Abstracts tagged "randomized trials and rheumatoid arthritis (RA)"

Abstract Number: 2910 • 2018 ACR/ARHP Annual Meeting
Development of a Rheumatoid Arthritis Global Outcome Measure to Enable Comparisons of Patient Experiences across Treatment Arms in Randomized Clinical Trials
Liana Fraenkel¹, W. Benjamin Nowell², Carole Wiedmeyer², Zhenglin Wei³, Kaleb Michaud⁴, Tuhina Neogi⁵, Christine Ramsey¹ and David Broniatowski³, ¹Yale University School of Medicine, New Haven, CT, ²Global Healthy Living Foundation, Upper Nyack, NY, ³George Washington University, Washington, DC, ⁴Rheumatology, University of Nebraska Medical Center, Omaha, NE, ⁵Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA
Background/Purpose: Randomized controlled trials currently report benefits and adverse events (AEs) separately, and therefore do not permit comparisons of patients’ overall experiences on one treatment…
Abstract Number: 1796 • 2017 ACR/ARHP Annual Meeting
Benefits and Sustainability of a Learning Collaborative for Implementation of Treat to Target in Rheumatoid Arthritis: Results of Phase II of a Cluster Randomized Controlled Trial
Daniel H. Solomon¹, Liana Fraenkel², Zhi Yu³, Bing Lu⁴, Asaf Bitton⁵, Agnes Zak⁶, Cassandra Corrigan⁷, Jen Agosti⁸, Leslie R Harrold⁹, Josef S. Smolen¹⁰, Jeffrey N. Katz¹¹ and Elena Losina¹², ¹Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ²Rheumatology, Rheumatology, Yale University School of Medicine, New Haven, CT, New Haven, CT, ³Rheumatology Immunology & Allergy, Brigham and Women's Hospital, Boston, MA, ⁴Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ⁵Medicine, Brigham and Women's Hospital, Boston, MA, ⁶Brigham and Women's Hospital, Boston, MA, ⁷Rheumatology, Brigham and Women's Hospital, Boston, MA, ⁸JRA Consulting, Andover, MA, ⁹University of Massachusetts Medical School, Worcester, MA, ¹⁰Medical University Vienna, Division of Rheumatology, Department of Internal Medicine III, Vienna, Austria, ¹¹Rheumatology, Immunology, and Allergy, Brigham & Women's Hospital, Boston, MA, ¹²Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham & Women's Hospital, Boston, MA
Background/Purpose: Treat to target (TTT) is a recommended strategy in the management of rheumatoid arthritis (RA), but its uptake in routine rheumatologic care in…
Abstract Number: 2788 • 2017 ACR/ARHP Annual Meeting
The Risk of Major Toxicity with Aspirin for Primary Cardiovascular Prevention in Rheumatoid Arthritis Patients Using Nsaids: A Secondary Cohort Analysis of a Randomized Controlled Clinical Trial
Daniel H. Solomon¹, Peter Libby², Qiuquing Wang³, Katherine E Wolski⁴, Lisa M Wisniewski⁴, Neville Yeomans⁵, Michael Lincoff⁶, Steven E Nissen⁷ and M. Elaine Husni⁸, ¹Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ²Cardiology, Brigham and Women's Hospital, Boston, MA, ³Cleveland Clinic, Cleveland, OH, ⁴Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, ⁵Western Sydney Medical School, Sydney, Australia, ⁶Cardiology, Cleveland Clinic Foundation, Cleveland, OH, ⁷Cardiovascular Medicine, Chair, Cleveland Clinic, Cleveland, OH, ⁸Rheumatology Dept A50, Cleveland Clinic Foundation, Cleveland, OH
