Medical Specialties Commons^™

Theta-Burst Stimulation Entrains Frequency-Specific Oscillatory Responses., Ethan A. Solomon, Michael R. Sperling, Ashwini D. Sharan, Paul A. Wanda, Deborah F. Levy, Anastasia Lyalenko, Isaac Pedisich, Daniel S. Rizzuto, Michael J. Kahana

Department of Neurology Faculty Papers

BACKGROUND: Brain stimulation has emerged as a powerful tool in human neuroscience, becoming integral to next-generation psychiatric and neurologic therapeutics. Theta-burst stimulation (TBS), in which electrical pulses are delivered in rhythmic bouts of 3-8 Hz, seeks to recapitulate neural activity seen endogenously during cognitive tasks. A growing literature suggests that TBS can be used to alter or enhance cognitive processes, but little is known about how these stimulation events influence underlying neural activity.

OBJECTIVE: Our study sought to investigate the effect of direct electrical TBS on mesoscale neural activity in humans by asking (1) whether TBS evokes persistent theta oscillations …

Outcomes Of Covid-19 In Patients With Rheumatoid Arthritis: A Multicenter Research Network Study In The United States., Rahul Raiker, Charles Deyoung, Haig Pakhchanian, Sakir Ahmed, Chengappa Kavadichanda, Latika Gupta, Sinan Kardeş

Student Papers, Posters & Projects

OBJECTIVES: To investigate outcomes of Coronavirus Disease-2019 (COVID-19) in patients with rheumatoid arthritis (RA) as compared to the general population. Additionally, outcomes were explored among RA patients stratified by sex, race, and medications use through sub-cohort analyses.

METHODS: This comparative cohort study used a US multicenter research network (TriNetX) to extract data on all adult RA patients who were diagnosed with COVID-19, and adults without RA who were diagnosed with COVID-19 (comparative cohort) anytime from January 20, 2020 to April 11, 2021. COVID-19 outcomes were assessed within 30 days after its diagnosis. Baseline characteristics that included demographics and comorbidities were …

Adhd In Adolescents And Adults, Hannah Facey, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives

• Understand the concept of neurodiversity
• Define ADHD
• Review the diagnostic criteria and challenges with diagnosis for ADHD in adults
• Explore our role as family medicine physicians in diagnosis and treatment
• Discover the prevalence of comorbid conditions associated with ADHD
• Obtain a general understanding of the categories of medical treatments available for adults with ADHD
• Gain a deeper appreciation for the role that biases play in the under- and misdiagnosis of women and BIPOC

Heart Failure Transitions Of Care Program, Samantha Macko, Pharmd

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives

• Heart failure overview; statistics, risk factors, signs and symptoms
• List heart failure therapeutic treatment options
• Explain importance of continuation of care for heart failure patients after initial hospital discharge
• Discuss importance of multidisciplinary approach to treatment of heart failure (HF) patients
• Discuss components of heart failure transitions of care (HFTOC) program at Thomas Jefferson University Hospital

Genetic Variants And Tumor Immune Microenvironment: Clues For Targeted Therapies In Inflammatory Breast Cancer (Ibc), Yulan Gong, Rajeswari Nagarathinam, Maria F. Arisi, Lorenzo Gerratana, Jennifer S Winn, Michael Slifker, Jianming Pei, Kathy Q Cai, Zachary Hasse, Elias Obeid, Julio Noriega, Christopher Sebastiano, Eric Ross, Katherine Alpaugh, Massimo Cristofanilli, Sandra V Fernandez

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

To better understand the etiology of inflammatory breast cancer (IBC) and identify potential therapies, we studied genomic alterations in IBC patients. Targeted, next-generation sequencing (NGS) was performed on cell-free DNA (cfDNA) (n = 33) and paired DNA from tumor tissues (n = 29) from 32 IBC patients. We confirmed complementarity between cfDNA and tumor tissue genetic profiles. We found a high incidence of germline variants in IBC patients that could be associated with an increased risk of developing the disease. Furthermore, 31% of IBC patients showed deficiencies in the homologous recombination repair (HRR) pathway (BRCA1, BRCA2, PALB2, RAD51C, ATM, BARD1) …

