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Kara M, Alp G, Koç AM. Diagnostic difficulties in polymyalgia rheumatica cases with normal erythrocyte sedimentation rate and C-reactive protein values. Medicine (Baltimore) 2023; 102:e35385. [PMID: 37773830 PMCID: PMC10545350 DOI: 10.1097/md.0000000000035385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
Polymyalgia Rheumatica (PMR) is an inflammatory disease which does not have specific diagnostic tests or pathological symptoms and is identified based on clinical characteristics. Among acute phase reactants (APR), the erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) are laboratory findings used in diagnosis and follow-up. In this study, it was aimed to determine the incidence of normal ESH and CRP in patients diagnosed with PMR and identify the distinguishing characteristics of these patients. PMR patients who were clinically diagnosed at a single center were reviewed. After the presence of bursitis was demonstrated with ultrasonography in patients with normal ESR and CRP rates, they were accepted to have PMR. Among all 54 patients (63% female), ESR and CRP values were normal in 8 patients (14%), and serum amyloid A (SAA) was determined to be elevated in all these patients. In the comparisons of the groups with normal and high levels of ESR and CRP, it was found that the group with normal ESR and CRP values had a younger age of diagnosis (P = .027), a longer symptom duration (P < .001), and a lower comorbidity rate (P = .010). PMR patients can have normal ESR and CRP values at the time of their diagnosis. While bursitis can be demonstrated with ultrasonography in patients who are clinically evaluated to have PMR, APRs such as SAA other than ESR and CRP can also be used.
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Affiliation(s)
- Mete Kara
- University of Health Sciences Izmir Bozyaka Research and Training Hospital, Rheumatology Department, Izmir, Turkey
| | - Gülay Alp
- Izmir Katip Celebi University Izmir Atatürk Research and Training Hospital, Rheumatology Department, Izmir, Turkey
| | - Ali Murat Koç
- Izmir Katip Celebi University Izmir Atatürk Research and Training Hospital, Department of Radiology, Izmir, Turkey
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González-Gay MA, Vicente-Rabaneda EF, Martínez-López JA, Largo R, Heras-Recuero E, Castañeda S. Challenges in the diagnosis of polymyalgia rheumatica and related giant cell arteritis. Expert Rev Clin Immunol 2023; 19:517-526. [PMID: 36896659 DOI: 10.1080/1744666x.2023.2189586] [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: 03/11/2023]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) has emerged as a relatively common condition in Western countries. Although the diagnosis is relatively straightforward in people over 50 years of age who complain of sudden onset of pain and stiffness in the shoulder and hip girdles along with elevation of biomarkers of inflammation, manifestations of polymyalgia can also occur in the context of different conditions. For this reason, a complete history and examination is required, including looking for symptoms and signs suggestive of giant cell arteritis (GCA). AREAS COVERED The review describes when and how to identify PMR, as well as when to suspect the presence of associated GCA or multiple conditions mimicking PMR. EXPERT OPINION PMR does not have a specific diagnostic test. For this reason, a thorough clinical history searching for clinical data of GCA is needed. Moreover, the possibility of other diseases mimicking PMR should be considered, particularly when atypical presentation or unusual clinical data are present.
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Affiliation(s)
- Miguel A González-Gay
- Rheumatology Division, IIS-Fundación Jiménez Díaz, Madrid, Spain.,Department of Medicine, University of Cantabria, Santander, Spain.,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Esther F Vicente-Rabaneda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | | | - Raquel Largo
- Rheumatology Division, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | | | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Catedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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3
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Bolhuis TE, Nizet LE, Owen C, den Broeder AA, van den Ende CH, van der Maas A. Measurement properties of the PolyMyalgia Rheumatica Activity Score (PMR-AS): a systematic literature review. J Rheumatol 2022; 49:627-634. [DOI: 10.3899/jrheum.211292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
Objective To perform a COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) based Systematic Literature Review of measurement properties of the Polymyalgia Rheumatica Activity Score (PMR-AS). Methods Pubmed, EMBASE, and CINAHL were broadly searched. English full text articles, with (quantitative) data on at least 5 PMR patients using the PMR-AS were selected. Seven hypotheses for construct validity and three for responsiveness, concerning associations with erythrocyte sedimentation rate, physical function, quality of life, clinical disease states, ultrasound, and treatment response, were formulated. Articles usable to assess - COSMIN based - structural validity, internal consistency, reliability, measurement error, or hypotheses on construct validity or responsiveness were selected and assessed based on COSMIN criteria. Results From the 26 articles using the PMR-AS we were able to use 12 articles. Structural validity, internal consistency, construct validity, and responsiveness were assessed in one, two, eight, and three articles respectively. Insufficient evidence was found to confirm structural validity and internal consistency. No data was found on reliability or measurement error. Although 60% and 67% of hypotheses tested for construct validity and responsiveness were confirmed respectively, there was insufficient evidence to meet criteria for good measurement properties. Conclusion Whilst there is some promising evidence for construct validity and responsiveness of the PMR-AS, it is lacking for other properties and overall falls short of criteria for good measurement properties. Therefore, further research is needed to assess its role in clinical research and care.
