Hamilton, Ontario, Canada.

OBJECTIVE

We sought to develop and evaluate the effectiveness of new EMR interface tools aimed at improving the quantity and the consistency of disease codes recorded within the disease registry across the MUSIC PBRN.

METHODS

We used a single-arm prospective trial design with preintervention and postintervention data analysis to assess the effect of the intervention on disease recording volume and quality. The MUSIC network holds data on over 75,080 patients, 37,212 currently rostered. There were 4 MUSIC network clinician champions involved in gap analysis of the disease coding process and in the iterative design of new interface tools. We leveraged terminology standards and factored EMR workflow and usability into a new interface solution that aimed to optimize code selection volume and quality while minimizing physician time burden. The intervention was integrated as part of usual clinical workflow during routine billing activities.

RESULTS

After implementation of the new interface (June 25, 2017), we assessed the disease registry codes at 3 and 6 months (intervention period) to compare their volume and quality to preintervention levels (baseline period). A total of 17,496 International Classification of Diseases, 9th Revision (ICD9) code values were recorded in the disease registry during the 11.5-year (2006 to mid-2017) baseline period. A large gain in disease recording occurred in the intervention period (8516/17,496, 48.67% over baseline), resulting in a total of 26,774 codes. The coding rate increased by a factor of 11.2, averaging 1419 codes per month over the baseline average rate of 127 codes per month. The proportion of preferred ICD9 codes increased by 17.03% in the intervention period (11,007/17,496, 62.91% vs 7417/9278, 79.94%; χ²₁=819.4; P<.001). A total of 45.03% (4178/9278) of disease codes were entered by way of the new screen prompt tools, with significant increases between quarters (Jul-Sep: 2507/6140, 40.83% vs Oct-Dec: 1671/3148, 53.08%; χ²₁=126.2; P<.001).

CONCLUSIONS

The introduction of clinician co-designed, workflow-embedded disease coding tools is a very effective solution to the issues of poor disease coding and quality in EMRs. The substantial effectiveness in a routine care environment demonstrates usability, and the intervention detail described here should be generalizable to any setting. Significant improvements in problem list coding within primary care EMRs can be realized with minimal disruption to routine clinical workflow.

Pediatric angioedema: Essential features and preliminary results from the Hereditary Angioedema Global Registry in Italy

Isolated angioedema, which is a localized, non-pitting, and transient swelling of the subcutaneous or submucosal tissue not associated with pruritus, urticaria, or anaphylaxis, may be classified, based on genetic pattern and mediators, respectively, as acquired or hereditary and histamine- or non-histamine-induced. The pediatric population with C1-INH-HAE (Hereditary angioedema due to C1-inhibitor deficiency) is mostly symptomatic. The frequency of symptoms in such a population compared to adults seems to be lower, but we need more prospective data to conclude on this point. The HGR (Hereditary angioedema global registry), which collects symptoms in real time, will probably provide such information. In terms of treatments, pediatric patients are significantly disadvantaged due to the few studies aimed at registering treatment for this population.

Value of the Rare Disease Registry of the Italian Region Friuli Venezia Giulia

BACKGROUND

The lack of epidemiological and clinical data is a major obstacle in health service planning for rare diseases. Patient registries are examples of real-world data that may fill the information gap.

OBJECTIVE

We describe the Rare Disease Registry of the Friuli Venezia Giulia region of Italy and its potential for research and health planning.

METHODS

The Rare Disease Registry data were linked with information on mortality, hospital discharges, ambulatory care, and drug prescriptions contained in administrative databases. All information is anonymous, and data linkage was based on a stochastic key univocal for each patient. Average annual costs owing to hospitalizations, outpatient care, and medications were estimated.

RESULTS

Implementation of the Registry started in 2010, and 4250 participants were registered up to 2017. A total of 2696 patients were living in the region as of January 1, 2017. The overall raw prevalence of rare diseases was 22 per 10,000 inhabitants, with higher prevalence in the pediatric population. The most common disease groups were congenital malformations, chromosomal and genetic syndromes, and circulatory and nervous diseases. In 2017, 30 patients died, 648 were hospitalized, and 2355 received some type of ambulatory care. The total annual estimated cost was approximately €6.5 million, with great variability in the average patient cost across diseases.

