Alexandra Balbir-Gurman

Rambam Medical Center, H̱efa, Haifa District, Israel

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Publications (70)174.37 Total impact

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    ABSTRACT: The objective of the study was to combine ultrasonographic (US) with clinical findings for comparing the effect of adalimumab (ADA) to methotrexate (MTX) on the thickness of tendons and enthesis in psoriatic arthritis (PsA) patients. Forty-three consecutive PsA patients were examined at baseline and after 6 and 12 weeks of treatment with ADA or MTX. The US assessment included thickness measurement of the extensor (ET) and flexor tendons (FT) of the second and third finger of both hands, plantar aponeurosis (PA) and the Achilles tendon (AT) bilaterally. Disease activity (DA) was assessed by the number of tender (TJ) and swollen joints (SJ), the number of inflamed enthesis (IE), pain assessment (PAI), and patient (PDAI) and physician (PHDAI) disease activity evaluations by visual activity score (VAS). Nineteen patients received MTX and 24 patients received ADA. All DA parameters improved in both groups. A decrease in thickness of tendons and enthesis was observed only in the ADA group, reaching a level of significance for the left AT (p = 0.01), left PA (p = 0.007), the second left FT (p = 0.04) and the third ET (p = 0.04). ADA patients showed a trend towards a better response to treatment compared to MTX patients that reach significance at week 6 of treatment for the thickness of left AT (p = 0.04), left PA (p = 0.03), the number of TJ (p = 0.0136), PAI (p = 0.0028), and PDAI (p = 0.029). ADA treatment for PsA compared to MTX significantly improved signs of DA and several US parameters. US assessment of enthesis can be an additional useful tool in the monitoring of psoriatic enthesopathy.
    Clinical rheumatology. 07/2014;
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    ABSTRACT: Rituximab is a monoclonal antibody directed against the CD20 antigen on the surface of normal and malignant B lymphocytes. Its use in autoimmune conditions is rapidly expanding. Late-onset neutropenia (LON) is a well-recognized side effect of rituximab therapy in lymphoma patients. Only a small number of cases of LON have been reported in patients with autoimmune disorders. The aim of this work is to review cases in Israel and to compare them to published cases in the literature thus adding to the body of knowledge regarding this unusual phenomenon. Members of the Israeli Rheumatology Association were encountered by e-mail, requesting reports of cases of LON after therapy with rituximab. Submitted cases were reviewed, with demographics and clinical data collated and tabled. Current cases were compared to previously published rheumatology cases. Twelve episodes of LON following rituximab therapy were reported. All patients were female with an average age of 50 years (range 22-78). LON occurred at an average of 155 days after therapy (range 71-330). The average leukocyte count was1,456 white cells, with an average of 413 neutrophils (range 0-1,170 neutrophils). Three of the patients underwent bone marrow biopsies which showed white cell line maturation arrest with an increased number of lymphocytes. No blasts were seen. Our results add support to the growing evidence that this adverse event usually follows a benign course and is not an absolute contraindication for repeat treatment if required in the future. However, vigilance is recommended with routine periodic blood counts, especially 5 months following rituximab administration when the risk is expected to be the highest.
    Clinical Rheumatology 03/2014; · 2.04 Impact Factor
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    ABSTRACT: A 44-year-old woman diagnosed with dermatomyositis 5 years ago based on progressive proximal muscle weakness, elevated creatine kinase, typical findings on electromyography and muscle biopsy. Despite the treatment, in contrast to improvement in her muscle symptoms, the heliotrope rash of her eyelids persisted. After several years, the patient developed multiple limited skin retraction lesions with hyperpigmentation on both lower limbs. Palpation of these lesions revealed dry, cold and very firm skin on both thighs and calves, particularly in the distal areas. X-ray and ultrasound imaging of the calves showed multiple subcutaneous calcifications in the distal muscles.
    BMJ case reports. 01/2014; 2014.
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    ABSTRACT: Infusions of aminobisphonates (ABP) activate Vγ9δ2T cells in vivo and induce an acute inflammatory response in 30% of patients treated for osteoporosis. Following the observation of digital thrombosis in a systemic sclerosis (SSc) patient after treatment with an intravenous ABP, zoledronate (Zol), we evaluated whether patient and control peripheral blood (PB) mononuclear cell (MC, PBMC) acquire a prothrombotic phenotype in response to Zol.
    Frontiers in Immunology 01/2014; 5:414.
