1
|
Ferdowsi N, Huq M, Stevens W, Hudson M, Wang M, Tay T, Burchell JL, Mancuso S, Rabusa C, Sundararajan V, Prior D, Proudman SM, Baron M, Nikpour M. Development and validation of the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI): a novel instrument to quantify organ damage in systemic sclerosis. Ann Rheum Dis 2019; 78:807-816. [DOI: 10.1136/annrheumdis-2018-214764] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 01/31/2023]
Abstract
ObjectiveWe sought to develop the first Damage Index (DI) in systemic sclerosis (SSc).MethodsThe conceptual definition of ‘damage’ in SSc was determined through consensus by a working group of the Scleroderma Clinical Trials Consortium (SCTC). Systematic literature review and consultation with patient partners and non-rheumatologist experts produced a list of potential items for inclusion in the DI. These steps were used to reduce the items: (1) Expert members of the SCTC (n=331) were invited to rate the appropriateness of each item for inclusion, using a web-based survey. Items with >60% consensus were retained; (2) Using a prospectively acquired Australian cohort data set of 1568 patients, the univariable relationships between the remaining items and the endpoints of mortality and morbidity (Physical Component Summary score of the Short Form 36) were analysed, and items with p<0.10 were retained; (3) using multivariable regression analysis, coefficients were used to determine a weighted score for each item. The DI was externally validated in a Canadian cohort.ResultsNinety-three (28.1%) complete survey responses were analysed; 58 of 83 items were retained. The univariable relationships with death and/or morbidity endpoints were statistically significant for 22 items, with one additional item forced into the multivariable model by experts due to clinical importance, to create a 23-item weighted SCTC DI (SCTC-DI). The SCTC-DI was predictive of morbidity and mortality in the external cohort.ConclusionsThrough the combined use of consensus and data-driven methods, a 23-item SCTC-DI was developed and retrospectively validated.
Collapse
|
2
|
Ross L, Stevens W, Rabusa C, Wilson M, Ferdowsi N, Walker J, Sahhar J, Ngian GS, Zochling J, Roddy J, Tymms K, Major G, Strickland G, Proudman SM, Nikpour M. The role of inflammatory markers in assessment of disease activity in systemic sclerosis. Clin Exp Rheumatol 2018; 36 Suppl 113:126-134. [PMID: 30277869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/12/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The role of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the assessment of disease activity in systemic sclerosis (SSc) remains controversial. We sought to evaluate the relationship between clinical features of SSc and raised inflammatory markers and to determine if changes in ESR and CRP reflect changes in other disease features over time. METHODS One thousand, five hundred and forty-five patients enrolled in the Australian Scleroderma Cohort Study were observed over a mean 3.52±2.91 years and assessed at 6,119 study visits. Generalised estimating equations were used to determine the relationship between ESR≥20mm/hr and CRP≥5mg/L and features of disease. The associations between change in inflammatory markers and change in skin scores and respiratory function tests were analysed. RESULTS Overall, there was a significant association between raised ESR and forced vital capacity (FVC)<80% predicted, diffusing capacity of the lung (DLCO)<80% predicted, pulmonary arterial hypertension (PAH), body mass index (BMI), proximal muscle strength, anaemia, and hypocomplementaemia (p<0.05). Raised CRP was significantly associated with modified Rodnan Skin Score>20, FVC<80%, DLCO<80%, PAH, digital ulcers, BMI, synovitis, tendon friction rub, anaemia, and hypocomplementaemia (p<0.05). A significant deterioration in respiratory function tests (RFTs) was associated with a 2-fold increase in both ESR and CRP (p<0.05). CONCLUSIONS Raised inflammatory markers are associated with pulmonary, cutaneous and musculoskeletal manifestations of SSc. Rising inflammatory markers are correlated with declining respiratory function tests. This suggests inflammatory markers have a role in the assessment of SSc disease activity.
