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Andreoli L, Guadagni I, Picarelli G, Principi M. Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages. Autoimmun Rev 2024; 23:103507. [PMID: 38142899 DOI: 10.1016/j.autrev.2023.103507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
Immuno-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease are characterised by pathophysiological mechanisms wherein the immune system erroneously targets the body's own tissues. This review explores the heightened vulnerability of women with IMIDs, influenced by hormonal modulators like estrogen and progesterone. The challenges this poses are multifaceted, encompassing the impact of active disease and medical treatments throughout life stages, including family planning, fertility, and menopause. From the perspectives of rheumatologists and gastroenterologists, we review current management strategies and underscore the need for a multidisciplinary and life-cycle approach to healthcare for women with IMIDs.
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Affiliation(s)
- Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | | | | | - Mariabeatrice Principi
- Emergency and Organ Transplantation Department, Section of Gastroenterology, AOU Policlinico, Bari, Italy
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2
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Sims CA, Eudy AM, Doss J, Rogers JL, Sadun RE, Criscione-Schreiber L, Sun K, Clowse ME. The impact of pregnancy planning and medical readiness on reproductive outcomes in women with systemic lupus erythematosus. Lupus 2023; 32:1666-1674. [PMID: 37966369 DOI: 10.1177/09612033231216602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Women with systemic lupus erythematosus (SLE) who get pregnant while SLE is active or while on teratogens have higher risk of poor pregnancy outcomes. The American College of Rheumatology (ACR) Reproductive Health Guidelines recommend women conceive when SLE is well controlled and treated with pregnancy-compatible medications. The Healthy Outcomes in Pregnancy with SLE Through Education of Providers (HOP-STEP) Intervention was created to ascertain pregnancy interest and contraceptive use followed by a personalized pregnancy prevention and/or planning discussion (https://www.LupusPregnancy.org). All study participants were adult females enrolled in a prospective registry who met ACR or SLICC criteria. Women were defined as "not medically ready for pregnancy" if they were currently prescribed a teratogen, had proteinuria ≥500 mg, or had elevated SLE activity according to the physician's global assessment. Two time periods were assessed: 2/2018-12/2019 and 10/2020-4/2021 to evaluate pre- and post-pandemic periods, with some post-pandemic visits taking place via telehealth. The interest in pregnancy was similar between the first time period (17%) and the second time period, whether in-person (18%) or virtual (18%). Pregnancy interest was assessed significantly more frequently during in-person visits (90%) compared to virtual encounters (67%) (p = .02). Contraceptive use was not significantly different during either time period with use of a teratogen or increased SLE activity. Of the 52 women in both time periods who were not medically ready for pregnancy and were not on effective contraception, three women (5.8%) conceived. None of the women who were using moderate or highly effective contraception became pregnant. Pregnancy outcomes were similar between unintended or high-risk and well-timed pregnancies. The HOP-STEP Intervention effectively identified pregnancy interest, giving rheumatologists the opportunity to address patient reproductive goals, optimize disease activity, and adjust medication regimens prior to conception.
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Affiliation(s)
- Catherine A Sims
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Amanda M Eudy
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jayanth Doss
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jennifer L Rogers
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Rebecca E Sadun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | | | - Kai Sun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Megan Eb Clowse
- Department of Rheumatology, Duke University, Durham, NC, United States
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Rebić N, Munro S, Garg R, Hazlewood G, Amiri N, Baldwin C, Ensworth S, Proulx L, De Vera MA. “The medications are the decision-makers…” Making reproductive and medication use decisions among female patients with rheumatoid arthritis: a constructivist grounded theory. Arthritis Res Ther 2022; 24:31. [PMID: 35065668 PMCID: PMC8783434 DOI: 10.1186/s13075-021-02704-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/11/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
To examine how female patients with RA form decisions about having children, pregnancy, and medication use.
Methods
We employed a constructivist grounded theory design and recruited female participants who are 18 years or older, have a rheumatologist-confirmed RA diagnosis, live in Canada, and are able to communicate in English or French. We collected data through semi-structured individual and focus group interviews using telephone or video conferencing technology. Data collection and analysis were iterative, employed theoretical sampling, reflexive journaling, and peer debriefing, and culminated in a theoretical model.