  • The Israel Medical Association journal: IMAJ 08/2013; 15(8):453-5. · 0.98 Impact Factor
  • The Israel Medical Association journal: IMAJ 04/2013; 15(4):195-7. · 0.98 Impact Factor
  • Ap Rozin, R Hoffman, T Hayek, A Balbir-Gurman
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    ABSTRACT: Felty's syndrome (FS) is characterized by neutropenia and splenomegaly in patients with seropositive (RF+, anti-CCP+) rheumatoid arthritis (RA). As a result of neutropenia, affected persons are increasingly susceptible to infections. In the majority of patients, FS appears in the course of long-standing and well-established RA. Manifestations of FS without clinical but only with laboratory features of RA are extremely rare. We present a case of severe neutropenia and mild splenomegaly in a patient with high titers of RF and anti-CCP. For 4 years, patient's neutropenia remained asymptomatic. The neutropenia reduction to agranulocytosis was followed by successful methotrexate-corticosteroid therapy. Efficacy of the standard anti-RA therapy confirmed autoimmune mechanism of the Felty's neutropenia. The most important lesion from our case is to recognize this condition in the range of autoimmune rheumatic diseases without delay. We reviewed literature with non-articular FS.
    Clinical Rheumatology 01/2013; · 2.04 Impact Factor
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    ABSTRACT: Rituximab (RTX) is a chimeric anti-CD20 antibody, approved for rheumatoid arthritis (RA) patients who failed anti-Tumor Necrosis Factor therapy. It has been used occasionally for life-threatening autoimmune diseases (AID). We report our center experience in the use of RTX in life-threatening complications or refractory AID. Clinical charts of patients treated with RTX at our center were reviewed, cases treated for life-threatening complications or refractory AID were analyzed. Acute damage to vital organs such as lung, heart, kidney, nervous system with severe functional impairment were defined as life-threatening complications; treatment failure with high-dose corticosteroids, cyclophosphamide, IVIG, plasmapheresis was defined as refractory autoimmune disease. During the years 2003-2009, 117 patients were treated with RTX, most of them for RA. Nine patients (6 females, mean age 51.5 years, mean disease duration 6.3 years) answered the criteria. The indications were as follows: pulmonary hemorrhage (1 patient with cryoglobulinemic vasculitis, 1 with systemic sclerosis, 1 with ANCA-associated vasculitis), catastrophic anti-phospholipid syndrome (2 SLE patients), non-bacterial endocarditis and pulmonary hypertension (1 patient with mixed connective tissue disease), vasculitis and feet necrosis (1 patient with systemic lupus erythematosus), severe lupus demyelinative neuropathy and acute renal failure (1patient), and severe rheumatoid lung disease with recurrent empyema and pneumothorax (1patient). B cell depletion was achieved in all patients. The median time since starting of complications to RTX administration was 3 weeks (range 2-15 weeks). Complete remission (suppression of the hazardous situation and return to previous stable state) was seen in 7 out of 9 patients. Partial remission (significant improvement) was achieved in the remained. The median time to response was 3 weeks (range 1-8 weeks), mean follow-up 47.2 months (range 6-60 months). A rapid tapering off of steroids was achieved in all patients. Two patients relapsed and were successfully retreated with RTX: the patient with severe RA lung relapsed after 3 years, one of the patients with ANCA-associated pulmonary alveolar hemorrhage relapsed after 10 months. There were no side effects during RTX infusion. Two episodes of serious infections were registered: fatal Gram-negative sepsis 6 months after RTX treatment, and septic discitis 4 months after receiving RTX. RTX serves as a safe, efficient, and prompt rescue therapy in certain life-threatening conditions and resistant to aggressive immunosuppression AID. RTX when administrated at an earlier stage, prevented irreversible vital organ damage, and allowed rapid steroid tapering off in already severe immunodepressed patients.
