ACR 2020 Highlights: COVID-19 Vaccine Updates, Microbiome News, RA Guidelines, Mental Health in JIA and Patient Education
Highlights from the last day of the American College of Rheumatology (ACR) annual meeting included topics related to vaccine updates for COVID-19, information related to the influence of the microbiome on arthritis and how resilience can have an impact on managing arthritis.
Update on Coronavirus Vaccine Development
Pfizer announced Monday that its COVID-19 vaccine is performing well so far in trials. But a presentation Sunday described some of the uphill challenges in creating a safe and effective vaccine, which will likely be needed along with public health measures to end the COVID-19 pandemic. Dan Barouch, MD, a professor at Harvard and director of the Center for Vaccine and Virology Research at Beth Israel Deaconess Medical Center, outlined the steps in creating a vaccine and addressed some important issues.
New ACR Guidelines for Rheumatoid Arthritis
The ACR last issued evidence-based guidelines for the treatment of rheumatoid arthritis (RA) in 2015. Since then, new drugs have hit the market, older drugs have been reassessed and there is more evidence for the role of nondrug treatments. The ACR released a draft of its updated its RA recommendations, with input from both rheumatologists and patients.
Of 44 recommendations, only seven were considered strong, meaning there is clear
evidence that the benefits of the treatment outweigh the risks and they are endorsed by most patients. The remaining recommendations are conditional because they lack clear evidence one way or the other. The new guidelines do not address nondrug therapies or vaccinations.
Here are some of the main takeaways:
“Grit, Gratitude and Grace” in Resilience
To discern nuances to an age-old question, “What makes some people more resilient than others when faced with adversity?” Afton L. Hassett, Psy.D., examined three key components — grit, gratitude and grace — in a scientific session. Hassett is associate professor in the Department of Anesthesiology, Chronic Pain and Fatigue Research Center, and director of clinical pain research in the Back & Pain Center at the University of Michigan,.
Grit , defined as perseverance and passion, is “a willingness to do whatever it takes to do something you love,” said Hassett. While grit has not been studied extensively in pain, there are some hints in research that key components of resilience — optimism and grit — were positively associated with greater pain tolerance and improved pain threshold, she said. “Another intriguing hint is in regard to one of the key elements of treatment for chronic pain, and that’s exercise. Grit was one of the best predictors of who would exercise longer,” said Hassett. Research revealed perseverance is the key ingredient for grit, and to build grit and perseverance, and researchers looked at changing mindsets in those with either a fixed or growth mindset — the latter allowing patients to grow perseverance and grit.
Gratitude has a dual meaning: one that occurs in interpersonal exchanges, and the other recognized in spiritual traditions of giving thanks. Research shows that gratitude broadened patients’ outlook and altered patients’ behaviors and mindsets in positive directions, said Hassett. “When we are under the influence of positive emotions, they have profound impact on our bodies.”
The body of evidence for the positive effects of gratitude is huge, said Hassett, including in the areas of acute and chronic pain, rheumatoid arthritis, osteoarthritis and back pain.
She suggested two effective ways to practice gratitude:
Grace , while often including the spiritual and humanity elements, Hassett is focused on the “purpose in life” element of grace — our passions and the reasons why we get up in the morning. It guides life decisions, influences behavior, shapes goal, offers a sense of direction and creates meaning, Hassett explained. This purpose can be associated with work and career or family, friends and community or religion and spirituality.
The bottom line: “Having a strong sense of purpose in life is good medicine,” she said. Scientific evidence shows it is associated with less anxiety and depression; healthier aging; better sleep, diet and nutrition; increased pain tolerance and willpower; decreased risk of heart attack and Alzheimer’s; and improved immune system functioning. “And when people have a sense of purpose, the little things aren’t so overwhelming and difficult,” she said.
Hassett recommends an exercise to help find purpose. Start by asking yourself the following questions:
Tied together — grit, gratitude and grace — all contribute to resilience, as demonstrated by Cassandra Metzger, a chronic pain patient who shared her diagnosis story and experiences, and how she has built resilience through meditation, breath work, yoga and yoga therapy (as both practitioner and certified therapist), movement and philosophy to cope and thrive. — BRYAN D. VARGO
The Influence of Diet on the Microbiome and Arthritis
Everyone has a unique microbial ecosystem (called the microbiome) that’s influenced by diet, medications, and experiences. In turn, microbes in and on our bodies influence health in profound ways. The rapid rise in inflammatory and autoimmune diseases such as rheumatoid arthritis (RA) has been traced to genetic factors interacting with an imbalanced gut microbiome. For at least the last decade, researchers have been laser-focused on the best way to restore balance in the gut microbiome to prevent and treat disease.