Gross Hematuria: An Unusual Presenting Symptom Of Systemic Wild-Type Transthyretinamyloidosis., Sage A. Vincent, Daniel Christensen, Perry R. Weiner

Department of Urology Faculty Papers

Amyloidosis of the urinary bladder is a rare cause of gross hematuria. In patients with systemic amyloidosis, identification is nearly always related to cardiac complaints; urologic presenting symptoms are extremely uncommon. We present a 77-year-old male patient with painless gross hematuria ultimately found to be secondary to systemic wild-type transthyretin amyloidosis. He underwent transurethral resection of the bladder lesion and was initiated on transthyretin stabilizing medication. In the 6 months since starting treatment, the patient has had no further episodes of gross hematuria, but will require cystoscopic surveillance for evidence of recurrence or concomittment urothelial carcinoma.

Long-Term Sports Participation And Satisfaction After Ucl Reconstruction In Amateur Baseball Players., Robert A Jack, Somnath Rao, Taylor D'Amore, Donald Willier Iii, Robert Gallivan, Steven B. Cohen, Christopher C Dodson, Michael G. Ciccotti

Rothman Institute Papers

Background: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes.

Purpose: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR.

Study Design: Case series; Level of evidence, 4.

Methods: We evaluated UCLR patients who were nonprofessional baseball athletes aged(KJOC), the Timmerman-Andrews (T-A) Elbow score, the Mayo Elbow Performance Score (MEPS), and a custom return-to-play questionnaire.

Results: A total of 91 baseball players met the inclusion criteria, and …

Advances In The Diagnosis And Treatment Of Krabbe Disease, David A Wenger, Paola Luzi, Mohammad Rafi

Department of Neurology Faculty Papers

Krabbe disease is an autosomal recessive leukodystrophy caused by pathogenic variants in the galactocerebrosidase (GALC) gene. GALC activity is needed for the lysosomal hydrolysis of galactosylceramide, an important component of myelin. While most patients are infants, older patients are also diagnosed. Starting in 1970, a diagnosis could be made by measuring GALC activity in leukocytes and cultured cells. After the purification of GALC in 1993, the cDNA and genes were cloned. Over 260 disease-causing variants as well as activity lowering benign variants have been identified. While some pathogenic variants can be considered “severe,” others can be considered “mild.” The combination …

Sanhuang Decoction Controls Tumor Microenvironment By Ameliorating Chronic Stress In Breast Cancer: A Report Of Ninety Cases., Ming Feng, Huanhuan Wang, Zhiyuan Zhu, Bowen Yao, Yongfei Li, Jingxian Xue, Sihan Cao, Xinyi Shao, Yanlei Xu, Ki Cheul Sohn, Im Hee Shin, Chang Yao

Student Papers, Posters & Projects

Long-term endocrine treatment which results in estrogen deprivation causes chronic stress associated with a series of uncomfortable symptoms leading not only to a decrease in quality of life but also to cancer recurrence, which may be mediated primarily through the enhanced expression of angiogenic factors, as well as a series of inflammatory microenvironmental changes that favor tumor progression. In this study, we designed a clinical trial and aimed to explore the effects of Sanhuang Decoction (SHD) treatment on chronic stress, inflammatory factors, and breast cancer recovery. A total of 90 patients with breast cancer who met the inclusion/exclusion criteria were …

Analysis Of Deep Brain Stimulation Lead Targeting In The Stimulation Of Anterior Nucleus Of The Thalamus For Epilepsy Clinical Trial., Robert E. Gross, Robert S. Fisher, Michael R. Sperling, Jonathon E. Giftakis, Paul H. Stypulkowski

Department of Neurology Faculty Papers

BACKGROUND: Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is an effective therapy for patients with drug-resistant focal epilepsy. Best practices for surgical targeting of the ANT can be refined as new information becomes available regarding effective stimulation sites.