    Rheumatology International 12/2012; · 2.21 Impact Factor
  • Alexandra Balbir-Gurman, Yolanda Braun-Moscovici
    The Israel Medical Association journal: IMAJ 12/2012; 14(12):757-9. · 0.98 Impact Factor
  • Alexander P Rozin, Kohava Toledano, Alexandra Balbir-Gurman
    The Journal of Rheumatology 12/2012; 39(12):2361. · 3.26 Impact Factor
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    ABSTRACT: OBJECTIVE: To assess the association between treatment with anti-tumor necrosis factor-α (TNF-α) agents and the occurrence of hospitalizations, their causes and complications, compared to treatment with traditional disease-modifying antirheumatic drugs in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). METHODS: A retrospective cohort study was conducted of patients with RA, AS, and PsA treated with anti-TNF-α agents between April 2002 and December 2007. Patients were assessed during the period of anti-TNF-α treatment (Group B) and compared to an equivalent period before initiation of anti-TNF-α therapy (Group A). All hospitalization charts were reviewed and diagnoses, comorbidities, concomitant medications, and clinical course were analyzed. Statistical analysis was performed using multivariate mixed Poisson regression. RESULTS: In the study period of 57 months, 735 hospitalization events of 327 patients were analyzed. Statistically significant decreases were seen in the total number of hospitalization events as well as hospitalizations due to exacerbation of rheumatic diseases in Group B compared to Group A (44.4 vs 74.2 and 21.9 vs 47.5 per 100 patient-years, respectively; p < 0.0001). More infectious events (7.4 in Group B compared to 4.6 per 100 patient-years in Group A; p = 0.043) were associated with anti-TNF-α treatment, older age, and underlying disease, because patients with RA had higher rates of infections compared to patients with PsA and patients with AS. CONCLUSION: The overall effect of anti-TNF-α therapy was a significant decline in total hospitalization events. The decrease was more prominent in patients with RA than in patients with AS and patients with PsA, and reflected the significant decrease in hospitalizations due to rheumatic disease exacerbation. The decrease was more pronounced than the observed increase in infectious events.
    The Journal of Rheumatology 10/2012; · 3.26 Impact Factor
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    ABSTRACT: Background: The aim of this study was to evaluate the effect of auto-immune diseases (AI) as well as anti TNF-α therapy on the clinical and immunological parameters of the periodontium. Methods: 36 AI patients [12 Rheumatoid arthritis (RA), 12 Psoriatic arthritis (PA) & 12 Systemic sclerosis (SSc)], were recruited together with 12 healthy (H) and 10 RA patients receiving anti TNF-α therapy (RA+). Periodontal indices including plaque index (PI), gingival index (GI), probing depth (PD), and bleeding on probing (BOP) were measured and gingival crevicular fluid (GCF) was collected from five deepest pockets using papers strips. The TNF-α level was analyzed using Enzyme-Linked Immunosorbent Assay (ELISA). ANOVA test was used for statistical comparison between groups while Pearson's linear correlation coefficient test was used to examine the association between TNF-α and periodontal status indices. Results: The three AI sub-groups were very similar in clinical and immunological parameters. GI was greater in the AI patients compared to the H and RA+ groups (1.91±0.54, 1.21±0.67, 1.45±0.30 respectively, p=0.0005). AI patients exhibited significantly more BOP than H and RA+ (46.45±17.08%, 30.08±16.86% and 21.13±9.51%; respectively, p=0.0002). PD in H and RA+ groups were lower than in the AI (3.47±0.33mm, 3.22±0.41mm, 3.91±0.49mm; p=0.0001). Number of sited with PD above 4 mm was higher in AI patients compared to H and RA+ (42.44±17.5 versus 24.33±15.62 versus 33.3±6.6, p=0.0002). GCF's TNF-α were higher amongst the AI patients (1.67±0.58 ng/site) compared to 1.07±0.33 ng/site for the H and 0.97±0.52 ng/site for the RA+ (p=0.0002). A significant positive correlation was found between PD and TNF-α levels in the GCF (r=0.4672, p=0.0002), BOP (r=0.7491, p=0.0001) and GI (r=0.5420, p=0.0001). Conclusion: Patients with AI diseases have higher periodontal indices & GCF TNF-α than healthy controls. Anti-TNF-α treatment appears to reverse this phenomenon.