Collapse
Affiliation(s)
- Laura Ross
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Candice Rabusa
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Michelle Wilson
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Nava Ferdowsi
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Jennifer Walker
- Rheumatology Unit, Flinders Medical Centre, Adelaide, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Department of Medicine, Monash Health & Monash University, Melbourne, Australia
| | - Gene-Siew Ngian
- Department of Rheumatology, Department of Medicine, Monash Health & Monash University, Melbourne, Australia
| | | | - Janet Roddy
- Department of Rheumatology, Fiona Stanley Hospital, Perth, Australia
| | - Kathleen Tymms
- Department of Rheumatology, Canberra Hospital, Canberra, Australia
| | - Gabor Major
- Department of Rheumatology, John Hunter Hospital, Newcastle, Australia
| | - Gemma Strickland
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| | - Susanna M Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, and Discipline of Medicine, University of Adelaide, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia
| |
Collapse
|
3
|
Morrisroe K, Stevens W, Sahhar J, Ngian GS, Rabusa C, Ferdowsi N, Hill C, Proudman S, Nikpour M. Quantifying the direct public health care cost of systemic sclerosis: A comprehensive data linkage study. Medicine (Baltimore) 2017; 96:e8503. [PMID: 29310332 PMCID: PMC5728733 DOI: 10.1097/md.0000000000008503] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To quantify the direct healthcare cost of systemic sclerosis (SSc) and identify its determinants. Healthcare use was captured through data linkage, wherein clinical and medication data for SSc patients from the state of Victoria enrolled in the Australian Scleroderma Cohort Study were linked with the Victorian hospital admissions and emergency presentations data sets, and the Medicare Benefits Schedule which contains all government subsidized ambulatory care services, for the period 2011-2015. Medication cost was determined from the Pharmaceutical Benefits Scheme. Costs were extrapolated to all Australian SSc patients based on SSc prevalence of 21.1 per 100,000 and an Australian population of 24,304,682 in 2015. Determinants of healthcare cost were estimated using logistic regression. Total healthcare utilization cost to the Australian government extrapolated to all Australian SSc patients from 2011 to 2015 was Australian Dollar (AUD)$297,663,404.77, which is an average annual cost of AUD$59,532,680.95 (US Dollar [USD]$43,816,040.08) and annual cost per patient of AUD$11,607.07 (USD$8,542.80). Hospital costs, including inpatient hospitalization and emergency department presentations, accounted for the majority of these costs (44.4% of total), followed by medication cost (31.2%) and ambulatory care cost (24.4%). Pulmonary arterial hypertension (PAH) and gastrointestinal (GIT) involvement were the major determinants of healthcare cost (OR 2.3 and 1.8, P = .01 for hospitalizations; OR 2.8 and 2.0, P = .01 for ambulatory care; OR 7.8 and 1.6, P < .001 and P = .03 for medication cost, respectively). SSc is associated with substantial healthcare utilization and direct economic burden. The most costly aspects of SSc are PAH and GIT involvement.
Collapse
Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne)
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Joanne Sahhar
- Department of Medicine, Monash University, Clayton and Monash Health, Victoria
| | - Gene-Siew Ngian
- Department of Medicine, Monash University, Clayton and Monash Health, Victoria
| | - Candice Rabusa
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Nava Ferdowsi
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Catherine Hill
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville Road, Woodville
- Discipline of Medicine, University of Adelaide, SA, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace
- Discipline of Medicine, University of Adelaide, SA, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne)
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| |
Collapse
|
4
|
Hao Y, Hudson M, Baron M, Carreira P, Stevens W, Rabusa C, Tatibouet S, Carmona L, Joven BE, Huq M, Proudman S, Nikpour M. Early Mortality in a Multinational Systemic Sclerosis Inception Cohort. Arthritis Rheumatol 2017; 69:1067-1077. [PMID: 28029745 DOI: 10.1002/art.40027] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 12/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine mortality and causes of death in a multinational inception cohort of subjects with systemic sclerosis (SSc). METHODS We quantified mortality as standardized mortality ratio (SMR), years of life lost, and percentage mortality in the first decade of disease. The inception cohort comprised subjects recruited within 4 years of disease onset. For comparison, we used a prevalent cohort, which included all subjects irrespective of disease duration at recruitment. We determined a single primary cause of death (SSc related or non-SSc related) using a standardized case report form, and we evaluated predictors of mortality using multivariable Cox regression. RESULTS In the inception cohort of 1,070 subjects, there were 140 deaths (13%) over a median follow-up of 3.0 years (interquartile range 1.0-5.1 years), with a pooled SMR of 4.06 (95% confidence interval [95% CI] 3.39-4.85), up to 22.4 years of life lost in women and up to 26.0 years of life lost in men, and mortality in the diffuse disease subtype of 24.2% at 8 years. In the prevalent cohort of 3,218 subjects, the pooled SMR was lower at 3.39 (95% CI 3.06-3.71). In the inception cohort, 62.1% of the primary causes of death were SSc related. Malignancy, sepsis, cerebrovascular disease, and ischemic heart disease were the most common non-SSc-related causes of death. Predictors of early mortality included male sex, older age at disease onset, diffuse disease subtype, pulmonary arterial hypertension, and renal crisis. CONCLUSION Early mortality in SSc is substantial, and prevalent cohorts underestimate mortality in SSc by failing to capture early deaths, particularly in men and those with diffuse disease.
