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Comparative Effectiveness Of Abatacept Versus Tocilizumab In Rheumatoid Arthritis Patients With Prior Tnfi Exposure In The Us Corrona Registry, Leslie R. Harrold, George W. Reed, Daniel H. Solomon, Jeffrey R. Curtis, Mei Liu, Jeffrey D. Greenberg, Joel M. Kremer 2017 University of Massachusetts Medical School

Comparative Effectiveness Of Abatacept Versus Tocilizumab In Rheumatoid Arthritis Patients With Prior Tnfi Exposure In The Us Corrona Registry, Leslie R. Harrold, George W. Reed, Daniel H. Solomon, Jeffrey R. Curtis, Mei Liu, Jeffrey D. Greenberg, Joel M. Kremer

Leslie R. Harrold

BACKGROUND: We compared the effectiveness of abatacept (ABA) vs tocilizumab (TCA) in tumor necrosis factor inhibitor (TNFi) experienced patients. METHODS: We identified rheumatoid arthritis (RA) patients from a large observational US cohort (1 January 2010-31 May 2014) who had discontinued at least one TNFi and initiated ABA or TCZ in moderate or high disease activity based on the Clinical Disease Activity Index (CDAI) and had no prior exposure to the comparator drug. Using propensity score matching (1:1) stratified by prior TNF use (1 TNFi vs ≥2 TNFis), effectiveness at 6 months after initiation was evaluated. Mean change in CDAI ...


Effects Of Glucosamine Versus Chondroitin Sulfate In Reducing Joint Space Narrowing In Knee Osteoarthritis, Caroline Horton, Ashani Andrews 2017 James Madison University

Effects Of Glucosamine Versus Chondroitin Sulfate In Reducing Joint Space Narrowing In Knee Osteoarthritis, Caroline Horton, Ashani Andrews

Physician Assistant Capstones

Objective: To determine if over the counter supplements, chondroitin sulfate and glucosamine, in combination or alone, are effective in the treatment of joint space narrowing (JSN) in knee osteoarthritis.

Design: Systematic Literature Review

Methods: Database search of PubMed and MEDLINE using the search terms “glucosamine”, “chondroitin sulfate”, “osteoarthritis”, and joint space narrowing. Filters were implemented to include articles that only dealt with human subjects, that were published in 2000 or later, and were full-text. Articles were excluded if they were cohort studies, reviews, non-English papers, or had pain as the only outcome.

Results: Sawitzke et al.primary outcomes revealed no ...


Factors In Patient Responsiveness To Directional Preference-Matched Treatment Of Neck Pain With Or Without Upper Extremity Radiation, Benjamin Holmes, Ruta Brazauskas, Laura D. Cassidy, Rachel A. Wiegand 2017 Aurora Sheboygan Clinic Spine Institute; Medical College of Wisconsin

Factors In Patient Responsiveness To Directional Preference-Matched Treatment Of Neck Pain With Or Without Upper Extremity Radiation, Benjamin Holmes, Ruta Brazauskas, Laura D. Cassidy, Rachel A. Wiegand

Journal of Patient-Centered Research and Reviews

Purpose

Patient-related predictive factors in responsiveness to directional preference therapy for neck pain with or without upper extremity radiation (NP/R) have not been reported. A directional preference is any neck movement that, when performed repeatedly to end range, results in centralization and/or alleviation of NP/R. It was hypothesized that patient compliance with a prescribed, directional preference-matched home exercise program would improve positive responsiveness to NP/R treatment.

Methods

Patient-related factors thought to affect responsiveness to care were collected retrospectively from charts and de-identified for patients with NP/R who underwent chiropractic treatment at a multispecialty spine clinic ...


