H R Schumacher

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (368)1699.66 Total impact

  • H Ralph Schumacher, Joan M Von Feldt
    Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 08/2014; 20(5):241-243. · 1.19 Impact Factor
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    ABSTRACT: To evaluate the safety and efficacy of once-weekly subcutaneous rilonacept 160 mg for prevention of gout flares in patients initiating or continuing urate-lowering therapy (ULT).
    The Journal of rheumatology. 07/2014;
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    ABSTRACT: Although there has been major progress in gout imaging, no gout classification criteria currently include advanced imaging techniques.
    Annals of the rheumatic diseases. 06/2014;
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    ABSTRACT: To determine the extent to which instruments that measure core outcome domains in acute gout fulfill the Outcome Measures in Rheumatology (OMERACT) filter requirements of truth, discrimination, and feasibility. Patient-level data from 4 randomized controlled trials of agents designed to treat acute gout and 1 observational study of acute gout were analyzed. For each available measure, construct validity, test-retest reliability, within-group change using effect size, between-group change using the Kruskall-Wallis statistic, and repeated measures generalized estimating equations were assessed. Floor and ceiling effects were also assessed and minimal clinically important difference was estimated. These analyses were presented to participants at OMERACT 11 to help inform voting for possible endorsement. There was evidence for construct validity and discriminative ability for 3 measures of pain [0 to 4 Likert, 0 to 10 numeric rating scale (NRS), 0 to 100 mm visual analog scale (VAS)]. Likewise, there appears to be sufficient evidence for a 4-point Likert scale to possess construct validity and discriminative ability for physician assessment of joint swelling and joint tenderness. There was some evidence for construct validity and within-group discriminative ability for the Health Assessment Questionnaire as a measure of activity limitations, but not for discrimination between groups allocated to different treatment. There is sufficient evidence to support measures of pain (using Likert, NRS, or VAS), joint tenderness, and swelling (using Likert scale) as fulfilling the requirements of the OMERACT filter. Further research on a measure of activity limitations in acute gout clinical trials is required.
    The Journal of Rheumatology 01/2014; · 3.26 Impact Factor
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    ABSTRACT: Objective: ACR and EULAR guidelines recommend colchicine to prevent gout flares in patients initiating and increasing uric acid lowering therapy until serum uric acid is maintained at ≤ 6 mg/dL. We aimed to evaluate how well colchicine prescribing practices adhere to these guidelines and examine factors associated with improved prescribing. Methods: Electronic medical records were reviewed for 126 patients with active colchicine prescriptions for prophylaxis of gout flares. Colchicine prescribing was defined as inappropriate if 1) no concurrent urate lowering therapy was prescribed, 2) uric acid was not at goal and urate lowering therapy had not been increased in the past 3 months, or 3) uric acid goals were met for > 1 year and flares had resolved in the absence of tophi. Results: Colchicine use was considered inappropriate in 93 (73.8%) patients. 34 were prescribed no urate lowering therapy, 50 were above uric acid goal without urate lowering therapy increase in the prior 3 months, and 9 were at uric acid goal for more than one year without flares or tophi. Patients appropriately prescribed colchicine were younger and were more likely to have been seen by Rheumatology. Allopurinol dose and allergy, uric acid level, and renal function were similar in the two groups. Conclusion: We found a high prevalence of what we considered inappropriate prophylactic colchicine use, driven largely by failure to prescribe concurrent urate lowering therapies or adequately increase these medications. Rheumatology consultation was associated with improved colchicine prescribing. © 2013 American College of Rheumatology.
    Arthritis care & research. 12/2013;
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    ABSTRACT: To determine the extent to which participants at the Outcome Measures in Rheumatology (OMERACT) 11 meeting agree that instruments used in clinical trials to measure OMERACT core outcome domains in acute gout fulfill OMERACT filter requirements of truth, discrimination, and feasibility; and where future research efforts need to be directed. Results of a systematic literature review and analysis of individual-level data from recent clinical studies of acute gout were presented to OMERACT participants. The information was discussed in breakout groups, and opinion was defined by subsequent voting in a plenary session. Endorsement was defined as at least 70% of participants voting in agreement with the proposition (where the denominator excluded those participants who did not vote or who voted "don't know"). The following measures were endorsed for use in clinical trials of acute gout: (1) 5-point Likert scale and/or visual analog scale (0 to 100 mm) to measure pain; (2) 4-point Likert scale for joint swelling; (3) 4-point Likert scale for joint tenderness; and (4) 5-point Likert scale for patient global assessment of response to treatment. Measures for the activity limitations domain were not endorsed. Measures of pain, joint swelling, joint tenderness, and patient global assessment in acute gout were endorsed at OMERACT 11. These measures should now be used in clinical trials of acute gout.
