Rheumatic and Immunologic Diseases

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OutcomesRheumatic and Immunologic Diseases

2006


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Outcomes | 2006

Quality counts when reerring patients to hospitals

and physicians, so Cleveland Clinic has created a series

o outcomes books similar to this one or its institutes

and departments. Designed or a health care provider

audience, the outcomes books contain a summary o

our surgical and medical trends and approaches; data

on patient volume and outcomes; and a review o new

technologies and innovations. We hope you nd these

data valuable. To view all our outcomes books, visit

Cleveland Clinics Quality Web site at

clevelandclinic.org/quality/outcomes.


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2 | Rheumatic and Immunologic Diseases 2006


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Rheumatic and Immunologic Diseases |

Chairmans Letter 5

Department Overview 6

Center or Osteoporosis & Metabolic Bone Diseases 10

Center or Vasculitis Care and Research 12

Recent Awards and Appointments 14

Selected Studies 15

Quality & Outcome Measures 20

Patient Experience 45

Innovations 46

New Knowledge 50

Sta Listing 56

Department Contacts | How to Reer Patients 60

Locations 61

Cleveland Clinic Overview 62

Online Services 6

Cleveland Clinic Contact Numbers 64

Table o Contents|


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Rheumatic and Immunologic Diseases | 5

Cleveland Clinics Department o Rheumatic and Immunologic Diseases has a

long-standing commitment to excellence in patient care and training physicians

or uture generations. The highest quality care depends on progress in clinical

trials, outcomes research and understanding illness at genetic, molecular and

cellular levels. Both clinical and basic research hold promises o discovering new

treatment strategies and cures or our patients.

The department has grown to include individuals with expertise in all areas o

clinical rheumatology. Recruitment has emphasized selection o aculty with

complementary skills in clinical, educational and research arenas. We have had

the good ortune o growing in an environment that is rich in opportunities or

collaboration in areas related to our own work in immunology, metabolic bonedisease, orthopaedics, cardiovascular medicine and surgery, pathology and

imaging. We have beneted rom research partnerships with valued colleagues

around the world. Opportunities or discovery are unprecedented and are likely

to bear ruit, in large part because o team eorts that ignore intellectual and

geographic boundaries.

In the ollowing pages, you will meet with members o our department and

specialty teams, and consider how we at the Clinic can best serve you and your

patients.

Gary S. Homan, M.D., M.S.

Chairman, Department o Rheumatic and Immunologic Diseases

Chairmans Letter|


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Department Overview|

A high volume o patients allowed the department to accomplish its primary goal

to provide care or the sick. It also allowed us to meet our complementary goals in

research and education.

Main Campus New Patient Visits

Main Campus Total Vists

1,500

1,000

500

02002 2003 2004 2005 2006

#

25,000

20,000

15,000

10,000

5,000

0

2002 2003 2004 2005 2006

#

Total new patient visits or Main Campus and Family Health

Centers or 2006 was 1,797.

Total visits or Main Campus and Family Health Centers or

2006 was 41,94.


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Top Primary Diagnoses

The breadth o skills within the Department o Rheumatic and Immunologic

Diseases attracts patients who have a wide range o illnesses, both common

and rare.

2002 2003 2004 2005 2006

Osteoporosis 504 566 709 1,077 1,569Rheumatoid Arthritis 1,06 1,215 1,280 1,251 1,565

Fibromyalgia 1,402 1,19 1,229 1,241 1,54

Systemic Lupus Erythematosus 446 402 472 48 562

Bursitis 256 265 288 204 518

Wegeners 242 25 264 29 65

Osteoarthritis 247 188 216 7 45

Gout 155 17 185 22

Psoriatic Arthritis 212 161 178 175 25

Arteritis NOS / Vasculitis 145 185 179 179 250

Scleroderma 14 117 168 21 241

Juvenile Rheumatoid Arthritis 242 195 216 214 218

Giant Cell Arteritis 81 8 128 108 110

Ankylosing Spondylitis 60 49 58 64 10

Polymyositis 80 78 77 85 101

Dermatomyositis 90 81 88 92 96

Takayasus Disease 5 58 81 81 78

Hypersensitivity Angiitis 4 42 4

Cerebral Arteritis 48 49 8 7 9

Bechets Disease 24 25 5 9

Polyarteritis Nodosa 48 0 22 6 27

Reiters Syndrome 19 11 26 22 26

Pseudogout 6 19 11 24 16

Henoch Schoenlein Purpura 11 11 7 10 12


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Grant support rom non-commercial sponsors continues to grow. This has been

most successul in the areas o vasculitis, metabolic bone disease and outcomes

research.

Active Research Grants14

7

02002 2003 2004 2005 2006

Federal and Foundation Grants

Commercial

#


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Total Publications

100

50

02002 2003 2004 2005 2006

#


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Center or Osteoporosis and Metabolic Bone Diseases

Chad Deal, M.D.

Main Campus Osteoporosis3,000

2,000

1,000

0

#

2002 2003 2004 2005 2006

Unique PatientTotal Patient Visits

The Center or Osteoporosis and Metabolic Bone Diseases is a multidisciplinary clinic

staed by rheumatologists, endocrinologists and radiologists.

In addition, the Center has strong ties with the Departments o Biomedical Engineering,

Orthopaedic Surgery and the Orthopaedic Research Center where molecular

mechanisms o bone ormation, skeletal repair and bone growth are active areas o

basic and clinical research using cell-based therapies.

Steady growth in aculty and patient numbers occurred in the Center or Osteoporosis

and Metabolic Bone Disease.


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Below is a graph demonstrating growth in Bone Densitometry since the opening o

the Center or Osteoporosis and Metabolic Bone Diseases.

Bone Densitometry20,000

10,000

02002 2003 2004 2005 2006

#

12,000

8,000

4,000

0

#

2006

Unique PatientTotal Patient Visits

Main Campus and Regional Medical PracticeOsteoporosis


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Center or Vasculitis Care and Research

Carol Langord, M.D.

Outpatient Vasculitis Cases*

New Patient VasculitisVolume*

1,000

750

500

250

0

2002 2003 2004 2005 2006

#

4,000

3,000

2,000

1,000

0

2002 2003 2004 2005 2006

#

Unique Vasculitis Patients

The Center or Vasculitis Care and Research is a major area o service, research and

educational commitment.

* Main campus only. Data does not include Family Health Centers.


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Some o the most commonly encountered vasculitis diagnoses are presented inthe table:

Unique Forms

o Vasculitis 2002 2003 2004 2005 2006

Wegeners 242 25 264 29 65

Arteritis NOS / Vasculitis 145 185 179 179 250

Giant Cell Arteritis 81 8 128 108 110

Takayasus Disease 5 58 81 81 78

Hypersensitivity Angiitis 4 42 4

Cerebral Arteritis 48 49 8 7 9

Bechets Disease 24 25 5 9

Polyarteritis Nodosa 48 0 22 22 27

Henoch Schonlein Purpura 11 11 7 10 12

Total Vasculitis Cases 686 727 787 847 957


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Recent awards and appointments: Highlights o 2006

Dr. Abby Abelson

Three-year Clinical Scholar Educator Award rom the American College o Rheumatology

Dr. Leonard Calabrese

Board o Directors o the Research and Education Foundation or the American College

o Rheumatology | Deputy Editor Arthritis Care and Research|American College o

Rheumatology Delegate to the Decade o the Bone and Joint World Health Organization.

Dr. Chad Deal, Chair, Advisory Group on US Rheumatology Workorce |

Investigator-initiated trial o zolendronic acid therapy ollowing Forteo or osteoporosis

(Novartis). The trial is designed to evaluate the eectiveness o an intravenous

bisphosphonate, zolendronic acid, ater patients nish a course o the anabolic agent or

osteoporosis, Forteo.

Dr. Gary Homan

Reappointment to the FDA Advisory Panel or arthritis drugs

Appointment as Editor o Current Opinion in Rheumatology

Sam and Maria Miller Award or Excellence in Clinical Research

Dr. Elaine Husni

Two-year Clinical Investigator Award rom the American College o Rheumatology

Research and Education und. This award supports investigation o atherosclerosis in

rheumatoid arthritis. Executive committee member o the PRECISION trial, worldwide

multicenter trial o over 20,000 patients to assess the cardiovascular risk prole o

three commonly used nonsteroidal anti-infammatory medications (celecoxib, ibuproen

and naproxen) in patients with osteoarthritis and rheumatoid arthritis.

Dr. Carol Langord

Pilot project grant, Rare Diseases Clinical Research Network (RDCRN), National Institutes

o Health | Mechanistic studies o T cell regulation in Wegeners granulomatosis | Co-

editors: Fauci AS and Langord CA. Harrisons Rheumatology. New York: McGraw Hill;

2006.

Dr. Brian Mandell

Editor ACP Medical Knowledge Sel Assessment Program 14. Rheumatology book.

2006. Chairman o the American College o Rheumatology National Meeting Planning

Committee|American College o Physicians annual meeting planning committee

(member)|Editor o the Merck Manual (Rheumatology and Immunology sections)


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Selected Studies and Why They Are Important

Stone JH, Holbrook JT, Marriott MA, Tibbs AK, Sejismundo LP, Min Y-I, Specks U,

Merkel PA, Spiera R, Davis JC, St. Clair EW, McCune WJ, Ytterberg SR, Allen NB,

Homan GS. Solid malignancies among patients in the Wegeners granulomatosis

etanercept trial. Arthritis Rheum 2006; 54:1608-1618.