Results
We recruited 21 participants with a mean age of 34 years and median 10 years since RA diagnosis. Overall, 33% had never been pregnant, 57% had previously been pregnant, and 10% were pregnant at the time of interview. Of those who had experienced pregnancy, 64% had at least one pregnancy while diagnosed with RA and of those, 56% used DMARD(s) during a pregnancy. We constructed a patient-centred framework depicting the dynamic relationships between 4 decision-making processes—(1) using medications, (2) having children, (3) planning pregnancy, and (4) parenting—and the substantial impact of healthcare providers on patients’ experiences making these decisions. These processes were further influenced by participants’ intersecting identities and contextual factors, particularly attitudes towards health and medications, disease onset and severity, familial support system, and experiences interacting with the healthcare system.
Conclusion
Our framework provides insight into how patients make reproductive decisions in the context of managing RA and the opportunities for providers to support them at each decision-making process. A patient-centred care approach is suggested to support female patients with RA in making reproductive and medication choices aligning with their individual desires, needs, and values.
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Edens C. The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy. Rheum Dis Clin North Am 2021; 48:113-140. [PMID: 34798942 DOI: 10.1016/j.rdc.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.
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Affiliation(s)
- Cuoghi Edens
- Department of Pediatrics, Section of Pediatric Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA; Department of Internal Medicine, Section of Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA.
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Edens C. Early Sexual Health and Reproductive Implications in Pediatric Rheumatic Diseases. Rheum Dis Clin North Am 2021; 48:91-112. [PMID: 34798961 DOI: 10.1016/j.rdc.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A comprehensive review of reproductive health subtopics, including puberty, menarche, sexual orientation, gender identity, and gynecologic cancers as they pertain to patients with pediatric rheumatic diseases and those who care for them. Rheumatic disease medications and their effect on reproductive health across childhood and adolescence are also reviewed.
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Affiliation(s)
- Cuoghi Edens
- Department of Pediatrics, Section Pediatric Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA; Department of Internal Medicine, Section of Rheumatology, University of Chicago Medicine, 5841 South Maryland Avenue, C104-A, MC5044, Chicago, IL 60637, USA.
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Scime NV, Brown HK, Metcalfe A, Brennand EA. Prevalence of Hysterectomy by Self-Reported Disability Among Canadian Women: Findings from a National Cross-Sectional Survey. WOMEN'S HEALTH REPORTS 2021; 2:557-565. [PMID: 34909762 PMCID: PMC8665278 DOI: 10.1089/whr.2021.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/25/2022]
Abstract
Introduction: Our objective was to investigate differences in prevalence of hysterectomy by self-reported disability status among Canadian women. Materials and Methods: We analyzed cross-sectional data from the Canadian Community Health Survey 2012 on 30,170 women aged ≥20 years. Disability was defined as reports of sometimes or often (vs. never) experiencing functional limitations or reduction in daily activities at home, school, or work. Frequency of these limitations was used as a proxy for disability severity. The outcome was self-reported hysterectomy status. Modified Poisson regression was used to quantify the prevalence ratio (PR) and 95% confidence interval (CI) for hysterectomy according to any, functional, or activity-limiting disability, after adjustment for household income, employment, education, ethnicity, and marital status. Results were stratified by age at time of data collection, categorized as childbearing (20–44 years), perimenopausal (45–59 years), and postmenopausal (60 years and older). Results: Disability was significantly and consistently associated with higher prevalence of hysterectomy in women. The strength of association was inversely related to age category, and PRs for a given age category were similar across disability types and severity levels. PRs for the association between any disability and hysterectomy were 2.18 (95% CI 1.36–3.50) for childbearing-aged women, 1.48 (95% CI 1.21–1.80) for perimenopausal women, and 1.12 (95% CI 1.02–1.24) for postmenopausal women. Conclusions: Prevalence of hysterectomy is disproportionately higher among women with self-reported disabilities compared with women without disabilities, with these differences most pronounced in women of childbearing age.