Impact Of Prior Biologic Use On Persistence Of Treatment In Patients With Psoriatic Arthritis Enrolled In The Us Corrona Registry, Leslie R. Harrold, Bradley S. Stolshek, Sabrina Rebello, David H. Collier, Alex Mutebi, Sally W. Wade, Wendi Malley, Jeffrey D. Greenberg, Carol J. Etzel 2017 University of Massachusetts Medical School

Impact Of Prior Biologic Use On Persistence Of Treatment In Patients With Psoriatic Arthritis Enrolled In The Us Corrona Registry, Leslie R. Harrold, Bradley S. Stolshek, Sabrina Rebello, David H. Collier, Alex Mutebi, Sally W. Wade, Wendi Malley, Jeffrey D. Greenberg, Carol J. Etzel

University of Massachusetts Medical School Faculty Publications

Psoriatic arthritis (PsA) is a chronic condition characterized by a diverse set of symptoms, from swollen joints to nail disease to skin disease. A variety of treatment options are available, including tumor necrosis factor inhibitors (TNFis). Little is known about treatment persistence in patients with PsA who initiate TNFi therapy, with and without prior biologic use. This study assessed persistence in these subgroups of patients with PsA and identified factors associated with persistence. This retrospective study utilized data from the Corrona registry of patients with PsA-with or without prior biologic experience-who initiated TNFi therapy between October 1, 2002, and March ...


Differential Burden Of Musculoskeletal Pain In African Americans And Whites Patients At The Time Of Total Joint Replacement Surgery, Leslie R. Harrold, Anthony Porter, Philip C. Noble, David C. Ayers, Jeroan J. Allison, Patricia D. Franklin 2017 University of Massachusetts Medical School

Differential Burden Of Musculoskeletal Pain In African Americans And Whites Patients At The Time Of Total Joint Replacement Surgery, Leslie R. Harrold, Anthony Porter, Philip C. Noble, David C. Ayers, Jeroan J. Allison, Patricia D. Franklin

Orthopedics and Physical Rehabilitation Publications and Presentations

Objective: African Americans patients have greater operative joint pain and functional limitation at the time of total joint replacement (TJR) compared to white patients. We examined the factors associated with this apparent disparity.

Methods: A consecutive sample of 5745 patients with advanced knee and hip osteoarthritis [who elected to undergo TJR in 2011-201] reported, preoperatively, medical comorbidities, operative and non-operative hip/ knee pain using Hip and Knee Disability and Osteoarthritis Outcome Scores (HOOS/KOOS), function using Short Form 36 Physical Component Score (PCS). Total burden of musculoskeletal pain was quantified as moderate/severe pain in non-operative hip and knee joints ...


Varying The Item Format Improved The Range Of Measurement In Patient-Reported Outcome Measures Assessing Physical Function, Gregor Liegl, Barbara L. Gandek, H. Felix Fischer, Jakob B. Bjorner, John E. Ware Jr., Matthias S. F. Rose, James F. Fries, Sandra Nolte 2017 Charité - Universitätsmedizin Berlin

Varying The Item Format Improved The Range Of Measurement In Patient-Reported Outcome Measures Assessing Physical Function, Gregor Liegl, Barbara L. Gandek, H. Felix Fischer, Jakob B. Bjorner, John E. Ware Jr., Matthias S. F. Rose, James F. Fries, Sandra Nolte

University of Massachusetts Medical School Faculty Publications

BACKGROUND: Physical function (PF) is a core patient-reported outcome domain in clinical trials in rheumatic diseases. Frequently used PF measures have ceiling effects, leading to large sample size requirements and low sensitivity to change. In most of these instruments, the response category that indicates the highest PF level is the statement that one is able to perform a given physical activity without any limitations or difficulty. This study investigates whether using an item format with an extended response scale, allowing respondents to state that the performance of an activity is easy or very easy, increases the range of precise measurement ...


Sex Differences In Gout Characteristics: Tailoring Care For Women And Men, Leslie R. Harrold, Carol J. Etzel, Allan Gibofsky, Joel Kremer, Michael H. Pillinger, Kenneth G. Saag, Naomi Schlesinger, Robert Terkeltaub, Vanessa Cox, Jeffrey D. Greenberg 2017 University of Massachusetts Medical School

Sex Differences In Gout Characteristics: Tailoring Care For Women And Men, Leslie R. Harrold, Carol J. Etzel, Allan Gibofsky, Joel Kremer, Michael H. Pillinger, Kenneth G. Saag, Naomi Schlesinger, Robert Terkeltaub, Vanessa Cox, Jeffrey D. Greenberg

University of Massachusetts Medical School Faculty Publications

BACKGROUND: To characterize the differences between women and men with gout.

METHODS: We analyzed a US national cohort of gout patients cared for by rheumatologists.