Background/Purpose: There are relatively clear guidelines for the use of low dose aspirin in the general population for primary cardiovascular (CV) prevention, but the risk-benefit…
Abstract Number: 350 • 2016 ACR/ARHP Annual Meeting
Change in Bone Mineral Density with High-Dose Prednisone in Patients with Rheumatoid Arthritis
Linda Rasch¹, Lilian van Tuyl¹, Martijn Kremer², Irene E.M. Bultink², Maarten Boers^3,4 and Willem F. Lems^1,4, ¹Amsterdam Rheumatology and immunology Center | VU University Medical Center, Amsterdam, Netherlands, Amsterdam, Netherlands, ²Rheumatology, Amsterdam Rheumatology and immunology Center | VU University Medical Center, Amsterdam, Netherlands, Amsterdam, Netherlands, ³Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, Netherlands, Amsterdam, Netherlands, ⁴Amsterdam Rheumatology and immunology Center | Reade, Amsterdam, Netherlands, Amsterdam, Netherlands
Background/Purpose: Recently, we showed that treatment with COBRA-light therapy including prednisone with initially 30 mg/day, was as effective as the original COBRA scheme, with initially…
Abstract Number: 2637 • 2016 ACR/ARHP Annual Meeting
Clinical Trials Aiming to Prevent the Development of Rheumatoid Arthritis Cannot Detect Prevention without Adequate Risk Stratification; A Trial Performed in UA-Patients As Example
Leonie E Burgers, Cornelia F Allaart, Tom WJ Huizinga and Annette HM van der Helm-van Mil, Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
Background/Purpose: Prevention of rheumatoid arthritis (RA) was the aim of several clinical trials performed in undifferentiated arthritis (UA). Overall these trials had negative results. As…
Abstract Number: 3214 • 2016 ACR/ARHP Annual Meeting
Implementation of Treat to Target in Rheumatoid Arthritis through a Learning Collaborative
Daniel H. Solomon¹, Bing Lu², Elena Losina³, Jen Agosti⁴, Agnes Zak⁵, Cassandra Corrigan⁵, Zhi Yu⁶, Sara Lee⁵, Asaf Bitton⁷, LR Harrold⁸, Theodore Pincus⁹, Helga Radner¹⁰, Josef Smolen¹¹, Liana Fraenkel¹² and Jeffrey N. Katz¹³, ¹Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, ²Brigham & Women's Hospital and Harvard Medical School, Boston, MA, ³Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ⁴JRA Consulting, Andover, MA, ⁵Brigham and Women's Hospital, Boston, MA, ⁶Rheumatology Immunology & Allergy, Brigham and Women's Hospital, Boston, MA, ⁷Medicine, Brigham and Women's Hospital, Boston, MA, ⁸University of Massachusetts Medical School, Worcester, MA, ⁹Rheumatology, Rush University Medical Center, Chicago, IL, ¹⁰Rheumatology, Medical University of Vienna, Vienna, Austria, ¹¹Division of Rheumatology, Medical University of Vienna and Hietzing Hospital, Vienna, Austria, ¹²Yale University School of Medicine, New Haven, CT, ¹³Rheumatology, Immunology, and Allergy, Brigham & Women's Hospital, Boston, MA
Background/Purpose: Treat to target (TTT) is a recommended strategy in the management of rheumatoid arthritis (RA), but various studies suggest that its uptake in routine…
Abstract Number: 1227 • 2015 ACR/ARHP Annual Meeting
Discrepancies Between Registered and Published Primary Outcomes in Randomized Controlled Trials of Rheumatoid Arthritis