This study demonstrated the concurrent use o etanercept and cyclophosphamide

is associated with an increased risk o solid tumors in patients with Wegeners

granulomatosis. The combined use o these agents should be avoided.

Villa-Forte A, Clark TM, Mascha E, Karaa MT, Gomes M, Carey JJ, Arrigain S,

Roberson G, Homan GS. Wegener granulomatosis: Customized treatment using

cyclophosphamide and methotrexate. A 12-year single-practice experience. Arthritis

Rheum 54 (S): 1178. 2006.

This study demonstrated minimizing cyclophosphamide use or, when possible,

avoiding it in patients with mild disease is associated with excellent outcomes and

survivals in patients with Wegeners granulomatosis.

Finkielman JD, Merkel PA, Schroeder D, Homan GS, Spiera R, St. Clair EW, Specks

U or the WGET Research Group. Antineutrophil cytoplasmic antibodies against

proteinase do not predict disease relapses in Wegeners granulomatosis. Arthritis

Rheum 2006;54: s85-86.

This study demonstrated that changes in ANCA titers correlate poorly with disease

activity and risk o relapse in Wegeners granulomatosis and should not be used as a

guide to therapy.

Koening CL, Langord CA, Kirchner HL, Homan GS. Renal grat survival in Wegeners

granulomatosis (WG): Comparison to systemic lupus erythematosus (SLE) rom a

national database. Arthritis Rheum 2006;54:s486.

This study demonstrated that patients with Wegeners granulomatosis who require

renal transplantation have excellent outcomes and only rarely have recurrent disease

within the grat.

Molloy ES, Langord CA, Clark TM, Gota CE, Calabrese LH, Homan GS. Durable

remission in patients with reractory Takayasus arteritis treated with infiximab and

etanercept. Arthritis Rheum 2006; 54:s487.

This study addressed the diculty in achieving lasting remissions or patients

with Takayasus arteritis. The experimental use o infiximab led to unprecedented

improvement in most patients who had previously been treatment-resistant.


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Lee MS, Smith SD, Galor A, Homan GS. Antiplatelet and anticoagulant therapy in

patients with giant cell arteritis. Arthritis Rheum 2006;54:06-09.

This study demonstrated the use o low-dose aspirin could reduce cerebral ischemicevents in giant cell arteritis by a actor o , without producing serious side eects.

Homan GS, Cid MC, Rendt KE, Merkel PA, Weyand CM, Stone JH, Salvarani C, Xu

W, Visvanathan S, Rahman MU or the Infiximab-GCA study group. Prednisone and

infiximab or giant cell arteritis: a randomized, double-blind, placebo-controlled,

multicenter study o ecacy and saety. Ann Intern MedMay 2007; 146(a):621-0.

This study was the rst-ever randomized double-blind trial o a biologic agent in GCA.

It demonstrated the use o infiximab in GCA did not add value to usual therapy withcorticosteroids.

Molloy E, Calabrese LH. Tumor-like mass lesions: an under-recognized presentation o

primary angiitis o the central nervous system. Arthritis & Rheum 2006; 54(9):S486.

This series highlights the potential or CNS vasculitis to present as mass lesions and

indicates when this presentation should be considered.

Bharadwaj SS, Hajj-Ali RA, Hammel JP, Calabrese LH. Evolution o the syndrome obenign angiopathy o the central nervous system (BACNS): retrospective review o 48

patients. Arthritis & Rheum 2006; 54(9):S485.

This study represents an important review o the clinical eatures, diagnoses and

treatments o BACNS.

Hajj-Ali RA, Yee A, Calabrese LH. Central nervous system vasculitis secondary to

sarcoidosis. Arthritis & Rheum 2006; 54(9):S492.

This report describes the clinical eatures seen when sarcoidosis maniests as a CNSvasculitis.

Deal C, Barr W, Harrington T, Hooker R, Hogan P, Bouchery E, Birnbaum N or the ACR

Workorce Subcommittee COTW. US Rheumatologist Supply and Demand: 2005-2006

Workorce Study. Arthritis Rheum 2007; 56():722-729.

This study developed a model to predict rheumatology supply and demand through

2025.

Solomon DH, Chibnik LB, Losina E, Huang J, Fossel AH, Husni ME, Katz JN.

Development o a preliminary index that predicts adverse events ater total knee

replacement. Arthritis Rheum 2006;54:156-42.

This paper examined patient and hospital level actors that may be important to predict

poor outcomes ollowing total knee replacement surgery.


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Harrington T, Deal C. Successes and ailures in improving osteoporosis care ater

ragility racture: results o a multi-site clinical improvement project. Arthritis Rheum

(Arthritis Care & Research). 2006;55:724-728.Demonstration o a practice improvement project to address the critical issue o

evaluation and treatment ater hip racture.

Calabrese LH, Zein N, Vassilopoulos D. Hepatitis B (HBV) reactivation with

immunosuppressive therapy in rheumatic diseases. Ann Rheum Dis 2006; 65:98-

989.

This review represents an important dialogue in the rheumatology proession or

examining and exploring the problem and proposing guidelines or avoiding seriousand/or atal cases o HBV reactivation.

Oliveira S, Ravelli A, Pistorio A, Castell E, Malattia C, Prieur AM, Saad-Magalhaes C,

Murray KJ, Sang-Cheol B, Joos R, Foeldvari I, Duarte C, Wulraat N, Lahdenne P,

Dolezalova P, de Inocencio J, Pratsidou-Gertsi P, Hoer M, Nikishina I, Ozgogan H,

Hashkes P, Martini A, Ruperto N or the Pediatric Rheumatology International Trials

Organization (PRINTO). Health related quality o lie o patients with juvenile idiopathic

arthritis: The PRINTO multinational quality o lie cohort study. Arthritis Rheum. Inpress. This very large international study included 6,667 subjects (,52 with juvenile

idiopathic arthritis (JIA) and ,15 controls) showed a signicant impairment o health-

related quality o lie among JIA patients, especially in the physical domains in all types

o JIA except persistent oligoarthritis.

Uziel Y, Butbul-Aviel Y, Barash J, Padeh S, Mukamel M, Gorodnitski N, Brik R, Hashkes

PJ. Recurrent transient synovitis o the hip in childhood: the long-term outcome among

9 patients. J Rheumatol2006;:810-811.This is the rst paper to study the long-term outcome o this very common orm o

episodic arthritis in children.

Husni, ME, Bershadsky B, Worley S, Barsoum W, Muschler G. Clinical variation in

health status and outcome ollowing primary hip and knee arthroplasty. American

Academy o Orthopedic Surgeons. 7rd Annual Meeting Proceedings Chicago, IL.

2006; 7:128.

This study examines preoperative clinical actors that may be important to predictoutcomes ollowing total knee and hip arthroplasty.


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Muschler GF, Husni ME, Lograsso M, Barsoum W, Thornton J, Worley S,Bershadsky B. Early outcome assessment comparison o unilateral and bilateral

primary total knee arthroplasty. American Association o Orthopedic Society. 2006.

American Academy o Orthopedic Surgeons. 7rd Annual Meeting Proceedings.

Chicago, IL. 2006; 7:12.

This study examines early outcomes o unilateral versus bilateral total knee

arthroplasty in a large academic setting.

Muschler GF, Rossi S, Lograsso M, Husni E, Gerz D, Emmerich C, Thornton J, WorleyS. A practical quality reporting system or hip and knee arthroplasty procedures.

American Association o Orthopedic Society. 2006. American Academy o Orthopedic

Surgeons. 7rd Annual Meeting Proceedings. Chicago, IL. 2006; 7:287.

This study assesses the use o an innovative patient sel report system ollowing total

knee and hip arthroplasty.

Qureshi AA, Cohen D, Mody E, Husni ME. Development and evaluation o PASE: A

sel-administered psoriatic arthritis screening and evaluation tool. J Am Acad Dermatol.2007. In press.

Given emerging therapies or psoriatic arthritis, this abstract demonstrates an

innovative, patient sel-report tool to help screen and evaluate or psoriatic arthritis.

Mody, E Qureshi AA, Husni, ME. Diagnosis o arthritis in psoriasis patients presenting

with joint pain to a dermatology-rheumatology clinic. Br J of Dermatol. 2007. In press

This study highlights the importance o proper diagnosis o musculoskeletal complaints

in patients with psoriasis and psoriatic arthritis. In patients with psoriasis, not all jointpain is consistent with psoriatic arthritis.

Whyte M, Mumm S, Deal C. Adult Hypophosphatasia Treated with Teriparatide. J Clini

Endocrinol Metab 2007; 92:120-1208.

This is the rst study to document eective treatment or hypophosphatasia.


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Carey JJ, Delaney MF, Richmond B, Cromer BA, Love TE, Lewis S, Thomas CA,Miller PD, Licata AA. Equivalence o technology generated T-scores and Z-scores in

young adult bone densitometry. J Bone Miner Res 2006; 21: S51.

This study showed that DXA-generated T-scores and Z-scores in young adults may

dier signicantly and substantially.

Schulte ME, Licata AA, Carey JJ, Delaney MF. Inappropriate PTH response to severe

vitamin D deciency in patients with chronic liver disease. J Bone Miner Res 2006;

21: S45.This study showed people with liver disease and vitamin D deciency have lower

than expected corresponding PTH levels.