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Owen CE, McMaster C, Liew DFL, Leung JL, Scott AM, Buchanan RRC. Neutrophil to lymphocyte ratio predicts glucocorticoid resistance in polymyalgia rheumatica. Int J Rheum Dis 2020; 24:56-62. [PMID: 33043616 DOI: 10.1111/1756-185x.14000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/11/2022]
Abstract
AIM Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) correlate with disease activity in several rheumatic diseases; however, their utility in polymyalgia rheumatica (PMR) remains unclear. This study evaluated their relationship with disease activity and glucocorticoid resistance in PMR. METHOD Data for disease activity (PMR-AS) and full blood examination was obtained from a prospective observational cohort comprising newly diagnosed, steroid-naïve PMR patients treated with low-dose glucocorticoid therapy. Glucocorticoid resistance was defined as non-response to prednisolone 15 mg/d or initial response followed by flare (PMR-AS ≥ 9.35 or ∆ ≥6.6) upon weaning to 5 mg/d. Univariable Bayesian linear regression analysis of the relationship between PMR-AS (baseline and mean) and NLR and PLR was performed. Predictors of glucocorticoid resistance were identified using a multivariable outcome model, with variables derived from Bayesian model selection. RESULTS Of the 32 included patients, 16 (50%) fulfilled the primary outcome measure of glucocorticoid resistance. These participants were older, typically female, and had higher baseline C-reactive protein than their glucocorticoid-responsive counterparts. A statistically significant relationship was identified between PMR-AS and both NLR (odds ratio [OR] 28.1; 95% CI 1.6-54.7) and PLR (OR 40.6; 95% CI 10.1-71.4) at baseline, with PLR also found to correlate with disease activity during follow-up (OR 15.6; 95% CI 2.7-28.2). Baseline NLR proved a statistically significant predictor of glucocorticoid-resistant PMR (OR 14.01; 95% CI 1.49-278.06). CONCLUSION Baseline NLR can predict glucocorticoid resistance in newly diagnosed PMR patients. Both NLR and PLR may be reliable biomarkers of disease activity in PMR.
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Affiliation(s)
- Claire E Owen
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | | | - David F L Liew
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Jessica L Leung
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Andrew M Scott
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,Department of Molecular Imaging and Therapy, Austin Health, Heidelberg, VIC, Australia.,Olivia Newton-John Cancer Research Institute, and School of Cancer Medicine, La Trobe University, Heidelberg, VIC, Australia
| | - Russell R C Buchanan
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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Twohig H, Owen C, Muller S, Mallen CD, Mitchell C, Hider S, Hill C, Shea B, Mackie SL. Outcomes Measured in Polymyalgia Rheumatica and Measurement Properties of Instruments Considered for the OMERACT Core Outcome Set: A Systematic Review. J Rheumatol 2020; 48:883-893. [PMID: 32739892 DOI: 10.3899/jrheum.200248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To systematically identify the outcome measures and instruments used in clinical studies of polymyalgia rheumatica (PMR) and to evaluate evidence about their measurement properties. METHODS Searches based on the MeSH term "polymyalgia rheumatica" were carried out in 5 databases. Two researchers were involved in screening, data extraction, and risk of bias assessment. Once outcomes and instruments used were identified and categorized, key instruments were selected for further review through a consensus process. Studies on measurement properties of these instruments were appraised against the COSMIN-OMERACT (COnsensus-based Standards for the selection of health Measurement Instruments-Outcome Measures in Rheumatology) checklist to determine the extent of evidence supporting their use in PMR. RESULTS Forty-six studies were included. In decreasing order of frequency, the most common outcomes (and instruments) used were markers of systemic inflammation [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], pain [visual analog scale (VAS)], stiffness (duration in minutes), and physical function (elevation of upper limbs). Instruments selected for further evaluation were ESR, CRP, pain VAS, morning stiffness duration, and the Health Assessment Questionnaire. Five studies evaluated measurement properties of these instruments, but none met all of the COSMIN-OMERACT checklist criteria. CONCLUSION Measurement of outcomes in studies of PMR lacks consistency. The critical patient-centered domain of physical function is poorly assessed. None of the candidate instruments considered for inclusion in the core outcome set had high-quality evidence, derived from populations with PMR, on their full range of measurement properties. Further studies are needed to determine whether these instruments are suitable for inclusion in a core outcome measurement set for PMR.