Sheila Lezcano¹, Saha Sajib², Ashley Fan³, Mohini Pathria³, Karina Marianne D. Torralba⁴ and Nasim A. Khan⁵, ¹Internal Medicine, Loma Linda University, Loma Linda, CA, ²Internal Medicine, University of California-Riverside, Riverside, CA, ³Loma Linda University, Loma Linda, CA, ⁴Division of Rheumatology, Department of Internal Medicine, Loma Linda University, Loma Linda, CA, ⁵Rheumatology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR
Background/Purpose: Selective outcome reporting may bias treatment effect estimates of clinical trials. Registration of clinical trials was established to improve transparency in their conduct and…
Abstract Number: 2167 • 2015 ACR/ARHP Annual Meeting
Application of Combined Reporting of Benefit and Harm (OMERACT 3×3 methodology) to the Rheumatoid Arthritis Comparison of Active Therapies Trial
Maarten Boers^1,2, Sarah Leatherman³, James R. O'Dell⁴ and Jeffrey R. Curtis⁵, ¹Rheumatology, Amsterdam Rheumatology and immunology Center, VU University medical center, Amsterdam, Netherlands, ²Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, Netherlands, ³MAVERIC CSPCC (151MAV), VA Boston Healthcare System, Boston, MA, ⁴University of Nebraska Medical Center, Omaha, NE, ⁵Birmingham VAMC, Birmingham, AL
Background/Purpose: The Outcome Measures in Rheumatology (OMERACT) Initiative has suggested an analysis of the occurrence of benefit and harm in trials simultaneously, at the individual…
Abstract Number: 3110 • 2015 ACR/ARHP Annual Meeting
In the Multicenter Randomized Controlled Rotation or Change Trial, a Non-TNF Targeted Therapy Has a Higher Efficacy Than a Second Anti-TNF at 3, 6 and 12 Months
Jacques Gottenberg¹, Olivier Brocq², Aleth Perdriger³, Slim Lassoued⁴, Jean-Marie Berthelot⁵, Daniel Wendling⁶, Liana Euller-Ziegler⁷, Martin Soubrier⁸, Christophe Richez⁹, Bruno Fautrel¹⁰, Arnaud Constantin¹¹, Xavier Mariette¹², Jacques Morel¹³, Mélanie Gilson¹⁴, Gregoire Cormier¹⁵, Jean Hugues Salmon¹⁶, Stephanie Rist Bouillon¹⁷, Frederic Lioté¹⁸, Hubert Marotte¹⁹, Christine Bonnet²⁰, Christian Marcelli²¹, Jeremie Sellam²², Olivier Meyer²³, Elisabeth Solau-Gervais²⁴, Sandrine Guis²⁵, Jean Marc Ziza²⁶, Charles Zarnitsky²⁷, Isabelle Chary-Valckenaere²⁸, O Vittecoq²⁹, Alain Saraux³⁰, Yves-Marie Pers³¹, Martine Gayraud³², Gilles Bolla³³, Pascal Claudepierre³⁴, Marc Ardizzone³⁵, Emmanuelle Dernis Labous³⁶, Maxime A. Breban³⁷, Olivier Fain³⁸, Jean Charles Balblanc³⁹, Ouafaa Aberkane⁴⁰, Marion Vazel⁴⁰, Christelle Back⁴⁰, Elodie Perrodeau⁴¹, Jean Sibilia⁴² and Philippe Ravaud³², ¹Hautepierre, Strasbourg, France, ²Hospital Center Princesse Grâce, Monaco, Monaco, ³Service de Rhumatologie, CHU de Rennes, Rennes, France, ⁴Rheumatology, Cahors, France, ⁵Rheumatology, University Hospital, Nantes, France, ⁶Université de Franche-Comté, Besançon, France, ⁷Rheumatology, Nice, France, ⁸Rheumatology department CHU Clermont-Ferrand, Clermont-Ferrand, France, ⁹Rheumatology, Bordeaux, France, ¹⁰Rheumatology, AP-HP Pitié-Salpêtrière Hospital / Pierre and Marie Curie University Paris 6 GRC-08 (EEMOIS), Paris, France, ¹¹Rheumatology, CHU Purpan - Hopital Pierre-Paul Riquet, Toulouse, France, ¹²Université Paris-Sud, AP-HP, Hôpitaux Universitaires Paris-Sud, Paris, France, ¹³Department of rheumatology, Lapeyronie Hospital and Montpellier University, Montpellier, France, ¹⁴Hospital Center, Grenoble, France, ¹⁵Rheumatology, La