Unsupervised Online Paired Associates Learning Task from the Cambridge Neuropsychological Test Automated Battery (CANTAB®) in the Brain Health Registry.

BACKGROUND: Unsupervised online cognitive assessments have demonstrated promise as an efficient and scalable approach for evaluating cognition in aging, and Alzheimer's disease and related dementias. OBJECTIVES: The aim of this study was to evaluate the feasibility, usability, and construct validity of the Paired Associates Learning task from the Cambridge Neuropsychological Test Automated Battery® in adults enrolled in the Brain Health Registry. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: The Paired Associates Learning task was administered to Brain Health Registry participants in a remote, unsupervised, online setting. In this cross-sectional analysis, we 1) evaluated construct validity by analyzing associations between Paired Associates Learning performance and additional participant registry data, including demographics, self- and study partner-reported subjective cognitive change (Everyday Cognition scale), self-reported memory concern, and depressive symptom severity (Patient Health Questionnaire-9) using multivariable linear regression models; 2) determined the predictive value of Paired Associates Learning and other registry variables for identifying participants who self-report Mild Cognitive Impairment by employing multivariable binomial logistic regressions and calculating the area under the receiver operator curve; 3) investigated feasibility by looking at task completion rates and statistically comparing characteristics of task completers and non-completers; and 4) evaluated usability in terms of participant requests for support from BHR related to the assessment. RESULTS: In terms of construct validity, in participants who took the Paired Associates Learning for the first time (N=14,528), worse performance was associated with being older, being male, lower educational attainment, higher levels of self- and study partner-reported decline, more self-reported memory concerns, greater depressive symptom severity, and self-report of Mild Cognitive Impairment. Paired Associates Learning performance and Brain Health Registry variables together identified those with self-reported Mild Cognitive Impairment with moderate accuracy (areas under the curve: 0.66-0.68). In terms of feasibility, in a sub-sample of 29,176 participants who had the opportunity to complete Paired Associates Learning for the first time in the registry, 14,417 started the task. 11,647 (80.9% of those who started) completed the task. Compared to those who did not complete the task at their first opportunity, those who completed were older, had more years of education, more likely to self-identify as White, less likely to self-identify as Latino, less likely to have a subjective memory concern, and more likely to report a family history of Alzheimer's disease. In terms of usability, out of 8,395 received requests for support from BHR staff via email, 4.4% (n=374) were related to PAL. Of those, 82% were related to technical difficulties. CONCLUSIONS: Our findings support moderate feasibility, good usability, and construct validity of cross-sectional Paired Associates Learning in an unsupervised online registry, but also highlight the need to make the assessment more inclusive and accessible to individuals from ethnoculturally and socioeconomically diverse communities. A future, improved version could be a scalable, efficient method to assess cognition in many different settings, including clinical trials, observational studies, healthcare, and public health.

RAD51 loss of function abolishes gene targeting and de-represses illegitimate integration in the moss Physcomitrella patens.

Gene targeting (GT) is a major tool for basic and applied research during which the transforming DNA, which shares sequence homology with a chromosomal target, integrates at the corresponding locus by homologous recombination (HR). In eukaryotes, GT recruits enzymes from the HR-mediated double strand break repair pathway. Different mechanisms of HR have been described which depend on the Rad52 epistasis group of genes, but which specific mechanism is used by the cell for GT remains unclear. In Saccharomyces cerevisiae, the RAD52 protein is essential for GT, and the RAD51 protein plays a minor role. In filamentous fungi and animal cells, however, GT depends on RAD51 and is weakly affected by suppression of RAD52. Genetic evidence also indicates that the non-homologous end-joining pathway of DSB repair has a negative impact on GT efficiencies, but how the balance between these two pathways is controlled is poorly understood. Here, we have examined the role of RAD51 in the only plant that exhibits high GT frequencies, the model bryophyte Physcomitrella patens. Our results show that the two RAD51 proteins have partially redundant functions in the maintenance of genome integrity and resistance to ionizing radiation. Furthermore, we demonstrate that loss of function of the two RAD51 proteins completely abolishes GT and strongly increases illegitimate integration rates in this moss. These findings demonstrate for the first time in plant the critical role of RAD51 in controlling the balance between targeted and random integration events observed upon transgenesis, and confirm that P. patens is a particularly interesting tool for studying GT in higher eukaryotes.