Collapse
Affiliation(s)
- Yanjie Hao
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia, and Peking University First Hospital, Beijing, China
| | - Marie Hudson
- Jewish General Hospital and Lady Davis Research Institute, Montreal, Quebec, Canada
| | - Murray Baron
- Jewish General Hospital and Lady Davis Research Institute, Montreal, Quebec, Canada
| | | | - Wendy Stevens
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Candice Rabusa
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Molla Huq
- St. Vincent's Hospital Melbourne and The University of Melbourne, Melbourne, Victoria, Australia
| | - Susanna Proudman
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Mandana Nikpour
- St. Vincent's Hospital Melbourne and The University of Melbourne, Melbourne, Victoria, Australia
| | | | | |
Collapse
|
5
|
Morrisroe K, Stevens W, Sahhar J, Rabusa C, Nikpour M, Proudman S. Epidemiology and disease characteristics of systemic sclerosis-related pulmonary arterial hypertension: results from a real-life screening programme. Arthritis Res Ther 2017; 19:42. [PMID: 28270192 PMCID: PMC5341425 DOI: 10.1186/s13075-017-1250-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/27/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc). Annual screening with echocardiogram (ECHO) is recommended. We present the methodological aspects of a PAH screening programme in a large Australian SSc cohort, the epidemiology of SSc-PAH in this cohort, and an evaluation of factors influencing physician adherence to PAH screening guidelines. METHODS Patient characteristics and results of PAH screening were determined in all patients enrolled in a SSc longitudinal cohort study. Adherence to PAH screening guidelines was assessed by a survey of Australian rheumatologists. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of risk factors with PAH. RESULTS Among 1636 patients with SSc, 194 (11.9%) had PAH proven by right-heart catheter. Of these, 160 were detected by screening. The annual incidence of PAH was 1.4%. Patients with PAH diagnosed on subsequent screens, compared with patients in whom PAH was diagnosed on first screen, were more likely to have diffuse SSc (p = 0.03), be in a better World Health Organisation (WHO) Functional Class at PAH diagnosis (p = 0.01) and have less advanced PAH evidenced by higher mean six-minute walk distance (p = 0.03), lower mean pulmonary arterial pressure (p = 0.009), lower mean pulmonary vascular resistance (p = 0.006) and fewer non-trivial pericardial effusions (p = 0.03). Adherence to annual PAH screening using an ECHO-based algorithm was poor among Australian rheumatologists, with less than half screening their patients with SSc of more than ten years disease duration. CONCLUSION PAH is a common complication of SSc. Physician adherence to PAH screening recommendations remains poor. Identifying modifiable barriers to screening may improve adherence and ultimately patient outcomes.
Collapse
Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Wendy Stevens
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Joanne Sahhar
- Monash University and Monash Health, 246 Clayton Road, Clayton, 3168 Victoria Australia
| | - Candice Rabusa
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, SA 5000 Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA 5000 Australia
| |
Collapse
|
6
|
Esposito J, Brown Z, Stevens W, Sahhar J, Rabusa C, Zochling J, Roddy J, Walker J, Proudman SM, Nikpour M. The association of low complement with disease activity in systemic sclerosis: a prospective cohort study. Arthritis Res Ther 2016; 18:246. [PMID: 27770830 PMCID: PMC5075219 DOI: 10.1186/s13075-016-1147-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/05/2016] [Indexed: 01/27/2023] Open
Abstract
Background In some rheumatic diseases such as systemic lupus erythematosus (SLE), low serum complement (‘hypocomplementaemia’) is a feature of active disease. However, the role of hypocomplementaemia in systemic sclerosis (SSc) is unknown. We sought to determine the frequency, clinical associations and relationship to disease activity of hypocomplementaemia in SSc. Methods The study included 1140 patients fulfilling the 2013 American College of Rheumatology criteria for SSc. Demographic, serological and clinical data, obtained prospectively through annual review, were analysed using univariable methods. Linear and logistic regression, together with generalised estimating equations, were used to determine the independent correlates of hypocomplementaemia ever, and at each visit, respectively. Results At least one episode of hypocomplementaemia (low C3 and/or low C4) occurred in 24.1 % of patients over 1893 visits; these patients were more likely to be seropositive for anti-ribonucleoprotein (OR = 3.8, p = 0.002), anti-Ro (OR = 2.2, p = 0.002), anti-Smith (OR = 6.3, p = 0.035) and anti-phospholipid antibodies (OR = 1.4, p = 0.021) and were more likely to display features of overlap connective tissue disease, in particular polymyositis (OR = 16.0, p = 0.012). However, no association was found between hypocomplementaemia and either the European Scleroderma Study Group disease activity score or any of its component variables (including erythrocyte sedimentation rate) in univariate analysis. Among patients with SSc overlap disease features, those who were hypocomplementaemic were more likely to have digital ulcers (OR = 1.6, p = 0.034), tendon friction rubs (OR = 2.4, p = 0.037), forced vital capacity <80 % predicted (OR = 2.9, p = 0.008) and lower body mass index (BMI) (OR for BMI = 0.9, p < 0.0005) at that visit, all of which are features associated with SSc disease activity and/or severity. Conclusions While hypocomplementaemia is not associated with disease activity in patients with non-overlap SSc, it is associated with some features of increased SSc disease activity in patients with overlap disease features.