OBJECTIVE: To conduct a retrospective analysis of the relationship between outcomes (seizure reduction during year 1) and DBS lead locations in subjects from the SANTÉ pivotal trial (Stimulation of ANT for Epilepsy) based upon recent clinical findings.

METHODS: Postoperative images from SANTÉ subjects (n = 101) were evaluated with respect to lead trajectory relative to defined anatomic …

Development Of The Biohybrid Assay: Combining Primary Human Vascular Smooth Muscle Cells And Blood To Measure Vascular Calcification Propensity, Armand M G Jaminon, Asim C Akbulut, Niko Rapp, Rafael Kramann, Erik A L Biessen, Lieve Temmerman, Barend Mees, Vincent Brandenburg, Robert Dzhanaev, Willi Jahnen-Dechent, Juergen Floege, Jouni Uitto, Chris P Reutelingsperger, Leon J Schurgers

Department of Dermatology and Cutaneous Biology Faculty Papers

BACKGROUND: Vascular calcification is an active process that increases cardiovascular disease (CVD) risk. There is still no consensus on an appropriate biomarker for vascular calcification. We reasoned that the biomarker for vascular calcification is the collection of all blood components that can be sensed and integrated into a calcification response by human vascular smooth muscle cells (hVSMCs).

METHODS: We developed a new cell-based high-content assay, the BioHybrid assay, to measure in vitro calcification. The BioHybrid assay was compared with the o-Cresolphthalein assay and the T50 assay. Serum and plasma were derived from different cohort studies including chronic kidney disease (CKD) …

Psychological Problems Among Patients With Chronic Medical Disorders During The Covid-19 Pandemic, Ali Akbar Asadi-Pooya, Seyed Ali Nabavizadeh, Saeid Sadeghian, Mina Shahisavandi, Zohreh Barzegar, Abdullah Nezafat, Nahid Ashjazadeh, Hamed Bazrafshan Drissi, Ali Sahraian

Department of Neurology Faculty Papers

The aim of the current study was to investigate the rates of stress, anxiety, and depression among people in south Iran (a group from the general population without a history of any chronic medical problems, and cohorts of patients were recruited from epilepsy, diabetes, and cardiac disease clinics). We surveyed a sample of people during September 2020: a group of the general population without a history of any chronic medical problems, people with epilepsy, people with diabetes mellitus (DM), and people with cardiac problems. The survey included four general questions and two COVID-19 specific questions [contracting COVID-19, relatives with COVID-19]. …

Photobiomodulation Therapy In Head And Neck Cancer-Related Lymphedema: A Pilot Feasibility Study., Jie Deng, John N Lukens, Samuel Swisher-Mcclure, Joy C Cohn, Bryan A Spinelli, Ryan J Quinn, Jesse Chittams, Erin Mcmenamin, Alexander Lin

Department of Medicine Faculty Papers

PURPOSE: Lymphedema is a common debilitating late effect among patients post-head and neck cancer (HNC) treatment. Head and neck lymphedema was associated with symptom burden, functional impairment, and decreased quality of life. The objective of this study was to determine the feasibility and potential efficacy of the use of photobiomodulation (PBM) therapy for head and neck lymphedema, symptom burden, and neck range of motion among HNC survivors.

METHODS: This was a single-arm, pre- and post-design clinical trial. Eligible patients included those with lymphedema after completion of complete decongestive therapy (CDT) and 3 to 18 months after completion of cancer therapy. …

Pharmaceutical Management Of Weight Loss, Jake Schutzman, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives

• Briefly review some context & consequences of the US obesity epidemic
• Review available prescription anti-obesity medications
• Discuss details specific to each of these medications
• Review other medications affecting weight

After this lecture, I hope you will:

• Have a greater understanding of available anti-obesity medications
• Be more comfortable in patient discussions & management of obesity

Validating Deep Learning Inference During Chest X-Ray Classification For Covid-19 Screening., Robbie Sadre, Baskaran Sundaram, Sharmila Majumdar, Daniela Ushizima