Monica Guma, MD, a rheumatologist and researcher at the University of California, San Diego, undertook a simple two-week study to see if dietary changes could nudge the microbiome into a healthier state in patients with RA. She designed an anti-inflammatory, probiotic-rich eating plan based on Mediterranean-style diets.
Interesting findings emerged:
Dr. Guma said her aim is to steer patients away from drugs and to think of food as medicine.
Curtis Huttenhower, PhD, who directs the Howard Chan Microbiome in Public Health Center, studies the microbiome from a population and public health perspective. He pointed out that gut health is systemic health. Unhealthy microbial populations can cause inflammation and disease throughout the body, including the joints. He noted that most people with arthritis have fewer anti-inflammatory microbes and more inflammatory ones than the general population, and that dietary nutrients are changed and processed differently by each person’s unique microbiome. It’s not a matter of different diets for different diseases but rather different diets for different people. — LINDA RATH
Mental Health Impacts on JIA
A growing number of studies show that children and teens with rheumatologic diseases have higher rates of mental health disorders, such as anxiety and depression, which was the topic of a presentation by Tamar Rubinstein, MD, of the Albert Einstein College of Medicine and Becky Lois, PhD, director of Pediatric Psychology for Integrated Behavioral Health at Hassenfeld Children’s Hospital, NYU Langone Health. In fact, an estimated 10% to 40% of youth with juvenile idiopathic arthritis (JIA) experience anxiety and depression, and rates of mental distress appear higher in children with arthritis than other children with chronic conditions. The COVID-19 pandemic has contributed even more to mental distress in children and parents of children with arthritis. Studies also find that children who experience anxiety and depression in childhood are more likely to develop mental health disorders as adults.
Mental health disorders can impact disease outcomes, and children who experience anxiety and depression are more likely to experience worse disease outcomes, increased pain, and lower quality of life. Moreover, children experiencing mental distress are less likely to comply with treatment plans and adhere to medications.
Factors that contribute to higher anxiety rates in children with arthritis include:
More routine mental health screenings, in addition to regular rheumatology appointments, are needed to quell the impacts of depression and anxiety on disease outcomes. However, a 2016 Childhood Arthritis and Rheumatology Research Alliance (CARRA) survey shows that only 2% of rheumatologists regularly screen for mental health disorders with a standardized tool. To close the gap between rheumatology care and mental health care, organizations are beginning to implement multidisciplinary programs, using rheumatologists, nurses and mental health professionals to regularly screen for anxiety and depression in children. Preliminary findings show that the impacts of these programs have a positive impact on mental health and disease outcome. — ROBYN ABREE
Improving Patient Education for Better Outcomes
Patient education and self-management are central to improving health outcomes, but barriers to these exist for both doctors and patients. Three presenters discussed some of the challenges and solutions in a session Monday.
Self-management is an individual’s ability to manage symptoms and treatments as well as “physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition,” said Mwidimi Ndosi, PhD, a researcher and senior lecturer in rheumatology nursing at the University of the West of England, Bristol. According to the European League Against Rheumatism (EULAR), it’s a “planned, interactive learning process,” he said. “It’s more than just giving out leaflets.”
At its crux are good communication and shared decision-making. Educational needs range from understanding the disease, side effects and risk factors to learning about nondrug treatments, pain control, physical activities and behaviors that may affect the disease or its symptoms, so education must be tailored to individual patients.
Health care providers cite time restraints as barriers to providing education and resources their patients need. Other barriers may be patients’ mistrust of providers and health care systems, lack of health literacy or language and cultural barriers, added Jillian A. Rose, PhD, director for community engagement, diversity and research at Hospital for Special Surgery (HSS).
A patient’s culture, religion and other factors may influence how they view their illness and how they and their family respond to it. And both providers and patients may bring implicit bias to their interactions based on culture, race, weight, sexual orientation and other considerations. This could unintentionally impact the examination, diagnosis interview, symptom management and treatment recommendations, Rose said.