    Journal of Periodontology 04/2012; · 2.40 Impact Factor
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    ABSTRACT: Pneumatosis cystoides intestinalis (PCI) is a rare life-threatening gastrointestinal complication in the course of connective tissue disease (CTD). PCI is characterised by the appearance of intramural clusters of gas in the small and large bowel wall on X-ray or computed tomography and often is accompanied by free air in the peritoneal cavity. We present three cases of PCI in patients with scleroderma-related conditions. A review of the English language literature published on MEDLINE from 1973 to 2008 was conducted using the terms: 'systemic sclerosis', 'connective tissue disease' and 'pneumatosis cystoides intestinalis'. This review focused on clinical features, diagnostic and treatment strategies of PCI in the context of CTD. Symptoms of PCI are non-specific: abdominal pain, vomiting, constipation, bloating and weight loss. Coexistence of PCI with other manifestations of CTD, such as intestinal pseudo-obstruction and/or bacterial overgrowth, complicates the clinical diagnosis. Treatment approach to PCI is mostly conservative: intestinal 'rest', parenteral nutrition, antibiotics, fluids and electrolyte supplementation, and inhaled oxygen. Surgical intervention should be performed only in cases of bowel perforation, ischaemia or necrosis. Patients with PCI have high mortality rates due to PCI itself but also to the severity and variety of basic CTD complications. Recognition of PCI, particularly in the context of underlying CTD, is necessary for proper therapeutic application. In patients with underlying CTD and symptoms of abdominal emergency, recruitment of multidisciplinary teams, including rheumatologist, gastroenterologist, imaging specialist and surgeons familiar with intestinal complications of CTD-related conditions, is warranted.
    Internal Medicine Journal 03/2012; 42(3):323-9. · 1.82 Impact Factor
  • Alexandra Balbir-Gurman, Yolanda Braun-Moscovici
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    ABSTRACT: Systemic sclerosis (SSc) is a multisystem disease with a variable clinical course and a poor prognosis corresponding to extent of microangiopathy and skin and internal organ fibrosis. Microvascular damage provokes immune cells to produce autoantibodies, pro-inflammatory and pro-fibrotic cytokines and chemokines. The hallmark of SSc is excessive collagen production by activated fibroblasts and myofibroblasts, and its accumulation in skin and internal organs. Better understanding of SSc pathogenesis resulted in the development of drugs, such as prostanoids, endothelin-1 and phosphodiesterase inhibitors, for treatment of pulmonary arterial hypertension and digital ulcers. The use of biological therapies and anti-fibrotic agents is under investigation. Stem cell transplantation seems to be promising in restarting the immune system to diminish fibrosis and restore microvasculature. Future research will be directed at genetic factors, diagnostic and prognostic markers for fibrosis and microangiopathy, and development of drugs directed to pathogenic key cells and mediators.
    Best practice & research. Clinical rheumatology 02/2012; 26(1):13-24. · 2.90 Impact Factor
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    ABSTRACT: Lipopolysaccharide (LPS) is a bacterial endotoxin. LPS-induced cartilage damage is widely used as a model to investigate the effec-tiveness of cartilage protective agents in vitro. Overwhelming liver LPS of intestinal origin break impaired liver barriers, achieve blood stream in low but sustained accounts and spread to joints. That results in LPS-binding protein (LBP) -CD14 activation of inflammato-ry response and development of degenerative joints changes (osteophyte formation and car-tilage loss). Easy penetration of LPS into circu-lation may be a result from liver dysfunction associated with fatty liver. We proposed an analogical in vivo model of bone degenerative changes related to fatty liver. Ultrasound (US) images of patients admitted to the emergency department for abdominal pain were revised. Fifty two patients were divided to two groups. The first included 26 patients (M/F =13/13, age of 56.2±8.5 years) with US features of fatty liver. The second comprised of 26 patients (M/F=13/13, age of 57.5±8.0 years, P=0.56) without US features of fatty liver. Retrospective analysis of images of the whole spine (X-ray, computed tomography) in both populations obtained from the hospital imag-ing data base, was performed. Four maximal size spinal osteophytes were measured. In order to reduce an influence of individual body size factors the spine osteophyte radial length/vertebral width (O/V) ratio was calculat-ed. Hence, the osteophyte size was measured as a part of a vertebral width. Correlation between osteophytes' size, patient age, and body mass index (BMI) in both groups was assessed. Spine osteophytes of patients with fatty liver had a bigger size (O/V=0.21±0.06) compared with patients with normal liver (O/V=0.14±0.03, P<0.001). Fatty liver patients had a higher BMI (32.7±5.4 kg/m 2) compared to normal liver patients (28.0±6.7kg/m 2 , P=0.031). Spine with normal liver had margin-al vertebral bulging less 0.17 or 17% of the ver-tebral width. Maximal osteophyte size was 0.3 of the vertebral width or 30% in fatty liver group. In order to distinguish an influence of BMI and fatty liver on O/V, patients of normal liver group were divided according to increased BMI (>25 kg/m 2) and normal one (<25 kg/m 2). O/V of both subgroups showed similar values: 0.14±0.03 (high BMI) and 0.13±0.02 (normal BMI) (P=0.52). BMI of the subgroups was significantly different: 31.8±5.4 (high BMI) and 21.3±1.7 (normal BMI) (P<0.001). No direct correlation was found between O/V and BMI in fatty liver and normal liver groups (P=0.81, P=0.51 respectively). In opposite, significant O/V and age correlation was found in normal liver group (P=0.014) and weak correlation in fatty liver group (P=0.063). Spine osteophytes of patients with fatty liver have a bigger size compared with patients with normal liver. Fatty liver may be considered as a predisposing factor in the pathogenesis of spine osteophytosis.