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Affiliation(s)
- Helen Twohig
- H. Twohig, MRCP, MRCGP, S. Muller, PhD, Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK;
| | - Claire Owen
- C. Owen, MBBS (Hons), FRACP, Department of Rheumatology, Austin Health, and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sara Muller
- H. Twohig, MRCP, MRCGP, S. Muller, PhD, Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | - Christian D Mallen
- C.D. Mallen, FRCGP, PhD, S. Hider, FRCP, PhD, Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, and Midlands Partnership Foundation Trust, Staffordshire, UK
| | - Caroline Mitchell
- C. Mitchell, FRCGP, MD, Academic Department of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Samantha Hider
- C.D. Mallen, FRCGP, PhD, S. Hider, FRCP, PhD, Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, and Midlands Partnership Foundation Trust, Staffordshire, UK
| | - Catherine Hill
- C. Hill, FRACP, MD, Rheumatology Unit, The Queen Elizabeth and Royal Adelaide Hospitals, and Discipline of Medicine, The University of Adelaide, Adelaide, Australia
| | - Beverley Shea
- B. Shea, PhD, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah L Mackie
- S.L. Mackie, MRCP, PhD, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Woodhouse, Leeds, UK
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Jung JY, Lee E, Suh CH, Kim HA. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are associated with disease activity in polymyalgia rheumatica. J Clin Lab Anal 2019; 33:e23000. [PMID: 31402523 PMCID: PMC6868401 DOI: 10.1002/jcla.23000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/02/2019] [Accepted: 07/17/2019] [Indexed: 12/16/2022] Open
Abstract
Background The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and monocyte‐to‐lymphocyte ratio (MLR) are indicators of systemic inflammation and are useful as markers in systemic rheumatic diseases. In this study, we compared the NLR, PLR, and MLR among patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA), and explored possible associations with clinical features, disease activity, and prognosis in patients with PMR. Methods The study enrolled 94 patients with PMR and 242 patients with RA who were initially diagnosed at the rheumatology clinic of a university‐based tertiary hospital. Symptoms, physical examination, and medical histories were collected with the results of laboratory tests. Results Neutrophil‐to‐lymphocyte ratio (4.5 ± 3.3 vs 2.8 ± 1.8), PLR (222.7 ± 115.5 vs 159.7 ± 78.1), and MLR (0.4 ± 0.3 vs 0.3 ± 0.2) were higher in patients with PMR compared with patients with RA (all P < .001). NLR, PLR, and MLR were correlated with specific laboratory values, including CRP and albumin, in patients with PMR. After disease activity resolved, NLR (2.95 ± 2.32, P < .001), PLR (137.5 ± 82.3, P < .001), and MLR (0.26 ± 0.16, P < .001) decreased significantly. By comparing patients according to the disease course, swollen joint counts were higher in the chronic course group compared with the remission group (P = .03), while the NLR, PLR, and MLR were similar. Conclusions Neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, and monocyte‐to‐lymphocyte ratio levels were associated with disease activity and specific clinical features, although they could not predict prognosis in patients with PMR.