Carey JJ, Delaney MF, Cromer BA, Love TE, Lewis S, Thomas CA, Miller PD, Licata

AA, Richmond B. Diagnostic agreement between DXA generated T-scores and Z-

scores in young adults. International Bone Densitometry Workshop, Kyoto, Japan.

November 2006. Oral presentation.

This study shows use o DXA-generated Z-scores instead o T-scores in young adultsresults in signicant diagnostic discordance using either 1994 W.H.O. or 2005

I.S.C.D. criteria.

Richmond B, Delaney MF, Cromer BA, Love TE, Lewis S, Thomas CA, Miller PD,

Licata AA, Carey JJ. The impact o body weight on DXA generated Z-scores in young

adults. International Bone Densitometry Workshop, Kyoto, Japan. November 2005.

Oral presentation.

This study shows adjustment or body weight accounts or a large part o thedierences seen between DXA-generated Z-scores and T-scores and that this

adjustment is inappropriate.

Sikon AL, Thacker HL, Carey JJ, Deal C, Licata AA. Secondary Osteoporosis: Are We

Recognizing It? J Womens Health. 2006; 15:1174-8.

This study demonstrates secondary causes o low bone mass should be screened

as they are very common in people with low Z-scores.


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Quality & OutcomesMeasures |

Prospective Randomized Evaluation o Celecoxib Integrated Saety Versus

Ibuproen or Naproxen (PRECISION)

Systemic rheumatic diseases aect approximately 20 million Americans, over 5%

o the population. In connective tissue diseases, such as rheumatoid arthritis and

systemic lupus erythematosus (SLE), there is a marked increase in cardiovascular

(CV) complications compared with patients without a systemic rheumatic disease. In

addition to CV risk, common treatments used or these diseases, non-steroidal anti-

infammatory drugs (NSAIDs) especially cyclooxygenase (COX)-2 inhibitors, may alsoincrease a patients CV risk.

What is the study purpose?

This clinical trial will evaluate the overall benet and risk o celecoxib, a Cox 2

inhibitor, compared to two commonly prescribed traditional (non-selective) non-

steroidal anti-infammatory drugs (NSAIDs) in the treatment o arthritis pain. The trial

denitively addresses the relative saety o celecoxib compared with ibuproen andnaproxen. While roecoxib was ound to signicantly increase CV events, the evidence

is less clear with celecoxib. Observational studies reported less CV risk with celecoxib

compared with roecoxib, but similar risks compared with naproxen or ibuproen. This

trial is unded by Pzer, but will be conducted at Cleveland Clinic under the leadership

o Dr. Steven E. Nissen; Dr. Elaine Husni will be the principal investigator.

What is the study design?

Approximately 20,000 patients with osteoarthritis (OA) or rheumatoid arthritis (RA) ona chronic analgesic regimen or >6 months, with existing CV disease or at high risk

or disease, will be randomized to celecoxib, ibuproen or naproxen in this double-

blind, triple-dummy, multicenter, multinational study utilizing a -arm parallel group

design. All patients will receive esomeprazole or gastro protection. Aspirin will be

administered or cardiovascular prophylaxis when clinically indicated.

Arthritis Clinical Research

Elaine Husni, M.D., M.P.H.


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Who qualies or this study?

Adult patients with a clinical diagnosis o OA or RA or at least 6 months and who

have required a chronic analgesic regimen or at least 6 months and patients with

established or who are at high risk or CV disease qualiy or this study.

What is the primary endpoint or this study?

The primary composite endpoint is the rst occurrence o cardiovascular death,

non-atal MI or non-atal stroke. This is an event-driven trial. Patients will be olloweda minimum o 18 months until 762 events have occurred.

The PRECISION trial is the rst study to enroll patients with existing CV disease

(or high risk o disease) undergoing treatment with a COX-2 inhibitor compared

with nonselective non-steroidal anti-infammatory agents. This large scale study

will dene the CV saety prole o celecoxib versus ibuproen and naproxen

and, thereby, help determine the optimal strategy or pain control in this at-risk

population.

1Visit 32 4 5 6 7 8 9 10 11 12 13

-3wks Rand M1 M2 M3 M4 M8 M12 M24 M30 M36 M42 M48

Screen

Established or at highrisk for CVD

Diagnosis of symptomaticosteoarthritis or

rheumatoid arthritis

Every 6 months

Minimum follow-up

Celecoxib 100-200 mg twice daily

Ibuprofen 600-800 mg three times daily

Naproxen 375-500 mg twice daily


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Development and Evaluation o PASE: A Sel-administered Psoriatic

Arthritis Screening and Evaluation Tool

M. Elaine Husni, M.D., M.P.H. and Abrar Qureshi, M.D., M.P.H.

Psoriatic arthritis may be an under-recognized disorder. Nearly one o three

patients with psoriasis alone may develop psoriatic arthritis and, oten, these

patients are solely ollowed by dermatology providers. Complications associated

with psoriatic arthritis can be prevented with early diagnosis and reerral to a

specialist. Our objective was to evaluate the reliability and validity o the PASE

questionnaire to detect infammatory arthritis in patients with psoriasis.

What is being studied?

We developed a sel-administered instrument (the Psoriatic Arthritis Screening and

Evaluation questionnaire PASE) that allows dermatologists to screen psoriasis

patients or signs and symptoms o infammatory arthritis. A multidisciplinary

team o experts was involved in the design o the questionnaire. PASE wasdeveloped using standardized methodology or the development o both unctional

and health-related instruments geared toward musculoskeletal diseases. This

study provided the means to evaluate the reliability and validity o PASE or

detecting an infammatory arthritis.

How was this studied?

Patients with psoriasis-like skin complaints who presented to a combined

dermatology/rheumatology clinic at an academic medical center were studied

rom October 2005 to September 2006 and stratied according to the clinical

diagnosis made by a Board-certied dermatologist and rheumatologist. All

patients completed a PASE questionnaire o 15 ve-choice questions divided

into two subscales: symptoms and unction. Diagnosis o psoriasis or psoriatic

arthritis was based on clinical evaluation, history and physical, and radiographs,

i necessary, by a Board-certied rheumatologist and dermatologist. The goal o

the analyses was to evaluate the ability o the PASE total, unction and symptom

scores, to distinguish psoriatic arthritis rom non-psoriatic arthritis patients.


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What were the study results?

A total o 108 psoriasis patients completed PASE questionnaires. Thirty-seven

patients were excluded due to missing data or inadequate responses. O 71

participants, 18 were diagnosed with psoriatic arthritis and 5 with psoriasis

alone. The PASE questionnaire distinguished psoriatic arthritis rom psoriasis with

specicity o 74% and sensitivity o 8%. The Wilcoxon rank sum test was used

to test or dierences between these groups. Receiver Operator Curves (ROC)

was used to choose the best cut-point or each score by optimizing sensitivity

and specicity in predicting psoriatic arthritis. In addition, 95% exact binomial

condence intervals were calculated. Both the subscale scales scores were

signicantly dierent between the psoriatic arthritis and non-psoriatic arthritis

groups. Cronbachs alpha coecient had good internal consistency (raw 0.97

and standardized 0.98).

What does this mean in clinical practice?

In patients with psoriasis, the PASE questionnaire is a reliable and valid tool tohelp screen patients or psoriatic arthritis. There is a need to identiy patients

with psoriatic arthritis so that earlier reerral to a rheumatologist can be made,

timely therapy can be initiated and long-term disability avoided.

Total PASE Score8

7

6

5

4

3

2

1

0

Psoriasis

#

Psoriatic Arthritis

Scatter plot o total PASE scores or participants with psoriasis and psoriatic

arthritis. The horizontal line represents a score o 47 which, in this study, best

dierentiates the psoriatic arthritis (PsA) group rom the non-PsA group.


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Sel Assessed Health Status and Outcome Following Primary Hip andKnee Arthroplasty

Elaine Husni, M.D. M.P.H., Wael Barsoum, M.D., George F. Muschler, M.D., and

Boris Bershadsky, Ph.D.

Total joint arthroplasty is generally considered an eective procedure, but the

current literature does not support specic recommendations about which

patients are most likely to benet rom this surgery. Previous studies ocused onbaseline unctional status, preoperative pain levels and prosthesis survival. Less

attention was been placed on patient reported outcomes which may have the

potential o being modiable prior to surgery.


The study is to determine i patient sel-assessment o health (including mental

health and psychosocial variables) and presence o comorbidities are associated

with outcome or patients undergoing primary total hip and knee replacementsurgery.

How did we study this?

A prospective arthroplasty registry that provided demographics, co-morbidities

and SF-6 data beore and one-year ater surgery was studied. Between

December 2000 and March 2004, 85 patients underwent primary total knee

arthroplasty (TKA) and 1,008 underwent primary total hip arthroplasty (THA). Atotal o 16 joint arthroplasty surgeons perormed the procedures. Data were

gathered on preoperative and postoperative inormation provided by 489 patients

(22 TKA and 257 THA). The relationship between unctional outcomes 1-year

postoperatively with patient characteristics, including mental health, associated

comorbidities and patient demographics, was assessed.


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What were the results?Preoperative SF 6 scores (physical component score (PCS), mental component

score (MCS), age, and number o co-morbid conditions) were signicant

predictors o the magnitude o improvement in PCS one year ollowing surgery.

Greater improvement o PCS was associated with better MCS, younger age, less

co-morbid conditions while higher body mass index (BMI) was associated with

worse PCS. In addition, greater BMI was associated with lower preoperative PCS.