    Rheumatology Reports. 01/2012; 4(1).
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    ABSTRACT: Since young women undergoing cyclophosphamide pulse therapy may suffer premature ovarian failure (POF) in almost 50% of cases, we examined the ability of GnRH-a administration to minimize the gonadotoxicity associated with cyclophosphamide pulse therapy (CPT). Retrospective analysis of medical charts of 44 women (age 16-38 years) who received CPT for autoimmune diseases. In 33 patients a monthly depot injection of GnRH-a was started before the alkylating agent. The ovarian function [spontaneous menstrual bleeding, hormonal profile, (FSH, LH, E(2), progesterone) pelvic sonography, and conceptions] was evaluated, 1 to 10 years after CPT. In the GnRH-a group, 30 women resumed cyclic ovarian function; 1 (a 37-year-old patient) developed POF (3%), and 2 were lost to follow-up. In the control (no GnRH-a) group, 5 of 11 patients suffered POF (45%). The mean age in the study group was 25.6 ± 5.2 years compared with 29.3 ± 5.8 years in the control group, and the mean cumulative cyclophosphamide dose was 9.9 g compared to 10.9 g, respectively. The difference in the long-term POF remained significant even after adjusting the groups for comparable age and cumulative cyclophosphamide doses. GnRH-a decreases cyclophosphamide-associated gonadotoxicity and POF in young women with systemic lupus erythematosus and other autoimmune diseases. Therefore this treatment should be considered and recommended to every young woman before gonadotoxic chemotherapy.
    Seminars in arthritis and rheumatism 08/2011; 41(3):346-52. · 4.72 Impact Factor
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    ABSTRACT: Pomegranate extract (POMx) consumption has been shown to reduce the incidence and severity of collagen-induced arthritis in mice. To investigate whether pomegranate consumption affects disease activity in patients with rheumatoid arthritis (RA), in relation to their serum oxidative status. In this pilot 12 week open-labeled study eight patients with active RA consumed POMx (10 ml/day) for 12 weeks. Patients' joint status and serum oxidative status (lipid peroxidation, total thiols group, paraoxonase 1 activity) were evaluated at baseline and at week 12. Six patients completed the study. POMx consumption significantly (P < 0.02) reduced the composite Disease Activity Index (DAS28) by 17%, which could be related mostly to a significant (P < 0.005) reduction in the tender joint count (by 62%). These results were associated with a significant (P < 0.02) reduction in serum oxidative status and a moderate but significant (P < 0.02) increase in serum high density lipoprotein-associated paraoxonase 1 (PON1) activity. The addition of POMx to serum from RA patients reduced free radical-induced lipid peroxidation by up to 25%. The pomegranate consumption reduced DAS28 in RA patients, and this effect could be related to the antioxidative property of pomegranates. Dietary supplementation with pomegranates may be a useful complementary strategy to attenuate clinical symptoms in RA patients.
    The Israel Medical Association journal: IMAJ 08/2011; 13(8):474-9. · 0.98 Impact Factor
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    ABSTRACT: To review pulmonary arteritis (PA) complicated by pulmonary arterial hypertension (PAH) in Takayasu's arteritis (TA). Two cases of PA and PAH in TA patients and similar cases published in the Medline database from 1975 to 2009 were reviewed. Forty-six cases (females 89.1%, Asians 65%, mean age 34.6 years) were analyzed, 42.2% of which had PAH. Isolated PA was reported in 31.8%. Respiratory symptoms were presented as dyspnea (75.5%), chest pain (48.9%), hemoptysis (42.2%), and cough (17.7%). Hypertension, vascular bruits, and diminished/absent pulses were reported in 48.9% of patients. A diagnosis of PA was based on abnormal uptake on pulmonary perfusion scan and a finding of stenosis, narrowing, occlusion, and irregularity on computed tomography or magnetic resonance imaging, and/or pulmonary angiography. Patients were treated with glucocorticoids (77.5%), disease-modified antirheumatic drugs (35%), and warfarin (20%); only a few were treated with biological agents. Vascular procedures were performed in 52.5% of cases, on pulmonary arteries in 37.5% with good results. The outcome was death in 20.5% of PA patient and 33.3% in PAH patients. TA may be complicated by life-threatening PA and PAH. Clinical signs are not specific and may be masked by involvement of the aorta and its branches. Treatment with glucocorticoids and disease-modified antirheumatic drugs has only partial effect, which may be intensified by biological agents. Invasive procedures on pulmonary arteries may be a complementary option. PA and PAH in TA patients should be recognized early and treated promptly for prevention of irreversible vascular damage.