RESULTS: Compared with the 1012 men with gout, women with gout (n = 262) were older (71 vs. 61 years, p < 0.001) and had a greater burden of comorbid conditions (p < 0.001 for hypertension, diabetes, renal disease and obesity). Risk factors for gout differed with women more often taking diuretics (p < 0.001), while men more frequently had dietary triggers (p < 0.05).

CONCLUSIONS: The profiles of women and men with gout are markedly different, suggesting a need to tailor treatment recommendations.


Antisense Oligonucleotides Used To Target The Dux4 Mrna As Therapeutic Approaches In Faciosscapulohumeral Muscular Dystrophy (Fshd), Eugenie Ansseau, Celine Vanderplanck, Armelle Wauters, Scott Q. Harper, Frederique Coppee, Alexandra Belayew 2017 University of Mons

Antisense Oligonucleotides Used To Target The Dux4 Mrna As Therapeutic Approaches In Faciosscapulohumeral Muscular Dystrophy (Fshd), Eugenie Ansseau, Celine Vanderplanck, Armelle Wauters, Scott Q. Harper, Frederique Coppee, Alexandra Belayew

Wellstone Center for FSHD Publications and Presentations

FacioScapuloHumeral muscular Dystrophy (FSHD) is one of the most prevalent hereditary myopathies and is generally characterized by progressive muscle atrophy affecting the face, scapular fixators; upper arms and distal lower legs. The FSHD locus maps to a macrosatellite D4Z4 repeat array on chromosome 4q35. Each D4Z4 unit contains a DUX4 gene; the most distal of which is flanked by a polyadenylation site on FSHD-permissive alleles, which allows for production of stable DUX4 mRNAs. In addition, an open chromatin structure is required for DUX4 gene transcription. FSHD thus results from a gain of function of the toxic DUX4 protein that normally ...


A Window Of Opportunity For Abatacept In Ra: Is Disease Duration An Independent Predictor Of Low Disease Activity/Remission In Clinical Practice, Leslie R. Harrold, Heather J. Litman, Sean E. Connolly, Sheila Kelly, Winnie Hua, Evo Alemao, Lisa Rosenblatt, Sabrina Rebello, Joel M. Kremer 2017 University of Massachusetts Medical School

A Window Of Opportunity For Abatacept In Ra: Is Disease Duration An Independent Predictor Of Low Disease Activity/Remission In Clinical Practice, Leslie R. Harrold, Heather J. Litman, Sean E. Connolly, Sheila Kelly, Winnie Hua, Evo Alemao, Lisa Rosenblatt, Sabrina Rebello, Joel M. Kremer

University of Massachusetts Medical School Faculty Publications

The objective of the study was to examine whether disease duration independently predicts treatment response among biologic-naive patients with rheumatoid arthritis (RA) initiating abatacept in clinical practice. Using the Corrona RA registry (February 2006-January 2015), biologic-naive patients with RA initiating abatacept with 12-month (+/-3 months) follow-up and assessment of disease activity (Clinical Disease Activity Index [CDAI]) at initiation and at 12 months were identified. The primary outcome was mean change in CDAI (DeltaCDAI) from baseline to 12 months. Secondary outcomes at 12 months included achievement of low disease activity (LDA; CDAI 10 years, n = 79). Increased disease duration was associated ...


Large Family Cohorts Of Lymphoblastoid Cells Provide A New Cellular Model For Investigating Facioscapulohumeral Muscular Dystrophy, Takako I. Jones, Charis L. Himeda, Daniel P. Perez, Peter L. Jones 2017 University of Massachusetts Medical School

Large Family Cohorts Of Lymphoblastoid Cells Provide A New Cellular Model For Investigating Facioscapulohumeral Muscular Dystrophy, Takako I. Jones, Charis L. Himeda, Daniel P. Perez, Peter L. Jones

Open Access Articles

Facioscapulohumeral muscular dystrophy (FSHD) is associated with aberrant epigenetic regulation of the chromosome 4q35 D4Z4 macrosatellite repeat. The resulting DNA hypomethylation and relaxation of epigenetic repression leads to increased expression of the deleterious DUX4-fl mRNA encoded within the distal D4Z4 repeat. With the typical late onset of muscle weakness, prevalence of asymptomatic individuals, and an autosomal dominant mode of inheritance, FSHD is often passed on from one generation to the next and affects multiple individuals within a family. Here we have characterized unique collections of 114 lymphoblastoid cell lines (LCLs) generated from 12 multigenerational FSHD families, including 56 LCLs from ...