Also important to consider are a patient’s economic stability, access to resources, stressors and other personal issues that can affect their disease management and health. In one survey, 40% of patients reported their family doctor was unaware of personal struggles, such as food insecurity, lack of transportation or inability to afford childcare for their multiple medical appointments, Rose said. She advises providers to actively listen to a patient with empathy, have open communication and make shared decisions based on what’s important to the patient.
She described one patient who was supposed to be receiving and taking a new biologic medication, but after several months she clearly wasn’t taking it. When gentle questioning revealed that she had lost her home so the medication wasn’t being delivered to her, Rose was able to help find other ways for her to get it, she said.
In addition to the patient, caregiver, support systems, doctor and health care team, peer support is key to better patient education and outcomes, Rose said. For example, HHS’s lupus program matches longer-term patients as mentors to newly diagnosed patients.
A collaborative approach among the health care team and organizational support — backed by patient and family advisory councils — can facilitate more effective patient education and better outcomes, added Sandra Mintz, RN, nurse navigator at Children’s Hospital Los Angeles with a background in rheumatology. Supporting self-management involves the whole care team as well as the patient and family, customizing education to each patient and making referrals to credible resources in the community and for information.
Technology can help in many ways. Telemedicine opens more access to health care providers, and there is endless information available online. However, Mintz said, many patients have little health literacy, and they need guidance on where to look for credible information and supportive patient groups and what to avoid. A few considerations for patients: Check for accuracy, authority, bias, timeliness and thoroughness on the site or app. Find out who runs it, what it’s offering, where does the information come from and when was it last reviewed, and why does the site exist.
Patient education needs to be an integral part of treatment from the beginning to help empower patients and give them the ability to manage their own disease and symptoms. — JILL TYRER
Update on Coronavirus Vaccine Development
Pfizer announced Monday that its COVID-19 vaccine is performing well so far in trials. But a presentation Sunday described some of the uphill challenges in creating a safe and effective vaccine, which will likely be needed along with public health measures to end the COVID-19 pandemic. Dan Barouch, MD, a professor at Harvard and director of the Center for Vaccine and Virology Research at Beth Israel Deaconess Medical Center, outlined the steps in creating a vaccine and addressed some important issues.
- Barouch’s animal trials found some natural immunity to SARS-CoV-2, which may help explain why certain people have very mild or no symptoms.
- The time from vaccination to immune response varies, depending on the type of vaccine, but most people respond within two weeks. For vaccines that require a booster shot, which might be given two weeks after the first, the time for a full response could stretch to six weeks.
- Most currently circulating SARS-CoV-2 strains feature a mutation in the spike protein that makes them more contagious. The mutation does not cause more-severe disease or worse outcomes, and it will not affect the effectiveness of vaccines now in development. Although the coronavirus is mutating at a surprisingly slow rate — much more slowly than HIV, for example — it is possible that future mutations might make potential vaccines less effective. It is also possible that vaccines themselves might cause the virus to mutate in ways that would negate the vaccine entirely. (Genetic mutations in the virus are monitored by large sequencing consortiums around the world and uploaded into public databases for everyone to see.)
- It is important to have several different vaccines because of potential mutations and because it is likely that some will be safer and more effective in certain populations, including older adults and people with underlying medical conditions. Dr. Barouch’s vaccine, which he is developing for Johnson & Johnson, has not been tested in people with compromised immune systems or rheumatic disease and in only a small number of seniors. It is not clear whether these groups are included in the trials by Pfizer-BioNTech, which announced Monday that its vaccine candidate was 90% effective in preventing COVID-19. But no safety or other data have been reported.
- Distributing a vaccine to billions of people worldwide is much harder than creating the vaccine itself. (The Pfizer vaccine requires ultra-cold storage, which makes the logistics even more daunting). — LINDA RATH
New ACR Guidelines for Rheumatoid Arthritis
The ACR last issued evidence-based guidelines for the treatment of rheumatoid arthritis (RA) in 2015. Since then, new drugs have hit the market, older drugs have been reassessed and there is more evidence for the role of nondrug treatments. The ACR released a draft of its updated its RA recommendations, with input from both rheumatologists and patients.
