Medicine and Health Sciences Commons^™

Impact Of Covid-19 Pandemic On Student-Run Free Clinic Services For An Underserved Urban Patient Population, Mina Sitto, Adlai Nelson, Sara L. Ma, Sara Kazyak, Nili Modi, Kathy Lu, Alexander Wind, Jennifer Schmidt, Robert Sherwin

Medical Student Research Symposium

Background:

The COVID-19 pandemic significantly impacted healthcare delivery in high density urban communities. This clinic provides free medical care to patients in an urban Midwestern community including limited prescriptions, vaccines, and over-the-counter medications. This study aims to understand how the patient demographics and medical services offered at the clinic have been impacted by the COVID-19 pandemic.

Methods:

Walk-in student-run clinics were held weekly on Saturday mornings in an urban Midwestern city, with patients consisting of underinsured and uninsured residents experiencing housing instability. Number of returning and new patients, physicals, flu shots, blood glucose readings, HbA1c, lipid panels, and …

M4-Intern Mentorship Project, Christian Freitag, Sahar Elmenini, Kyla Kosidowski

Medical Student Research Symposium

Wayne State University School of Medicine (WSUSOM) in 2018 formed Learning Communities (LCs), that facilitate student engagement, comradery, and mentoring. These programs include medical student-premed, near-peer, and faculty/attending mentorships. There has been an identified gap in mentorship between near-peer and faculty/attending mentorship, and that is near-peer mentors at WSUSOM have yet to complete the residency process to guide other students through it. Moreover, faculty/attending mentors are more removed from residency and may not have relevant advice for students. As resident physicians are recent graduates, they are more likely to provide relevant insight about residency applications, academic challenges, and efficiency than …

Are Chatgpt Responses To Urologic Health Inquiries Readable And Supported By American Urological Association Guidelines?, Chase Morrison, Jack Vercnocke Md, Isaiah Dennis, Michael Cher Md, Steven Lucas Md, John Cochrane Md, Aron Liaw Md, Kevin Ginsburg Md

Medical Student Research Symposium

Introduction and Objective:

ChatGPT is widely accessible to patients, but it is unknown if the responses provided by the chatbot are supported by corresponding American Urological Association’s (AUA) guidelines. Our primary objective was to assess if cGPT’s responses to a hypothetical patient’s question regarding their urologic conditions were supported by the AUA guidelines.

Methods:

Thirty prompts, each addressing one or more AUA Guideline, were written from the perspective of a patient. Responses were assessed by 8 evaluators consisting of practicing Urologists and current Urology Residents. Each response was evaluated using a Support Score (SS) and Quality Score (QS) (Table 1). …

Anatomy And Physiology Of Intraosseous Infusion, Andrew Mizerowski, James Paxton

Medical Student Research Symposium

The introduction of fluids and medications via intraosseous (IO) infusion is highly dependent upon many unique aspects of bone anatomy and physiology. Key considerations include differences in the medullary cross-sectional area between insertion sites, age- and location-dependent variation in the distribution of red and yellow bone marrow, volume and pressure capacity within the venous system, and the influence of hormones and other chemical messengers on vasomotor tone. In addition to an exploration of these concepts, this chapter will also discuss the physiologic basis for pharmacokinetic relationships reported in the prevailing literature and propose methods to optimize the use of IO …

Alcohol And Cannabis Use Among Women With Infertility: Associations With Psychological Distress, Attempts To Conceive, And Engagement In Fertility Treatment, Genevieve E. M. Joseph-Mofford Ms, Leah M. Hecht Phd, Rory Iacobelli Bs, Amy M. Loree Phd, Lisa R. Miller-Matero Phd

Medical Student Research Symposium

Objective: An infertility diagnosis can lead to distress. Although substance use is common and can also lead to distress, little is known about use among those with an infertility diagnosis. This is important since substance use can have implications for fertility. The purpose of this study was to estimate the rate of alcohol and cannabis use among women with infertility and examine whether substance use had associations with psychiatric symptoms, attempts to conceive, and engagement in fertility treatments.