Fear conditioning in frontotemporal lobar degeneration and Alzheimer's disease.

Emotional blunting and abnormal processing of rewards and punishments represent early features of frontotemporal lobar degeneration (FTLD). Better understanding of the physiological underpinnings of these emotional changes can be facilitated by the use of classical psychology approaches. Fear conditioning (FC) is an extensively used paradigm for studying emotional processing that has rarely been applied to the study of dementia. We studied FC in controls (n = 25), Alzheimer's disease (n = 25) and FTLD (n = 25). A neutral stimulus (coloured square on a computer screen) was repeatedly paired with a 1 s burst of 100 db white noise. Change in skin conductance response to the neutral stimulus was used to measure conditioning. Physiological-anatomical correlations were examined using voxel-based morphometry (VBM). Both patient groups showed impaired acquisition of conditioned responses. However, the basis for this deficit appeared to differ between groups. In Alzheimer's disease, impaired FC occurred despite normal electrodermal responses to the aversive stimulus. In contrast, FTLD patients showed reduced skin conductance responses to the aversive stimulus, which contributed significantly to their FC deficit. VBM identified correlations with physiological reactivity in the amygdala, anterior cingulate cortex, orbitofrontal cortex and insula. These data indicate that Alzheimer's disease and FTLD both show abnormalities in emotional learning, but they suggest that in FTLD this is associated with a deficit in basic electrodermal response to aversive stimuli, consistent with the emotional blunting described with this disorder. Deficits in responses to aversive stimuli could contribute to both the behavioural and cognitive features of FTLD and Alzheimer's disease. Further study of FC in humans and animal models of dementia could provide a valuable window into these symptoms.

Family-specific approaches to the analysis of case-control family data.

Case-control studies augmented by the values of responses and covariates from family members allow investigators to study the association between the response and genetics and environment by relating differences in the response directly to within-family differences in covariates. However, existing approaches for case-control family data parameterize covariate effects in terms of the marginal probability of response, the same effects that one estimates from standard case-control studies. This article focuses on the estimation of family-specific covariate effects and develops efficient methods to fit family-specific models such as binary mixed-effects models. We also extend the approach to cover any setting where one has a fully specified model for the vector of responses in a family. We illustrate our approach using data from a case-control family study of brain cancer and consider the use of weighted and conditional likelihood methods as alternatives.

A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.

BACKGROUND: It is uncertain whether the administration of benzodiazepines by paramedics is an effective and safe treatment for out-of-hospital status epilepticus. METHODS: We conducted a randomized, double-blind trial to evaluate intravenous benzodiazepines administered by paramedics for the treatment of out-of-hospital status epilepticus. Adults with prolonged (lasting five minutes or more) or repetitive generalized convulsive seizures received intravenous diazepam (5 mg), lorazepam (2 mg), or placebo. An identical second injection was given if needed. RESULTS: Of the 205 patients enrolled, 66 received lorazepam, 68 received diazepam, and 71 received placebo. Status epilepticus had been terminated on arrival at the emergency department in more patients treated with lorazepam (59.1 percent) or diazepam (42.6 percent) than patients given placebo (21.1 percent) (P=0.001). After adjustment for covariates, the odds ratio for termination of status epilepticus by the time of arrival in the lorazepam group as compared with the placebo group was 4.8 (95 percent confidence interval, 1.9 to 13.0). The odds ratio was 1.9 (95 percent confidence interval, 0.8 to 4.4) in the lorazepam group as compared with the diazepam group and 2.3 (95 percent confidence interval, 1.0 to 5.9) in the diazepam group as compared with the placebo group. The rates of respiratory or circulatory complications (indicated by bag valve-mask ventilation or an attempt at intubation, hypotension, or cardiac dysrhythmia) after the study treatment was administered were 10.6 percent for the lorazepam group, 10.3 percent for the diazepam group, and 22.5 percent for the placebo group (P=0.08). CONCLUSIONS: Benzodiazepines are safe and effective when administered by paramedics for out-of-hospital status epilepticus in adults. Lorazepam is likely to be a better therapy than diazepam.

Regeneration of a lytic central vacuole and of neutral peripheral vacuoles can be visualized by green fluorescent proteins targeted to either type of vacuoles.