Preoperative SF 6 scores (PCS and MCS) were signicant predictors o the

magnitude o improvement in their MCS score at one year ollowing surgery.

How does this improve patient care?

Our results suggest an association between preoperative mental health and BMI

with outcome measured by improvement in PCS in patients undergoing hip and

knee arthroplasty. This suggests a role o preoperative intervention targeting

patients with higher BMI and worse mental component scores in order to improve

outcomes. Reasons that may explain the association o poor mental healthpreoperatively and worse unctional status include reduced activity levels, lack

o motivation to overcome unctional impairments and inability to adopt healthier

liestyles. This supports current literature ndings or the importance o targeting

this patient population with increased education and emotional support prior to

total knee and hip replacement surgery.

Risk actors and associated interventions to improve outcomes o patients

undergoing total knee and hip arthroplasty.

Potentialinterventions

Maintain healthypre op weight

Preoperative counseling

More frequentpost op counseling

SF-36

Risk factorsfor poor outcome

High BMI

Low mental score


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Patients Undergoing Total Hip (THA) Versus Total Knee Arthroplasty (TKA):Does One Procedure Have a Better Outcome?

Elaine Husni, M.D. M.P.H., Wael Barsoum, M.D., George F. Muschler, M.D., and

Boris Bershadsky, Ph.D.

Orthopedic outcomes or total knee arthroplasty and total hip arthroplasty are well

described in the orthopedic literature. Little published data, however, compares

the health outcomes o each procedure. Conficting reviews exist on which typeo arthroplasty procedure, hip or knee, provides greater overall improvement.

Current literature suggests patients who undergo total hip replacements improve

more than patients who undergo total knee replacements.


To address gaps in the literature, a large sample o patients who underwent

TKA and THA was studied. One-year postoperative outcomes were analyzed

using the most comprehensive model. We propose that measuring SF-6preoperatively and one-year postoperatively may be a practical resource to

identiy characteristics o the cohort that may lead to better outcomes.

How did we study this?

The primary objective o this study was to prospectively compare THA versus

total TKA with respect to improvement in general health-related quality-o-lie

(HRQoL) outcomes.

What were the results?

The improvement in postoperative PCS or hip and knee replacement is highly

dependent on comprehensive review o baseline characteristics o the patient

cohort. In examining THA and TKA, improvement in PCS is associated with lower

age, lower BMI and lower number o comorbidities. Better MCS at baseline is

signicantly associated with better improvement in the physical component.


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How does this improve patient care?It is critically important to include health-related quality-o-lie variables (socio-

demographic data, body mass index, comorbidities and social/emotional status)

to help isolate characteristics associated with improved outcomes or each

procedure. The comparisons between THA and TKA can better allow patients and

surgeons to understand the relative risks and benets o the procedures when

similar criteria are used.

Risk adjustment should be included as a mandatory component or orthopedicobservational studies. The non adjusted comparison o observations studies has

potential or selection bias. Future research should be aimed at developing a

minimal core set o risk adjustors needed to demonstrate baseline equivalency

o comparing two groups. This will help clinicians make more inormed decisions

regarding which types o patients will benet most rom which particular joint

replacement surgery.

Interpretation o DXA Generated T-scores and Z-scores

Carey JJ, Delaney MF, Love TE, Cromer BA, Richmond BJ, Miller PD, Manilla-McIntosh M,

Thomas CL, Lewis SA, Licata AA. The Cleveland Clinic, Case Western Reserve University

and The Colorado Center or Bone Research.

Background

Bone density (DXA) measures bone density in grams per centimeter2 (g/cm2).

Using this measurement, DXA sotware calculates a T-score and Z-score. Clinicalguidelines or the management o osteoporosis incorporate T-scores rather than

actual bone density in g/cm2. T-scores are not used in premenopausal women

or men under age 50 where only Z-scores are reported. For these patients,

low bone mass or age is diagnosed at a Z-score


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Conceptually, T-scores and Z-scores should be identical or very similar in young adults.At the Center or Osteoporosis and Metabolic Bone Disease, however, surprisingly

large dierences in some young individuals have been noticed. We undertook a

comprehensive study o this phenomenon in order to better understand the magnitude

of these differences and their implications for clinical practice and osteoporosis guidelines.

Methods

A retrospective cohort was used to evaluate the equivalence o DXA generated T-scores

and Z-scores in young adults scanned on either Hologic or Lunar machines. Multipleanalyses were perormed to describe and compare dierences between measures.

Results

Young adult Z-scores and T-scores diered substantially and signicantly in men and

women or both technologies. These dierences resulted in signicant diagnostic

discordance i Z-scores were substituted or T-scores, using either 1994 World Health

Organization or 2005 International Society or Clinical densitometry diagnostic criteria.The olded empirical cumulative distribution plot o the dierences between the T-score

and Z-score at the total hip site or one technology is shown.

Conclusions and SignicanceLarge dierences may be seen between T-scores and Z-scores in young adults.

Substitution o Z-scores or T-scores may result in signicant ascertainment bias.

DXA-generated Z-scores should be interpreted with caution in clinical practice.

Standardization o Z-score denition and method o calculation is needed to avoid

mistakes in both diagnoses and evaluation recommendations.

10

0

40

30

20

50

-2.0 -1.5 -1.0 -0.5

hip z-score - hip t-score

0.0 0.5 1.0 1.5

%


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Transplant Evaluation: Center or Osteoporosis and Metabolic BoneDisease

Miriam Delaney, M.D., Chad Deal, M.D., Abby Abelson, M.D., Angelo Licata, M.D.,

Ph.D., John Carey, M.D.

Cleveland Clinic has one o the largest organ transplant programs in the United

States. In 2006, there were 594 transplants perormed. These patients are at

risk or osteoporosis because o underlying disease (liver disease with vitaminD deciency or alcohol use) or lung disease (steroid treatment o chronic

obstructive pulmonary disease (COPD), low body weight and malabsorption with

cystic brosis), or bone marrow transplant (grat versus host disease and steroid

use). All transplant recipients receive steroids at the time o transplant and,

oten, or long periods o time ater surgery. Fracture rate in this population is

signicant.

In 2004, the Center or Metabolic Bone Disease established a transplantevaluation program in coordination with the transplant center. The purpose was

to evaluate clinically and obtain a bone density and treat patients at the time o

transplant evaluation or soon ater transplantation. The percent o liver transplant

patients having a bone center evaluation increased rom 22% in 2004 to 4%

in 2005 to 69.2% in 2006. A similar program is ongoing or cardiac and lung

transplant patients.

80

60

40

20

0

2004

%

2005 2006

Liver Transplant Patients with Osteoporosis Clinic Evaluations


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Characteristics Number o Cases Percentage

Total n=48

Mean Age 4.8 years+ 11.6 years

Male age 4.1 + 5.0 years

Female age 44.9 + 11.6 years

Females 4/48 89.6

Race

Caucasian 7/48 77.1

Arican American 5/48 10.4

Others 6/48 12.5Associated Triggers

Postpartum state 2/48 4.1

Sympathomimmetic amines 4/48 8.

Social marijuana 7/48 14.6

Smoking history 20/48 41.7

PMHx Migraine 11/48 22.9

Clinical Signs/SymptomsHeadache (HA) 4/48 89.6

Classic thunderclap HA 18/48 7.5

Thunderclap like 14/48 29.1

Migraine HA 6/48 12.5

Coitus HA 7/48 14.5

Exercise HA 4/48 8.

Valsalva HA 8/48 16.6

Recurrent Headaches 20/48 41.6

Neurological s/s 7/48 14.6

Focal /48 6.2

Diuse /48 6.2

Both 1/48 2.0

Seizures 2/48 4.2

Transient ischemic attack /48 6.

Isolated visual symptoms 10/48 20.8without stroke (blurry, diplopia,

transient loss, foaters, etc.)

Sought medical care on day o 18/48 7.5

Symptom onset


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Summary o Critical Elements or Diagnosis o RCVS

1. Transemoral angiography or indirect (CT or MR) angiography documenting

segmental cerebral artery vasoconstriction.

2. No evidence or aneurysmal subarachnoid hemorrhage.

. Normal or near-normal cerebrospinal fuid analysis (proteins o


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Rheumatic and Immunologic Diseases |

This is a cerebral angiography o a 40 y/o emale who presented with weekso severe headaches and an episode o transient paresis o her let arm. An MRIwas normal and CSF studies were normal. Her angiogram revealed multiple areaso stenosis and dilatation in multiple vessels (let) which resolved one month atertreatment with prednisone 60 mg/day and verapamil 240 mg/day (right). RCVSwas diagnosed.

The outcome was avorable in the majority with persistent morbidity related towhether or not the patient experienced stroke at presentation.

Outcome

Total recovery 2/48

Recovery with residual neurological decits 16/48

Death 0/48

Relapse /48

Not known/lost to ollow-up 6/48

In 2007, working with colleagues at the Massachusetts General Hospital andthe Mayo Clinic, a denitive review o this disorder was published in the Annalsof Internal Medicine which, or the rst time, integrates the clinical eatures andpathophysiologic concepts into a single review or a broad medical audience.

Hajj-Ali R, Furlan A, Abou-Chebel A, Calabrese LH: Benign angiopathy o the central nervous system

(BACNS): Cohort o 16 patients with clinical course and long-term ollow-up. Arthritis Care and Research

2002;47:662-669.