Roche Sur Yon, France, ¹⁶Hôpital Maison Blanche, Rheumatology, REIMS, France, ¹⁷Rhumatologie, Hopital La Source, La Source, France, ¹⁸Rheumatology, Lariboisière, France, ¹⁹INSERM 1059 / LBTO, Université de Lyon, Saint-Etienne; Rheumatology Department, Saint-Etienne, France, ²⁰Rheumatology, CHU Dupuytren, Limoges, France, ²¹Rheumatology, Caen, France, ²²Rheumatology, PARIS, France, ²³Rheumatology, Hopital Bichat, Paris, France, ²⁴Rhumatologie, University Hospital, Poitiers, France, ²⁵Rheumatology, Marseille, France, ²⁶Hopital Croix-Saint-Simon, Paris Cedex 20, France, ²⁷Rheumatology, Le Havre, France, ²⁸Rheumatology, Nancy, France, ²⁹University Hospital, Rouen, France, ³⁰Rheumatology, Brest, France, ³¹Rheumatology, Montpellier, France, ³²Rheumatology, Paris, France, ³³Rheumatology, Cannes, France, ³⁴Rheumatology, Université Paris Est Créteil, Créteil, France, ³⁵Rheumatology, Centre Hospitalier de Mulhouse, Mulhouse, France, ³⁶Réseau Hôpital et Ville en Rhumatologie (RHEVER) Network, Paris, France, ³⁷Rheumatology, A. Paré University Hospital, Boulogne-Billancourt, France, ³⁸Internal Medicine Department, Saint Antoine Hospital, Paris, France, ³⁹Rheumatology, Belffort, France, ⁴⁰Rheumatology, Strasbourg, France, ⁴¹Epidemiologist, Paris, France, ⁴²Department of Rheumatology, Strasbourg University Hospital, Strasbourg, France
Background/Purpose: As many as one third of patients show insufficient response to their first TNF inhibitor (TNF-insufficient response, TNF-IR). The lack of efficacy of one…
Abstract Number: 2373 • 2014 ACR/ARHP Annual Meeting
Compliance in the Rheumatoid Arthritis Comparison of Active Therapies Trial: Triple Vs Etanercept
Sarah Leatherman¹, Hongsheng Wu^2,3, Edward Keystone⁴, Mary Brophy¹ and James O'Dell^5,6, ¹MAVERIC CSPCC (151MAV), VA Boston Healthcare System, Boston, MA, ²VA Boston Healthcare System, Boston, MA, ³Computer Science and Systems, Wentworth Institute of Technology, Boston, MA, ⁴Mount Sinai Hospital, Toronto, ON, Canada, ⁵VA Nebraska-Western Iowa Health Care System, Omaha, NE, ⁶University of Nebraska Medical Center, Omaha, NE
Background/Purpose In the 48-week, double-blinded, noninferiority RACAT trial, 353 methotrexate suboptimal responders were randomized to two treatment strategies, either the addition of sulfasalazine and hydroxychloroquine…
Abstract Number: 1523 • 2014 ACR/ARHP Annual Meeting
Follow-up Data on the Rheumatoid Arthritis Comparison of Active Therapies Trial: Observational Cohort
Robert Lew¹, Denis Rybin², Keri Hannagan³, Hongsheng Wu^4,5, Edward Keystone⁶, Ted R. Mikuls⁷ and James O' Dell⁷, ¹VA Boston Heathcare System, Boston, MA, ²MAVERIC, VA Boston Healthcare System, Boston, MA, ³MAVERIC, VA Boston Heathcare System, Boston, MA, ⁴Computer Science and Systems, Wentworth Institute of Technology, Boston, MA, ⁵VA Boston Healthcare System, Boston, MA, ⁶Mount Sinai Hospital, Toronto, ON, Canada, ⁷Omaha VA Medical Center and University of Nebraska Medical Center, Omaha, NE
Background/Purpose In this 48-week, double-blinded, non-inferiority trial, 353 methotrexate suboptimal-responders were randomized to two treatment strategies, either the addition of sulfasalazine and hydroxychloroquine (triple therapy…