Protein trafficking to two different types of vacuoles was investigated in tobacco (Nicotiana tabacum cv SR1) mesophyll protoplasts using two different vacuolar green fluorescent proteins (GFPs). One GFP is targeted to a pH-neutral vacuole by the C-terminal vacuolar sorting determinant of tobacco chitinase A, whereas the other GFP is targeted to an acidic lytic vacuole by the N-terminal propeptide of barley aleurain, which contains a sequence-specific vacuolar sorting determinant. The trafficking and final accumulation in the central vacuole (CV) or in smaller peripheral vacuoles differed for the two reporter proteins, depending on the cell type. Within 2 d, evacuolated (mini-) protoplasts regenerate a large CV. Expression of the two vacuolar GFPs in miniprotoplasts indicated that the newly formed CV was a lytic vacuole, whereas neutral vacuoles always remained peripheral. Only later, once the regeneration of the CV was completed, the content of peripheral storage vacuoles could be seen to appear in the CV of a third of the cells, apparently by heterotypic fusion.

The internal propeptide of the ricin precursor carries a sequence-specific determinant for vacuolar sorting.

Ricin is a heterodimeric toxin that accumulates in the storage vacuoles of castor bean (Ricinus communis) endosperm. Proricin is synthesized as a single polypeptide precursor comprising the catalytic A chain and the Gal-binding B chain joined by a 12-amino acid linker propeptide. Upon arrival in the vacuole, the linker is removed. Here, we replicate these events in transfected tobacco (Nicotiana tabacum) leaf protoplasts. We show that the internal linker propeptide is responsible for vacuolar sorting and is sufficient to redirect the ricin heterodimer to the vacuole when fused to the A or the B chain. This internal peptide can also target two different secretory protein reporters to the vacuole. Moreover, mutation of the isoleucine residue within an NPIR-like motif of the propeptide affects vacuolar sorting in proricin and in the reconstituted A-B heterodimer. This is the first reported example of a sequence-specific vacuolar sorting signal located within an internal propeptide.

Demonstration in yeast of the function of BP-80, a putative plant vacuolar sorting receptor.

BP-80, later renamed VSR(PS-1), is a putative receptor involved in sorting proteins such as proaleurain to the lytic vacuole, with its N-terminal domain recognizing the vacuolar sorting determinant. Although all VSR(PS-1) characteristics and in vitro binding properties described so far favored its receptor function, this function remained to be demonstrated. Here, we used green fluorescent protein (GFP) as a reporter in a yeast mutant strain defective for its own vacuolar receptor, Vps10p. By expressing VSR(PS-1) together with GFP fused to the vacuolar sorting determinant of petunia proaleurain, we were able to efficiently redirect the reporter to the yeast vacuole. VSR(PS-1) is ineffective on GFP either alone or when fused with another type of plant vacuolar sorting determinant from a chitinase. The plant VSR(PS-1) therefore interacts specifically with the proaleurain vacuolar sorting determinant in vivo, and this interaction leads to the transport of the reporter protein through the yeast secretory pathway to the vacuole. This finding demonstrates VSR(PS-1) receptor function but also emphasizes the differences in the spectrum of ligands between Vps10p and its plant equivalent.

Assessing change with longitudinal and clustered binary data.

Investigators often gather repeated measures on study subjects to directly measure how a subject's response changes with changes in explanatory variables. This paper focuses on several statistical issues related to assessing change with longitudinal and clustered binary data. Many popular approaches for analyzing repeated binary outcomes measure cross-sectional or between-subject, rather than within-subject, effects of covariates. The class of models known as cluster specific measures within-subject effects of covariates on responses but are subject to additional statistical complications. It is useful to decompose covariates into between- and within-cluster components. This paper describes several approaches that yield consistent estimates of the within-subject covariate effects of interest. Example data from three studies illustrate the results.

Living arrangements affect dietary quality for U.S. adults aged 50 years and older: NHANES III 1988-1994.

