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Accuracy of Canadian health administrative databases in identifying patients with rheumatoid arthritis: a validation study using the medical records of rheumatologists.

https://arctichealth.org/en/permalink/ahliterature114676
Source
Arthritis Care Res (Hoboken). 2013 Oct;65(10):1582-91
Publication Type
Article
Date
Oct-2013
Author
Jessica Widdifield
Sasha Bernatsky
J Michael Paterson
Karen Tu
Ryan Ng
J Carter Thorne
Janet E Pope
Claire Bombardier
Author Affiliation
University of Toronto, Toronto, Ontario, Canada.
Source
Arthritis Care Res (Hoboken). 2013 Oct;65(10):1582-91
Date
Oct-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Algorithms
Arthritis, Rheumatoid - diagnosis - epidemiology
Data Mining - statistics & numerical data
Databases, Factual - statistics & numerical data
Drug Prescriptions - statistics & numerical data
Fees and Charges - statistics & numerical data
Female
Hospitalization - statistics & numerical data
Humans
Male
Medical Records Systems, Computerized - statistics & numerical data
Middle Aged
Ontario - epidemiology
Reproducibility of Results
Retrospective Studies
Rheumatology - statistics & numerical data
Single-Payer System - statistics & numerical data
Abstract
Health administrative data can be a valuable tool for disease surveillance and research. Few studies have rigorously evaluated the accuracy of administrative databases for identifying rheumatoid arthritis (RA) patients. Our aim was to validate administrative data algorithms to identify RA patients in Ontario, Canada.
We performed a retrospective review of a random sample of 450 patients from 18 rheumatology clinics. Using rheumatologist-reported diagnosis as the reference standard, we tested and validated different combinations of physician billing, hospitalization, and pharmacy data.
One hundred forty-nine rheumatology patients were classified as having RA and 301 were classified as not having RA based on our reference standard definition (study RA prevalence 33%). Overall, algorithms that included physician billings had excellent sensitivity (range 94-100%). Specificity and positive predictive value (PPV) were modest to excellent and increased when algorithms included multiple physician claims or specialist claims. The addition of RA medications did not significantly improve algorithm performance. The algorithm of "(1 hospitalization RA code ever) OR (3 physician RA diagnosis codes [claims] with =1 by a specialist in a 2-year period)" had a sensitivity of 97%, specificity of 85%, PPV of 76%, and negative predictive value of 98%. Most RA patients (84%) had an RA diagnosis code present in the administrative data within ±1 year of a rheumatologist's documented diagnosis date.
We demonstrated that administrative data can be used to identify RA patients with a high degree of accuracy. RA diagnosis date and disease duration are fairly well estimated from administrative data in jurisdictions of universal health care insurance.
PubMed ID
23592598 View in PubMed
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Anticitrullinated protein antibodies and rheumatoid factor fluctuate in early inflammatory arthritis and do not predict clinical outcomes.