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Affiliation(s)
- Natalie V. Scime
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hilary K. Brown
- Department of Health and Society, University of Toronto Scarborough, Toronto, Ontario, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynaecology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin A. Brennand
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynaecology, University of Calgary, Calgary, Alberta, Canada
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Birru Talabi M, Eudy AM, Jayasundara M, Haroun T, Nowell WB, Curtis JR, Crow-Hercher R, White W, Ginsberg S, Clowse MEB. Tough Choices: Exploring Medication Decision-Making During Pregnancy and Lactation Among Women With Inflammatory Arthritis. ACR Open Rheumatol 2021; 3:475-483. [PMID: 34114738 PMCID: PMC8281053 DOI: 10.1002/acr2.11240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/27/2021] [Indexed: 01/04/2023] Open
Abstract
Objective This study explored how women’s beliefs about drug safety and interactions with their health care providers influenced their decisions to continue arthritis medications during pregnancy and lactation. Methods We collaborated with ArthritisPower, a patient‐powered research network, and CreakyJoints, its partner online community, to develop and disseminate a survey among members with inflammatory arthritis who had at least one pregnancy after diagnosis. Participants’ free‐text responses were evaluated by using thematic analysis. Results Women in the sample were 40 years old on average (N = 66). Nineteen of their pregnancies had ended in fetal loss. Fifteen percent of all pregnancies were exposed to methotrexate. Among women who used safe arthritis medications, up to 80% discontinued treatment either in preparation for pregnancy or during pregnancy or lactation. Women’s decisions to continue medications during pregnancy were influenced by their perceptions of safety and advisement from health care providers, although they often described that advice about medication safety was inconsistent between providers. Conclusion Women often chose to endure active inflammatory arthritis rather than to use disease‐modifying antirheumatic drugs because of concerns about medication safety during pregnancy and lactation. Conflicting medical advice from health care providers undermined patients’ trust in their providers and in the safety of their medications. The high rate of peripartum exposure to methotrexate, a fetotoxic drug, underscores the need for better family planning care for women with childbearing potential.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | - W Benjamin Nowell
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | | | | | - Whitney White
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
| | - Seth Ginsberg
- Global Healthy Living Foundation, CreakyJoints, Upper Nyack, New York
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Leech MM, Stransky OM, Talabi MB, Borrero S, Roe AH, Kazmerski TM. Exploring the reproductive decision support needs and preferences of women with cystic fibrosis . Contraception 2020; 103:32-37. [PMID: 33068614 DOI: 10.1016/j.contraception.2020.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES As women with cystic fibrosis (CF) live longer, healthier lives, they increasingly face decisions related to their reproductive health. This qualitative study explores their unique decision support needs and preferences to aid in the development of a CF-specific reproductive goals decision aid. STUDY DESIGN Womenwith CF age 18-44 years participated in individual, semi-structured, telephone-based interviews, and women with CF age 18 years and older participated in semi-structured focus group discussions (FGDs). Both explored experiences and attitudes surrounding parenthood, pregnancy, contraception, and preferences for reproductive health care provision.FGDs also explored the use, content, and format of a reproductive goals decision aid for women with CF. We transcribed interviews and FGDs and conducted content and thematic analyses using an inductive approach. RESULTS Twenty women (age range 20-42 years) participated in interviews and 18 women (age range 26-63 years) participated in three FGDs. Major themes identified included: 1) CF complicates pregnancy and parenting decisions; 2) Women make contraceptive decisions within the context of their CF; 3) Women with CF prefer to receive reproductive health counseling from their CF team; 4) Women with CF desire defragmented, coordinated reproductive health care; and 5) A disease-specific reproductive goals decision aid would encourage relevant parenting, pregnancy, and contraceptive discussions. CONCLUSION Women with CF have unique reproductive health care needs and often face uncertainty and disjointed care when making reproductive health and contraceptive decisions. IMPLICATIONS This study underscores the central role of the CF team and illustrates opportunities to better support women with CF in their decisions surrounding sexual and reproductive health, including through a patient-centered, disease-specific, reproductive goals decision aid.