Department of Radiology Faculty Papers

The new coronavirus unleashed a worldwide pandemic in early 2020, and a fatality rate several times that of the flu. As the number of infections soared, and capabilities for testing lagged behind, chest X-ray (CXR) imaging became more relevant in the early diagnosis and treatment planning for patients with suspected or confirmed COVID-19 infection. In a few weeks, proposed new methods for lung screening using deep learning rapidly appeared, while quality assurance discussions lagged behind. This paper proposes a set of protocols to validate deep learning algorithms, including our ROI Hide-and-Seek protocol, which emphasizes or hides key regions of interest …

Primary Leiomyosarcoma Of The Distal Tibia: A Case Report., Sachin Dheer, Pamela Gekas, Faith Schick, Homyar Karanjia, Nicholas Taweel

Department of Radiology Faculty Papers

The authors present an unusual case of a leiomyosarcoma of the distal tibia. Leiomyosarcoma tumors typically originate from smooth muscle tissue. It is rare for it to derive from bone and even rarer to be found in a bone of the lower limb. Given this extreme rarity in addition to nonspecific findings on plain film radiographs and magnetic resonance imaging (MRI), biopsy was needed in this case. It was only through immunochemistry staining that a definitive diagnosis was made. As such, this case is an illustrative example of an aggressive, though rare, primary lesion of the bone which should be …

Ischemic Bowel Disease In 2021, Monjur Ahmed

Division of Gastroenterology and Hepatology Faculty Papers

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is …

A Pilot Exploration Using Optical Coherence Tomography Angiography Analysis Of Capillary Vascular Density And Foveal Avascular Zone For The Diagnosis Of Uveal Melanoma, Jason Chien, Alicia Valverde-Megías, Gwo Farn Chien, Carol L Shields

Wills Eye Hospital Papers

No abstract provided.

Contraception For Pcps 2021, Krys Foster, Md, Mph, Faafp

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives:

• Review evidence-based, flexible and patient-centered approaches to contraceptive management in individuals with reproductive potential
• Discuss updates in contraceptive prescribing and management
• Highlight considerations for management of contraception in the time of COVID-19 and in special populations

Outline

• Introduction
• Approach to initiation of contraception
• Overview of methods of contraception
• Special Considerations
• Resources (Medical Eligibility and Special Practice Recommendations; Contraception App)
• Summary
• References

Copd Topic Discussion, Clarice Resso, Pharmd, Farzana Tarannum, Pharmd

Department of Family & Community Medicine Presentations and Grand Rounds

No abstract provided.

Hur Plays A Positive Role To Strengthen The Signaling Pathways Of Cd4+T Cell Activation And Th17 Cell Differentiation, Shiguang Yu, Morgan Tripod, Ulus Atasoy, Jing Chen

Department of Neurology Faculty Papers

After antigen and/or different cytokine stimulation, CD4⁺ T cells activated and differentiated into distinct T helper (Th) cells via differential T cell signaling pathways. Transcriptional regulation of the activation and differentiation of naïve CD4⁺ T cells into distinct lineage Th cells such as Th17 cells has been fully studied. However, the role of RNA-binding protein HuR in the signaling pathways of their activation and differentiation has not been well characterized. Here, we used HuR conditional knockout (HuR KO) CD4⁺ T cells to study mechanisms underlying HuR regulation of T cell activation and differentiation through distinct signaling pathways. …

Development Of Personas To Communicate Narrative-Based Information About The Hpv Vaccine On Twitter, Philip M Massey, Shawn C Chiang, Meredith Rose, Regan M Murray, Madeline Rockett, Elikem Togo, Ann C Klassen, Jennifer A Manganello, Amy Leader

Department of Medical Oncology Faculty Papers

Introduction: Personas are based on real-life typologies of people that can be used to create characters and messages to communicate important health information through relatable narrative storylines. Persona development is data-driven and can involve multiple phases of formative research and evaluation; however, personas are largely underutilized in digital health research. The purpose of this study was to create and document persona development to deliver narrative-focused health education for parents on Twitter with the goal of increasing uptake of HPV vaccination among adolescents. Methods: Leveraging data from a mixed-method study conducted in the U.S. with a diverse population of parents with …