https://arctichealth.org/en/permalink/ahliterature116618
Source
J Rheumatol. 2013 Aug;40(8):1259-67
Publication Type
Article
Date
Aug-2013
Author
Lillian Barra
Vivian Bykerk
Janet E Pope
Boulos P Haraoui
Carol A Hitchon
J Carter Thorne
Edward C Keystone
Gilles Boire
Author Affiliation
Department of Medicine, Division of Rheumatology, St. Joseph's Health Care London, University of Western Ontario, London, Ontario, Canada. lbarra2@uwo.ca
Source
J Rheumatol. 2013 Aug;40(8):1259-67
Date
Aug-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antibodies, Anti-Idiotypic - blood
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - blood - drug therapy
Biological Markers - blood
Canada
Cohort Studies
Disability Evaluation
Female
Follow-Up Studies
Humans
Male
Middle Aged
Peptides, Cyclic - immunology
Predictive value of tests
Questionnaires
Regression Analysis
Rheumatoid Factor - blood
Sensitivity and specificity
Severity of Illness Index
Treatment Outcome
Abstract
In inflammatory arthritis, rheumatoid factor (RF) and anticitrullinated protein antibodies (ACPA) are believed to be associated with more severe clinical outcomes. Our objective was to determine whether ACPA and RF remain stable in early inflammatory arthritis and whether their trajectories over time or baseline levels predicted clinical outcomes.
The study population consisted of patients enrolled in the Canadian Early Arthritis Cohort Study with baseline and at least 12-month followup values of RF and ACPA. Primary outcomes were Disease Activity Score (DAS) remission and the presence of erosions at 12 and 24 months. Other objectives included swollen joint count, Health Assessment Questionnaire score, and DAS.
At baseline, 225/342 (66%) patients were ACPA-positive and 334/520 (64%) were RF-positive. At 24 months, 15/181 (8%) ACPA-positive patients became negative. A larger number of patients changed from ACPA-negative to positive: 13/123 (11%). For RF, fluctuations were more common: 67/240 (28%) reverted from positive to negative and 21/136 (18%) converted from negative to positive. RF and ACPA fluctuations did not predict disease outcomes. Patients who remained ACPA-positive throughout followup were more likely to have erosive disease (OR 3.86, 95% CI 1.68, 8.92).
RF and ACPA have the potential to revert and convert during the early course of disease. Fluctuations in RF and ACPA were not associated with clinical outcomes.
PubMed ID
23378461 View in PubMed
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Are there differences between young- and older-onset early inflammatory arthritis and do these impact outcomes? An analysis from the CATCH cohort.

https://arctichealth.org/en/permalink/ahliterature105048
Source
Rheumatology (Oxford). 2014 Jun;53(6):1075-86
Publication Type
Article
Date
Jun-2014
Author
Michael B Arnold
Vivian P Bykerk
Gilles Boire
Boulos P Haraoui
Carol Hitchon
Carter Thorne
Edward C Keystone
Janet E Pope
Source
Rheumatology (Oxford). 2014 Jun;53(6):1075-86
Date
Jun-2014
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Age Factors
Age of Onset
Aged
Aged, 80 and over
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - diagnosis - drug therapy - epidemiology
Biological Products - therapeutic use
Canada - epidemiology
Cohort Studies
Comorbidity
Drug Utilization - statistics & numerical data
Female
Humans
Male
Middle Aged
Prognosis
Remission Induction
Severity of Illness Index
Sex Factors
Treatment Outcome
Young Adult
Abstract
The aim of this study was to determine the impact of age on disease and remission in suspected early RA (ERA).
Data from the Canadian Early Arthritis Cohort (CATCH) were examined at baseline, 6 and 12 months. Patients were divided into three groups based on age. Analysis of variance (ANOVA) and regression models were performed to determine the impact of age on the 28-joint DAS (DAS28) and remission at 12 months.
A total of 1809 patients were initially assessed: 442 (24.4%) young (
PubMed ID
24501240 View in PubMed
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The Canadian Early Arthritis Cohort (CATCH): patients with new-onset synovitis meeting the 2010 ACR/EULAR classification criteria but not the 1987 ACR classification criteria present with less severe disease activity.