Calabrese LH, Gragg LH, Furlan AJ: Benign angiography: A distinct subset o angiographically dened

primary angiitis o the central nervous system. J Rheumatology199;20:2046-2050.

Calabrese LH, Dodick DW, Schwendt T, Singhal A: Narrative review: reversible cerebral vasoconstrictive

syndromes. Ann Int Med 2007;146:4-44.

Optimal treatment or this disorder has not yet been established, as opposed topatients with true vasculitis o the central nervous system who require prolonged

therapy with glucocorticoids and cytotoxic drugs. RCVS patients can oten betreated with observation or calcium channel blockers alone.


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Renal Grat Survival in Wegeners Granulomatosis (WG): Comparison to

Systemic Lupus Erythematosus (SLE) rom a National Database

Curry L. Koening, Carol A. Langord, H.L. Kirchner, Gary S. Homan

Nearly three-ourths o Wegeners granulomatosis (WG) patients will develop

glomerulonephritis at some time during their disease course. Despite treatment

with immunosuppressive drugs, up to 20% o patients develop end-stage renal

disease (ESRD). For patients with ESRD, kidney transplantation is an important

medical advance. Although case reports and small cohort studies reportexcellent grat survival rates in WG, it is not known how these results compare to

patients who undergo renal transplant or more common rheumatic conditions.

This led us to compare renal grat survival rates in patients transplanted or WG

to patients transplanted or systemic lupus erythematosus (SLE). The study used

data rom the Organ Procurement and Transplantation Networks (OPTN) national

transplant database. Renal grat survival rates were compared among patients

who received a rst episode renal transplantation or either WG or SLE betweenOctober 1987 and February 2006. A total o 982 patients received renal

transplantation or WG and 6,574 patients or SLE.

100

75

50

25

0

%Survival

WGSLE

Log-Rank P < 0.0001

2000 400 600 800 1,000

Weeks to Failure

Center or Vasculitis Care and Research

Carol Langord, M.D.


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Wegeners Granulomatosis Systemic Lupus Erythematosus

Rate (95% CI) Rate (95% CI)

Survival Rate

6 month 95.6% (94.1-96.7) 92.7% (92.1-9.)

1 year 95.2% (9.6-96.4) 90.7% (90.0-91.4)

5 year 90.0% (87.9-91.7) 79.7% (78.7-80.7)

Kaplan Meier analysis o the two groups showed patients transplanted or WG had

better grat survival rates at 6 months, 1 year, and 5 years compared to patients

transplanted or SLE. Ater adjusting or various conounding actors, patients

transplanted or SLE had a 71% (P


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Substitution o Methotrexate or Cyclophosphamide in Wegeners

Granulomatosis

A 12-year Single-practice Experience

Alexandra Villa-Forte, Tiany M. Clark, Marcelo Gomes, John Carey, Edward

Mascha, Matthew T. Karaa, Susana Arrigain, Gerald Roberson and Gary S.

Homan

ObjectiveThe objective o the study is to assess outcomes o therapy in newly-diagnosed

Wegeners granulomatosis (WG) using methotrexate (MTX) or mild-to-moderate

disease or short-term treatment with cyclophosphamide ollowed by MTX or

severe disease.

Methods

Retrospective review: Patients with WG were included i their initial plan o therapy

and subsequent care were directly supervised by the Cleveland Clinic Center or

Vasculitis Care and Research. Severe disease (i.e. immediately lie-threatening

or involving critical organs) was initially treated with cyclophosphamide and

glucocorticoids. Mild-to-moderate disease was initially treated with MTX and

glucocorticoids i serum creatinine was less than 2mg/dl. Following initial

improvement o severe disease, treatment was changed to MTX i serum

creatinine was originally less than 2mg/dl or had diminished to less than 2mg/dl.

Disease activity was determined at each visit and later converted to a BirminghamVasculitis Activity Score, modied or Wegeners granulomatosis (BVAS/WG).

Laboratory monitoring o disease and treatment toxicity was initially weekly and

never less oten than monthly.

Results

Eighty-two (2%) o 25 patients reerred to the Center or Vasculitis Care and

Research with WG met eligibility criteria. Ineligible patients did not have new

onset disease or were not able to be ollowed principally in our center. Seventypercent o patients (57/82) initially had severe disease and received a short

course o cyclophosphamide or remission-induction. In over hal o these

patients, illness was judged to be severe because o pulmonary hemorrhage,

rapidly progressive glomerulonephritis, including need or dialysis, or neurologic

abnormalities.


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All patients improved; remission was achieved in 50% (41/82) o patients within

6 months and 72% (59/82) within 12 months. Sustained remission (BVAS/WG

= 0, or at least 6 consecutive months) was ultimately achieved in 77% (6/82)

o patients. Among patients with sustained remissions, the mean duration o

remission prior to relapse was 20.5 months (SD 21.2).

Seventy-ve patients (91%) achieved remissions o any duration [mean duration

SD = 11.2 16.8 months]. Among the 75 (91%) patients who achieved

remission o any duration, 45% relapsed within 1 year and 66% relapsed within

2 years ater remission. Eighty-two percent o relapsed patients achieved

subsequent remissions ater additional treatment. About three-ourths o relapses

were mild and promptly responded to treatment.

Seventeen percent o patients developed serious inections. Cyclophosphamide-

associated cystitis or bladder cancer did not occur in any patients. At least one

orm o permanent morbidity rom WG alone was noted in 74% o patients. Three

patients (.7%) died over a median ollow-up period o 4.5 years. No deaths were

due to active disease.

Although treatment was primarily directed toward achieving clinical improvement

and not calculated to achieve marked lymphopenia, patients in whom treatmentproduced lymphocyte counts o less than < 500/mm, sustained over a median

time o 4 (quartiles, 1-8.5) months, were .8 times more likely to achieve a

sustained remission (> 6 months; p = 0.015). Conversely, ollowing remission,

an absolute lymphocyte count o >1000/mm was associated with a hazard ratio

or relapse o .0, although the latter dierence was not statistically signicant.

100

75

50

25

0

%

BVAS/WG of zero

10 3 3

Years (follow-up)

Time to Remission


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ConclusionsIn patients with Wegeners granulomatosis, a strategy that limits or avoids

cyclophosphamide therapy has produced excellent results as judged by requency

o remissions, survival and avoidance o long-term cyclophosphamide toxicity.

Relapses, however, were common and incremental permanent morbidity occurred

in most patients. While not a goal o therapy, when treatment produced marked

lymphopenia, prolonged remissions were more likely.

Evolution o the Syndrome o Benign Angiopathy o the Central Nervous

System (BACNS)

Retrospective review o 48 patients

Swati S. Bharadwaj, Rula A. Hajj-Ali, Jerey P. Hammel, Leonard H. Calabrese

Purpose

The entity o BACNS was rst proposed in 199 as a subset o Primary Angiitiso Central Nervous System (PACNS), dened by acute headache and/or stroke,

benign cerebrospinal fuid, high probability cerebral angiogram and a avorable

clinical outcome without intense immunosuppression. In 2002, we described a

series o 16 patients with BACNS with rapid reversal o angiographic changes

suggesting the underlying mechanism was reversible vasoconstriction rather than

true vasculitis. Recognizing this entity is clinically important to spare patients

rom aggressive studies such as a brain biopsy and the toxicities o unnecessaryimmunosuppression. The clinical description o BACNS was extended with a

larger cohort o 48 patients in an attempt to rene our diagnostic and treatment

strategies.

Methods

A retrospective chart review was conducted on BACNS patients. Diagnosis was

based on prior descriptions (Hajj-AliArth Rheum

2002; 47:662-669). Inormationwas collected on demographics, triggers, strokes, headaches, visual symptoms,

seizures, laboratory markers, spinal taps, brain biopsies, initial and ollow-up

neuroimaging, treatments, outcomes and dates. Inormation was entered into an

Oracle Database and a descriptive analysis conducted.


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Takayasus Arteritis: Guarded Outcomes in an American Cohort

Kathleen Maksimowicz-McKinnon, Tiany M. Clark, Gary S. Homan

Purpose

1) To describe clinical, laboratory, and radiographic maniestations o Takayasus

arteritis (TAK) in an American cohort. 2) To evaluate response to interventions,

remission and relapse rates and disease progression. ) Compare observations

to cohorts rom the United States, Japan, India, Italy and Mexico.

Methods

Seventy-ve patients were retrospectively studied using a uniorm database that

included clinical, laboratory and imaging data. Vascular imaging studies were

perormed at least yearly to monitor disease progression.

Results

Ninety-two percent o patients were Caucasian; 89% emale. Median age at onset

was 26 years; median duration o ollow-up was years. Common maniestations

included loss or asymmetry o pulse (57%), limb blood pressure discrepancy

(5%) and bruits (5%). Eleven percent o patients were asymptomatic prior to

disease diagnosis. Angiographic studies demonstrated aortic abnormalities in

79% o patients. Subclavian (65%) and carotid (4%) arteries were also requently

aected.

Ninety-three percent o longitudinally ollowed patients attained disease remissiono any duration, but only 28% attained a sustained remission o at least 6 months

duration while receiving less than 10 mg/day o prednisone. Both angioplasty

and vascular surgery procedures were initially successul, but recurrent stenosis

occurred in 78% o angioplasty and 6% o bypass/reconstruction procedures.

Vascular claudication limited routine daily activities in 60%. Cerebral ischemic

disease occurred in 17%. Complete occupational disability occurred in 2%

which correlated with number o relapses. There were two disease-related

deaths.