Two Cases Of Lyme Arthritis In Winter In New England: A Case Series, Jennifer Baima, Lauren Woo 2017 University of Massachusetts Medical School

Two Cases Of Lyme Arthritis In Winter In New England: A Case Series, Jennifer Baima, Lauren Woo

Orthopedics and Physical Rehabilitation Publications and Presentations

Case Diagnosis: Lyme Arthritis

Case Description: Patient 1 is a 26 year old male who presented in March with severe right knee pain and swelling for two weeks. He had a similar episode a month prior, but it resolved. The second episode progressed with pain from knee to foot and numbness on top of the foot. He had no known history of tick bites, travel, or trauma, but endorsed contact with a dog. On physical exam, he had a right knee effusion with limited ROM, diffuse joint line tenderness, positive McMurray’s, and pain with ligamentous testing. Synovial fluid of ...


What Outcomes Are Important For Gout Patients? In-Depth Qualitative Research Into The Gout Patient Experience To Determine Optimal Endpoints For Evaluating Therapeutic Interventions, Sophi Tatlock, Katja Rudell, Charlotte Panter, Rob Arbuckle, Leslie R. Harrold, William J. Taylor, Tara Symonds 2017 Adelphi Values

What Outcomes Are Important For Gout Patients? In-Depth Qualitative Research Into The Gout Patient Experience To Determine Optimal Endpoints For Evaluating Therapeutic Interventions, Sophi Tatlock, Katja Rudell, Charlotte Panter, Rob Arbuckle, Leslie R. Harrold, William J. Taylor, Tara Symonds

University of Massachusetts Medical School Faculty Publications

BACKGROUND AND OBJECTIVES: Characterized by sudden onset of severe joint pain, swelling, redness, and tenderness to touch, gout 'flare ups' have a substantial impact on quality of life (QoL). This research employed a patient-centered approach to explore the symptoms and impacts of gout, and assess the content validity of existing patient-reported outcomes (PROs).

METHODS: Qualitative interviews were conducted with 30 US gout patients (non-tophaceous: n = 20, tophaceous: n = 10) and five expert rheumatologists. Each interview included both concept elicitation (CE) questioning to learn about the patient experience and cognitive debriefing to assess the content validity of three PRO instruments (HAQ-DI ...


Important Patient Characteristics Differ Prior To Total Knee Arthroplasty And Total Hip Arthroplasty Between Switzerland And The United States, Patricia D. Franklin, Hermes Miozzari, Panayiotis Christofilopoulos, Pierre Hoffmeyer, David C. Ayers, Anne Lubbeke 2017 University of Massachusetts Medical School

Important Patient Characteristics Differ Prior To Total Knee Arthroplasty And Total Hip Arthroplasty Between Switzerland And The United States, Patricia D. Franklin, Hermes Miozzari, Panayiotis Christofilopoulos, Pierre Hoffmeyer, David C. Ayers, Anne Lubbeke

University of Massachusetts Medical School Faculty Publications

BACKGROUND: Outcomes after total knee (TKA) and hip (THA) arthroplasty are often generalized internationally. Patient-dependent factors and preoperative symptom levels may differ across countries. We compared preoperative patient and clinical characteristics from two large cohorts, one in Switzerland, the other in the US.

METHODS: Patient characteristics were collected prospectively on all elective primary TKAs and THAs performed at a large Swiss hospital and in a US national sample. Data included age, sex, education level, BMI, diagnosis, medical co-morbidities, PROMs (WOMAC pain/function), global health (SF-12).

RESULTS: Six thousand six hundred eighty primary TKAs (US) and 823 TKAs (Swiss) were evaluated ...