https://arctichealth.org/en/permalink/ahliterature121576
Source
J Rheumatol. 2012 Nov;39(11):2071-80
Publication Type
Article
Date
Nov-2012
Author
Vivian P Bykerk
Shahin Jamal
Gilles Boire
Carol A Hitchon
Boulos Haraoui
Janet E Pope
J Carter Thorne
Ye Sun
Edward C Keystone
Author Affiliation
Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. vbykerk@gmail.com
Source
J Rheumatol. 2012 Nov;39(11):2071-80
Date
Nov-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antirheumatic Agents - therapeutic use
Canada
Cohort Studies
Europe
Female
Finger Joint - radiography
Humans
Male
Methotrexate - therapeutic use
Middle Aged
Patient Selection
Prospective Studies
Rheumatoid Factor - blood
Severity of Illness Index
Societies, Medical
Synovitis - classification - diagnosis - drug therapy
United States
Abstract
Our objective was to describe characteristics of Canadian patients with early arthritis and examine differences between those fulfilling 1987 and 2010 rheumatoid arthritis (RA) classification criteria.
The Canadian Early Arthritis Cohort (CATCH) is a national, multicenter, observational, prospective cohort of patients with early inflammatory arthritis, receiving usual care, recruited since 2007. Inclusion criteria include age > 16 years; symptom duration 6-52 weeks; swelling of = 2 joints or = 1 metacarpophalangeal/proximal interphalangeal joint; and 1 of rheumatoid factor = 20 IU, positive anticitrullinated protein antibodies (ACPA), morning stiffness = 45 min, response to nonsteroidal antiinflammatory drug, or positive metatarsophalangeal joint squeeze test. Data from patients enrolled to March 15, 2011, were analyzed.
In total, 1450 patients met the eligibility criteria (1187 were followed). At baseline, mean age was 53 ± 15 years, symptom duration was 6.1 ± 3.2 months, Disease Activity Score (DAS28) was 4.9 ± 1.6, Health Assessment Questionnaire-Disability Index was 1.0 ± 0.7. Forty-one percent (n = 450) of patients had moderate (3.2 5.1) disease activity; 28% of those with baseline radiographs (n = 250/908) had radiographic evidence of erosions. ACPA status was available for 70% (n = 831) of patients; 55% (n = 453) tested positive. Sixty percent (n = 718) of patients were treated with methotrexate (MTX) initially. Of 612 patients without erosions, 63% and 83% fulfilled 1987 and 2010 RA classification criteria, respectively. Seventy-three percent (n = 166) of those who did not fulfill 1987 criteria were newly identified by the 2010 criteria. These patients had less severe disease and more were MTX-naive compared to those satisfying the 1987 criteria. Forty-seven percent of all patients achieved remission at 1 year.
Patients with early RA present with moderate high disease activity;
Notes
Comment In: J Rheumatol. 2012 Nov;39(11):2062-323118277
PubMed ID
22896026 View in PubMed
Less detail

Canadian recommendations for clinical trials of pharmacologic interventions in rheumatoid arthritis: inclusion criteria and study design.

https://arctichealth.org/en/permalink/ahliterature132908
Source
J Rheumatol. 2011 Oct;38(10):2095-104
Publication Type
Article
Date
Oct-2011
Author
Jacob Karsh
Edward C Keystone
Boulos Haraoui
J Carter Thorne
Janet E Pope
Vivian P Bykerk
Walter P Maksymowych
Michel Zummer
William G Bensen
Majed M Kraishi
Author Affiliation
The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9, Canada. jkarsh@ottawahospital.on.ca
Source
J Rheumatol. 2011 Oct;38(10):2095-104
Date
Oct-2011
Language
English
Publication Type
Article
Keywords
Arthritis, Rheumatoid - drug therapy
Canada
Clinical Trials as Topic
Humans
Patient Selection
Research Design
Abstract
Current clinical trial designs for pharmacologic interventions in rheumatoid arthritis (RA) do not reflect the innovations in RA diagnosis, treatment, and care in countries where new drugs are most often used. The objective of this project was to recommend revised entry criteria and other study design features for RA clinical trials.
Recommendations were developed using a modified nominal group consensus method. Canadian Rheumatology Research Consortium (CRRC) members were polled to rank the greatest challenges to clinical trial recruitment in their practices. Initial recommendations were developed by an expert panel of rheumatology trialists and other experts. A scoping study methodology was then used to examine the evidence available to support or refute each initial recommendation. The potential influence of CRRC recommendations on primary outcomes in future trials was examined. Recommendations were finalized using a consensus process.
Recommendations for clinical trial inclusion criteria addressed measures of disease activity [Disease Activity Score 28 using erythrocyte sedimentation rate (DAS28-ESR) > 3.2 PLUS = 3 tender joints using 28-joint count (TJC28) PLUS = 3 swollen joint (SJC28) OR C-reactive protein (CRP) or ESR > upper limit of normal PLUS = 3 TJC28 PLUS = 3 SJC28], functional classification, disease classification and duration, and concomitant RA treatments. Additional recommendations regarding study design addressed rescue strategies and longterm extension.
There is an urgent need to modify clinical trial inclusion criteria and other study design features to better reflect the current characteristics of people living with RA in the countries where the new drugs will be used.
Notes
Comment In: J Rheumatol. 2011 Oct;38(10):2087-821965690
PubMed ID
21765109 View in PubMed
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Canadian variation by province in rheumatoid arthritis initiating anti-tumor necrosis factor therapy: results from the optimization of adalimumab trial.