Disease maniestations in our cohort are similar to the NIH, Italian, Japanese and

Mexican cohorts in emale predominance and disease maniestations, but diered

rom the Indian cohort in that the latter group had a higher requency o males,

abdominal aortic involvement and hypertension.


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Cohort Comparisons: Demographics And Diagnostic Evaluations

Cohort Patient Mean Age Caucasian Female Vascular PTA/surgical Mortality (%)(#) at onset (%) (%) imaging (%) intervention (%)

CCF 5 26 92 89 100 48

NIH () 60 25 * 75 97 100 50

Italy (6) 104 40 99 88 100 50 NR

India (7) 106 27 NR 61 90** 1 11

Japan (8)

(Ueda) 52 24 NR 81 90** NR 12 ***

Japan (9)

(Nakao) 84 NR NR 86 64 NR 7

Japan (10)

(Ishikawa) 120 0 * 0 9 NR** 12 1

Mexico (11)

(Lupi-Herrera) 107 NR NR 84 100 21 14

NR = not reported. *Only median age reported. **Diagnosis and disease eatures were assessed at least once in theentire cohort by vascular imaging, at the time o surgery, or at autopsy. ***Based on reported number o patients thatunderwent autopsy.

*Instances in which data were not provided or a cohort are indicated by absence o a comparison bar.

Aortic arch

Thoracic aorta

Abdominal aorta

Left carotidRight carotid

Left subclavian

Right subclavian

Celiac

Superior mesenteric

Left renal

Right renal

Left iliac

Right iliac

250 50 75 100

% Affected

CC

NIH

Italy

Japan

India

Mexico

*

**

**

*

*

Maniestations at disease onset in the American,Italian, and Indian cohorts.*


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Vascular Interventions and Outcomes in the Longitudinal Cohort*

Aneurysm/dilatation Site Bypass/reconstruction (#) Patent (%)**

Stenosis Site Bypass (#) Patent (%) Angioplasty (#) Patent (%)

* 21 o 0 patients in longitudinal cohort required revascularization procedures.**Sustained over the period o observation, without urther intervention required.

***1 patient with ilioemoral bypass and one with ilioemoral angioplasty had partial

restenosis at ollow-up imaging.

Conclusions

Takayasus arteritis in the United States is characterized by chronic, relapsing disease

in the majority o patients. Although most patients are able to attain remission with

the use o glucocorticosteroid therapy, attaining sustained steroid-ree remission

is uncommon. The majority o disease relapses in our cohort occurred while

patients were on immunosuppressive therapy. Seventy percent o patients required

revascularization procedures.

In contrast to prior studies rom Indian cohorts, sustained vascular patency ollowing

angioplasty was inrequent. Sustained vascular patency at years was superior orarterial bypass/reconstruction (68%) compared with angioplasty (25%). Although

mortality rates were low, chronic morbidity and disability were requent in this young

population. The requency o disease relapse and the need or revascularization

highlight the inadequacy o current therapy or Takayasus arteritis.

Aortic root 7 86

Descending aorta 1 100

Axillary 1 100

Abdominal aorta NA NA 1 100Carotid 7 71 2 0

Axillary 0 2 100

Subclavian 5 80 4 0

Coronary 12 50 1 100

Mesenteric 2 100 NA NA

Renal 5 60 8 0

Ilioemoral 1 100 2 100*** ***


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Durable Remission in Patients with Reractory Takayasus Arteritis Treatedwith Infiximab or Etanercept

Eamonn S. Molloy, Carol A. Langord, Tiany M. Clark, Carmen E. Gota, Leonard

H. Calabrese, Gary S. Homan

While up to 20% o Takayasus arteritis (TAK) patients have a monophasic

illness, most have a relapsing/remitting course, typically requiring prolonged

treatment with glucocorticoids and additional immunosuppressive agents, suchas methotrexate, azathioprine and, in severe cases, cyclophosphamide. More

than one-third o patients are unable to achieve adequate disease control on

these therapies. As tumor necrosis actor alpha (TNFa) is critical or granuloma

homeostasis and granulomatous infammation is the pathologic hallmark o

TAK, TNFa is an attractive therapeutic target in TAK; anti-TNF therapy has been

employed in TAK patients with encouraging results.

We sought to assess the ecacy o anti-TNF therapy in patients with TAKreractory to other therapies. Twenty-eight TAK patients were identied as having

received anti-TNF therapy; patients were excluded because o insucient ollow-

up data. No patient was in remission at the time o initiation o anti-TNF therapy;

1 had not achieved remission at any time since initial diagnosis. Twenty-ve

patients were treated with anti-TNF therapy or up to 6.5 years. Twenty patients

were treated with infiximab (INF) with a mean ollow-up o 27 months (range 2-76).

Nine patients were treated with etanercept (ETA) with a mean ollow-up o months (range 4-78). Four patients received both agents (all initially treated with

ETA, later switched to INF). No patients were treated with adalimumab.

O 25 patients, 22 were emale; mean age was 5 years (range 15-6). Patients

ethnicities were Caucasian, 20, Asian,, Hispanic,1, and one unknown. Median

disease duration was 108 months (range 1-6). All patients were previously

treated with prednisone and a mean o 2 additional immunosuppressive agents(range 0-6) including 22 methotrexate, 10 cyclophosphamide, and 12 with a

variety o other agents.


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Major Outcomes in Reractory TAK Patients Treated withanti-TNF Therapy.

Anti-TNF Agent Infiximab Etanercept

Patients treated 20 9

Complete remission* 12 4

Partial remission** 5 2

Discontinuation within 6 months Treatment ailure 1

- Adverse event 1 -

- Other 1 -

*Complete remission dened as resolution o symptoms, lack o new changes

on vascular imaging and discontinuation o glucocortocoids or at least 6 months.**Partial remission dened as resolution/improvement in symptoms, lack o new

changes on vascular imaging and tapering o glucocortocoids to


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Innovations |

The Future o the Rheumatology Workorce in the United States 2005-2025.

Authors: Chad Deal, M.D., Chair, Subcommittee on Workorce, Roderick Hooker, Ph.D.,

P.A., Timothy Harrington, M.D., Neal Birnbaum, M.D., Paul Hogan, Ellen Bouchery,

Marisa Klein-Gitelman, Walter Barr, M.D.

The American College o Rheumatology (ACR) retained the Lewin Group to conduct a

workorce study in 2005-2006. The purpose was to develop and apply a model thatallows prediction o current and uture supply and demand or rheumatology services in

the United States. A supply model was developed using the age and sex distribution o

current physicians, retirement and mortality rates, the number o ellowship slots and ll

rates, and practice patterns o rheumatologists. A survey instrument was designed and

sent to 1,68 U.S. rheumatologists to obtain more detailed inormation, including work

eort, productivity, measures o excess demand, and retirement plans. A computer-

based Markov projection model was created to project supply and permit sensitivityanalyses o actors aecting the uture workorce. Supply and demand was assumed

to be equal in 2005, although there is likely to be current excess demand or adult and

pediatric services. (The computer model can be adjusted to refect dierent scenarios.)

The number o adult rheumatologists in 2005 was 4,946. Male and emale

rheumatologists are equally distributed up to age 44, though above age 44, males

are more predominate. By 2025, the percent o women in the adult rheumatology

workorce is projected to increase rom 0.2% to 4.6% and in the pediatric workorce,

rom 51.5% to 62.7%. The mean number o patient visits is ,758 or male and 2,800

or emale rheumatologists. The productivity o rheumatologists under age 40 was

lower than older rheumatologists. I the supply and demand in 2025 were assumed

to be equal, the demand or rheumatologists is projected to exceed supply by 2,576

adult (supply=4,64, demand=7,219) and pediatric (supply=254, demand=287)

rheumatologists. (Current data suggest the pediatric rheumatology workorce is

experiencing a substantial excess o demand versus supply.)

Primary actors in the excess demand include: an aging population (which will increase

the number o people with rheumatic disorders), growth in the real per capita income

and fat rheumatology supply due to xed numbers entering the workorce and retiring.


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Unknown aects that could infuence these projections include technology advances,

practice redesign, changes in insurance reimbursement and shiting liestyles. Based

on assessment o supply and demand under current scenarios, the demand or

rheumatologists is expected to exceed supply in the coming decades. Strategies

or the proession to adapt to this changing healthcare landscape include: increasing

the number o ellows (an additional 188 slots would be required), utilizing physician

assistants and nurse practitioners in greater numbers and improving practiceeciency.

The R.J. Fasenmyer Center or Clinical Immunology is dedicated to

patient care, education and research in clinical immunology with an emphasis on

autoimmunity and chronic viral illness. As part o our goal to support education,

the construction o a state-o-the art meeting center within the Department o

Rheumatic and Immunologic Diseases will occur in 2008. This center will expand

the educational mission o the Fasenmyer Center and the Department o Rheumatic

and Immunologic Diseases to students, residents and physicians. A comprehensive

immunology curriculum has been developed with ongoing lectures in immunology

and autoimmunity.

Julie C. Huang, Stanley L. Hazen, Gary Homan, Elaine Husni.

Abstract

Impact o a Best Practice Clinical Alert on Preventive Cardiology Reerral

or Patients with Systemic Rheumatic Disease

Julie C. Huang, Stanley L. Hazen, Gary Homan, Elaine Husni.