Of 44 recommendations, only seven were considered strong, meaning there is clear
evidence that the benefits of the treatment outweigh the risks and they are endorsed by most patients. The remaining recommendations are conditional because they lack clear evidence one way or the other. The new guidelines do not address nondrug therapies or vaccinations.
Here are some of the main takeaways:
- Methotrexate alone (monotherapy) is strongly recommended as the first treatment of choice. It is strongly recommended over hydroxychloroquine, sulfasalazine, biologics and small molecule drugs such as janus kinase (JAK) inhibitors. Methotrexate monotherapy is also strongly recommended over methotrexate plus a tumor necrosis factor (TNF) blocker, and conditionally recommended over double or triple therapy with other conventional disease-modifying antirheumatic drugs (DMARDs).
- In an effort to greatly limit the use of corticosteroids (steroids), even as a bridge treatment, the guidelines strongly recommend against long-term steroid use and conditionally recommend against short-term steroid use.
- Doctors and patients are encouraged to switch to biosimilars — drugs that are similar in safety and effectiveness to brand-name biologics but are expected to drive costs dowm.
- A treat-to-target approach is strongly recommended for patients who have not taken biologics or small molecule drugs (targeted DMARDs). In treat-to-target, doctors and patients decide on a goal and adjust treatment until the goal is reached. Though everyone hopes for remission, it might not be achievable for many patients. A more realistic aim is low disease activity, which keeps symptoms under control and helps maintain a good quality of life. Still, the goal should be tailored to each patient and remission should be the target when possible.
- Tapering off medications can be considered after six months of controlled symptoms. Dose reduction is preferred to stopping treatment completely. This is one area where doctors and patients strongly disagreed. Doctors want patients to stay on medications; patients want to get off them.
- The most important factor in all treatment considerations is shared decision-making, where patients have a full voice in their own care. — LINDA RATH
“Grit, Gratitude and Grace” in Resilience
To discern nuances to an age-old question, “What makes some people more resilient than others when faced with adversity?” Afton L. Hassett, Psy.D., examined three key components — grit, gratitude and grace — in a scientific session. Hassett is associate professor in the Department of Anesthesiology, Chronic Pain and Fatigue Research Center, and director of clinical pain research in the Back & Pain Center at the University of Michigan,.
Grit , defined as perseverance and passion, is “a willingness to do whatever it takes to do something you love,” said Hassett. While grit has not been studied extensively in pain, there are some hints in research that key components of resilience — optimism and grit — were positively associated with greater pain tolerance and improved pain threshold, she said. “Another intriguing hint is in regard to one of the key elements of treatment for chronic pain, and that’s exercise. Grit was one of the best predictors of who would exercise longer,” said Hassett. Research revealed perseverance is the key ingredient for grit, and to build grit and perseverance, and researchers looked at changing mindsets in those with either a fixed or growth mindset — the latter allowing patients to grow perseverance and grit.
Gratitude has a dual meaning: one that occurs in interpersonal exchanges, and the other recognized in spiritual traditions of giving thanks. Research shows that gratitude broadened patients’ outlook and altered patients’ behaviors and mindsets in positive directions, said Hassett. “When we are under the influence of positive emotions, they have profound impact on our bodies.”
“We see that positive emotions increase immune functioning, there’s a cardiovascular benefit, reduced risk of stroke and shorter and less episodes of depression.” —Afton Hassett
The body of evidence for the positive effects of gratitude is huge, said Hassett, including in the areas of acute and chronic pain, rheumatoid arthritis, osteoarthritis and back pain.
She suggested two effective ways to practice gratitude:
- Keep a gratitude diary. Every day write down three things for which you are grateful — family and friends, feeling sunshine on your face, being able to walk, for examples. Establishing a set time every day to do this works best. The three things must be different each time — no repeats. To help you feel grateful, smile as you write them down. In as much detail as you like, write why you are grateful for each thing. “The first day is usually easy,” said Hassett. “You may write down my family, my health, my pets. But by day 21, you really begin searching the world for things that make you happy — a beautiful fall leaf, the chocolate chips in that chocolate chip cookie. Whatever it is, it teaches you to look for these positive things in your life. And even better yet, look back on these things over time and spend a few minutes reflecting.”
- Send a gratitude text. Text a note of gratitude to someone you care about whom you have not spoken to in a while and might enjoy a moment of appreciation. “Text them, ‘I've been thinking about you and I’m grateful for …’ something they did, perhaps something you didn’t express to them before. Reconnecting with folks, just by sending a little gratitude message, can be something that can really boost your day.”