CONCLUSIONS

The possibility of following the detailed real-world care experience of patients with each specific rare disease and assessing the costs related to each step in their care path represents a unique opportunity to identify inefficiencies, optimize care, and reduce waste of resources.

Kerala Atrial Fibrillation Registry: a prospective observational study on clinical characteristics, treatment pattern and outcome of atrial fibrillation in Kerala, India, cohort profile

PURPOSE

Limited published data exist on the clinical epidemiology of atrial fibrillation (AF) in South Asia including India. Most of the published data are from the Western countries and the Far East. The Kerala AF registry was initiated to collect systematic, prospective data on clinical characteristics, risk factors, treatment pattern and outcomes of consecutive AF patients who consulted cardiologists across the state of Kerala, India.

PARTICIPANTS

All newly diagnosed and previously reported patients aged ≥18 years with documented evidence of AF on ECG were included. Patients with transient AF due to infection, acute myocardial infarction, alcohol intoxication, metabolic abnormalities and AF seen in postoperative cases and critically ill patients with life expectancy less than 30 days were excluded.

FINDINGS TO DATE

A total of 3421 patients were recruited from 53 hospitals across Kerala from April 2016 to April 2017. There were 51% (n=1744) women. The median age of the cohort was 65 (IQR 56-74) years. Hypertension, diabetes mellitus and dyslipidaemia were present in 53.8%, 34.5% and 42.2% patients, respectively. Chronic kidney disease was observed in 46.6%, coronary artery disease in 34.8% and heart failure (HF) in 26.5% of patients. Mean CHA₂DS₂-VASc score of the cohort was 2.9, and HAS-BLED score was 1.7. Detailed information of antithrombotic and antiarrhythmic drugs was collected at baseline and on follow-up. During 1-year follow-up, 443 deaths (12.9%) occurred of which 332 (9.7%) were cardiac death and 63 (1.8%) were due to stroke. There were 578 (16.8%) hospitalisations mainly due to acute coronary syndrome, arrythmias and HF.

FUTURE PLANS

Currently, this is the largest prospective study on AF patients from India, and the cohort will be followed for 5 years to observe the treatment patterns and clinical outcomes. The investigators encourage collaborations with national and international AF researchers.

TRIAL REGISTRATION NUMBER

CTRI/2017/10/010097.

Trends in Incidence of ESKD in People With Type 1 and Type 2 Diabetes in Australia, 2002-2013

RATIONALE & OBJECTIVE

The number of people with diabetes and end-stage kidney disease (ESKD) is increasing worldwide, but it is unknown whether this indicates an increasing risk for ESKD in people with diabetes. We examined temporal trends in the incidence of ESKD within the Australian population with diabetes from 2002 to 2013.

STUDY DESIGN

Follow-up study using a national health care services registry.

SETTING & PARTICIPANTS

Registrants with type 1 or type 2 diabetes in Australia's National Diabetes Services Scheme (NDSS).

PREDICTORS

Age, sex, indigenous status, diabetes type, and calendar year.

OUTCOME

Incidence of ESKD (dialysis or kidney transplantation) or death ascertained using the Australian and New Zealand Dialysis and Transplant Registry and the Australian national death index.

ANALYTICAL APPROACH

NDSS registrants were followed up from 2002 or date of registration until onset of ESKD, death, or December 31, 2013. The incidence of ESKD in type 1 diabetes was calculated only in those younger than 55 years.

RESULTS

Among 1,375,877 registrants between 2002 and 2013, a total of 9,977 experienced incident ESKD, representing an overall incidence of ESKD in people with diabetes of 10.0 (95% CI, 9.8-10.2) per 10,000 person-years. Among those with type 1 diabetes, the age-standardized annual incidence was stable during the study period. Among those with type 2 diabetes, the incidence increased in nonindigenous people (annual percentage change, 2.2%; 95% CI, 0.4%-4.1%) with the greatest increases in those younger than 50 and those older than 80 years. No significant change over time was observed in indigenous people, although the adjusted incident rate ratio for indigenous versus nonindigenous was 4.03 (95% CI, 3.68-4.41).

LIMITATIONS

Lack of covariates such as comorbid conditions, medication use, measures of quality of care, and baseline kidney function.