Collapse
Affiliation(s)
- James Esposito
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Zoe Brown
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health and Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Medicine, Monash Health and Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Candice Rabusa
- Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jane Zochling
- Department of Rheumatology, Menzies Institute for Medical Research, Private Bag 23, Hobart, TAS, 7001, Australia
| | - Janet Roddy
- Department of Rheumatology, Royal Perth Hospital, 197 Wellington Street, GPO Box X2213, Perth, WA, 6001, Australia
| | - Jennifer Walker
- Department of Rheumatology, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia
| | - Susanna M Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia. .,Department of Rheumatology, St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| |
Collapse
|
7
|
Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman SM, Nikpour M. Risk factors for development of pulmonary arterial hypertension in Australian systemic sclerosis patients: results from a large multicenter cohort study. BMC Pulm Med 2016; 16:134. [PMID: 27677579 PMCID: PMC5039932 DOI: 10.1186/s12890-016-0296-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is the leading cause of mortality in patients with systemic sclerosis (SSc). We sought to determine the incidence, prevalence and risk factors for PAH development in a large Australian SSc cohort. METHODS PAH was diagnosed on right heart catheterisation (mPAP >25 and PAWP <15 mmHg at rest). Patients with PH secondary to interstitial lung disease (ILD; defined as abnormal HRCT scan and FVC < 60 %) were excluded. Summary statistics, chi-square tests, univariate and multivariable logistic regression along with post-estimation diagnostics were used to determine the associations of different combinations of risk factors with PAH. RESULTS Among 1579 SSc patients, 8.4 % (132 patients) were diagnosed with PAH over a mean (±SD) follow-up of 3.2 (±2.5) years. The incidence of PAH in this cohort was 0.7 % per annum. Of these, 68.9 % had limited disease subtype (lcSSc). In multivariable regression analysis, the presence of anti-centromere antibody (ACA) (OR 1.6, 95 % CI 1.1-2.5, p = 0.03), oesphageal stricture (OR 2.0, 95 % CI 1.2-3.3, p = 0.006), calcinosis (OR 1.9, 95 % CI 1.2-2.9, p = 0.003), sicca symptoms (OR 1.6, 95 % CI 1.1-2.5, p = 0.03), mild ILD (OR 2.3, 95 % CI 1.5-3.7, p < 0.001) and digital ulcers (OR 1.6, 95 % CI 1.0-2.4, p = 0.03) were predictive of PAH. This model had an area under the curve of 0.7 and concordance of 91.8 %. When analysed by disease subtype, the presence of calcinosis (OR 2.2, 95 % CI 1.4-3.7, p = 0.01), sicca symptoms (OR 2.6, 95 % CI 1.5-4.6, p = 0.001), mild ILD (OR 2.3, 95 % CI 1.4-3.8, p = 0.001) and digital ulcers (OR 1.9, 95 % CI 1.2-3.7, p = 0.01) were predictive of PAH in lcSSc; and oesophageal stricture (OR 4.4, 95 % CI 1.9-10.5, p = 0.001), mild ILD (OR 2.8, 95 % CI 1.2-6.8, p = 0.02) and ACA (OR 5.2, 95 % CI 1.8-14.8, p = 0.002) were predictive of PAH in dcSSc. CONCLUSIONS The incidence and prevalence of PAH in this cohort are 0.7 % per annum and 8.4 %, respectively. The clinical-serologic risk factors for PAH differ based on disease subtype. In both subtypes, mild ILD is associated with PAH, suggesting the possibility of common pathogenic mechanisms underlying both of these disease manifestations. This model identifies a subset of patients at an appreciably higher risk of developing PAH, who should be screened and would in future, benefit from preventative therapies.