Abstract Number: 462 • 2014 ACR/ARHP Annual Meeting
Infections and Gastrointestinal Side Effects in a Comparison of Rheumatoid Arthritis Therapies
Bei-Hung Chang^1,2, Lien Quach¹, Mary Brophy³, Keri Hannagan⁴, Edward C. Keystone⁵, Ted R. Mikuls⁶ and James R. O'Dell⁷, ¹VA Boston Healthcare System, Boston, MA, ²Qualitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, ³VA Boston Heathcare System, Boston, MA, ⁴MAVERIC, VA Boston Heathcare System, Boston, MA, ⁵Medicine, University of Toronto, Toronto, ON, Canada, ⁶Omaha VA Medical Center and University of Nebraska Medical Center, Omaha, NE, ⁷Veteran Affairs Nebraska Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, NE
Background/Purpose TNF inhibitors and combinations of conventional disease-modifying antirheumatic drugs are commonly added to treat methotrexate non-responsive rheumatoid arthritis patients. In the 48-week double blind,…
Abstract Number: L6 • 2014 ACR/ARHP Annual Meeting
A PHASE 2, Randomized, Double-Blind Comparison of the Efficacy and Safety of PF-04171327 (1, 5, 10, 15 mg QD) Vs 5 and 10 Mg Prednisone QD or Placebo in Subjects with Rheumatoid Arthritis (RA) over 8 Weeks Followed By a 4-Week Taper of Study Drug
Vibeke Strand¹, Frank Buttgereit², Dorothy McCabe³, Sheela Kolluri³, Brinda Tammara³, Ricardo Rojo³ and Judith Hey-Hadavi^3,4, ¹Biopharmaceutical Consultant, Portola Valley, CA, ²Charité University Hospital, Berlin, Germany, ³Pfizer Inc, New York, NY, ⁴Pfizer Inc, NewYork, NY
Background/Purpose: PF-04171327 is a dissociated agonist of the glucocorticoid receptor (DAGR), a selective high-affinity partial agonist of the GR with potent anti-inflammatory activity at exposures…
Abstract Number: 2781 • 2014 ACR/ARHP Annual Meeting
Cost-Effectiveness of Adding Etanercept Vs. Sulfasalazine and Hydroxychloroquine to Methotrexate Therapy: A Randomized Noninferiority Trial
Nick Bansback¹, Ciaran Phibbs², Huiying Sun³, James R. O'Dell⁴, Mary Brophy⁵, Edward C. Keystone⁶, Sarah Leatherman⁷, Ted R. Mikuls⁴ and Aslam H. Anis³, ¹School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, ²Health Economics Resource Center (152), Palo Alto VA Health Care System, Menlo Park, CA, ³St. Paul's Hospital, Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada, ⁴Omaha VA Medical Center and University of Nebraska Medical Center, Omaha, NE, ⁵VA Boston Heathcare System, Boston, MA, ⁶Medicine, University of Toronto, Toronto, ON, Canada, ⁷VA Boston Heatlhcare System, Boston, MA
Background/Purpose: To estimate the incremental cost-effectiveness of etanercept plus methotrexate versus a triple regimen of disease-modifying anti rheumatic drugs (methotrexate, sulfasalazine, and hydroxychloroquine) over 24…
Abstract Number: 1469 • 2013 ACR/ARHP Annual Meeting
Therapeutic Strategy In Patients With Rheumatoid Arthritis and Insufficient Response To a 1^st Anti-TNF: Results of the Multicenter Randomized Controlled “ROC” Trial