The number and proportion of older U.S. adults who live alone have increased dramatically in the past three decades, and there is concern that these individuals may have particularly poor dietary quality. We examined the association of four living arrangements (living with a spouse only, with a spouse plus someone else, with someone other than a spouse or living alone) with dietary quality (the number of low nutrients out of a possible 15, with low defined as <67% of the recommended dietary allowance) among 6525 U.S. adults aged 50-64 y and those >/=65 y in the third National Health and Nutrition Examination Survey (NHANES III 1988-1994). Among non-Hispanic Caucasian adults, those who lived with a spouse only had better dietary quality, with significant differences ranging from 0.8 to 1.5 fewer low nutrients compared with those with other living arrangements. Effects of living arrangements on dietary quality were also seen among non-Hispanic African-Americans, Mexican-Americans, and those of "other" races, but differences were significant only for African-American men aged >65 y living with a spouse plus others (1.6 additional low nutrients compared with those living with a spouse only). Energy intake was strongly associated with dietary quality, but did not account for the associations between living arrangements and dietary quality. Although middle-aged and older adults with living arrangements other than living with a spouse only (including those living alone) tended to have poorer dietary quality, the effects varied substantially across age, gender and ethnic categories.

Do triglycerides provide meaningful information about heart disease risk?

BACKGROUND: Prior research suggests that adding triglyceride determinations to measurements of total cholesterol and cholesterol subfractions may improve the prediction of coronary heart disease (CHD). OBJECTIVE: To determine the additional value of measuring triglyceride levels, in addition to cholesterol levels and subfractions, for predicting CHD. STUDY DESIGN: A set of secondary analyses of previously reported studies. METHODS: We performed secondary analyses of data from the Multiple Risk Factor Intervention Trial, the Lipid Research Clinics Coronary Primary Prevention Trial, and the Lipid Research Clinics Prevalence and Mortality Follow-Up Study. Predictor variables included the levels of fasting triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and fasting blood glucose; age; blood pressure; cigarette smoking; body mass index; and postmenopausal estrogen use. Analytic methods included Cox proportional hazards models, calculation of stratified crude incidence rates, and measurement of the area under the receiver operating characteristic curve. MAIN OUTCOME MEASURES: Outcome variables were fatal and nonfatal myocardial infarctions. RESULTS: With few exceptions, no significant interactions between cholesterol subfractions and triglyceride levels were found and receiver operating characteristic curve analyses revealed that triglyceride measurements did not improve discrimination between those subjects who did and did not suffer CHD events. In men, categorical analyses employing both triglyceride and cholesterol levels were similar to those using cholesterol categories alone. In the one study of women, those subjects with both a high-risk cholesterol profile and high triglyceride levels were more likely to have a CHD event, though this finding was based on fewer subjects and CHD events. CONCLUSION: These data suggest that, in men, measurement of serum triglyceride levels does not provide clinically meaningful information about CHD risk beyond that obtainable by measurement of serum cholesterol subfractions alone.

Effect of receptive oral sex and smoking on the incidence of hairy leukoplakia in HIV-positive gay men.

We sought to determine whether hairy leukoplakia (HL), an Epstein-Barr virus-related oral lesion, is associated with receptive oral sex activity and cigarette smoking among HIV-positive gay men. Oral examinations were conducted every 6 months among San Francisco Men's Health Study participants over a 6-year period. We fitted time-to-lesion regression models to compare the incidence of HL among men who had mouth-to-penis contact with various numbers of partners, while controlling for cigarette smoking and CD4 count. The 6-year incidence of HL was 32% among 291 HIV-positive men. We found no significant increase in the hazard of developing HL for each additional insertive-oral-sex male partner in the past 6 months (relative hazard = 1.01; 95% confidence interval [CI], 0.99, 1.02), and a similar lack of association when number of sex partners was categorized. However, the hazard of developing HL doubled with any 300-unit decrease in CD4 count (95% CI, 1.4, 2.7), or if men smoked > or =20 cigarettes/day compared with nonsmokers (95% CI, 1.2, 3.9). This finding, which may suggest one effect that smoking produces on the oral mucosa's local immune response, merits further investigation.

Subcellular localization and in vivo identification of the putative movement protein of olive latent virus 2.