Grace , while often including the spiritual and humanity elements, Hassett is focused on the “purpose in life” element of grace — our passions and the reasons why we get up in the morning. It guides life decisions, influences behavior, shapes goal, offers a sense of direction and creates meaning, Hassett explained. This purpose can be associated with work and career or family, friends and community or religion and spirituality.
The bottom line: “Having a strong sense of purpose in life is good medicine,” she said. Scientific evidence shows it is associated with less anxiety and depression; healthier aging; better sleep, diet and nutrition; increased pain tolerance and willpower; decreased risk of heart attack and Alzheimer’s; and improved immune system functioning. “And when people have a sense of purpose, the little things aren’t so overwhelming and difficult,” she said.
Hassett recommends an exercise to help find purpose. Start by asking yourself the following questions:
- What am I passionate about? It could be family, adventure, nature, love, compassion, justice, faith, wisdom, success, fun, etc. These are your values.
- What are my character strengths? Are you naturally creative, curious, kind, brave, just, caring, adventurous, studios, bright, etc. To help identify strengths, use this free character strength survey: org .
- What am I good at (skills and talents) or trained for? These are the roles in which you are already competent and most likely to succeed.
- How will I know I am successful? These are the metrics by which you will judge your progress. Or what will people say about you after you are gone?
Tied together — grit, gratitude and grace — all contribute to resilience, as demonstrated by Cassandra Metzger, a chronic pain patient who shared her diagnosis story and experiences, and how she has built resilience through meditation, breath work, yoga and yoga therapy (as both practitioner and certified therapist), movement and philosophy to cope and thrive. — BRYAN D. VARGO
The Influence of Diet on the Microbiome and Arthritis
Everyone has a unique microbial ecosystem (called the microbiome) that’s influenced by diet, medications, and experiences. In turn, microbes in and on our bodies influence health in profound ways. The rapid rise in inflammatory and autoimmune diseases such as rheumatoid arthritis (RA) has been traced to genetic factors interacting with an imbalanced gut microbiome. For at least the last decade, researchers have been laser-focused on the best way to restore balance in the gut microbiome to prevent and treat disease.
Monica Guma, MD, a rheumatologist and researcher at the University of California, San Diego, undertook a simple two-week study to see if dietary changes could nudge the microbiome into a healthier state in patients with RA. She designed an anti-inflammatory, probiotic-rich eating plan based on Mediterranean-style diets.
Interesting findings emerged:
- Some patients saw a 50% improvement in pain and swelling from baseline by the second or third day. A few went into remission — a goal not easily reached by most people with arthritis.
- Not everyone responded to the diet. Those who did ate more healthfully to begin with. It may be that two weeks wasn’t long enough for nonresponders with poorer diets at baseline to see improvement (or they may not have stuck as well to the diet).
- The diversity of gut microbes didn’t shift dramatically, but the trend was toward greater diversity — a sign of gut health. Responders had more microbial diversity at baseline than nonresponders.
Dr. Guma said her aim is to steer patients away from drugs and to think of food as medicine.
Curtis Huttenhower, PhD, who directs the Howard Chan Microbiome in Public Health Center, studies the microbiome from a population and public health perspective. He pointed out that gut health is systemic health. Unhealthy microbial populations can cause inflammation and disease throughout the body, including the joints. He noted that most people with arthritis have fewer anti-inflammatory microbes and more inflammatory ones than the general population, and that dietary nutrients are changed and processed differently by each person’s unique microbiome. It’s not a matter of different diets for different diseases but rather different diets for different people. — LINDA RATH
Mental Health Impacts on JIA
A growing number of studies show that children and teens with rheumatologic diseases have higher rates of mental health disorders, such as anxiety and depression, which was the topic of a presentation by Tamar Rubinstein, MD, of the Albert Einstein College of Medicine and Becky Lois, PhD, director of Pediatric Psychology for Integrated Behavioral Health at Hassenfeld Children’s Hospital, NYU Langone Health. In fact, an estimated 10% to 40% of youth with juvenile idiopathic arthritis (JIA) experience anxiety and depression, and rates of mental distress appear higher in children with arthritis than other children with chronic conditions. The COVID-19 pandemic has contributed even more to mental distress in children and parents of children with arthritis. Studies also find that children who experience anxiety and depression in childhood are more likely to develop mental health disorders as adults.