Collapse
Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Molla Huq
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Wendy Stevens
- Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Candice Rabusa
- Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, 5000, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia. .,Department of Rheumatology St Vincent's Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065, VIC, Australia.
| | | |
Collapse
|
8
|
Quinlivan A, Thakkar V, Stevens W, Morrisroe K, Prior D, Rabusa C, Youssef P, Gabbay E, Roddy J, Walker JG, Zochling J, Sahhar J, Nash P, Lester S, Rischmueller M, Proudman SM, Nikpour M. Cost savings with a new screening algorithm for pulmonary arterial hypertension in systemic sclerosis. Intern Med J 2016; 45:1134-40. [PMID: 26337683 DOI: 10.1111/imj.12890] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 08/20/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Screening for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) is now standard care in this disease. The existing Australian Scleroderma Interest Group algorithm (ASIGSTANDARD ) is based on transthoracic echocardiography (TTE) and pulmonary function tests (PFT). Recently, ASIG has derived and validated a new screening algorithm (ASIGPROPOSED ) that incorporates N-terminal pro-B-type natriuretic peptide level together with PFT in order to decrease reliance on TTE, which has some limitations. Right heart catheterisation (RHC) remains the gold standard for the diagnosis of PAH in patients who screen 'positive'. AIM To compare the cost of PAH screening in SSc with ASIGSTANDARD and ASIGPROPOSED algorithms. METHODS We applied both ASIGSTANDARD and ASIGPROPOSED algorithms to 643 screen-naïve SSc patients from the Australian Scleroderma Cohort Study (ASCS), assuming a PAH prevalence of 10%. We compared the costs of screening, the number of TTE required and both the total number of RHC required and the number of RHC needed to diagnose one case of PAH, and costs, according to each algorithm. We then extrapolated the costs to the estimated total Australian SSc population. RESULTS In screen-naïve patients from the ASCS, ASIGPROPOSED resulted in 64% fewer TTE and 10% fewer RHC compared with ASIGSTANDARD , with $1936 (15%) saved for each case of PAH diagnosed. When the costs were extrapolated to the entire Australian SSc population, there was an estimated screening cost saving of $946 000 per annum with ASIGPROPOSED , with a cost saving of $851 400 in each subsequent year of screening. CONCLUSIONS ASIGPROPOSED substantially reduces the number of TTE and RHC required and results in substantial cost savings in SSc-PAH screening compared with ASIGSTANDARD .
Collapse
Affiliation(s)
- A Quinlivan
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine at St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - V Thakkar
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Rheumatology, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - W Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - K Morrisroe
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - D Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine at St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - C Rabusa
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - P Youssef
- Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - E Gabbay
- The University of Notre Dame, Fremantle, Australia
| | - J Roddy
- Department of Rheumatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - J G Walker
- Department of Rheumatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - J Zochling
- Menzies Institute for Medical Research, Hobart, Tasmania, Australia
| | - J Sahhar
- Department of Rheumatology, Monash University, Monash Health, Melbourne, Victoria, Australia
| | - P Nash
- Rheumatology Research Unit, Department of Medicine, University of Queensland, Sunshine Coast, Queensland, Australia
| | - S Lester
- Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - M Rischmueller
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - S M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - M Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine at St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman SM, Nikpour M. Determinants of unemployment amongst Australian systemic sclerosis patients: results from a multicentre cohort study. Clin Exp Rheumatol 2016; 34 Suppl 100:79-84. [PMID: 27463997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES We sought to assess employment status, risk factors for unemployment and the associations of unemployment with patients' health related quality of life (HRQoL). METHODS All patients enrolled in a systemic sclerosis (SSc) longitudinal cohort study, completed an employment questionnaire on enrolment. Clinical manifestations were defined based on presence at the time of enrolment. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of various risk factors with employment. RESULTS Among 1587 SSc patients, 160 (20%) were unemployed at the time of cohort enrolment excluding retired patients. Of these, 63% had limited disease subtype. Mean (±SD) age at enrollment was 51.9 (±10.4) years; 13 years below the average retirement age in Australia. Mean (±SD) disease duration at recruitment was 11.1 (±10.9) years. Multivariable regression analysis revealed the presence of digital amputation (OR 3.9, 95%CI 1.7-9.1, p=0.002), diffuse disease subtype (OR 2.2, 95%CI 1.3-3.5, p-value=0.002), sicca symptoms (OR 2.7, 95%CI 1.6-4.4, p<0.001), a physical job (OR 1.8, 95%CI 1.1-3.1, p=0.03) and pulmonary arterial hypertension (OR 2.2, 95%CI 1.1-4.5, p=0.02) to be associated with unemployment. Unemployed patients had consistently poorer HRQoL scores in all domains (physical, emotional and mental health) of the SF-36 form than those who were employed. CONCLUSIONS SSc is associated with substantial work disability and unemployment, which is in turn associated with poor quality of life. Raising awareness, identifying modifiable risk factors and implementing employment strategies and work place modifications are possible ways of reducing this burden.