    Seminars in arthritis and rheumatism 07/2011; 41(3):461-70. · 4.72 Impact Factor
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    ABSTRACT: The objectives of this study are to assess the vitamin D status in patients (pts) with inflammatory joint diseases (IJD), and its correlation with disease activity. 121 consecutive pts (85 rheumatoid arthritis (RA), 22 psoriatic arthritis (PSA), 14 ankylosing spondylitis (AS)) underwent clinical and laboratory evaluation which included kidney and liver function tests, serum calcium and phosphor levels, 25(OH)D and parathyroid hormone (PTH). Disease activity was assessed by DAS 28 in RA and PSA pts and by BASDAI in AS pts, sedimentation rate (ESR) and CRP. According to activity indexes, pts were divided into subgroups with low (DAS28 < 3.2 and BASDAI < 4), and moderate-to-high disease activity (DAS28 > 3.2 and BASDAI > 4). Associations between serum levels of 25(OH)D and age, gender, ethnicity, type and disease duration, treatment, (anti-tumor necrosis factorα (TNFα) agents or DMARDs), seasonal variations, and disease activity were assessed. Vitamin D deficiency was found in 51 pts (42.1%). The incidence was higher among Arab pts (76.7%) compared to Jews (23%). The difference of 25(OH)D levels between Arabs (mean 9.4 ± 4.2 ng/ml) and Jews (mean 17.8 ± 8.4 ng/ml) was statistically significant (p < 0.0001). We did not find correlation between vitamin D levels and the other evaluated factors. A surprisingly high incidence of vitamin D deficiency was found in IJD patients in a sunny Mediterranean country. This finding justifies the inclusion of vitamin D in the routine lab work-up of pts with IJD. The only statistical significant correlation was found between vitamin D level and ethnic origin. Further studies are needed to look for genetic polymorphism of vitamin D receptors.
    Rheumatology International 04/2011; 31(4):493-9. · 2.21 Impact Factor
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    ABSTRACT: A cohort of patients with recently diagnosed axial spondyloarthritis (SpA) was characterized with emphasis on gender differences and factors leading to delay in diagnosis. Clinical, laboratory, and imaging data of 151 consecutive patients diagnosed with ankylosing spondylitis or undifferentiated SpA in 2004-2009 and satisfying the new ASAS classification criteria for axial SpA, was collected and analyzed. Seventy-nine men and 72 women were enrolled. Both groups (men and women) had similar age of onset of disease-related symptoms, as well as similar delay time to diagnosis, follow-up duration and frequency of anti-TNF treatment. Inflammatory back pain, as a first symptom related to SpA, was reported more often by men, while women had more pelvic, heel, and widespread pain (WP) during the course of the disease. At the time of diagnosis, men were more limited in chest expansion and showed increased occiput-to-wall distance compared to women. Elevated erythrocyte sedimentation rate and/or C-reactive protein were detected in a similar proportion of men and women. Presence of WP in women almost doubled the delay in the diagnosis of SpA. No other differences in disease presentation or burden were demonstrated to correlate with delay in diagnosis.
    Clinical Rheumatology 03/2011; 30(8):1075-80. · 2.04 Impact Factor

Publication Stats

625 Citations
174.37 Total Impact Points


  • 1999–2014
    • Rambam Medical Center
      • • Department of Internal Medicine D
      • • Department of Rheumatology
      H̱efa, Haifa District, Israel
  • 2003–2013
    • Ministry of Health (Israel)
      Yerushalayim, Jerusalem District, Israel
  • 2011
    • Tel Aviv University
      Tell Afif, Tel Aviv, Israel
  • 1999–2011
    • Technion - Israel Institute of Technology
      • Rambam Medical Center
      H̱efa, Haifa District, Israel
  • 2009
    • Tel Aviv Sourasky Medical Center
      • Rheumatology
      Tel Aviv, Tel Aviv, Israel