Materials and Methods: Patients from one healthcare system were eligible if they received a female infertility diagnosis within the past 2 years. …

Vulnerable Neighborhoods Had Smaller Gains In Health Insurance Coverage During Early Covid-19, Ismail Mustafa Aijazuddin, Ammar Sukari

Medical Student Research Symposium

Background:

The Covid-19 pandemic has illuminated the inequities that jeopardize health, prompting rapid interventions to promote care access. However, such efforts have had mixed success in eradicating disparities. One focus is the equity of improvements in insured rates.

Methods:

Self-reported health insurance coverage rates among adults aged 18-64 were obtained from the CDC’s PLACES datasets for collection years 2018 and 2021, at the Census Tract level. These data were merged with the CDC’s 2018 Social Vulnerability Index (SVI), which ranks Tracts on 15 measures of social determinants of health. Across Tracts nationally and by state, univariate correlations between Overall SVI …

Improvement Of Total Body Weight Loss In A Comprehensive Weight Loss Program At A Community Gastroenterology Practice With Consistent Support Group Attendance, Nishant S. Kumar Bs, Sejal Gunaratnam Ms, Sangini Tolia Md, Mallory Evans Rd, Naresh Gunaratnam Md Agaf

Medical Student Research Symposium

Introduction

Obesity-related gastrointestinal disorders, including non-alcoholic fatty liver disease (NAFLD), account for over 30% of visits to GI practices. Total body weight loss (TBWL) of 10% or more is associated with reversal of NAFLD-associated fibrosis and steatosis. Support groups have proven to help individuals recover from other lifestyle diseases. This study assesses the impact of support group attendance on a patient achieving 10% TBWL while enrolled in a community-based weight loss program.

Methods

Patients participated in a 6-month support group with weekly meetings. TBWL was calculated by taking the difference between the patient’s starting weight and their 6-month weight divided …

Reduced Venous Blood Oxygen Saturation May Associate With Cognitive Decline In Patients With Multiple Sclerosis, Hasan Sawan, Chenyang Li, Sagar Buch, Fahad Malik, Ying Wang, Evanthia Bernitsas, E Mark Haacke, Yulin Ge, Yongsheng Chen

Medical Student Research Symposium

Introduction: Reduced brain oxygen metabolism may be associated with neuronal activity in individuals with Multiple sclerosis (MS). Quantitative susceptibility mapping (QSM), an advanced MRI technique, can measure venous blood oxygen saturation via deoxyhemoglobin levels. It remains unknown whether QSM-derived venous blood susceptibility can be used as an imaging biomarker of neuronal activity in MS. The objective of this study was to investigate the susceptibility of internal cerebral veins (ICVs) in patients with relapsing-remitting MS (RRMS), and their correlations with clinical measures.

Methods: We recruited 18 patients with RRMS and 10 age-matched healthy controls (HC). Participants were scanned on a 3T …

Perception Of Trust, Virtual Care, And Access Among The Uninsured Population: A Multi-Site Study At Student Run Free Clinics, Hanna Simmons, Ahmad Chouman, Juliann Binienda Phd

Medical Student Research Symposium

Introduction/Problem:

Since the onset of the COVID-19 pandemic, utilization of virtual visits has significantly increased. Advantages of virtual visits include lower healthcare costs and improved access to healthcare. Although one of the main goals of implementing virtual visits is to increase access to the underserved population, there have been few studies with a focus on the opinions of African Americans or the uninsured. Moreover, distrust in physicians and healthcare, although universal, is more prevalent among the African American and uninsured populations. It is also known that trust leads to better self-reported health outcomes, patient satisfaction, health behaviors, quality of life, …

Characteristics Of Patients With Low Hepatitis C Treatment Rates In Urban Medical Center Clinics, Rana Khamis, Crisshy Auguste, Paul H. Naylor Phd, Milton G. Mutchnik Md

Medical Student Research Symposium

The objective of this study was to determine whether there were different characteristics between HCV patients who were treated and those not treated after their first visit to a Gastroenterology (GI) or Infectious Disease (ID) clinic. This information might identify potential targets for remedial actions that could be performed to increase the number of treated patients.

Data was collected from 2019 HCV patient EMR charts including patient demographics, treatment history, and laboratory studies. We defined success as receiving treatment by July 2020 (6-18 months after the first visit).