CONCLUSIONS

The age-standardized annual incidence of ESKD increased in Australia from 2002 to 2013 for nonindigenous people with type 2 diabetes but was stable for people with type 1 diabetes. Efforts to prevent the development of ESKD, especially among indigenous Australians and those with early-onset type 2 diabetes, are warranted.

The Glomerular Disease Study and Trial Consortium: A Grassroots Initiative to Foster Collaboration and Innovation

Glomerular kidney disorders account for a significant proportion of chronic kidney disease and end-stage renal disease worldwide. Nevertheless, major obstacles make breakthrough progress in diagnosis and cure an ongoing challenge. Here we report the creation of a "grassroots" initiative that aims to provide new opportunities for nephrologists, pathologists, basic and clinical scientists, patients, and industry partners to collaborate in the field of glomerular kidney disease. Members of the medical community, including trainees, nephrologists, and nephropathologists, can participate in the open-access, Web-based, multidisciplinary clinical video case conferences, which provide "peer-to-peer" exchange of clinical and pathological expertise combined with a formal didactic curriculum. Participants can also join other aspects of the broader initiative. These include the participation in a multisite research study to facilitate enrollment of patients into a longitudinal clinical data and biorepository for glomerular kidney disorders. Items included in this prospective registry include the following: an ontology-based patient medical history, which is regularly updated; interval collection and storage of blood and urine samples; DNA collection; and a contact registry for patients who wish to participate in clinical trials. Participating sites and external scientists can leverage access to the database to pursue genetic, biomarker, epidemiological, and observational clinical effectiveness studies. Patients can independently sign up for a supplementary contact registry to participate in clinical trials if eligible. The broad spectrum of activities within this initiative will foster closer collaboration among trainees, practicing nephrologists, pathologists, and researchers, and may help to overcome some of the barriers to progress in the field of glomerular kidney disease.

Characteristics and Outcomes of Patients With Systemic Sclerosis (Scleroderma) Requiring Renal Replacement Therapy in Europe: Results From the ERA-EDTA Registry

RATIONALE & OBJECTIVE

Data for outcomes of patients with end-stage renal disease (ESRD) secondary to systemic sclerosis (scleroderma) requiring renal replacement therapy (RRT) are limited. We examined the incidence and prevalence of ESRD due to scleroderma in Europe and the outcomes among these patients following initiation of RRT.

STUDY DESIGN

Registry study of incidence and prevalence and a matched cohort study of clinical outcomes.

SETTING & PARTICIPANTS

Patients represented in any of 19 renal registries that provided data to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry between 2002 and 2013.

PREDICTOR

Scleroderma as the identified cause of ESRD.

OUTCOMES

Incidence and prevalence of ESRD from scleroderma. Recovery from RRT dependence, patient survival after ESRD, and graft survival after kidney transplantation.

ANALYTICAL APPROACH

Incidence and prevalence were calculated using population data from the European Union and standardized to population characteristics in 2005. Patient and graft survival were compared with 2 age- and sex-matched control groups without scleroderma: (1) diabetes mellitus as the cause of ESRD and (2) conditions other than diabetes mellitus as the cause of ESRD. Survival analyses were performed using Kaplan-Meier analysis and Cox regression.

RESULTS

342 patients with scleroderma (0.14% of all incident RRT patients) were included. Between 2002 and 2013, the range of adjusted annual incidence and prevalence rates of RRT for ESRD due to scleroderma were 0.11 to 0.26 and 0.73 to 0.95 per million population, respectively. Recovery of independent kidney function was greatest in the scleroderma group (7.6% vs 0.7% in diabetes mellitus and 2.0% in other primary kidney diseases control group patients, both P<0.001), though time required to achieve recovery was longer. The 5-year survival probability from day 91 of RRT among patients with scleroderma was 38.9% (95% CI, 32.0%-45.8%), whereas 5-year posttransplantation patient survival and 5-year allograft survival were 88.2% (95% CI, 75.3%-94.6%) and 72.4% (95% CI, 55.0%-84.0%), respectively. Adjusted mortality from day 91 on RRT was higher among patients with scleroderma than observed in both control groups (HRs of 1.25 [95% CI, 1.05-1.48] and 2.00 [95% CI, 1.69-2.39]). In contrast, patient and graft survival after kidney transplantation did not differ between patients with scleroderma and control groups.