The gene encoding the 36.5 kDa ('36K') nonstructural protein located on RNA3 of olive latent virus 2 (OLV-2) was cloned, expressed with the Escherichia coli pGEX-2T system and the purified protein used to raise a polyclonal antiserum. Immunoblot analysis of OLV-2-infected Nicotiana benthamiana plants showed that the 36K protein accumulated in the early stages of infection and was associated with a subcellular fraction enriched in cytoplasmic membranes. In infected cells there were tubular structures, some containing virus-like particles, scattered in the cytoplasm or protruding from or penetrating the cell wall at the plasmodesmata. Immunogold labelling localized the 36K protein in the plasmodesmata of OLV-2-infected cells and showed it to be associated with virus-containing tubules. Leaf trichome cells of N. tabacum plants, transformed with a 36K-green fluorescent protein (GFP) fusion construct, revealed localized fluorescence in the cell walls, possibly due to association of the fusion protein with plasmodesmata. When the same 36K-GFP fusion protein was expressed in N. tabacum protoplasts, long tubular fluorescent structures protruded from the protoplast surface, suggesting that the 36K protein is responsible for tubule induction. The conclusion is drawn that this protein is likely to be the OLV-2 movement protein, mediating cell-to-cell virus movement, and that movement is by a tubule-guided mechanism.

Dental care access and use among HIV-infected women.

OBJECTIVES: This study sought to identify predictors of dental care use in HIV-infected women. METHODS: In a cross-sectional survey of HIV-infected women enrolled in the northern California site of the Women's Interagency HIV Study, dental care use and unmet need were assessed in relation to selected variables. RESULTS: Among 213 respondents, who were predominantly Black and younger than 45 years, 43% had not seen a dentist and 53% (among dentate women) reported no dental cleaning in more than a year (although 67% had dental insurance coverage, mainly state Medicaid). Nine percent were edentulous. Among nonusers of dental care, 78% reported that they wanted care but failed to get it. Barriers included fear of and discomfort with dentists, not getting around to making an appointment, and not knowing which dentist to visit. Multivariate analysis showed that lack of past-year dental care was associated mainly with unemployment, a perception of poor oral health, and edentulism. CONCLUSIONS: HIV-positive women appear to be underusing dental care services. Fear and lack of information regarding available resources, in addition to unemployment and perception of poor oral health, may be important barriers.

Differential immune system changes with acute and persistent stress for optimists vs pessimists.

This study investigated whether acute and persistent stressors and life change events were followed by changes in immune status, and whether dispositional optimism moderated these relationships. Thirty-nine healthy women ages 18-45 were followed prospectively for 3 months, with weekly assessment of acute and persistent stressors and monthly assessment of life events and immune parameters (NK cell cytotoxicity, and CD4 and CD8 T cell subsets). The study used an autoregressive linear model to examine how weekly appraised acute and persistent stress levels were associated with immune parameters in the subsequent week. Analyses revealed that the immune outcomes were differentially affected by acute and persistent stressors. Further, the association between acute stress and subsequent immune parameters was buffered by an optimistic perspective. However, when stress persisted at high levels, optimists showed more subsequent immune decrements than pessimists.

Persistent stress as a predictor of genital herpes recurrence.

BACKGROUND: Results of several studies suggest that psychological stress and negative mood can trigger genital herpes recurrences, but results are inconsistent. OBJECTIVE: To determine whether short-term or persistent psychological stress or specific negative moods are predictive of genital herpes recurrences in women. METHODS: A prospective cohort study followed up participants for 6 months using weekly assessments of stress and mood, monthly assessments of life change events, and diary reports of genital herpes recurrences confirmed by medical examination when feasible. The community sample consisted of 58 women, aged 20 to 44 years, with a 1- to 10-year history of visible genital herpes recurrence and at least 1 recurrence in the previous 6 months. RESULTS: Persistent stress predicted recurrence in the subsequent week (odds ratio, 1.08 per unit increase in stress; 95% confidence interval, 1.01-1.15; P=.03). After adjusting for recurrence in the previous week, the more weekly persistent stress reported, the greater the likelihood of recurrence the following week. Also, an increased recurrence rate occurred after the month during which participants experienced their highest levels of anxiety (P =.03). There were no significant associations between recurrence and short-term stress, life events, depressive mood, anger, or phase of menstrual cycle. CONCLUSIONS: Persistent stressors and highest level of anxiety predicted genital herpes recurrence, whereas transient mood states, short-term stressors, and life change events did not. Women with herpes can be reassured that short-term stressful life experiences and dysphoric mood states do not put them at risk for increased outbreaks of recurrent genital herpes.