Collapse
Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Molla Huq
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology, St .Vincent's Hospital, Melbourne, Victoria, Australia
| | - Candice Rabusa
- Department of Rheumatology, St .Vincent's Hospital, Melbourne, Victoria, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace; and Discipline of Medicine, University of Adelaide, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, and Department of Rheumatology, St. Vincent's Hospital, Melbourne, Victoria, Australia.
| |
Collapse
|
10
|
Owen C, Ngian GS, Elford K, Moore O, Stevens W, Nikpour M, Rabusa C, Proudman S, Roddy J, Zochling J, Hill C, Sturgess A, Tymms K, Youssef P, Sahhar J. Mycophenolate mofetil is an effective and safe option for the management of systemic sclerosis-associated interstitial lung disease: results from the Australian Scleroderma Cohort Study. Clin Exp Rheumatol 2016; 34 Suppl 100:170-176. [PMID: 27049330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 12/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To report the efficacy and tolerability of mycophenolate mofetil (MMF) and azathioprine (AZA) in the management of systemic sclerosis-associated interstitial lung disease (SSc-ILD). METHODS Patients in the Australian Scleroderma Cohort Study treated with at least 3 months of MMF or AZA for SSc-ILD confirmed on high resolution computed tomography (HRCT) chest were identified and their pulmonary function tests (PFTs) retrieved. Individuals with available results for T-1 (12 months prior to treatment commencement), T0 (date of treatment commencement) and at least one subsequent time point were included in the drug efficacy analysis. The Wilcoxon signed-rank test was used to compare absolute FVC at T1, T0, 12 months (T1), 24 months (T2) and 36 months (T3). Analysis of drug tolerability included all identified patients treated with MMF or AZA. RESULTS 18/22 patients treated with MMF and 29/49 treated with AZA had adequate PFTs for inclusion in the drug efficacy analysis. Median absolute FVC at T1 for MMF treatment was 2.50L, declining to 2.12L at T0 (p=0.02). Following MMF therapy, FVC results were stable at T1 (2.13L, p=0.86), T2 (2.17L, p=0.65) and T3 (2.25L, p=0.78). In the AZA group, a statistically significant decline did not occur prior to treatment, however FVC results remained stable at T1, T2 and T3.Adverse events leading to early discontinuation (<12 months treatment) were less common in the MMF group (4/22 vs. 13/49). Gastrointestinal complications were the main cause of discontinuation in both groups. CONCLUSIONS In patients with SSc-ILD with declining pulmonary function, MMF therapy was associated with stability for up to 36 months. Early adverse events leading to discontinuation occurred less frequently in patients treated with MMF than in AZA treated patients.