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Eunyoung Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea.,Office of Biostatistics, Ajou Research Institute for Innovative Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Polymyalgia rheumatica with normal values of both erythrocyte sedimentation rate and C-reactive protein concentration at the time of diagnosis: a four-point guidance. Reumatologia 2018; 56:1-2. [PMID: 29686435 PMCID: PMC5911650 DOI: 10.5114/reum.2018.74740] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 11/17/2022] Open
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Duarte C, Ferreira RJDO, Mackie SL, Kirwan JR, Pereira da Silva JA. Outcome Measures in Polymyalgia Rheumatica. A Systematic Review. J Rheumatol 2015; 42:2503-11. [DOI: 10.3899/jrheum.150515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To identify the instruments used to assess polymyalgia rheumatica (PMR) in published studies.Methods.A systematic literature review of clinical trials and longitudinal observational studies related to PMR, published from 1970 to 2014, was carried out. All outcome and assessment instruments were extracted and categorized according to core areas and domains, as defined by the OMERACT (Outcome Measures in Rheumatology) Filter 2.0.Results.Thirty-five articles (3221 patients) were included: 12 randomized controlled trials (RCT); 3 nonrandomized trials; and 20 observational studies. More than 20 domains were identified, measured by 29 different instruments. The most frequently used measures were pain, morning stiffness, patient global assessment and physician global assessment, erythrocyte sedimentation rate, and C-reactive protein. The definition of outcomes varied considerably between studies.Conclusion.The outcome measures and instruments used in PMR are numerous and diversely defined. The establishment of a core set of validated and standardized outcome measurements is needed.
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McCarthy EM, MacMullan PA, Al-Mudhaffer S, Madigan A, Donnelly S, McCarthy CJ, Molloy ES, Kenny D, McCarthy GM. Plasma Fibrinogen Along with Patient-reported Outcome Measures Enhances Management of Polymyalgia Rheumatica: A Prospective Study. J Rheumatol 2014; 41:931-7. [DOI: 10.3899/jrheum.131055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective.We sought to prospectively examine the responsiveness of a number of patient-reported outcome (PRO) measures in polymyalgia rheumatica (PMR), as well as their relationship to the biomarkers erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and plasma fibrinogen.Methods.Sixty patients with PMR were divided into active (n = 25) or inactive (n = 35) disease groups based on symptoms; physician assessment; and the biomarkers ESR, CRP, and plasma fibrinogen. Groups underwent assessment at baseline and 6 weeks. Disease activity measures and relevant PRO measures were recorded. Measures of responsiveness were compared for all PRO and biomarkers.Results.Visual analog scale disease activity (VASDA) and VAS quality of life (VASQOL) are more responsive to change in disease activity than VAS pain, morning stiffness, Health Assessment Questionnaire (HAQ), and PMR-activity score (AS). Analysis of PMR-AS versus VASDA, VASQOL, and HAQ showed correlation coefficients of 0.87 (p < 0.001), 0.80 (p < 0.001), and 0.68 (p < 0.001), respectively. Receiver-operating curve (ROC) analysis revealed VASDA to be more specific than either HAQ (0.95 vs 0.85; p < 0.001) or VASQOL (0.95 vs 0.93; p < 0.001) for the detection of response to treatment in active PMR. Overall, fibrinogen showed superior correlation coefficients with the various PRO than either of the standard biomarkers ESR or CRP. In addition, standardized response means for fibrinogen, ESR, and CRP were 1.63, 1.2, and 1.05, respectively, indicating that plasma fibrinogen was the most responsive biomarker for assessment of change in disease activity.Conclusion.VASDA and VASQOL are the most responsive PRO to changes in disease activity in PMR. In addition, plasma fibrinogen demonstrated greater responsiveness to changes in disease activity and superior correlation with the various PRO measures recorded than did the standard biomarkers ESR and CRP.
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Pipitone N, Salvarani C. Update on polymyalgia rheumatica. Eur J Intern Med 2013; 24:583-9. [PMID: 23579169 DOI: 10.1016/j.ejim.2013.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/02/2013] [Accepted: 03/06/2013] [Indexed: 11/25/2022]
Abstract
Polymyalgia rheumatica is an inflammatory disease of unknown etiology affecting individuals aged fifty years and older, mainly of Caucasian ethnicity. Polymyalgia rheumatica is associated with giant cell arteritis more frequently than expected by chance alone. In both conditions, females are affected two to three times more often than males. The clinical hallmark manifestations of polymyalgia rheumatica are aching and morning stiffness in the shoulder girdle and often in the pelvic girdle and neck. Serum inflammatory markers are typically elevated, while the most consistent abnormal finding on imaging studies is bursitis in the symptomatic areas. A dramatic response to glucocorticoids is characteristic of polymyalgia rheumatica. Many patients are able to discontinue glucocorticoids six months to two years after the onset of clinical symptoms, but some patients may require longstanding glucocorticoid treatment. Glucocorticoid-sparing agents may be helpful in patients with chronic relapsing courses and those at high risk of glucocorticoid-related adverse events.
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Affiliation(s)
- Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
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