A Multi-Modal Intervention For Activating Patients At Risk For Osteoporosis (Apropos): Rationale, Design, And Uptake Of Online Study Intervention Material, Maria I. Danila, Jeroan J. Allison, Frederick A. Anderson Jr., Robert A. Yood, Kenneth G. Saag 2016 University of Alabama at Birmingham

A Multi-Modal Intervention For Activating Patients At Risk For Osteoporosis (Apropos): Rationale, Design, And Uptake Of Online Study Intervention Material, Maria I. Danila, Jeroan J. Allison, Frederick A. Anderson Jr., Robert A. Yood, Kenneth G. Saag

University of Massachusetts Medical School Faculty Publications

OBJECTIVE: To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake.

METHODS: Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race ...


Comparative Effectiveness Of Abatacept Versus Tocilizumab In Rheumatoid Arthritis Patients With Prior Tnfi Exposure In The Us Corrona Registry, Leslie R. Harrold, George W. Reed, Daniel H. Solomon, Jeffrey R. Curtis, Mei Liu, Jeffrey D. Greenberg, Joel M. Kremer 2016 University of Massachusetts Medical School

Comparative Effectiveness Of Abatacept Versus Tocilizumab In Rheumatoid Arthritis Patients With Prior Tnfi Exposure In The Us Corrona Registry, Leslie R. Harrold, George W. Reed, Daniel H. Solomon, Jeffrey R. Curtis, Mei Liu, Jeffrey D. Greenberg, Joel M. Kremer

University of Massachusetts Medical School Faculty Publications

BACKGROUND:

We compared the effectiveness of abatacept (ABA) vs tocilizumab (TCA) in tumor necrosis factor inhibitor (TNFi) experienced patients.

METHODS:

We identified rheumatoid arthritis (RA) patients from a large observational US cohort (1 January 2010-31 May 2014) who had discontinued at least one TNFi and initiated ABA or TCZ in moderate or high disease activity based on the Clinical Disease Activity Index (CDAI) and had no prior exposure to the comparator drug. Using propensity score matching (1:1) stratified by prior TNF use (1 TNFi vs ≥2 TNFis), effectiveness at 6 months after initiation was evaluated. Mean change in CDAI ...


Risk Of Infection Associated With Subsequent Biologic Agent Use After Rituximab: Results From A National Rheumatoid Arthritis Patient Registry, Leslie R. Harrold, George W. Reed, Chitra Karki, Robert P. Magner, Ashwini Shewade, Ani John, Joel Kremer, Jeffrey D. Greenberg 2016 University of Massachusetts Medical School

Risk Of Infection Associated With Subsequent Biologic Agent Use After Rituximab: Results From A National Rheumatoid Arthritis Patient Registry, Leslie R. Harrold, George W. Reed, Chitra Karki, Robert P. Magner, Ashwini Shewade, Ani John, Joel Kremer, Jeffrey D. Greenberg

University of Massachusetts Medical School Faculty Publications

OBJECTIVE: To assess whether the time between the last rituximab infusion and initiation of a different biologic agent influenced infection risk in patients with rheumatoid arthritis (RA).

METHODS: Patients with RA who newly initiated rituximab within the Consortium of Rheumatology Researchers of North America registry were included if they switched to a nonrituximab biologic agent and had > /=1 followup visit within 12 months of switching. Patients were categorized by duration of time between their last rituximab infusion and initiation of a subsequent biologic agent (< /=5 months, 6-11 months, and > /=12 months). The primary outcome was time to first infectious event. Adjusted Cox regression models estimated ...


Defining An International Standard Set Of Outcome Measures For Patients With Hip Or Knee Osteoarthritis: Consensus Of The International Consortium For Health Outcomes Measurement Hip And Knee Osteoarthritis Working Group, Ola Rolfson, David C. Ayers, Patricia D. Franklin 2016 Sahlgrenska University

Defining An International Standard Set Of Outcome Measures For Patients With Hip Or Knee Osteoarthritis: Consensus Of The International Consortium For Health Outcomes Measurement Hip And Knee Osteoarthritis Working Group, Ola Rolfson, David C. Ayers, Patricia D. Franklin

Open Access Articles

OBJECTIVE: To define a minimum Standard Set of outcome measures and case-mix factors for monitoring, comparing, and improving health care for patients with clinically diagnosed hip or knee osteoarthritis (OA), with a focus on defining the outcomes that matter most to patients.