LIMITATIONS

No data for extrarenal manifestations, treatment, or recurrence.

CONCLUSIONS

Survival of patients with scleroderma who receive dialysis for more than 90 days was worse than for those with other causes of ESRD. Patient survival after transplantation was similar to that observed among patients with ESRD due to other conditions. Patients with scleroderma had a higher rate of recovery from RRT dependence than controls.

Congenital Heart Defects in Nigerian Children: Preliminary Data From the National Pediatric Cardiac Registry

BACKGROUND

Congenital heart defects (CHDs) are common birth defects with significant impact on morbidity and mortality. We aimed to compare regional patterns of CHDs in Nigeria using a registry-based approach.

METHODS

Children with echocardiography-confirmed CHDs at 17 medical centers across the country were enrolled in a pilot National Pediatric Cardiac Registry from January to December 2014.

RESULTS

A total of 1,296 children (52.9% male; median age 0.9 years) with CHDs were enrolled. Patients enrolled in Northern Nigeria constituted 34.6% of the study population and were older compared to those enrolled from Southern Nigeria (2.9 ± 3.6 vs 2.4 ± 3.5 years; P = .02). Ventricular septal defects were significantly more prevalent in the North (37.4%) compared with the South (18.5%; P < .0001), while severe CHDs were more prevalent in the South ( P = .004). Of the 208 (16.0%) children who received corrective cardiac intervention, only 43 (20.7%) of them had the intervention done in country. More patients in the South received intervention compared to the North (19.02% vs 10.5%; P < .0001).

CONCLUSION

This is the first prospective, registry-based, multicenter study of CHDs in Nigerian children. We demonstrate important differences between the Northern and the Southern geographical regions of the country in terms of age at diagnosis, type, and severity of lesion as well as access to cardiac surgery. The findings demonstrate the utility of a national CHDs registry for understanding clinical epidemiology of CHDs in low- and middle-income countries and its potential to serve as a basis for research and planning.

Registries supporting new drug applications

PURPOSE

Knowledge of the benefits and risks of new drugs is incomplete at the time of marketing approval. Registries offer the possibility for additional, post-approval, data collection. For all new drugs, which were approved in the European Union between 2007 and 2010, we reviewed the frequency, the type, and the reason for requiring a registry.

METHODS

The European Public Assessment Reports, published on the website of the European Medicine Agency, were reviewed for drugs approved by the Committee for Medicinal Products for Human Use. We searched for key characteristics of these drugs, including therapeutic area (ATC1 level), level of innovation (the score is an algorithm based on availability of treatment and therapeutic effect), and procedural characteristics. In addition, we identified if these registries were defined by disease (disease registry) or exposure to a single drug (drug registry).

RESULTS

Out of 116 new drugs approved in the predefined period, for 43 (37%), 1 to 6 registry studies were identified, with a total of 73 registries. Of these 46 were disease registries and 27 (single) drug registries. For 9 drugs, the registry was a specific obligation imposed by the regulators. The level of innovation and the orphan status of the drugs were determinants positively predicting post-approval registries (OR 10.3 [95% CI 1.0-103.9] and OR 2.8 [95% CI 1.0-7.5], respectively).

CONCLUSIONS

The majority of registries required by regulators are existing disease registries. Registries are an important and frequently used tool for post-approval data collection for orphan and innovative drugs.

Testosterone treatment is not associated with increased risk of prostate cancer or worsening of lower urinary tract symptoms: prostate health outcomes in the Registry of Hypogonadism in Men

OBJECTIVES

To evaluate the effects of testosterone-replacement therapy (TRT) on prostate health indicators in hypogonadal men, including rates of prostate cancer diagnoses, changes in prostate-specific antigen (PSA) levels and lower urinary tract symptoms (LUTS) over time.