We found that of 587 patients with HCV who were seen at …

Pessary Use In Urology Clinics, Kathy Z. Lu Bs, Emily Brodowsky Md, Alex Stephens Ms, Samantha Raffee Md, Humphrey Atiemo Md

Medical Student Research Symposium

Introduction: Pessaries are a non-invasive treatment option for patients with pelvic organ prolapse (POP) or stress urinary incontinence (SUI). There is currently limited data regarding pessary usage among urology patients. The aim of this study is to determine the patient characteristics that predict long term pessary usage versus surgical intervention.

Methods: A 10-year retrospective review of pessary usage in women with either SUI or POP was performed. Patients were stratified into pessary longevity of less than or greater than one year. Quality of life measures before and after pessary use included pads per day, incontinence symptom index (ISI) scores, and …

Predicting Risk Of Atrial Fibrillation In Hematopoietic Stem Cell Transplant, Min Yi Wu, Madhulata Reddy, Shatha Farhan

Medical Student Research Symposium

Background

Atrial fibrillation (AF) in hematopoietic stem cell transplant (HSCT) recipients is associated with significant morbidity. We have previously reported that obstructive sleep apnea (OSA), older age and presence of dilated left atrium (LA) are significant predictors of AF early post HSCT. In the current study, we sought to evaluate if TSH pre HSCT and serum electrolytes and eGFR at engraftment in patients undergoing HSCT are associated with increased risk of AF.

Methods

This is a single center retrospective study, involving 748 consecutive patients undergoing autologous and allogenic HSCT from 2012 to 2022. Patients’ charts were reviewed to acquire clinical …

Activating Neuroprotective Effects Of Glial Cells In Vps13d-Associated Ataxia, Abrielle Fretz

Medical Student Research Symposium

Ataxia is a common symptom among many neurological conditions. Due to its high prevalence and quality of life impact, there is significant interest in understanding the underlying cause, as well as potential therapeutic approaches to mitigate its severity. Our lab uses a model of Vps13D-associated ataxia in the fruit fly, Drosophila Melanogaster, which recapitulates aspects of the human disease including age-dependent motor deficits.

The anti-oxidant compounds gastrodin and 4-HBA were found to have neuroprotective effects in Drosophila and mouse models of Parkinson’s disease. Previous work has demonstrated that these compounds can activate the Nrf2-pathway, a master regulator of anti-oxidant defenses. …

Anterior Cruciate Ligament Hybrid Remnant Preservation Reconstruction Demonstrates Similar Outcomes As Traditional Reconstruction After 6 Months: A Randomized Control Trial, Joshua P. Castle, Eleftherios L. Halkias, Brittaney Pratt, Ashley Frei, Matthew A. Gasparro, Vasilios Moutzouros

Medical Student Research Symposium

Background

The anterior cruciate ligament (ACL) is often debrided during reconstruction (ACLR) to improve visualization. However, remnant ACL tissue contains nerve fibers and including remnant tissue in ACLR could provide benefit. Therefore, a technique was developed that preserves the tibial remnant and incorporates it into ACLR: Hybrid Remnant Preservation Reconstruction (HRPR) ACLR. This study compares HRPR-ACLR to traditional reconstruction by comparing patient reported outcomes and complications.

Methods

Patients presenting to one surgeon's clinic with an ACL injury are screened. Exclusion criteria are patient age<14 years, multi-ligament injury, chronic tears, and revision ACLR. Patients are consented and randomized to HRPR or traditional ACLR. Demographics, patient-reported outcomes, range of motion (ROM) and complications were collected.

Results

Thirty-three patients were included, 20 HRPR and 13 controls. No demographic differences were noted. PROMIS-PF, …

Home Visits: A Way To Build Genuine Connection And Learn From A Vulnerable Refugee Population, Shirley M. Elfishawy

Medical Student Research Symposium

Among non-immigrant populations, maternal psychosocial stress was associated with impaired maternal bonding. Parents’ stress and depressive symptoms were associated with lower levels of supportive coparenting and impaired child development. To date, no studies have evaluated whether coparenting is related to maternal bonding in immigrant families. The goal of this study was to examine the relationship between maternal psychosocial stress (acculturative stress, posttraumatic stress, maternal depression), coparenting, and maternal bonding with the child among a sample of Arab-American immigrant and refugee mothers. As a first-generation Egyptian-American medical student, I was part of the team who went to the homes of immigrant …

Exploring Arab Americans’ Preferences Towards Telemedicine As A Mental Health Treatment, George G. Kidess, Liam Browning, Nicole Oska, Liza Hinchey, Arwa Saleem, Sadie Knill, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Introduction

Arab Americans—a large minority group in the United States—experience higher rates of mental illness and relatively lower rates of treatment compared to the general population. While some factors leading to this disparity have been proposed, data in the literature remains lacking. This study aims to explore Arab-American mental health perspectives with regards to their preferences towards telemental health as a treatment option.