METHODS: An international working group of patients, arthroplasty register experts, orthopedic surgeons, primary care physicians, rheumatologists, and physiotherapists representing 10 countries was assembled to review existing literature and practices for assessing outcomes of pharmacologic and nonpharmacologic OA therapies, including surgery. A series of 8 teleconferences, incorporating a modified Delphi process, were held to reach consensus.

RESULTS: The working ...


When It Isn’T Always Lyme: Expanding The Differential Diagnosis For Acute-Onset Polyarthralgia In The West Virginia Eastern Panhandle, Natalie A. Moffett, Rosemarie Lorenzetti 2016 West Virginia University

When It Isn’T Always Lyme: Expanding The Differential Diagnosis For Acute-Onset Polyarthralgia In The West Virginia Eastern Panhandle, Natalie A. Moffett, Rosemarie Lorenzetti

Marshall Journal of Medicine

This case presentation discusses a 36 year-old female animal care worker presenting with an acute-onset polyarthropathy during the summer months in a Lyme endemic region. Though she appeared to be a good candidate for the diagnosis of Lyme borreliosis, her screening serology reported negative results and alternative diagnoses were considered. Her subsequent diagnosis with parvovirus B19 acts to remind the general practitioner to have confidence in the accuracy of a negative Lyme screen and, upon negative result, to expand the differential to include less common infections including parvovirus B19. It also highlights the need to remember parvovirus B19 in a ...


Ataluren Stimulates Ribosomal Selection Of Near-Cognate Trnas To Promote Nonsense Suppression, Bijoyita Roy, Westley J. Friesen, Yuki Tomizawa, John D. Leszyk, Jin Zhuo, Briana Johnson, Jumana Dakka, Christopher R. Trotta, Xiaojiao Xue, Venkateshwar Mutyam, Kim M. Keeling, James A. Mobley, Steven M. Rowe, David M. Bedwell, Ellen M. Welch, Allan Jacobson 2016 University of Massachusetts Medical School

Ataluren Stimulates Ribosomal Selection Of Near-Cognate Trnas To Promote Nonsense Suppression, Bijoyita Roy, Westley J. Friesen, Yuki Tomizawa, John D. Leszyk, Jin Zhuo, Briana Johnson, Jumana Dakka, Christopher R. Trotta, Xiaojiao Xue, Venkateshwar Mutyam, Kim M. Keeling, James A. Mobley, Steven M. Rowe, David M. Bedwell, Ellen M. Welch, Allan Jacobson

Microbiology and Physiological Systems Publications and Presentations

A premature termination codon (PTC) in the ORF of an mRNA generally leads to production of a truncated polypeptide, accelerated degradation of the mRNA, and depression of overall mRNA expression. Accordingly, nonsense mutations cause some of the most severe forms of inherited disorders. The small-molecule drug ataluren promotes therapeutic nonsense suppression and has been thought to mediate the insertion of near-cognate tRNAs at PTCs. However, direct evidence for this activity has been lacking. Here, we expressed multiple nonsense mutation reporters in human cells and yeast and identified the amino acids inserted when a PTC occupies the ribosomal A site in ...


The Changing Landscape Of Biosimilars In Rheumatology, Thomas Dorner, Vibeke Strand, Paul Cornes, Joao Goncalves, Laszlo Gulacsi, Jonathan Kay, Tore K. Kvien, Josef S. Smolen, Yoshiya Tanaka, Gerd R. Burmester 2016 Charite Universitätsmedizin

The Changing Landscape Of Biosimilars In Rheumatology, Thomas Dorner, Vibeke Strand, Paul Cornes, Joao Goncalves, Laszlo Gulacsi, Jonathan Kay, Tore K. Kvien, Josef S. Smolen, Yoshiya Tanaka, Gerd R. Burmester

Jonathan Kay

Biosimilars remain a hot topic in rheumatology, and some physicians are cautious about their application in the real world. With many products coming to market and a wealth of guidelines and recommendations concerning their use, there is a need to understand the changing landscape and the real clinical and health-economic potential offered by these agents. Notably, rheumatologists will be at the forefront of the use of biosimilar monoclonal antibodies/soluble receptors. Biosimilars offer cost savings and health gains for our patients and will play an important role in treating rheumatic diseases. We hope that these lower costs will compensate for ...


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