    The Journal of Rheumatology 12/2013; · 3.26 Impact Factor
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    ABSTRACT: Abstract Objectives: To describe histological, immunohistochemical and ultrastructural features of synovial biopsies of amyloid arthropathy associated with multiple myeloma (MM). Methods: Synovial biopsies from affected joints of two patients with MM and amyloid arthropathy were examined with light and electron microscopy, and immunohistochemically for expression of CD3, CD8, CD20, CD38, CD68, Ki-67 and vWF. Results were compared to values from osteoarthritis (OA, n = 26), rheumatoid arthritis (RA, n = 24) and normal (n = 15) synovial membranes. Results: There was no or only mild lining hyperplasia. Vascular density was not elevated, and there were few Ki-67+ proliferating cells in the stroma. The Krenn synovitis score classified one specimen as "low-grade" and one as "high-grade" synovitis. CD68+ and CD3+ cells were the predominant mononuclear inflammatory cells, whereas CD20+ and CD38+ cells were absent from both synovial membrane and synovial fluid sediment. Electron microscopy demonstrated amyloid phagocytosis by synovial macrophages. In hierarchical clustering the two amyloid arthropathy specimens were more closely related to OA than to RA or normal synovium. Conclusions: This first detailed immunohistological analysis of MM-associated amyloid arthropathy suggests that it is a chronic synovitis that evolves despite the loss of humoral immunity seen in advanced MM. Instead, amyloid phagocytosis by synovial macrophages likely triggers and perpetuates local disease.
    Amyloid: the international journal of experimental and clinical investigation: the official journal of the International Society of Amyloidosis 11/2013; · 2.51 Impact Factor
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    ABSTRACT: Amyloid deposition in multiple myeloma (MM) may lead to an arthropathy resembling rheumatoid arthritis (RA). Since a systematic description of its natural history is lacking, we have performed a systematic analysis of all published cases. Literature review featuring backward and forward database searches and direct inspection of reference lists. Inclusion criteria were as follows: publication between 1931 and 2012, diagnosis of multiple myeloma, and demonstration of light chain amyloid (AL) in any organ or in synovial fluid, arthritis, or synovitis. Overall, 101 cases were identified. Median age was 59 years and the male-to-female ratio was 1:1. A systemic manifestation of MM was reported in 88 cases. In 53 of these, characteristic physical findings (carpal tunnel syndrome, macroglossia, shoulder pad, and soft tissue swelling/masses) were present. Arthritis manifested before the diagnosis of MM in 63 cases, with 33 cases initially misdiagnosed as RA. There were 72 cases of poly-, 17 of oligo-, and three of monoarthritis. The shoulder joint was most commonly affected, followed by small hand joints. Median synovial fluid leukocyte count was 2460 cells/mm(3), and was normal in seven cases. Synovial histopathology often featured mild synovitis without plasma cell infiltration. Imaging revealed articular or periarticular inflammation in many cases and bone lesions near 22% of affected joints. Treatments varied but led to some improvement in the majority of cases. These results solidify previous experience that MM arthropathy tends to feature a symmetric RF-negative nonerosive polyarthritis. However, the results also highlight the diversity of its presentations and stress the importance of arthropathy as a potentially under-recognized presenting manifestation of MM.
    Seminars in arthritis and rheumatism 08/2013; · 4.72 Impact Factor
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    ABSTRACT: Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study. The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT). This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray-confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese "Bi" syndrome approach to knee pain, using either standard needles or Streitberger non-skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks. Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age. Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.
    Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 08/2013; · 1.19 Impact Factor
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    ABSTRACT: This study aims to investigate the disease-related knowledge of gout patients and doctors in south China and to identify the important targets of education for patients and doctors. A cross-section survey of 154 primary gout patients and 185 doctors who may see gout patients was conducted with a modified questionnaire with ten items of gout-related knowledge. The participants were considered to have gout-related knowledge if he or she correctly answered seven or more items. One hundred and forty-nine valid questionnaires from patients, 33 from rheumatology physicians, and 151 from non-rheumatology doctors were collected for statistical analysis. The mean correctly answered items of three groups were 6.6 ± 2.2, 9.6 ± 0.53, and 8.0 ± 1.4, with rate of being considered to have knowledge about gout 51.7, 100, and 90.1 %, respectively (P < 0.05). The correct answer rate for each particular item was over 80 % in the rheumatology physician group. Patients or non-rheumatology doctors knew the optimal serum uric acid (sUA) level (48.3 vs 55.6 %), the need to take lifelong urate-lowering drugs (29.5 vs 43.6 %), that allopurinol is a urate-lowering drug (55.7 vs 76.0 %), and how to prevent attacks induced by urate-lowering therapy (ULT) (60.4 vs 74.0 %). Logistic regression showed that higher education predicted which patients had gout-related knowledge. Both the gout patients and non-rheumatology doctors in south China had poor knowledge on ULT. Since many gout patients do not see rheumatologists, our data suggest that further education should focus on patients and non-rheumatologists and emphasize the use of urate-lowering drugs, treatment duration, the target sUA level, and prophylaxis against acute attacks.
    Clinical Rheumatology 07/2013; · 2.04 Impact Factor
  • Ashwini Komarla, H Ralph Schumacher, Peter A Merkel
    Arthritis & Rheumatology 07/2013; · 7.48 Impact Factor
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    ABSTRACT: OBJECTIVE: To assess the efficacy of tart cherry juice in treating pain and other features of knee osteoarthritis (OA). METHODS: 58 non-diabetic patients with Kellgren grade 2-3 OA were randomized to begin treatment with cherry juice or placebo. Two 8 oz bottles of tart cherry juice or placebo were consumed daily for 6 weeks with a 1 week washout period before switching treatments (crossover design). Western Ontario McMaster Osteoarthritis Index (WOMAC) scores and walking times were recorded prior to and after each treatment period. Additionally, plasma urate, creatinine and high sensitivity C-reactive protein (hsCRP) were recorded at baseline, after the first treatment period and after the second treatment period. Acetaminophen was allowed as a rescue drug and self reported after each treatment period. Treatment effect was examined with repeated measures ANOVA using an intention-to-treat analysis. RESULTS: There were 5 withdrawals during the cherry juice treatment (4 adverse events) and 7 withdrawals during the placebo treatment (3 adverse events). WOMAC scores decreased significantly (P<0.01) after the cherry juice treatment but not after the placebo treatment (P=0.46); differences between treatments were not significant (P=0.16). hsCRP declined during the cherry juice treatment versus placebo (P<0.01). The decline in hsCRP was associated with WOMAC improvement (P<0.01). Walking time, acetominophen use, plasma urate and creatnine were unaffected by treatments. CONCLUSIONS: Tart cherry juice provided symptom relief for patients with mild to moderate knee OA, but this effect was not significantly greater than placebo. Tart cherry juice lowered hsCRP levels and this effect was associated with improved WOMAC scores.
    Osteoarthritis and Cartilage 05/2013; · 4.26 Impact Factor
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    ABSTRACT: Objective: Web-based patient education materials and printed pamphlets are frequently used by providers to inform patients about their rheumatic disease. Little attention has been given to the readability and appropriateness of patient materials. The objective of this study was to examine the readability and suitability of commonly used patient education materials for osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and vasculitis. Methods: Five or six popular patient resources for each disease were chosen for evaluation. Readability was measured using the Flesch-Kincaid Reading Grade Level and suitability was determined by the Suitability Assessment of Materials (SAM), a score that considers characteristics such as content, graphics, layout/topography, and cultural appropriateness. Three different reviewers rated the SAM score and means were used in the analysis. Results: Twenty-three resources written on the four diseases were evaluated. The education material for all four diseases studied had readability above the 8(th) grade level and readability did not differ among the diseases. Only 5 of the 23 resources received superior suitability scores and three of these five resources were written for OA. All four diseases received adequate suitability scores with OA have the highest mean suitability score. Conclusion: Most patient education materials for rheumatic diseases are written at readability levels above the recommended sixth-grade reading level and have only adequate suitability. Developing more appropriate educational resources for patients with rheumatic diseases may improve patient comprehension. © 2013 American College of Rheumatology.