https://arctichealth.org/en/permalink/ahliterature140779
Source
J Rheumatol. 2010 Dec;37(12):2469-74
Publication Type
Article
Date
Dec-2010
Author
Christopher Pease
Janet E Pope
Carter Thorne
Boulos Paul Haraoui
Don Truong
Claire Bombardier
Jessica Widdifield
Eliofotisti Psaradellis
John S Sampalis
Ashley Bonner
Author Affiliation
University of Western Ontario, London, Ontario, Canada.
Source
J Rheumatol. 2010 Dec;37(12):2469-74
Date
Dec-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antibodies, Monoclonal - economics - therapeutic use
Antirheumatic Agents - economics - therapeutic use
Arthritis, Rheumatoid - drug therapy - pathology - physiopathology
Canada
Female
Humans
Insurance, Health, Reimbursement
Middle Aged
Multicenter Studies as Topic
Questionnaires
Randomized Controlled Trials as Topic
Registries
Treatment Outcome
Tumor Necrosis Factor-alpha - immunology
Abstract
We compared variations among Canadian provinces in rheumatoid arthritis (RA) initiating anti-tumor necrosis factor (TNF) therapy.
Data were obtained from the Optimization of Humira trial (OH) and from the Ontario Biologics Research Initiative (OBRI). Baseline characteristics were compared between regions: Ontario (ON), Quebec (QC), and other provinces (OTH). We compared Ontario OH to OBRI patients who were initiating anti-TNF therapy.
In 300 OH patients, mean age was 54.8 years (13.3). There were 151 (50.3%) ON patients, 57 from QC (19%), and 92 from OTH (30.7%). Regional differences were seen in the number of disease-modifying antirheumatic drugs (DMARD) ever taken (ON: 3.8 ± 1.4, QC: 3.1 ± 1.1, OTH: 3.3 ± 1.4; p
PubMed ID
20843910 View in PubMed
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Care gap in patients with early inflammatory arthritis with a high fracture risk identified using FRAX(®).

https://arctichealth.org/en/permalink/ahliterature141497
Source
J Rheumatol. 2010 Nov;37(11):2221-5
Publication Type
Article
Date
Nov-2010
Author
Carly K Cheng
Heather McDonald-Blumer
Gilles Boire
Janet E Pope
Boulos Haraoui
Carol A Hitchon
Carter Thorne
Ye Sun
Vivian P Bykerk
Author Affiliation
Division of Rheumatology, Mount Sinai Hospital, 60 Murray Street, 2nd floor, Toronto, Ontario M5T 3L9, Canada.
Source
J Rheumatol. 2010 Nov;37(11):2221-5
Date
Nov-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Analysis of Variance
Arthritis - complications
Body Weight
Bone Density
Canada
Chi-Square Distribution
Female
Humans
Male
Middle Aged
Osteoporosis - complications
Osteoporotic Fractures - etiology
Questionnaires
Risk assessment
Risk factors
Severity of Illness Index
Abstract
To determine the proportion of patients with early inflammatory arthritis in a Canadian cohort who are at high risk for a major osteoporotic fracture using the Fracture Risk Assessment Tool (FRAX(®)), and to determine if a care gap exists in high-risk patients.
FRAX was applied to 238 patients enrolled in the Canadian Early Arthritis Cohort (CATCH) study based on norms from the United States and the United Kingdom, without the use of bone mineral density measurements.
FRAX identified 5%-13% of patients at high risk for fracture, using a conservative analysis. Based on US norms, there was a significant correlation between increasing fracture risk groups and oral glucocorticoid use (p = 0.012) and baseline erosions (p = 0.040). Calcium or vitamin D use did not vary among the different fracture risk groups (p = NS), nor did bisphosphonate use (p = NS). The Disease Activity Score with 28 joint count in the high-risk group was significantly higher compared to the low-risk group (p = 0.048).
Patients at increased risk had higher disease activity, more frequent glucocorticoid use, and more baseline erosions compared to patients at low risk. A care gap exists, in that a very low proportion of patients at high risk are being treated with calcium, vitamin D, and/or bisphosphonates. A higher fracture risk was calculated in our cohort using the US FRAX calculation tool compared to the UK calculation tool. These data highlight the need to identify and modify fracture risk in patients with early inflammatory arthritis.
PubMed ID
20716658 View in PubMed
Less detail