Methods

Responses were collected through an anonymous bilingual Qualtrics survey from both Arab and non-Arab participants (n=294, ages 18+). Participants’ perceptions towards telemental health and mental illness stigma were assessed, performing comparisons between Arabs and non-Arabs, as …

A Retrospective Study Characterizing Myocardial Strain Patterns In Patients With Mitral Annular Disjunction With And Without Mitral Valve Prolapse, John A. Gallagher, Ahmad El-Moussa Md, John Dawdy Md, Luis Afonso Md

Medical Student Research Symposium

Background: Mitral annular disjunction (MAD) is an atrial displacement of the mitral valve hinge point. MAD may occur with or without mitral valve prolapse (MVP) and has been linked to ventricular arrhythmias (VA) and sudden cardiac death (SCD). Although cardiac magnetic resonance imaging (cMRI) is the gold standard for MAD detection, it is not practical for screening. We used 2D transthoracic echocardiography (TTE) with speckle tracking echocardiography (STE) to characterize segmental and global longitudinal myocardial strain (SLMS, GLMS) patterns in patients with MAD, +/-MVP.

Methods: 43 subjects were identified by searching “MAD” in our institution’s database. GLMS and …

Neural Correlates Of Fear Extinction: Investing The Impact Of Puberty And Sex In Children And Adolescents Through Neuroimaging, Sneha Bhargava, Clara Zundel, Samantha Ely, Carmen Carpenter, Reem Tamimi, Leah Gowatch, Mackenna Shampine, Emilie-Clare O'Mara, Jovan Jande, Shravya Chanamolu, Ahmad Almaat, Hilary Marusak

Medical Student Research Symposium

Fear-based disorders, including anxiety and posttraumatic stress disorder, are more prevalent in females than males. Steroid hormones (e.g., estradiol) are involved in fear extinction learning and later recall—a process implicated in the pathophysiology of fear-based disorders. Fear-based disorders commonly emerge during the transition from childhood to adolescence, a period marked by the onset of puberty and a natural increase of steroid hormones. Here, we examined the effects of puberty, sex, and their interaction on extinction recall and underlying neural circuitry in youth. Eighty-five youth (6-17 years, 46% female) completed a two-day Pavlovian fear extinction paradigm while undergoing functional magnetic resonance …

Mental Health Attitudes And Perspectives Of Arab Americans: Beliefs Associated With Stigma, Treatment, And The Origins Of Pathology, Sadie Knill, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Arwa Saleem, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Purpose:

Arab Americans are one of the largest ethnic groups in the United States. Despite elevated incidence of mental illness and diminished rates of treatment within this community, the mental health of Arab Americans, along with their attitudes towards mental health, has not received adequate study. Unique cultural interpretations of mental illness may engender stigma, exacerbating disparities in treatment. This study aimed to assess the attitudes and perspectives of Arab Americans concerning mental illness, with the goal of identifying and addressing barriers to treatment.

Methods:

Using an anonymous bilingual Qualtrics survey, we assessed Arab and non-Arab participants (n = 294; …

Amniotic Bladder Therapy In Covid-Associated Cystitis (Cac), Michael C. Wang, Jack Vercnocke Md, Codrut Radoiu, Cullen Hudson, Emma Ross, Raghav Madan, Steve Lucas, Nivedita C. Dhar

Medical Student Research Symposium

Introduction:

SARS-coV-2 is linked to genitourinary symptoms of overactive bladder (OAB), marked by increased frequency, urgency, and nocturia, and has been recently labeled COVID-associated cystitis (CAC). The predominant pathophysiology is proposed to be overexpression of pro-inflammatory cytokines causing bladder inflammation, fibrosis, and bothersome urinary symptoms. Research supports that amniotic membrane (AM) can be used to induce apoptosis of pro-inflammatory cells, inhibit differentiation of pro-fibrotic cells, and expedite wound healing. We investigated the therapeutic response and safety of AM in 5 CAC patients with resistant OAB symptoms.