PATIENTS AND METHODS

The Registry of Hypogonadism in Men (RHYME) is a multi-national patient registry of treated and untreated, newly-diagnosed hypogonadal men (n = 999). Follow-up assessments were performed at 3-6, 12, 24, and 36 months. Baseline and follow-up data collection included medical history, physical examination, blood sampling, and patient questionnaires. Prostate biopsies underwent blinded independent adjudication for the presence and severity of prostate cancer; PSA and testosterone levels were measured via local and central laboratory assays; and LUTS severity was assessed via the International Prostate Symptom Score (IPSS). Incidence rates per 100 000 person-years were calculated. Longitudinal mixed models were used to assess effects of testosterone on PSA levels and IPSS.

RESULTS

Of the 999 men with clinically diagnosed hypogonadism (HG), 750 (75%) initiated TRT, contributing 23 900 person-months of exposure. The mean testosterone levels increased from 8.3 to 15.4 nmol/L in treated men, compared to only a slight increase from 9.4 to 11.3 nmol/L in untreated men. In all, 55 biopsies were performed for suspected prostate cancer, and 12 non-cancer related biopsies were performed for other reasons. Overall, the proportion of positive biopsies was nearly identical in men on TRT (37.5%) compared to those not on TRT (37.0%) over the course of the study. There were no differences in PSA levels, total IPSS, or the IPSS obstructive sub-scale score by TRT status. Lower IPSS irritative sub-scale scores were reported in treated compared to untreated men.

CONCLUSIONS

Results support prostate safety of TRT in newly diagnosed men with HG.

Evaluating the Impact of Information Technology Tools to Support the Asthma Medical Home

This study aimed to evaluate the impact of information technology tools on the outcomes of children with asthma in the medical home. A registry was established for children aged 4 to 18 years with an ICD-9 code for asthma. Changes to the electronic health record included modifications to notes, care plans, and orders. A retrospective analysis of emergency department and in-patient utilization for a cohort of patients was conducted from July 2009 through June 2013. Of the study population (n = 1217), 65% had a classification of asthma severity and 63% were risk-stratified. Seventy percent had a control assessment at least once. Care plan use increased from 5% to 22% and enrollment in care coordination increased from 0.1% to 4%. After 3 years, there was a reduction of emergency department and inpatient admissions for asthma (P < .05 and P < .005, respectively). The implementation of information technology tools was associated with improved asthma outcomes.

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial

BACKGROUND

Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry.

METHODS

SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices.

DISCUSSION

Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care.

TRIAL REGISTRATION

NCT02318108.

Data quality and completeness in a web stroke registry as the basis for data and process mining

Electronic health records often show missing values and errors jeopardizing their effective exploitation. We illustrate the re-engineering process needed to improve the data quality of a web-based, multicentric stroke registry by proposing a knowledge-based data entry support able to help users to homogeneously interpret data items, and to prevent and detect treacherous errors. The re-engineering also improves stroke units coordination and networking, through ancillary tools for monitoring patient enrollments, calculating stroke care indicators, analyzing compliance with clinical practice guidelines, and entering stroke units profiles. Finally we report on some statistics, such as calculation of indicators for assessing the quality of stroke care, data mining for knowledge discovery, and process mining for comparing different processes of care delivery. The most important results of the re-engineering are an improved user experience with data entry, and a definitely better data quality that guarantees the reliability of data analyses.

The European Cystic Fibrosis Society Patient Registry: valuable lessons learned on how to sustain a disease registry

BACKGROUND

Disease registries have the invaluable potential to provide an insight into the natural history of the disease under investigation, to provide useful information (e.g. through health indicators) for planning health care services and to identify suitable groups of patients for clinical trials enrolment. However, the establishment and maintenance of disease registries is a burdensome initiative from economical and organisational points of view and experience sharing on registries management is important to avoid waste of resources. The aim of this paper is to discuss the problems embedded in the institution and management of an international disease registry to warn against common mistakes that can derail the best of intentions: we share the experience of the European Cystic Fibrosis Society Patient Registry, which collects data on almost 30,000 patients from 23 countries.

METHODS

We discuss the major problems that researchers often encounter in the creation and management of disease registries: definition of the aims the registry has to reach, definition of the criteria for patients referral to the registry, definition of the information to record, set up of a data quality process, handling of missing data, maintenance of data confidentiality, regulation of data use and dissemination of research results.