There is known increased risk o cardiovascular morbidity and mortality in patients

with systemic rheumatic diseases. Despite signicant cardiovascular risk, there is

low utilization o preventive cardiology services at our institution.

Purpose

To assess the impact o a best practice clinical alert on reerral patterns o patients

with systemic rheumatic diseases rom the Cleveland Clinic Department o Rheumatic

and Immunologic Diseases to the Section o Preventive Cardiology.


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MethodsAn automatic clinician alert system was implemented via the electronic medical record

in June 2006. Any patient with a diagnosis o systemic rheumatic disease seen in

the Cleveland Clinic Department o Rheumatic and Immunologic Diseases triggered a

pop-up alert recommending reerral to Preventive Cardiology or cardiovascular risk

assessment. The Section o Preventive Cardiology PreCIS database was then queried

using SAS data retrieval or a monthly report o patients reerred rom Rheumatology

or or a diagnosis o systemic rheumatic disease. The reerral pattern was compared

to that prior to implementation o the best practice clinical alert to assess its impact on

reerrals to Preventive Cardiology.

Results

In the three months ollowing implementation o the best practice clinical alert system,

the monthly average reerral rate increased by 1,495%. The majority o patients

required some orm o cardiac risk intervention, including initiation o statin therapy or

dyslipidemia, electrocardiogram, and/or non invasive cardiac testing or suspicion ocoronary artery disease.

Conclusion

Use o a best practice clinician alert system is a highly eective means o increasing

reerral o patients with systemic rheumatic diseases to preventive cardiology.

Addressing cardiovascular risk in this high risk patient population is critical. Further

research will be needed to determine whether adoption o best practice clinical alerts

results in reduced cardiovascular burden in this group o patients.

Education

Abby Abelson, M.D., Education Program Director o the Department o Rheumatic

and Immunologic Diseases, was awarded the Clinical Scholar Educator Grant o the

American College o Rheumatology Research and Education Foundation or July 2007-2010.

Decisions about career choices are oten made during medical school and early in

resident training. Medical school curricula include rheumatology sections in the rst two

years. Clinical rheumatology aculty teach medical students and residents during clinical


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rotations. We eel a well-designed Web-based curriculum that would be available to all

rheumatology aculty could improve students, residents and ellows understanding o

the eld o rheumatology and provide more inormed decisions on career choices.

Dr. Abelsons grant provides support to develop an interactive Web-based, case-based

rheumatology curriculum that will acilitate the teaching o the clinical and basic science

o rheumatic disease to medical students, residents and rheumatology ellows. The

ormat will be case-based, problem-based learning (PBL) curriculum and will increasemedical students and residents knowledge o the rapidly evolving eld o rheumatic

diseases. Cleveland Clinic College o Medicine at Case Western University has

established expertise in Web- and case-based medical education that will be utilized or

curriculum development. The diversity o the disease mechanisms, illnesses, prognoses

and large numbers o new eective therapies will be addressed in this curriculum. The

fexible Web-based ormat will allow the curriculum to be utilized in a variety o settings,

rom individual sel-directed learning to small conerence or larger group seminarsettings, thereore maximizing the opportunities or medical educators to expose

students and residents to the depth and breadth o rheumatology.

Best Practices: Steroid Alert in Epic

Steroids are requently used to treat many diseases across all medical specialties.

Current American College o Rheumatology guidelines recommend a bone density in

patients on more than 5 mg o prednisone or more than three months. In addition,

treatment with a bisphosphonate is recommended in patients at initiation o steroid

therapy and in patients with ongoing steroids at T-score < -1.0.

To improve compliance with ACR guidelines, a best practice alert system was initiated

in the Department o Rheumatic and Immunologic Diseases and or all rheumatologists

in the Cleveland Clinic system. Epicare evaluates the patients medical record or steroiduse o more than three months, whether a bone density has been done in the last 12

months and an alert screen is generated with a smart orm that allows the clinician to

order a bone density test i indicated.


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New Knowledge|

Selected Publication Highlights

Calabrese LH. Primary Angiitis o the Central Nervous System. In Rheumatology. 4th

ed. Hochberg M, Silman A, Smolen J, Weinblatt M, Weisman MH, eds. St. Louis, Mo.:

Mosby; 2006.

Vassilopoulos D, Calabrese LH. Rheumatic aspects o human immunodeciency virus

inection and other immunodeciency states. In Rheumatology. 4th ed. Hochberg M,Silman A, Smolen J, Weinblatt M, Weisman MH, eds St. Louis, Mo.: Mosby; 2006.

Fauci AS, Langord CA, eds. Harrisons Rheumatology. New York: McGraw Hill; 2006.

Homan GS, Langord CA, Calabrese LH. In Vasculitis Hospital Medicine 2nd ed.

Wachter RM, Goldman L, Hollander H, eds. Philadelphia, Pa: Lippincott, Williams and

Wilkins; 2005: 1121-.

Stone JH, Homan GS. In Rheumatology 4th ed. Hochberg MC, Silman AJ, Smolen JS,

Weinblatt ME, Weisman MH, eds. Wegeners granulomatosis. St. Louis, Mo.: Mosby;

2007. In press. Chapter in book

Villa-Forte A, Santos A, Homan GS. In Head and Neck Maniestations o Systemic

Diseases. Harris J, Weisman M, eds. Vasculitis and Otolaryngology; New York, Marcel

Dekker; 2007.

Hajj-Ali R, Mandell BF. Rajagopalan, Mukherjee, eds. Approach to and Management

o Infammatory Vascular Disease in Manual o Vascular Diseases. Philadelphia, Pa:

Lipincott, Williams and Wilkins; 2005.


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Mandell BF, Johnson B. The patient with arthritis or systemic autoimmune disease.

In Just the Facts in Perioperative Medicine, Cohn, Smetana, Weed, eds. New York.:

McGraw Hill; 2006.

Mandell BF. Dierential diagnosis o arthritis. American College o Physicians Medical

Knowledge Sel Assessment Project. 14. Rheumatology. 2006.

Mandell BF. Septic Arthritis. American College o Physicians Medical Knowledge Sel

Assessment Project. 14. Rheumatology. 2006.

Mandell BF. Crystal Disease. American College o Physicians Medical Knowledge Sel

Assessment Project. 14. Rheumatology. 2006.

Mandell BF. Perioperative management o the patient with rheumatologic disease. In:Medical Consultation o the Surgical Patient. Merli, Weitz eds Philadelphia, Pa: Lipincott

Press; In press 2007.

Mandell BF. Dale D, ed. Systemic Vasculitis. ACP Scientic American Medicine. 2006.

Deal C, Abelson A, Carey J. Management o Osteoporosis. In: Rheumatology. 4th ed.

Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. St Louis, MO:

Mosby; In press 2007.


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Oliveira S, Ravelli A, Pistorio A, Castell E, Malattia C, Prieur AM, Saad-Magalhaes C,

Murray KJ, Sang-Cheol B, Joos R, Foeldvari I, Duarte C, Wulraat N, Lahdenne P,

Dolezalova P, de Inocencio J, Pratsidou-Gertsi P, Hoer M, Nikishina I, Ozgogan H,

Hashkes P, Martini A, Ruperto N or the Pediatric Rheumatology International Trials

Organization (PRINTO). Health-related quality o lie o patients with juvenile idiopathic

arthritis: The PRINTO multinational quality o lie cohort study. Arthritis Rheum

2007;57;5-4.

Karlson, EW, Costenbader, KH, McAlindon TE. Massarotti EM, Fitzgerald LM, Jajoo

R, Husni ME, Wright EA., Pankey H, and Fraser PA. High Sensitivity, specicity and

predictive value o the connective tissue disease screening questionnaire (CSQ) among

urban Arican-American women. Lupus 2005;14:82-86.

Solomon DH, Chibnik LB, Losina E, Huang J, Fossel AH, Husni ME, Katz JN.

Development o a preliminary index that predicts adverse events ater total kneereplacement. Arthritis Rheum 2006; May; 54 (5):156-42.

Stone JH, Homan GS, Liota L et al. A serum proteomic approach to gauging the state

o remission in Wegeners granulomatosis. Arthritis Rheum 2005;52:902-910.

The WGET Research Group. (PI: Stone JH, Co-PI- Homan GS). Etanercept plus standard

therapy in patients with Wegeners granulomatosis. N Engl J Med2005; 52:51-61.

Merkel PA, Lo GH, Holbrook JT, Tibbs AK, Allen NB, Davis JC, Homan GS, McCune

J, St. Clair EW, Specks U, Spiera R, Petri M, Stone JH or The WGET Research Group.

Incidence o venous thrombotic events among patients with Wegeners granulomatosis.

Ann Intern Med2005;142:620-626.


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Seo P, Min YI, Holbrook JT, Homan GS, Merkel PA, Spiera R, Davis JC, Ytterberg SR,

St Clair EW, McCune WJ, Specks U, Allen NB, Luqmani RA, Stone JH. Damage caused

by Wegeners granulomatosis and its treatment: prospective data rom the Wegeners

Granulomatosis Etanercept Trial (WGET). Arthritis Rheum 2005;28;52:2168-2178.

Homan GS, Cid MC, Rendt KE, Merkel PA, Weyand CM, Stone JH, Salvarani C, Xu

W, Visvanathan S, Rahman MU or the Infiximab-GCA study group. Prednisone and

infiximab or giant cell arteritis: a randomized, double-blind, placebo-controlled,

multicenter study o ecacy and saety. Ann Intern Med2007. 146(9):621-60.