Fifteen-Year Trends In Incidence Of Cardiogenic Shock Hospitalization And In-Hospital Mortality In The United States., Mohammed Osman, Moinuddin Syed, Saikrishna Patibandla, Samian Sulaiman, Babikir Kheiri, Mahek K. Shah, Christopher Bianco, Sudarshan Balla, Brijesh Patel

Division of Cardiology Faculty Papers

BACKGROUND: There is a lack of contemporary data on cardiogenic shock (CS) in-hospital mortality trends.

METHODS AND RESULTS: Patients with CS admitted January 1, 2004 to December 31, 2018, were identified from the US National Inpatient Sample. We reported the crude and adjusted trends of in-hospital mortality among the overall population and selected subgroups. Among a total of 563 949 644 hospitalizations during the period from January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to CS. There has been a steady increase in hospitalizations attributed to CS from 122 per 100 000 hospitalizations in 2004 …

Pathophysiology Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review., William S. Dodd, Dimitri Laurent, Aaron S. Dumont, David M. Hasan, Pascal M. Jabbour, Robert M. Starke, Koji Hosaka, Adam J. Polifka, Brian L. Hoh, Nohra Chalouhi

Department of Neurosurgery Faculty Papers

Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have …

Simultaneous Ck2/Tnik/Dyrk1 Inhibition By 108600 Suppresses Triple Negative Breast Cancer Stem Cells And Chemotherapy-Resistant Disease., Katsutoshi Sato, Amol A. Padgaonkar, Stacey J. Baker, Stephen C. Cosenza, Olga Rechkoblit, D.R.C. Venkata Subbaiah, Josep Domingo-Domenech, Alison Bartkowski, Elisa R. Port, Aneel K. Aggarwal, M. V. Ramana Reddy, Hanna Y. Irie, E. Premkumar Reddy

Department of Medical Oncology Faculty Papers

Triple negative breast cancer (TNBC) remains challenging because of heterogeneous responses to chemotherapy. Incomplete response is associated with a greater risk of metastatic progression. Therefore, treatments that target chemotherapy-resistant TNBC and enhance chemosensitivity would improve outcomes for these high-risk patients. Breast cancer stem cell-like cells (BCSCs) have been proposed to represent a chemotherapy-resistant subpopulation responsible for tumor initiation, progression and metastases. Targeting this population could lead to improved TNBC disease control. Here, we describe a novel multi-kinase inhibitor, 108600, that targets the TNBC BCSC population. 108600 treatment suppresses growth, colony and mammosphere forming capacity of BCSCs and induces G2M arrest …

Targeted Provider Education And Pre-Visit Planning Increase Rates Of Formal Depression Screening In Childhood-Onset Sle., Evan Mulvihill, Rebecca Furru, Alana Goldstein-Leever, Kyla Driest, Stephanie Lemle, Darby Macdonald, Emily Frost, Vidya Sivaraman

Department of Pediatrics Faculty Papers

BACKGROUND: Despite being at high risk for depression, patients with childhood-onset systemic lupus erythematosus (c-SLE) are infrequently and inconsistently screened for depression by their pediatric rheumatologists. We aimed to systematically increase rates of formal depression screening for c-SLE patients in an academic Pediatric Rheumatology clinic.

METHODS: Our multi-disciplinary quality improvement (QI) team used electronic health record (EHR) documentation to retroactively calculate baseline rates of documented depression screening using the Patient Health Questionnaire-9 (PHQ-9). We then engaged key stakeholders to develop a clinical workflow for formal depression screening in the clinic. We also provided education to providers regarding mental health disorders …

Level Of Utilization And Provider-Related Barriers To The Use Of Hydroxyurea In The Treatment Of Sickle Cell Disease Patients In Jos, North-Central Nigeria, Akinyemi O.D. Ofakunrin, Edache S. Okpe, Tolulope O. Afolaranmi, Rasaq Olaosebikan, Patience U. Kanhu, Kehinde Adekola, Nantok Dami, Atiene S. Sagay

Department of Pharmacology and Experimental Therapeutics Faculty Papers

Background: Hydroxyurea is underutilized by sickle cell health-care providers in Nigeria despite available evidence of its effectiveness in reducing the manifestations and complications of sickle cell disease (SCD).