    Arthritis care & research. 05/2013;
  • H Ralph Schumacher
    Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 05/2013; · 1.19 Impact Factor
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    ABSTRACT: The definitive classification or diagnosis of gout normally relies upon the identification of MSU crystals in SF or from tophi. Where microscopic examination of SF is not available or is impractical, the best approach may differ depending upon the context. For many types of research, clinical classification criteria are necessary. The increasing prevalence of gout, advances in therapeutics and the development of international research collaborations to understand the impact, mechanisms and optimal treatment of this condition emphasize the need for accurate and uniform classification criteria for gout. Five clinical classification criteria for gout currently exist. However, none of the currently available criteria has been adequately validated. An international project is currently under way to develop new validated gout classification criteria. These criteria will be an essential step forward to advance the research agenda in the modern era of gout management.
    Rheumatology (Oxford, England) 04/2013; · 4.24 Impact Factor
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    ABSTRACT: Objective. To evaluate the efficacy and safety of IL-1 inhibitor rilonacept (IL-1 Trap) for gout flare (GF) prevention during initiation of uric acid-lowering therapy (ULT) with allopurinol in a multiregional phase 3 clinical trial.Methods. Hyperuricaemic adults (n = 248) from South Africa, Germany and Asia with gout and two or more GFs within the past year were initiated on allopurinol and randomized 1:1:1 to once-weekly s.c. treatment with placebo (PBO), rilonacept 80 mg (R80) or rilonacept 160 mg (R160) for 16 weeks. The primary endpoint was the number of GFs per patient through week 16.Results. The population was predominantly male and racially diverse (white, 53.2%; Asian, 33.1%; black, 13.7%). Across treatments, most patients completed the study (87.8-92.9%). At 16 weeks the mean number of GFs per patient was reduced by 71.3% with R80 (0.35) and by 72.6% with R160 (0.34) relative to PBO (1.23; both P < 0.0001). The proportion of patients without GFs was higher with R80 (74.4%) and R160 (79.5%) than with PBO (43.9%; both P ≤ 0.0001), and the proportions of patients on rilonacept with multiple GFs were significantly lower (P < 0.001). Overall, the incidence of adverse events (AEs) was similar between PBO (61.0%) and rilonacept (65.1%). Injection site reactions, generally mild, were the most frequent AE with rilonacept (1.2% PBO, 12.2% R80 and 17.9% R160); none of these injection site reactions led to withdrawal. There were no study drug-related serious AEs or deaths.Conclusion. Rilonacept significantly reduced the occurrence of GFs associated with initiation of ULT, with >70% of patients having no flares, and demonstrated an acceptable safety and tolerability profile.Trial registration: ClinicalTrials.gov, http://clinicaltrials.gov/, NCT00958438.
    Rheumatology (Oxford, England) 03/2013; · 4.24 Impact Factor
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    ABSTRACT: OBJECTIVE: To identify a comprehensive list of features that might discriminate between gout and other rheumatic musculoskeletal conditions, to be used subsequently for a case-control study to develop and test new classification criteria for gout. METHODS: Two Delphi exercises were conducted using Web-based questionnaires: one with physicians from several countries who had an interest in gout and one with patients from New Zealand who had gout. Physicians rated a list of potentially discriminating features that were identified by literature review and expert opinion, and patients rated a list of features that they generated themselves. Agreement was defined by the RAND/UCLA disagreement index. RESULTS: Forty-four experienced physicians and 9 patients responded to all iterations. For physicians, 71 items were identified by literature review and 15 more were suggested by physicians. The physician survey showed agreement for 26 discriminatory features and 15 as not discriminatory. The patients identified 46 features of gout, for which there was agreement on 25 items as being discriminatory and 7 items as not discriminatory. CONCLUSION: Patients and physicians agreed upon several key features of gout. Physicians emphasized objective findings, imaging, and patterns of symptoms, whereas patients emphasized severity, functional results, and idiographic perception of symptoms.