Collapse
MESH Headings
- Adult
- Aged
- Australia
- Azathioprine/therapeutic use
- Databases, Factual
- Drug Therapy, Combination
- Female
- Humans
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Longitudinal Studies
- Lung/drug effects
- Lung/physiopathology
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/drug therapy
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/physiopathology
- Male
- Middle Aged
- Mycophenolic Acid/adverse effects
- Mycophenolic Acid/therapeutic use
- Respiratory Function Tests
- Retrospective Studies
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/drug therapy
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
Collapse
Affiliation(s)
- Claire Owen
- Department of Rheumatology, Monash Health, Clayton VIC, Australia
| | - Gene-Siew Ngian
- Department of Rheumatology, Monash Health, Clayton VIC, Australia
| | - Kathleen Elford
- Department of Rheumatology, Monash Health, Clayton VIC, Australia
| | | | | | - Mandana Nikpour
- St. Vincent's Hospital, Melbourne VIC, Australia; and University of Melbourne, Parkville VIC, Australia
| | | | - Susanna Proudman
- Royal Adelaide Hospital, North Terrace SA, Australia; and Discipline of Medicine, University of Adelaide, SA, Australia
| | | | - Jane Zochling
- Menzies Institute for Medical Research, Hobart TAS, Australia
| | - Catherine Hill
- The Queen Elizabeth Hospital, Woodville South SA, Australia; and Discipline of Medicine, University of Adelaide, SA, Australia
| | | | | | - Peter Youssef
- Royal Prince Alfred Hospital, Camperdown NSW, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health, Clayton VIC, Australia; and Department of Medicine, Monash University, Clayton, VIC, Australia.
| |
Collapse
|
11
|
Thakkar V, Stevens W, Prior D, Rabusa C, Sahhar J, Walker JG, Roddy J, Lester S, Rischmueller M, Zochling J, Nash P, Gabbay E, Youssef P, Proudman SM, Nikpour M. The role of asymmetric dimethylarginine alone and in combination with N-terminal pro-B-type natriuretic peptide as a screening biomarker for systemic sclerosis-related pulmonary arterial hypertension: a case control study. Clin Exp Rheumatol 2016; 34 Suppl 100:129-136. [PMID: 27214686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 01/08/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Asymmetric dimethylarginine (ADMA) is a novel biomarker of endothelial cell dysfunction. In this proof of concept study, we sought to evaluate the role of ADMA as a screening biomarker for incident systemic sclerosis-related pulmonary arterial hypertension (SSc-PAH). METHODS ADMA levels were measured using high performance liquid chromatography in 15 consecutive treatment-naive patients with newly-diagnosed SSc-PAH and compared with 30 SSc-controls without PAH. Logistic regression models were used to evaluate the independent association of ADMA with PAH. The optimal cut-point of ADMA for SSc-PAH screening was determined. NT-proBNP levels were previously measured in the same patients and the optimal cut-point of NT-proBNP of ≥210ng/mL was coupled with the optimal cut-point of ADMA to create a screening model that combined the two biomarkers. RESULTS The PAH group had significantly higher mean ADMA levels than the control group (0.76±0.14 μM versus 0.59±0.07 μM; p<0.0001). ADMA levels remained significantly associated with PAH after the adjustment for specific disease characteristics, cardiovascular risk factors and other SSc-related vascular complications (all p<0.01). An ADMA level ≥0.7 μM had a sensitivity of 86.7%, specificity of 90.0% and AUC of 0.86 for diagnosing PAH. A screening model that combined an NT-proBNP ≥210ng/mL and/ or ADMA ≥0.7 ng/mL resulted in a sensitivity of 100% and specificity of 90% for the detection of SSc-PAH. CONCLUSIONS In this small study, use of ADMA in combination with NT-proBNP produced excellent sensitivity and specificity for the non-invasive identification of SSc-PAH. The role of ADMA as a screening biomarker for SSc-PAH merits further evaluation.
Collapse
Affiliation(s)
- Vivek Thakkar
- Department of Medicine; Department of Rheumatology, St. Vincent's Hospital Melbourne, Fitzroy; Department of Rheumatology, Liverpool Hospital, Liverpool; and School of Medicine, University of Western Sydney, Penrith, Australia
| | - Wendy Stevens
- Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Candice Rabusa
- Department of Rheumatology, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Medical Centre, Clayton, Australia
| | - Jennifer G Walker
- Department of Rheumatology, Flinders Medical Centre, Bedford Park, Australia
| | - Janet Roddy
- Department of Rheumatology, Royal Perth Hospital, Perth, Australia
| | - Susan Lester
- Rheumatology Department, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Maureen Rischmueller
- Rheumatology Department, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Jane Zochling
- Department of Rheumatology, The Menzies Institute, Hobart, Australia
| | - Peter Nash
- Rheumatology Research Unit, Department of Medicine, University of Queensland, Maroochydore, Australia
| | - Eli Gabbay
- The University of Notre Dame, Fremantle, Australia
| | - Peter Youssef
- Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Susanna M Proudman
- Royal Adelaide Hospital, North Terrace; and Discipline of Medicine, University of Adelaide, Australia
| | - Mandana Nikpour
- Department of Medicine; and Department of Rheumatology, St. Vincent's Hospital Melbourne, Fitzroy, Australia.