Mental health disorders can impact disease outcomes, and children who experience anxiety and depression are more likely to experience worse disease outcomes, increased pain, and lower quality of life. Moreover, children experiencing mental distress are less likely to comply with treatment plans and adhere to medications.
Factors that contribute to higher anxiety rates in children with arthritis include:
- Dealing with the emotional burden of having a chronic disease
- Increased risk of disability
- Medications (i.e, steroids, which may affect a child’s mood directly or indirectly by causing changes in appearance)
More routine mental health screenings, in addition to regular rheumatology appointments, are needed to quell the impacts of depression and anxiety on disease outcomes. However, a 2016 Childhood Arthritis and Rheumatology Research Alliance (CARRA) survey shows that only 2% of rheumatologists regularly screen for mental health disorders with a standardized tool. To close the gap between rheumatology care and mental health care, organizations are beginning to implement multidisciplinary programs, using rheumatologists, nurses and mental health professionals to regularly screen for anxiety and depression in children. Preliminary findings show that the impacts of these programs have a positive impact on mental health and disease outcome. — ROBYN ABREE
Improving Patient Education for Better Outcomes
Patient education and self-management are central to improving health outcomes, but barriers to these exist for both doctors and patients. Three presenters discussed some of the challenges and solutions in a session Monday.
Self-management is an individual’s ability to manage symptoms and treatments as well as “physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition,” said Mwidimi Ndosi, PhD, a researcher and senior lecturer in rheumatology nursing at the University of the West of England, Bristol. According to the European League Against Rheumatism (EULAR), it’s a “planned, interactive learning process,” he said. “It’s more than just giving out leaflets.”
At its crux are good communication and shared decision-making. Educational needs range from understanding the disease, side effects and risk factors to learning about nondrug treatments, pain control, physical activities and behaviors that may affect the disease or its symptoms, so education must be tailored to individual patients.
Health care providers cite time restraints as barriers to providing education and resources their patients need. Other barriers may be patients’ mistrust of providers and health care systems, lack of health literacy or language and cultural barriers, added Jillian A. Rose, PhD, director for community engagement, diversity and research at Hospital for Special Surgery (HSS).
A patient’s culture, religion and other factors may influence how they view their illness and how they and their family respond to it. And both providers and patients may bring implicit bias to their interactions based on culture, race, weight, sexual orientation and other considerations. This could unintentionally impact the examination, diagnosis interview, symptom management and treatment recommendations, Rose said.
Also important to consider are a patient’s economic stability, access to resources, stressors and other personal issues that can affect their disease management and health. In one survey, 40% of patients reported their family doctor was unaware of personal struggles, such as food insecurity, lack of transportation or inability to afford childcare for their multiple medical appointments, Rose said. She advises providers to actively listen to a patient with empathy, have open communication and make shared decisions based on what’s important to the patient.
She described one patient who was supposed to be receiving and taking a new biologic medication, but after several months she clearly wasn’t taking it. When gentle questioning revealed that she had lost her home so the medication wasn’t being delivered to her, Rose was able to help find other ways for her to get it, she said.
In addition to the patient, caregiver, support systems, doctor and health care team, peer support is key to better patient education and outcomes, Rose said. For example, HHS’s lupus program matches longer-term patients as mentors to newly diagnosed patients.
A collaborative approach among the health care team and organizational support — backed by patient and family advisory councils — can facilitate more effective patient education and better outcomes, added Sandra Mintz, RN, nurse navigator at Children’s Hospital Los Angeles with a background in rheumatology. Supporting self-management involves the whole care team as well as the patient and family, customizing education to each patient and making referrals to credible resources in the community and for information.
Technology can help in many ways. Telemedicine opens more access to health care providers, and there is endless information available online. However, Mintz said, many patients have little health literacy, and they need guidance on where to look for credible information and supportive patient groups and what to avoid. A few considerations for patients: Check for accuracy, authority, bias, timeliness and thoroughness on the site or app. Find out who runs it, what it’s offering, where does the information come from and when was it last reviewed, and why does the site exist.
Patient education needs to be an integral part of treatment from the beginning to help empower patients and give them the ability to manage their own disease and symptoms. — JILL TYRER