Methods:

All study patients were admitted for treatment of COVID-19 in spring 2019 and …

Addressing Barriers To Black Americans Participation In Clinical Trials: A Faith-Based Community Survey, Alexandra Stone, Lydell Lettsome Md, Brian A. Stone Md, Clinical Diversity Solutions

Medical Student Research Symposium

Background: The underrepresentation of high-risk minority groups in clinical trials remains a crisis in American healthcare. Despite pressures from the NIH to increase Black-American participation in trials, recruitment and retention in this group rarely match population demographics. Our company launched an opinion survey polling 260 Blacks regarding their thoughts and awareness about clinical trial participation.

Methods: We created a web-based survey consisting of 38 items and subdivided it into three main sections: (1) cultural affinity, (2) trust, and (3) background information. The survey was conducted using Jotform, a HIPAAcompliant web-based application. Our target population was Black Americans in central Alabama. …

Investigating Arab American Perspectives On Barriers To Mental Health Treatment, Arwa Saleem, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Sadie Knill, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Purpose: Compared to the general population, Arab Americans experience higher rates of mental illness and lower rates of mental health treatment. While some causes of this discrepancy have been suggested, there are many gaps in the literature since Arab Americans are not recognized as an ethnic group in the United States. This study aims to analyze Arab-Americans’ outlook on mental health by identifying and addressing the barriers to receiving mental health treatment.

Methods: An anonymous bilingual Qualtrics survey was conducted and responses were collected from Arab and non-Arab participants (n=294, ages 18+). The participants’ viewpoints on barriers between Arabs and …

The Roles Of Lower Glycolytic Enzymes And Transporters In Regulating The Integrity Of Retinal Vascular Endothelial Cell Barrier, Nicole Oska, Shaimaa Eltanani, Mohamed Shawky, Thangal Yumnamcha, Ahmed S. Ibrahim

Medical Student Research Symposium

Purpose: Damage to the retinal endothelial cells (RECs) is implicated in the progression of retinal degenerative diseases, including diabetic retinopathy and diabetic macular edema. While the role of glycolysis in glucose homeostasis is well-established, its contribution to REC barrier assembly remains unclear. In this study we investigated the importance of lower glycolytic components in maintaining the barrier integrity of human RECs (HRECs). Methods: Electric cell-substrate impedance sensing (ECIS) technology was employed to analyze the real-time impact of various glycolytic enzymes and transporters on the maintenance of HREC barrier integrity, represented by resistance (R) across the cells. Heptelidic acid was used …

Trauma And Anxiety: The Narratives Of Syrian Youth Resettled As Refugees, Jessica Declercq, Lana Ruvolo Grasser, Rasheed Alahmad, Bassem Saad, Hiba Abu Suhaiban, Dalia F. Mammo, Celine Bazzi, Ragda Izar, Noor Abou-Rass, Ayat Abed Ali, Raya Nashef, Tanja Jovanovic, Arash Javanbakht

Medical Student Research Symposium

Background

Civilian war trauma and forced migration are among the most traumatic life experiences. There are approximately 36.4 million refugees worldwide; 40% are children. There is a paucity of mixed methods approaches that quantify properties of trauma narratives of refugee youth. This approach could assist in identifying individuals who could benefit from early clinical care.

Methods

Participants were 68 youth resettled as refugees of Syria in Southeast Michigan ages 7-17 (31F, M_age = 12.85), originally recruited from clinics during health screenings within one month of arrival in the United States. Those enrolled in this study consented to additional data …

The Long-Term Economic Implications Of Burn Injury For Burn Survivors, Jacob M. Dougherty Bs, Hannan A. Maqsood Mbbs, Zhaohui Fan Md Mph, Stewart C. Wang Md Phd, Mark R. Hemmila Md, Naveen F. Sangji Md Mph

Medical Student Research Symposium

Introduction: The long-term economic implications of burn injury on patients and payors has not been well described. Burn injury can be costly due to prolonged intensive care, wound care, rehabilitation, psychological care, and reconstructive surgery that may be required well after the initial injury. We investigated index and post-acute payor and out-of-pocket (OOP) costs related to burn injury for in-patient care at 30 days, and up to 36 months post-discharge to understand the long-term economic implications for burn survivors.