| |
Collapse
|
12
|
Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman S, Nikpour M. FRI0249 Risk Factors for Development of Pulmonary Arterial Hypertension in Australian Scleroderma Patients. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
13
|
Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman S, Nikpour M. SAT0235 Survival in Systemic Sclerosis Related Pulmonary Arterial Hypertension in The Modern Treatment Era: Results from A Multicentre Australian Cohort Study: Table 1. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.5368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
14
|
Morrisroe K, Huq M, Stevens W, Rabusa C, Proudman S, Nikpour M. AB0607 Determinants of Unemployment amongst Australian Systemic Sclerosis Patients: Table 1. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.5354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
15
|
Hao Y, Thakkar V, Stevens W, Morrisroe K, Prior D, Rabusa C, Youssef P, Gabbay E, Roddy J, Walker J, Zochling J, Sahhar J, Nash P, Lester S, Rischmueller M, Proudman SM, Nikpour M. A comparison of the predictive accuracy of three screening models for pulmonary arterial hypertension in systemic sclerosis. Arthritis Res Ther 2015; 17:7. [PMID: 25596924 PMCID: PMC4332896 DOI: 10.1186/s13075-015-0517-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 01/05/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION There is evidence that early screening for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) improves outcomes. We compared the predictive accuracy of two recently published screening algorithms (DETECT 2013 and Australian Scleroderma Interest Group (ASIG) 2012) for SSc-associated PAH (SSc-PAH) with the commonly used European Society of Cardiology/European Respiratory Society (ESC/ERS 2009) guidelines. METHODS We included 73 consecutive SSc patients with suspected PAH undergoing right heart catheterization (RHC). The three screening models were applied to each patient. For each model, contingency table analysis was used to determine sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for PAH. These properties were also evaluated in an 'alternate scenario analysis' in which the prevalence of PAH was set at 10%. RESULTS RHC revealed PAH in 27 (36.9%) patients. DETECT and ASIG algorithms performed equally in predicting PAH with sensitivity and NPV of 100%. The ESC/ERS guidelines had sensitivity of 96.3% and NPV of only 91%, missing one case of PAH; these guidelines could not be applied to three patients who had absent tricuspid regurgitant (TR) jet. The ASIG algorithm had the highest specificity (54.5%). With PAH prevalence set at 10%, the NPV of the models was unchanged, but the PPV dropped to less than 20%. CONCLUSIONS In this cohort, the DETECT and ASIG algorithms out-perform the ESC/ERS guidelines, detecting all patients with PAH. The ESC/ERS guidelines have limitations in the absence of a TR jet. Ultimately, the choice of SSc-PAH screening algorithm will also depend on cost and ease of application.
Collapse
Affiliation(s)
- Yanjie Hao
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia. .,Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku Street, Beijing, China.
| | - Vivek Thakkar
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia. .,Department of Rheumatology, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia. .,School of Medicine, University of Western Sydney, Locked bag 1797, Penrith, NSW 2751, Australia.
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Kathleen Morrisroe
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Candice Rabusa
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Peter Youssef
- Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Queen Elizabeth II building, Missendon Road, Camperdown, NSW 2050, Australia.
| | - Eli Gabbay
- The University of Notre Dame, 19 Mouat Street, Fremantle, WA, 6959, Australia.
| | - Janet Roddy
- Department of Rheumatology, Royal Perth Hospital, Wellington Street, GPO Box X2213, Perth, WA, 6001, Australia.
| | - Jennifer Walker
- Department of Rheumatology, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia.
| | - Jane Zochling
- Department of Rheumatology, The Menzies Institute Tasmania, Private Bag 23, Hobart, TAS 7001, Australia.
| | - Joanne Sahhar
- Department of Rheumatology, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Australia.
| | - Peter Nash
- Rheumatology Research Unit, Department of Medicine, University of Queensland, PO Box 368, Maroochydore, QLD 4558, Australia.
| | - Susan Lester
- Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, 5011, Australia.
| | - Maureen Rischmueller
- Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, 5011, Australia. .,Discipline of Medicine, University of Adelaide, North Terrace, SA, 5000, Australia.
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, SA, 5000, Australia. .,Discipline of Medicine, University of Adelaide, North Terrace, SA, 5000, Australia.
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia. .,Department of Medicine at St Vincent's Hospital Melbourne, The University of Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| |
Collapse
|