    The Journal of Rheumatology 02/2013; · 3.26 Impact Factor
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    ABSTRACT: INTRODUCTION: In phase-3 clinical trials, the interleukin (IL-1) blocker, rilonacept (IL-1 Trap), demonstrated efficacy for gout flare prevention during initiation of urate-lowering therapy. This trial evaluated rilonacept added to a standard-of-care, indomethacin, for treatment of acute gout flares. METHODS: Adults, aged 18-70 years, with gout presenting within 48 hours of flare onset and having at least moderate pain as well as swelling and tenderness in the index joint were randomized to subcutaneous (SC) rilonacept 320 mg at baseline plus oral indomethacin 50 mg TID for 3 days followed by 25 mg TID for up to 9 days (n=74); SC placebo at baseline plus oral indomethacin as above (n=76); or SC rilonacept 320 mg at baseline plus oral placebo (n=75). The primary efficacy endpoint was change in pain in the index joint (patient-reported using a Likert scale [0=none; 4=extreme]) from baseline to the average of values at 24, 48 and 72 hours (composite time-point) for rilonacept plus indomethacin versus indomethacin alone. Comparison of rilonacept monotherapy with indomethacin monotherapy was dependent on demonstration of significance for the primary endpoint. Safety evaluation included clinical laboratory and adverse event (AE) assessments. RESULTS: Patient characteristics were comparable among the groups; the population was predominantly male (94.1%), white (75.7%), with mean +/- SD age of 50.3+/-10.6 years. All treatment groups reported within-group pain reductions from baseline (P<0.0001). Although primary endpoint pain reduction was greater with rilonacept plus indomethacin ( 1.55+/-0.92) relative to indomethacin alone (-1.40+/-0.96), the difference was not statistically significant (P=0.33), so formal comparison between monotherapy groups was not performed. Pain reduction over the 72-hour period with rilonacept alone (-0.69+/-0.97) was less than that in the other groups, but pain reduction was similar among groups at 72 hours. Treatment with rilonacept was well-tolerated with no reported serious AEs related to rilonacept. Across all groups, the most frequent AEs were headache and dizziness. CONCLUSIONS: Although generally well-tolerated, rilonacept in combination with indomethacin and rilonacept alone did not provide additional pain relief over 72 hours relative to indomethacin alone in patients with acute gout flare. Trial registration: ClinicalTrials.gov registration number NCT00855920).
    Arthritis research & therapy 02/2013; 15(1):R25. · 4.27 Impact Factor
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    Philip C Robinson, H Ralph Schumacher
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    ABSTRACT: Patient education is an important aspect of gout management, but there is evidence that many patients lack adequate knowledge of their condition. Our aim was to examine the characteristics of gout patient education resources. Ten gout patient information resources were examined for readability (Flesch-Kincaid reading level, the Simple Measure of Gobbledygook measure and the Flesch Reading Ease Score), qualitative characteristics such as figure and jargon use and whether they included information on the major points of gout. The median readability grade level of the examined resources was 8.5. The difference in readability grade level between the highest and the lowest education resource was 6.3 grade levels. The information content of the resources was high with an average of only 3.9 proposed criteria of 19 (19 %) absent from the resources. Jargon use was low and concepts were usually explained. However, important information regarding acute flare prophylaxis during urate-lowering therapy initiation and titration and treating serum uric acid to target was absent from 60 % of the patient education resources. There was poor use of key messages at the start. Gout patient resources have a wide range of readability. Thirty percent of resources were above the average reading level of rheumatology outpatients reported in previous studies. Sixty percent of gout patient resources omit education items that could impact on patient adherence and in turn patient outcomes. Further research is needed into the literacy levels and education requirements of patients with gout.
    Clinical Rheumatology 01/2013; · 2.04 Impact Factor
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    ABSTRACT: Traditionally, differences in absolute numbers of cells expressing a certain marker (e.g., positive staining cells per mm(2)) have been used in immunohistological synovial tissue classification. We have begun to evaluate the relative composition of the inflammatory infiltrates, i.e. percentages of inflammatory cell types in inflammatory infiltrates, as an alternate classification tool that may potentially improve tissue diagnostics, subgrouping in clinical trials, and understanding of pathogenesis of inflammatory and noninflammatory arthropathies. Synovial tissue specimens (normal synovium, n=15; orthopedic arthropathies, n=6; osteoarthritis, n=26; early undifferentiated arthritis, n=10; rheumatoid arthritis, n=26; chronic septic arthritis, n=11) were stained for CD15, CD68, CD3, CD20, and CD38. Densities of cells expressing a given marker were determined in the superficial subintima. Binary and multicategory receiver operating characteristic (ROC) analysis and naïve Bayes classifier were used to compare the abilities of (1) the absolute densities of cells expressing a given marker (absolute method) with (2) the percentages of these cells in the inflammatory cell population (relative method) to differentiate among the six tissue classes. The inflammatory infiltrates in normal synovium and the orthopedic arthropathies consisted almost exclusively of CD68+ and CD3+ cells. Notable fractions of CD20+ and CD38+ cells appeared in a subset of osteoarthritis samples, and increased further in early, rheumatoid and chronic septic arthritis. ROC analyses and naïve Bayes classifier ranked the absolute method above the relative method in terms of overall discriminatory ability. The relative method became slightly superior when the samples were also stratified according to the total number of inflammatory cells/mm(2). This exploratory investigation featuring a variety of joint disorders revealed that measuring the relative proportions of inflammatory cell types may aid in synovial tissue classification if the samples are also stratified according to the intensity of inflammation.