RESULTS

We give examples on how many crucial aspects were solved by the European Cystic Fibrosis Society Patient Registry regarding objectives, inclusion criteria and variables definition, data management, data quality controls, missing data handling, confidentiality maintenance, data use and results dissemination.

CONCLUSIONS

We suggest an extensive literature research and discussions in working groups with different stake holders, including patient representatives, on the objectives, inclusion criteria and the information to record. We propose to pilot the recording of few variables and test the applicability of their definition first. The use of a shared electronic platform for data collection that automatically computes derived variables, and automatically performs basic data quality controls is a good data management practice, that also helps in reducing missing data. We found crucial for success the collaboration with existing national and international registries, cystic fibrosis organisations and patients' associations.

Project VALOR: design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.

First signs and symptoms of spondyloarthritis--data from an inception cohort with a disease course of two years or less (REGISPONSER-Early)

OBJECTIVE

To determine the first signs and symptoms, and the clinical, biological and radiological characteristics of patients with early SpA.

METHODS

A total of 150 SpA patients were selected from 2367 listed in REGISPONSER (Registro Español de Espondiloartritis de la Sociedad Española de Reumatología). The inclusion criterion was a disease course of

RESULTS

Forty-six patients had AS, 51 psoriatic SpA (Ps-SpA), 43 uSpA, 5 ReA, 4 IBD arthropathy and 1 JCA. The mean age at onset of symptoms and at diagnosis was higher in Ps-SpA group (48.1 +/- 13.6 and 48.5 +/- 13.6 yrs) than in AS group (38.1 +/- 12.8 and 38.9 +/- 12.7 yrs) and uSpA group (36.3 +/- 11.5 and 36.9 +/- 11.4 yrs). The most frequent signs or symptoms were back pain: 72% AS group and 56% uSpA group. Lower limb arthritis was the first symptom in 57% Ps-SpA patients, 35% uSpA patients and 20% AS patients; upper limb arthritis was the first symptom in 53% Ps-SpA group and <16% of the remainder. Compared with longer duration disease, at onset, AS patients report upper limb arthritis more frequently and uSpA patients report more of enthesitis. Early radiological sacroiliitis was observed in all AS patients, of whom 54% had Grade II, 39% had Grade III and 7% had Grade IV.

CONCLUSIONS

In our population, the first manifestations of SpA were low back pain and SI syndrome in AS and uSpA patients and peripheral arthritis in the Ps-SpA group. We can find early SI joint affectation in AS patients.

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Key Words

• spas
• as
• uspa
• spa's cohort
• epidemiology
• disease registry

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MESH Headings

• Adult
• Age of Onset
• Analysis of Variance
• Arthritis/diagnosis
• Arthritis/diagnostic imaging
• Arthritis, Psoriatic/diagnosis
• Arthritis, Psoriatic/diagnostic imaging
• Back Pain/diagnosis
• Back Pain/diagnostic imaging
• Cohort Studies
• Female
• Humans
• Irritable Bowel Syndrome/diagnosis
• Irritable Bowel Syndrome/diagnostic imaging
• Male
• Middle Aged
• Prohibitins
• Radiography
• Sacroiliac Joint/diagnostic imaging
• Spondylarthritis/diagnosis
• Spondylarthritis/diagnostic imaging
• Spondylitis, Ankylosing/diagnosis
• Spondylitis, Ankylosing/diagnostic imaging

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Affiliation(s)

Marena Rojas-Vargas Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Elisa Muñoz-Gomariz Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Alejandro Escudero Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Pilar Font Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Pedro Zarco Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Raquel Almodovar Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Jordi Gratacós Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Juan Mulero Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Xavier Juanola Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Carlos Montilla Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Estefanía Moreno Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
Eduardo Collantes-Estevez Rheumatology Department, Hospital Universitario Reina Sofía, Unit Methodology and Support to the Research (FIBICO), H. U. Reina Sofía, Córdoba, Rheumatology Department, H. FUNDACIÓN de Alcorcón, Madrid, Rheumatology Department, H. Parc Taulí, Badalona, Rheumatology Department, H. U. Puerta de Hierro, Madrid, Rheumatology Department, H. U. Bellvitge, Barcelona, Rheumatology Department, H. Virgen de la Vega, Salamanca and Rheumatology Department, H. San Rafael, Barcelona, Spain
on behalf of REGISPONSER working group

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