Specific accumulation of GFP in a non-acidic vacuolar compartment via a C-terminal propeptide-mediated sorting pathway.

The green fluorescent protein (GFP) from Aequorea victoria can be detected in living plant cells after transient transformation of protoplasts. Expression of the GFP can be used to monitor protein trafficking in a mixed cell population and also to study the different function and importance of organelles in different cell types. We developed a vacuolar form of GFP that was obtained by replacing the C-terminal endoplasmic reticulum (ER)-retention motif of mGFP5-ER by the vacuolar targeting peptide of tobacco chitinase A. The vacuolar GFP was transported and accumulated in the vacuole as expected. However, we found two patterns of GFP accumulation after prolonged incubation (18-24 h) depending on the cell type. Most chloroplast-rich protoplasts had a fluorescent large central vacuole. In contrast, most chloroplast-poor protoplasts accumulated the GFP in one smaller vacuole but not in the large central vacuole, which was visible under a light microscope in the same cell. This differential accumulation reflected the existence of two different vacuolar compartments as described recently by immunolocalization of several vacuolar markers. We were able to characterize the vacuolar compartment to which GFP is specifically targeted as non-acidic, since it did not accumulate neutral red while acidic vacuoles did not accumulate GFP.

Sorting of proteins to vacuoles in plant cells.

An individual plant cell may contain at least two functionally and structurally distinct types of vacuoles: protein storage vacuoles and lytic vacuoles. Presumably a cell that stores proteins in vacuoles must maintain these separate compartments to prevent exposure of the storage proteins to an acidified environment with active hydrolytic enzymes where they would be degraded. Thus, the organization of the secretory pathway in plant cells, which includes the vacuoles, has a fascinating complexity not anticipated from the extensive genetic and biochemical studies of the secretory pathway in yeast. Plant cells must generate the membranes to form two separate types of tonoplast, maintain them as separate organelles, and direct soluble proteins from the secretory flow specifically to one or the other via separate vesicular pathways. Individual soluble and membrane proteins must be recognized and sorted into one or the other pathway by distinct, specific mechanisms. Here we review the emerging picture of how separate plant vacuoles are organized structurally and how proteins are recognized and sorted to each type.

Between- and within-cluster covariate effects in the analysis of clustered data.

Standard methods for the regression analysis of clustered data postulate models relating covariates to the response without regard to between- and within-cluster covariate effects. Implicit in these analyses is the assumption that these effects are identical. Example data show that this is frequently not the case and that analyses that ignore differential between- and within-cluster covariate effects can be misleading. Consideration of between- and within-cluster effects also helps to explain observed and theoretical differences between mixture model analyses and those based on conditional likelihood methods. In particular, we show that conditional likelihood methods estimate purely within-cluster covariate effects, whereas mixture model approaches estimate a weighted average of between- and within-cluster covariate effects.

Variation among rheumatologists in clinical outcomes and frequency of office visits for rheumatoid arthritis.

OBJECTIVE: To estimate the variation among rheumatologists in clinical outcomes and frequency of office visits for patients with rheumatoid arthritis (RA), after accounting for patient demographic and clinical characteristics and treatments prescribed. METHODS: Multiple regression analysis using random effects for rheumatologists and adjustments for patient characteristics and treatments received, based on data derived from a panel study of persons with RA. RESULTS: During the years 1984-1993, rheumatologists accounted for a moderate amount of the total variation in clinical outcomes and nearly one-third of the total variation in frequency of office visits. For example, in 1993 rheumatologist associated variation in 4 clinical outcomes ranged from 16 to 25%, while the variation in office visit frequency attributable to rheumatologists stood at 46% of the total variation. However, rheumatologist associated variation in clinical outcomes was not statistically significant in any year, while variation in office visits was highly significant in all years (p < or = 0.0001). Although there was an increase in the percentage of variation attributable to rheumatologists for all outcomes examined across the years of this study, the time trend reached statistical significance only for frequency of office visits (2.4% per year; p = 0.0135) and functional status (1.6% per year; p = 0.0034). CONCLUSION: The magnitude and strength of rheumatologist associated variation in frequency of office visits, without comparable strength in the variation in clinical outcomes, may suggest inefficiencies in the use of resources for the care of persons with RA. Further work is needed to directly examine the relationship between health outcomes and resource utilization.