Determining best practices in early rheumatoid arthritis by comparing differences in treatment at sites in the Canadian Early Arthritis Cohort.

https://arctichealth.org/en/permalink/ahliterature107248
Source
J Rheumatol. 2013 Nov;40(11):1823-30
Publication Type
Article
Date
Nov-2013
Author
Jamie A Harris
Vivian P Bykerk
Carol A Hitchon
E C Keystone
J Carter Thorne
Gilles Boire
Boulos Haraoui
Glen Hazlewood
Ashley J Bonner
Janet E Pope
Author Affiliation
From the Rheumatology Centre, St. Joseph's Health Care, London, Ontario, Canada; the Hospital for Special Surgery, New York, New York, USA; the Arthritis Centre, University of Manitoba, Winnipeg, Manitoba; the University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket, Ontario; the Faculty of Medicine and Health Sciences, Division of Rheumatology, Université de Sherbrooke, Sherbrooke, Quebec; the Rheumatic Disease Unit, Institut de Rhumatologie, Montreal, Quebec; McMaster University, Hamilton, Ontario; and Western University, London, Ontario, Canada.
Source
J Rheumatol. 2013 Nov;40(11):1823-30
Date
Nov-2013
Language
English
Publication Type
Article
Keywords
Adult
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - drug therapy
Canada
Disease Progression
Drug Therapy, Combination
Female
Humans
Male
Methotrexate - therapeutic use
Middle Aged
Practice Guidelines as Topic
Remission Induction - methods
Severity of Illness Index
Standard of Care
Treatment Outcome
Abstract
To determine site variation by comparing outcomes across sites in an early rheumatoid arthritis cohort.
Sites from the Canadian Early Arthritis Cohort database with at least 40 patients were studied. Comparisons were made among sites in change in 28-joint Disease Activity Score (DAS28), proportion of patients in DAS28 remission, and treatment strategies.
The study included 1138 baseline patients at 8 sites, with baseline (SD) age 52 years (16.9); 72% women; 23% erosions; 54% ever smokers; 51% rheumatoid factor-positive; 37% anticitrullinated protein antibody-positive; disease duration 187 (203) days; DAS28 4.5 (1.4). Site had an effect on outcomes when adjusting for confounders. At 6 and 12 months, sites B and H, the 2 largest sites, had the best changes in DAS28 (-1.82 and -2.09, respectively, at 6 mos, and -2.27 for both at 12 mos; p
PubMed ID
24037554 View in PubMed
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Early management of newly diagnosed rheumatoid arthritis by Canadian rheumatologists: a national, multicenter, retrospective cohort.