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Affiliation(s)
- Mary M Leech
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Olivia M Stransky
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA
| | - Mehret Birru Talabi
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; UPMC, Pittsburgh, PA, USA
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; UPMC, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Traci M Kazmerski
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Carandang K, Mruk V, Ardoin SP, Huynh B, Clowse MEB, Berlan ED, Edens C. Reproductive health needs of adolescent and young adult women with pediatric rheumatic diseases. Pediatr Rheumatol Online J 2020; 18:66. [PMID: 32807193 PMCID: PMC7433038 DOI: 10.1186/s12969-020-00460-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify reproductive health knowledge gaps and topics that concern adolescent and young adult (AYA) women with pediatric rheumatic diseases and their parents. METHODS Data collection occurred in two cohorts. In the first cohort, young women (15-20 years old) with pediatric-onset rheumatic conditions and their parents were recruited from a single, academic pediatric rheumatology center. In the second cohort, young women (18-25 years old) with pediatric-onset rheumatic conditions were recruited from a national conference for families with pediatric rheumatic diseases. This resulted in 20 adolescents and young adults (18.3 ± 2.4 years old), and 7 parent focus group participants. Focus group leaders facilitated discussions centered on reproductive health topics that participants identified as important, their sources of knowledge, and preferences for patient education and ongoing follow-up. Data were summarized independently by 4 researchers to reduce potential bias and subsequently analyzed using rapid qualitative analysis. RESULTS All participants, regardless of diagnosis, medication, current sexual activity, or current intention to have children, expressed concern about the effect of their rheumatic condition and medications on fertility, risks to mother and child during and after pregnancy, and obtaining safe and effective contraception. Additionally, some participants discussed the burden of disease and its potential impact on motherhood. Finally, participants raised concern around the effect of disease and medication on routine reproductive health care, such as menstrual cycles, feminine self-care, and preventive exams. Three themes emerged: 1) participants had been advised to avoid unplanned pregnancy, however reported receiving inadequate explanation to support this instruction, 2) participants conceptualized reproductive health as tied to rheumatic disease management and thus suggested ways to include family members in discussion, and 3) rheumatology practitioners were not considered a resource of reproductive health information. CONCLUSIONS Young women and their parents reported dissatisfaction with the availability, quantity, and quality of reproductive health information they received, particularly when related to their pediatric-onset rheumatic disease. These findings provide an initial step in understanding the patient perspective of reproductive health in rheumatology, and how to address these concerns in the care of young women with rheumatic diseases.
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Affiliation(s)
- Kristine Carandang
- Department of Psychiatry, University of California, La Jolla, San Diego, California, USA. .,Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, California, 92123, USA.
| | - Veronica Mruk
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA ,grid.261331.40000 0001 2285 7943The Ohio State University, Columbus, OH USA
| | - Stacy P. Ardoin
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA ,grid.261331.40000 0001 2285 7943The Ohio State University, Columbus, OH USA
| | - Brittany Huynh
- grid.257413.60000 0001 2287 3919Indiana University School of Medicine, Indianapolis, IN USA
| | - Megan E. B. Clowse
- grid.189509.c0000000100241216Duke University Medical Center, Durham, North Carolina USA
| | - Elise D. Berlan
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA ,grid.261331.40000 0001 2285 7943The Ohio State University, Columbus, OH USA
| | - Cuoghi Edens
- grid.170205.10000 0004 1936 7822University of Chicago, Chicago, IL USA
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Lockshin MD. Assisted reproductive technologies for women with rheumatic AID. Best Pract Res Clin Obstet Gynaecol 2019; 64:85-96. [PMID: 31791669 DOI: 10.1016/j.bpobgyn.2019.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 12/19/2022]
Abstract
Assisted reproductive technology (ART) procedures are safe for women with rheumatic autoimmune diseases (rAID) when illness is inactive. Medications incompatible with pregnancy should be replaced with alternative pregnancy-compatible medications months before planned ART procedures to allow time to verify the substitute medication's efficacy and tolerability. Medications compatible with pregnancy should be continued, as should anticoagulation (warfarin changed to low-molecular-weight heparin) before pregnancy begins. Protocols that provide details for specific medications are available. All patients with rAID should be screened for diagnosis-relevant organ system damage, and those intending to carry their own pregnancies must be tested for aPL and anti-Ro/La autoantibodies. Patients with organ damage and/or positive tests for aPL and anti-Ro/La should be counseled about fetal and maternal risks, including implications to the child and family of maternal disability or death. Sperm donors with rAID may need to discontinue medications. REI and physicians treating patients with rAID (usually rheumatologists) must work together to plan and accomplish ART.
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Affiliation(s)
- Michael D Lockshin
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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