Methods: An observational cohort study was conducted using a commercial claims database from IBM Watson Health® Marketscan. Patients age ≤ …

Natural Spaces, A Social Determinant Of Health, And Self-Rated Health Among Medical Students, Josiah P. Stryd, Anil N. F. Aranha

Medical Student Research Symposium

Background and Purpose: Natural spaces are areas which have a majority of natural ground cover such as vegetation or water. These spaces have positive effects on both physical and mental health. The purpose of this study was to investigate whether medical students who have greater accessibility and use of natural spaces have better self-rated health.

Methods: M2-M4 students from Wayne State University School of Medicine received an email link to the Qualtrics-based study. Variables evaluated included: sociodemographics, residence zip code, natural spaces access frequency, distance, and transportation method. Self-rated physical and mental health was measured using the Healthy Days measure …

A Quantitative Analysis Of Microglia Morphology In Adult Zebrafish Retinas, Yasmeen Berry, Ashley Kramer, Justin Carthage, Ryan Thummel

Medical Student Research Symposium

No abstract provided.

Interpatient Differences In Neural Recruitment Patterns During Pudendal Nerve Stimulation – A Computational Investigation, Amolak S. Jhand, Luis C. Ruiz, Nystha Baishya, Ehsan Mirzakhalili, Gaurang Shah, Priyanka Gupta, Tim M. Bruns, Scott F. Lempka

Medical Student Research Symposium

Bladder dysfunction impairs the quality of life for millions of individuals around the world. Common causes of bladder dysfunction include aging, trauma, and neurological disorders. Due to inadequacies in conventional treatments, neuromodulation therapies to address bladder dysfunction, such as sacral nerve stimulation, have emerged. However, patient needs still remain unmet. Pudendal nerve stimulation (PNS) has recently gained clinical interest as a promising treatment for bladder dysfunction. While PNS has been extensively investigated in preclinical settings, there is a gap in our understanding of the mechanisms of action and efficacy of PNS as limited studies of PNS have been performed on …

Purine And Pyrimidine Monophosphate Vs Polyphosphate Homeostasis In Human Retinal Endothelial Cells, Andrew Gregory, Jenna Hart, Thangal Yumnamcha, Mohamed Shawky, Shaimaa El Tanani, Ahmed Ibrahim

Medical Student Research Symposium

Introduction: A major cause of blindness is proliferative diabetic retinopathy (PDR), and there is limited data on the nucleic acid (NA) profiles in PDR. We characterized the profiles of NAs in human retinal endothelial cells (HRECs) subjected to high glucose (HG) and hypoxia (Hyp) - common risk factors associated with PDR.

Methods: HRECs were treated with osmotic control (Mannitol, 25 mM) or high glucose (HG, 25 mM) for 5 days, followed by normoxia or hypoxia (Hyp, 2% O2) for 24 hours. Pathway enrichment analysis from the significant metabolites in the Hyp+HG vs control comparison was subsequently performed.

Results: The precursors …

Amniotic Bladder Therapy In Patients With Interstitial Cystitis/Bladder Pain Syndrome, Jack Considine, Codrut Radoiu, Sophie Wittenberg, Nivedita Dhar Md, Raghav Madan Md, Jack Vernocke Md, Aron Liaw Md, Alaa Hamada Md

Medical Student Research Symposium

Introduction and Objectives: Our study hypothesis postulates that if patients with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) bladders exhibit increased inflammation, fibrosis, and urothelial dysfunction, then treatment modalities that modulate inflammation and fibrosis, while promoting a regeneration may have a therapeutic effect in such patients. Amniotic membrane (AM) has been shown to foster a regenerative wound-healing environment. This study investigates the safety and efficacy of bladder injections of AM in patients with treatment resistant IC/BPS.

Methods: Fifteen consecutive treatment resistant IC/BPS patients (mean age 50.7 ± 14.4 years) with a median disease duration of 7 years (5-12 years) were …