https://arctichealth.org/en/permalink/ahliterature131696
Source
J Rheumatol. 2011 Nov;38(11):2342-5
Publication Type
Article
Date
Nov-2011
Author
Ruben Tavares
Janet E Pope
Jean-Luc Tremblay
Carter Thorne
Vivian P Bykerk
Juris Lazovskis
Kenneth L N Blocka
Mary J Bell
Diane Lacaille
Carol A Hitchon
Avril A Fitzgerald
Wesley K Fidler
Arthur A M Bookman
James M Henderson
Dianne P Mosher
Dalton E Sholter
Majed Khraishi
Boulos Haraoui
Hong Chen
Xiuying Li
Andreas Laupacis
Gilles Boire
George Tomlinson
Claire Bombardier
Author Affiliation
McMaster University, Hamilton, Canada. ruben.tavares@sympatico.ca
Source
J Rheumatol. 2011 Nov;38(11):2342-5
Date
Nov-2011
Language
English
Publication Type
Article
Keywords
Adult
Antirheumatic Agents - therapeutic use
Canada - epidemiology
Cohort Studies
Disability Evaluation
Disease Management
Drug Therapy, Combination
Female
Humans
Male
Middle Aged
Outcome Assessment (Health Care)
Physician's Practice Patterns
Retrospective Studies
Rheumatic Fever - diagnosis - drug therapy - epidemiology
Severity of Illness Index
Treatment Outcome
Abstract
To describe early rheumatologic management for newly diagnosed rheumatoid arthritis (RA) in Canada.
A retrospective cohort of 339 randomly selected patients with RA diagnosed from 2001-2003 from 18 rheumatology practices was audited between 2005-2007.
The most frequent initial disease-modifying antirheumatic drugs (DMARD) included hydroxychloroquine (55.5%) and methotrexate (40.1%). Initial therapy with multiple DMARD (15.6%) or single DMARD and corticosteroid combinations (30.7%) was infrequent. Formal assessment measures were noted infrequently, including the Health Assessment Questionnaire (34.6%) and Disease Activity Score for 28 joints (8.9%).
Initial pharmacotherapy is consistent with guidelines from the period. The infrequent reporting of multiple DMARD combinations and formal assessment measures has implications for current clinical management and warrants contemporary reassessment.
Notes
Comment In: J Rheumatol. 2011 Nov;38(11):2287-922045932
PubMed ID
21885485 View in PubMed
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Effectiveness and safety of etanercept in patients with psoriatic arthritis in a Canadian clinical practice setting: the REPArE trial.

https://arctichealth.org/en/permalink/ahliterature134507
Source
J Rheumatol. 2011 Jul;38(7):1355-62
Publication Type
Article
Date
Jul-2011
Author
Dafna D Gladman
Claire Bombardier
Carter Thorne
Boulos Haraoui
Majed Khraishi
Proton Rahman
William Bensen
Jerry Syrotuik
Melanie Poulin-Costello
Author Affiliation
Toronto Western Hospital (University of Toronto) and University Health Network, Toronto, Ontario, Canada. dafna.gladman@utoronto.ca
Source
J Rheumatol. 2011 Jul;38(7):1355-62
Date
Jul-2011
Language
English
Publication Type
Article
Keywords
Adult
Antirheumatic Agents - adverse effects - therapeutic use
Arthritis, Psoriatic - drug therapy - physiopathology
Canada
Disability Evaluation
Efficiency - physiology
Fatigue - epidemiology - physiopathology
Female
Health status
Humans
Immunoglobulin G - adverse effects - therapeutic use
Incidence
Interviews as Topic
Longitudinal Studies
Male
Middle Aged
Receptors, Tumor Necrosis Factor - therapeutic use
Treatment Outcome
Tumor Necrosis Factor-alpha - antagonists & inhibitors
Abstract
To describe the longterm effectiveness and safety of etanercept in Canadian patients with psoriatic arthritis (PsA), treated over 24 months in clinical practice.
Patients with active PsA (= 3 tender and = 3 swollen joints) were recruited from 22 centers. Etanercept was administered at 50 mg/week subcutaneously. In addition to clinical assessment of skin and joint disease, conducted at baseline and at Months 6, 12, 18, and 24, regular patient interviews were conducted by telephone. Patient responses related to health status, disability, and work productivity were scored using the patient global assessment tool, the Health Assessment Questionnaire (HAQ), the Health and Labour Questionnaire (HLQ), and the Fatigue Severity Scale.
Out of 110 patients, 71 (65%) maintained etanercept treatment through the end of our study. All clinical measures of disease severity, including joint tenderness/pain, joint swelling, and Psoriasis Area and Severity Index score, improved significantly between baseline and Month 6 of etanercept treatment and remained constant thereafter. By the end of our study, 79% of patients achieved a Psoriatic Arthritis Response Criteria response, and 56% of patients achieved a 0.5-point improvement on HAQ, indicating clinically significant improvement in disability; 14% of patients finished our study free of disability (HAQ = 0). Patients' work productivity and fatigue improved significantly in parallel with these clinical and functional improvements.
Continuous treatment with etanercept over 2 years in a clinical setting improved clinical symptoms of PsA while reducing fatigue, improving work productivity, and ameliorating or eliminating disability.
PubMed ID
21572156 View in PubMed
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21 records – page 1 of 3.