Jacques-Eric Gottenberg¹, Olivier Brocq², Aleth Perdriger³, Slim Lassoued⁴, Jean-Marie Berthelot⁵, Daniel Wendling⁶, Liana E. euller-Ziegler⁷, Martin Soubrier⁸, Christophe Richez⁹, Bruno Fautrel¹⁰, Arnaud L. Constantin¹¹, Xavier Mariette¹², Jacques Morel¹³, Melanie Gilson¹⁴, Grégoire Cormier¹⁵, Jean Hugues Salmon¹⁶, Stephanie Rist¹⁷, Frédéric Liote¹⁸, Hubert Marotte¹⁹, Christine Bonnet²⁰, Christian Marcelli²¹, Jeremie Sellam²², Olivier Meyer²³, Elisabeth Solau-Gervais²⁴, Sandrine Guis²⁵, Jean-Marc Ziza²⁶, Charles Zarnitsky²⁷, Isabelle Valckenaere²⁸, Olivier Vittecoq²⁹, Alain Saraux³⁰, Yves-Marie Pers³¹, Martine Gayraud³², Gilles Bolla³³, Pascal Claudepierre³⁴, Marc Ardizzone³⁵, Emmanuelle Dernis³⁶, Maxime A. Breban³⁷, Olivier Fain³⁸, Jean-Charles Balblanc³⁹, Ouafaa Aberkane¹, Marion Vazel¹, Christelle Back¹, Elodie Perrodeau⁴⁰, Philippe Ravaud⁴¹ and Jean Sibilia⁴², ¹Strasbourg University Hospital, Strasbourg, France, ²Hospital of Princesse Grâce de Monaco, Monaco, France, ³Rheumatology, Hôpital Sud, Rennes, France, ⁴Cahors Hospital, Cahors, France, ⁵Rheumatology Unit, Nantes University Hospital, Nantes, France, ⁶Rheumatology, University Hospital, Besancon, France, ⁷Service de Rhumatologie, L Archet Hospital (University), Nice CEDEX 3, France, ⁸Rheumatology, CHU CLERMONT-FERRAND, Clermont-Ferrand, France, ⁹Pellegrin Hospital, Bordeaux, France, ¹⁰Rheumatology, UPMC - Paris 6 University, Paris, France, ¹¹Rheumatology, Purpan University Hospital, Toulouse, France, ¹²Rheumatology Service, Bicêtre University Hospital, Le Kremlin Bicetre, France, ¹³Montpellier University Hospital, Montpellier, France, ¹⁴CH Grenoble Hopital Sud, Grenoble, France, ¹⁵CHD Les Oudairies, LA ROCHE SUR YON, France, ¹⁶Reims Hospital, Reims, France, ¹⁷Rheumatology, Orleans Hospital, Orleans, France, ¹⁸Hôpital Lariboisière, Paris, France, ¹⁹INSERM U1059 and University Hospital, Hôpital Nord, Saint-Etienne, France, ²⁰department of Rheumatology, CHU Dupuytren Limoges, Limoges, France, ²¹Rheumatology Department, Caen University Hospital, CAEN, France, ²²Rheumatology, Hopital Saint-Antoine, Pierre et Marie Curie University Paris 6, AP-HP, 75012, France, ²³Rheumatology, Hopital Bichat, Paris, France, ²⁴Poitiers University Hospital, Poitiers, France, ²⁵Rheumatology1, CRMBM UMR CNRS 7339, Aix Marseille Univ; AP-HM, Marseille, France, ²⁶Rheumatology, Croix Saint Simon Hospital, Paris, France, ²⁷Rheumatology, CH du Havre, Le Havre, France, ²⁸Nancy University Hospital, Nancy, France, ²⁹RouenUniversity Hospital, Rouen, France, ³⁰Rhumatologie, CHU de la Cavale Blanche, Brest Cedex, France, ³¹Department of Immuno-Rhumatology, CHU Lapeyronie, Montpellier, France, ³²Institut Montsouris, Paris, France, ³³Cannes Hospital, Cannes, France, ³⁴Rheumatology, Henri Mondor Teaching Hospital, AP-HP, Créteil, France, ³⁵Mulhouse Hospital, Mulhouse, France, ³⁶Le Mans Hospital, Le Mans, France, ³⁷Ambroise Paré Hospital (AP-HP), and Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, France, ³⁸Internal Medicine, Jean Verdier Hospital, Bondy, France, ³⁹Rheumatology, Centre Hospitalier Général de Belfort, Belfort, France, ⁴⁰Epidemiology, Hotel Dieu, Paris, France, ⁴¹Epidemiology, Hopital Hotel Dieu, Paris Descartes University, Paris, France, ⁴²Rheumatology, CHU Hautepierre, Strasbourg, France
Background/Purpose: TNF inhibitors often represent the 1st biologic prescribed to patients with rheumatoid arthritis (RA). Approximately one third of patients fail to respond. However, therapeutic…

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