    PLoS ONE 01/2013; 8(8):e72494. · 3.73 Impact Factor

Publication Stats

8k Citations
1,699.66 Total Impact Points

Institutions

  • 1978–2014
    • University of Pennsylvania
      • • Division of Rheumatology
      • • Department of Medicine
      Philadelphia, Pennsylvania, United States
  • 2013
    • Lenox Hill Hospital
      New York City, New York, United States
    • University of Queensland
      Brisbane, Queensland, Australia
    • Sun Yat-Sen University
      • Department of Rheumatology
      Guangzhou, Guangdong Sheng, China
    • Sohag University
      Sawhāj, Sūhāj, Egypt
  • 2011–2013
    • Helmholtz Centre for Infection Research
      • Department of Infection Genetics (INFG)
      Brunswyck, Lower Saxony, Germany
    • University of Alabama at Birmingham
      • Department of Medicine
      Birmingham, AL, United States
    • University of Otago
      • Department of Medicine (Dunedin)
      Dunedin, Otago, New Zealand
    • University of Auckland
      • Department of Medicine
      Auckland, Auckland, New Zealand
  • 2004–2013
    • Philadelphia University
      Philadelphia, Pennsylvania, United States
    • University of Cincinnati
      Cincinnati, Ohio, United States
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
    • University of Minnesota Twin Cities
      Minneapolis, Minnesota, United States
  • 2012
    • Cleveland Clinic
      Cleveland, Ohio, United States
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2011–2012
    • University of Alabama
      • Center for Mental Health and Aging
      Tuscaloosa, AL, United States
    • Shanxi Medical University
      Yangkü, Shanxi Sheng, China
  • 1972–2011
    • Hospital of the University of Pennsylvania
      • • Department of General Internal Medicine
      • • Division of Rheumatology
      • • Department of Medicine
      Philadelphia, Pennsylvania, United States
  • 1999–2010
    • Wayne State University
      • • Department of Immunology and Microbiology
      • • School of Medicine
      Detroit, MI, United States
  • 2009
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 2008
    • Technische Universität Dresden
      • Klinik und Poliklinik für Kinder- und Jugendmedizin
      Dresden, Saxony, Germany
  • 1992–2008
    • The Children's Hospital of Philadelphia
      • • Division of Rheumatology
      • • Department of Pediatrics
      • • Department of Pathology and Laboratory Medicine
      Philadelphia, PA, United States
  • 2007
    • Geisinger Medical Center
      Danville, Pennsylvania, United States
  • 1996–2007
    • Emory University
      • • Department of Psychiatry and Behavioral Sciences
      • • Department of Internal Medicine
      Atlanta, GA, United States
  • 2006
    • University of Florida
      Gainesville, Florida, United States
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
    • Cooper Hospital
      United States
  • 2005–2006
    • University of Chicago
      • Pritzker School of Medicine
      Chicago, Illinois, United States
    • Spokane VA Medical Center
      Spokane, Washington, United States
    • Rush University Medical Center
      Chicago, Illinois, United States
    • Oregon Health and Science University
      Portland, Oregon, United States
    • Long Island University
      • Division of Pharmaceutics and Industrial Pharmacy
      New York City, NY, United States
  • 1999–2006
    • Rutgers New Jersey Medical School
      • Department of Medicine (RWJ Medical School)
      Newark, NJ, United States
  • 2002
    • University of Santo Tomas Hospital
      Manila, National Capital Region, Philippines
  • 2000
    • The University of the Arts in Philadelphia
      Philadelphia, Pennsylvania, United States
    • University of Toronto
      • Department of Medicine
      Toronto, Ontario, Canada
  • 1998–1999
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
    • Allegheny University
      Philadelphia, Pennsylvania, United States
  • 1997–1999
    • National Institutes of Health
      • National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
      Bethesda, MD, United States
    • Sheba Medical Center
      Gan, Tel Aviv, Israel
  • 1993
    • Penn State Hershey Medical Center and Penn State College of Medicine
      • Pediatrics
      Hershey, PA, United States
  • 1988
    • University of British Columbia - Vancouver
      • Department of Medicine
      Vancouver, British Columbia, Canada