Stone JH, Holbrook JT, Marriott MA, Tibbs A, Sejismundo LP, Min Y-I, Specks U, Merkel

PA, Spiera R, Davis JC, St. Clair EW, McCune J, Ytterberg SR, Allen NB, and Homan

GS or the WGET Research Group. Solid malignancies in the Wegeners Granulomatosis

Etanercept Trial. Arthritis Rheum 2006; 54:1608-1618.

Wung PK, Holbrook JT, Homan GS, Tibbs AK. Stone JH or the WGET Research

Group. Herpes Zoster in immunocompromised patients. Incidence, timing and risk

actors. Am J Med2005; 118: 1409-1416.


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Lee MS, Smith SD, Galor A, Homan GS. Antiplatelet and anticoagulant therapy in

patients with giant cell arteritis. Arthritis Rheum 2006;54:06-09.

Deal C, Omizo M, Schwartz,E, et al.Combination teriparatide and raloxiene therapy or

postmenopausal osteoporosis: Results rom a 6-month double-blind placebo-controlled

trial. J Bone Miner Res 2005;20:1905-1911.

Harrington T, Deal C. Successes and ailures in improving osteoporosis care aterragility racture: results o a multi-site clinical improvement project. Arthritis Rheum

(Arthritis Care & Research) 2006;55:724-728.

Deal C, Barr W, Harrington T, Hooker R, Hogan P, Bouchery E, Birnbaum N or the ACR

Workorce Subcommittee COTW7. U.S. Rheumatologist Supply and Demand: 2005-

2006 Workorce Study. Arthritis Rheum 2007;56:722-729.

Calabrese LH, Dodick DW, Schwendt T, Singhal A. Narrative review: reversible cerebralvasoconstrictive syndromes. Ann Intern Med2007;146:4-44.


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Chairman, Department o Rheumatic and Immunologic

Diseases

Appointed: 1992

Medical School: Virginia Commonwealth University Medical

College, Richmond, Va.

Specialty Training: Residency Dartmouth Medical School

and Mary Hitchcock Memorial Hospital, Hanover, N.H.;

Fellowship Dartmouth Medical School and Mary Hitchcock

Memorial Hospital, Hanover, N.H.; National Institutes o Health,

NIAID, Vasculitis

Other Education: B.A. State University o New York at

Binghamton, Binghamton, N.Y.; M.S. Howard University,

Washington, D.C.

Specialty Interests: Vasculitis

Sta Listing | Chairman


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Chairman


Quality Review Ocer

Chad Deal, M.D.

Center or Osteoporosis and

Metabolic Bone Diseases

Chad Deal, M.D., Director

Abby Abelson, M.D., Education Director

John Carey, M.D., M.S.

Elizabeth File, M.D.

Angelo Licata, M.D., Ph.D., Clinical Trials Director

General Rheumatology

Matthew Bunyard, M.D., Director of Clinical Operations

Abby Abelson, M.D., Education Program Director

John Carey, M.D., M.S.

Soumya Chatterjee, M.D., M.S.

John Clough, M.D.

Carmen Gota, M.D.

Rula Hajj-Ali, M.D.

Elaine Husni, M.D., M.P.H.

Anna Koo, M.D.

Brian Mandell, M.D., Ph.D.

Daniel Mazanec, M.D., Head Center for the Spine

Raymond Scheetz, M.D.William Wilke, M.D.

Sta Listing |


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Section o Clinical Immunology

Leonard Calabrese, D.O., Section Head

Elizabeth Kirchner, C.N.P.

Section o Pediatric Rheumatology

Philip Hashkes, M.D., MSc. Section HeadSteven Spalding, M.D.

Center or Vasculitis Care

and Research

Carol Langord, M.D., M.H.S., Director

Leonard Calabrese, D.O.

Carmen Gota, M.D.Rula Hajj-Ali, M.D.

Gary Homan, M.D., M.S., Chairman

Tiany Clark, C.N.P.

Center or Clinical Research

Debora Bork, M.F.A., Administrator

Sonya Crook, R.N.Louise Kincade, R.N.

Katherine Tuthill, C.N.P.


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Regional Medical Practices

Feyrouz Al-Ashkar, M.D. Lorain

Chad Deal, M.D. Solon

Rajul Desai, M.D. M.P.H. Solon

Howard Epstein, M.D. BeachwoodElizabeth File, M.D. Strongsville

Janice Granieri, M.D., Ph.D. Willoughby

Stephen MacIntyre, M.D., Ph.D. Westlake

Judith Manzon, M.D. Westlake

Susan Mathai, M.D. Westlake

Alla Modell, M.D. Independence

Denise Smith Hauser, C.N.P. Independence

Rochelle Rosian, M.D. Solon

Jerey Wisnieski, M.D. Willoughby


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For Hospital Transers or Physician Consults

800.55.5056

24 hours a day, seven days a week

Main Campus

9500 Euclid Avenue Desk A50

Cleveland, Ohio 44105

Appointment Oce: 216.444.562

Financial Counselor: 216.444.665

Research Oce: 216.445.85

Toll-Free Number: 800.22.227

www.clevelandclinic.org/arthritis

Department Contacts| How to Reer Patients


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Main Campus

9500 Euclid Avenue Desk A50

Cleveland, Ohio 44105

216.444.562

Rheumatology RegionalMedical Practices

Beachwood Family Health and

Surgery Center

26900 Cedar Road

Beachwood, Ohio 44122

216.89.000

Independence Family Health Center

5001 Rockside Road

Independence, Ohio 4411

216.986.4000

Toll Free Number: 800.544.6

Lorain Family Health Center

5700 Cooper Foster Park Road

Lorain, Ohio 4405

440.204.7400


Solon Family Health Center

29800 Bainbridge Road

Solon, Ohio 4419

440.519.6800


Strongsville Family Health and

Surgery Center

16761 Southpark Center

Strongsville, Ohio 4416

440.878.2500

Westlake Family Health Center

00 Clemens Road

Westlake, Ohio 44145

440.899.5555


Willoughby Hills Family Health Center

2570 SOM Center Road

Willoughby Hills, Ohio 44094

440.94.2500

Lake Erie

ClevelandClinicCleveland

Lorain

Solon

Westlake

Independence

Strongsville

Beachwood

Willoughby Hills

Locations


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Cleveland Clinic Overview |

Cleveland Clinic, ounded in 1921, is a not-or-prot academic medical center

that integrates clinical and hospital care with research and education. Today,

1,700 Cleveland Clinic physicians and scientists practice in 120 medical

specialties and subspecialties.

Cleveland Clinics main campus, with 41 buildings on 10 acres in Cleveland,

Ohio, includes a 1,000-bed hospital, outpatient clinic, subspecialty centers and

supporting labs and acilities. Cleveland Clinic also operates 1 amily health

centers, eight community hospitals, two aliate hospitals, and a medical acility

in Weston, Florida.

At the Cleveland Clinic Lerner Research Institute, hundreds o principal investigators,

project scientists, research associates and postdoctoral ellows are involved in

laboratory-based research. Total annual research expenditures exceed $150 million

rom ederal agencies, non-ederal societies and associations, and endowmentunds. In an eort to bring research rom bench to bedside, Cleveland Clinic

physicians are involved in more than 2,400 clinical studies at any given time.

In September 2004, Cleveland Clinic Lerner College o Medicine o Case Western

Reserve University opened and will graduate its rst 2 students as physician-

scientists in 2009.

For more details about Cleveland Clinic, visit clevelandclinic.org


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Online Services|

eCleveland Clinic

eCleveland Clinic uses state-o-the-art digital inormation systems to oer several

services, including remote second opinions through a secure Web site to patients

around the world; personalized medical record access or patients; patient

treatment progress access or reerring physicians (see below); and imaging

interpretations by the Department o eRadiologys subspecialty trained academic

radiologists. For more inormation, please visit eclevelandclinic.org.

DrConnectOnline Access to Your Patients Treatment Progress

Whether you are reerring rom near or ar, our new eCleveland Clinic service,

DrConnect, can streamline communication rom Cleveland Clinic physicians

to your oce. This new online tool oers you secure access to your patients

treatment progress at Cleveland Clinic. With one-click convenience, you can

track your patients care using the secure DrConnect Web site. To establish a

DrConnect account, visit eclevelandclinic.org or e-mail [email protected].

MyConsult

MyConsult Remote Second Medical Opinion is a secure, online service providing

specialist consultations and remote second medical opinions or more than 600

lie-threatening and lie-altering diagnoses. MyConsult remote second medical

opinion service allows you to gather inormation rom nationally recognized

specialists without the time and expense o travel. For more inormation,

visit eclevelandclinic.org/myconsult , e-mail [email protected] or call

800.22.227, ext 422.


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How to Reer Patients

24/7 Hospital Transers or Physician Consults

800.55.5056

General Inormation

216.444.2200

Hospital Patient Inormation216.444.2000

Patient Appointments

216.444.227 or 800.22.227

Medical Concierge

Complimentary assistance or out-o-state patients and amilies

800.22.227, ext. 55580, or email: [email protected]

International Center

Complimentary assistance or international patients and amilies

216.444.6404 or visit www.clevelandclinic.org/ic

Cleveland Clinic in Florida

866.29.7866

www.clevelandclinic.org

Cleveland Clinic Contact Numbers |


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Cleveland Clinic is determined to exceed the expectations o patients,

amilies and reerring physi

Rheumatic and Immunologic Diseases

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