Objectives: To assess the level of utilization and provider-related barriers to the use of hydroxyurea in SCD therapy in Jos, Nigeria.

Methods: A cross-sectional study conducted among 132 medical doctors providing care for SCD patients. Data on so- cio-demographics, utilization and barriers to hydroxyurea use were obtained. The barriers were fed cumulatively into the logistic regression model as predictors of utilization.

Results: Of the 132 care providers, 88 (67%) had been in …

Interactive Machine Learning-Based Multi-Label Segmentation Of Solid Tumors And Organs, Dimitrios Bounias, Ashish Singh, Spyridon Bakas, Sarthak Pati, Saima Rathore, Hamed Akbari, Michel Bilello, Benjamin Greenberger, Joseph Lombardo, Rhea Chitalia, Nariman Jahani, Aimilia Gastounioti, Michelle Hershman, Leonid Roshkovan, Sharyn Katz, Bardia Yousefi, Carolyn Lou, Amber Simpson, Richard Do, Russell Shinohara, Despina Kontos, Konstantina Nikita, Christos Davatzikos

Department of Radiation Oncology Faculty Papers

We seek the development and evaluation of a fast, accurate, and consistent method for general-purpose segmentation, based on interactive machine learning (IML). To validate our method, we identified retrospective cohorts of 20 brain, 50 breast, and 50 lung cancer patients, as well as 20 spleen scans, with corresponding ground truth annotations. Utilizing very brief user training annotations and the adaptive geodesic distance transform, an ensemble of SVMs is trained, providing a patient-specific model applied to the whole image. Two experts segmented each cohort twice with our method and twice manually. The IML method was faster than manual annotation by 53.1% …

Digital Literacy At An Urban Cancer Center: Implications For Technology Use And Vulnerable Patients, Amy Leader, Lisa M. Capparella, L. Waldman, Ba, Rebecca Cammy, Alison Petok, Rebecca Dean, Ayako Shimada, Liana Yocavitch, Kristin L. Rising, Gregory Garber, Brooke Worster, Adam Dicker

Kimmel Cancer Center Faculty Papers

PURPOSE: eHealth literacy, or the ability to seek, find, understand, and appraise health information from electronic sources, has become increasingly relevant in the era of COVID-19, when so many aspects of patient care became dependent on technology. We aimed to understand eHealth literacy among a diverse sample of patients with cancer and discuss ways for health systems and cancer centers to ensure that all patients have access to high-quality care.

METHODS: A cross-sectional survey of patients with cancer and caregivers was conducted at an NCI-designated cancer center to assess access to the Internet, smartphone ownership, use of mobile apps, willingness …

Perceptions And Challenges Experienced By African Physicians When Prescribing Methotrexate For Rheumatic Disease: An Exploratory Study, Carol A Hitchon, Girsh M Mody, Candace H Feldman, Yan Lau, Steven Shi, Michele Meltzer, Rosie Scuccimarri, Michael E Weinblatt, Ines Colmegna

Department of Medicine Faculty Papers

OBJECTIVE: Guidelines for methotrexate (MTX) use in rheumatic disease may not be feasible for physicians practicing in the least developed countries. We aimed to understand the experiences of MTX prescribers relating to MTX use for rheumatic disease in African countries to inform the development of culturally and geographically appropriate recommendations.

METHODS: African physicians who self-identified as MTX prescribers from countries classified as having a low versus a medium or high Human Development Index (L-HDI versus MH-HDI) participated in semistructured interviews between August 2016 and September 2017. Interviews were transcribed verbatim, coded thematically, and stratified by HDI.

RESULTS: Physicians (23 rheumatologists; …