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Roberson EDO, Mesa RA, Morgan GA, Cao L, Marin W, Pachman LM. Transcriptomes of peripheral blood mononuclear cells from juvenile dermatomyositis patients show elevated inflammation even when clinically inactive. Sci Rep 2022; 12:275. [PMID: 34997119 PMCID: PMC8741808 DOI: 10.1038/s41598-021-04302-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022] Open
Abstract
In juvenile dermatomyositis (JDM), the most common pediatric inflammatory myopathy, weakness is accompanied by a characteristic rash that often becomes chronic and is associated with vascular damage. We hoped to understand the molecular underpinnings of JDM, particularly when untreated, which would facilitate the identification of novel mechanisms and clinical targets that might disrupt disease progression. We studied the RNA-Seq data from untreated JDM peripheral blood mononuclear cells (PBMCs; n = 11), PBMCs from a subset of the same patients when clinically inactive (n = 8/11), and separate samples of untreated JDM skin and muscle (n = 4 each). All JDM samples were compared to non-inflammatory control tissues. The untreated JDM PBMCs showed a strong signature for type1 interferon response, along with IL-1, IL-10, and NF-κB. Surprisingly, PBMCs from clinically inactive JDM individuals had persistent immune activation that was enriched for IL-1 signaling. JDM skin and muscle both showed evidence for type 1 interferon activation and genes related to antigen presentation and decreased expression of cellular respiration genes. Additionally, we found that PBMC gene expression correlates with disease activity scores (DAS; skin, muscle, and total domains) and with nailfold capillary end row loop number (an indicator of microvascular damage). This included otoferlin, which was significantly increased in untreated JDM PBMCs and correlated with all 3 DAS domains. Overall, these data demonstrate that PBMC transcriptomes are informative of molecular disruptions in JDM and provide transcriptional evidence of chronic inflammation despite clinical quiescence.
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Affiliation(s)
- Elisha D O Roberson
- Division of Rheumatology, Department of Medicine, Washington University, 660 South Euclid Avenue, MSC 8045-0020-10, St. Louis, MO, 63110, USA. .,Department of Genetics, Washington University, St. Louis, MO, USA.
| | - Rosana A Mesa
- Division of Rheumatology, Department of Medicine, Washington University, 660 South Euclid Avenue, MSC 8045-0020-10, St. Louis, MO, 63110, USA
| | - Gabrielle A Morgan
- Division of Pediatric Rheumatology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 50, Chicago, IL, 60611, USA
| | - Li Cao
- Division of Rheumatology, Department of Medicine, Washington University, 660 South Euclid Avenue, MSC 8045-0020-10, St. Louis, MO, 63110, USA
| | - Wilfredo Marin
- Cure JM Center of Excellence in Juvenile Myositis (JM) Research and Care, Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Lauren M Pachman
- Division of Pediatric Rheumatology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 50, Chicago, IL, 60611, USA. .,Cure JM Center of Excellence in Juvenile Myositis (JM) Research and Care, Stanley Manne Children's Research Institute, Chicago, IL, USA. .,Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Gargh K, Al-Abadi E, Low S, Harrison K, Coles W, Davis P, Johnson K. Juvenile Dermatomyositis Magnetic Resonance Imaging Score (JIS) does not correlate with criteria for clinically inactive disease: a single-centre retrospective evaluation. Rheumatol Int 2021; 42:1221-1226. [PMID: 34796407 PMCID: PMC9203389 DOI: 10.1007/s00296-021-05049-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022]
Abstract
The Paediatric Rheumatology International Trials Organisation (PRINTO) criteria for clinically inactive disease (CID) and their proposal for glucocorticoid tapering do not consider MRI findings, despite the growing use of MRI and development of reliable MRI scoring tools. We aim to evaluate how CID correlates with MRI scores and physician decision making. We retrospectively used the Juvenile Dermatomyositis Imaging Score (JIS) to score MRIs of all children with JDM over a 10-year period. Demographic, diagnosis, treatment and core set measures data were collected. Correlation between CID and JIS was assessed as well as correlation with the physician treatment decision. There were 25 patients with 59 follow-up episodes to analyse correlation between physician treatment decision and JIS; and 50 episodes for the CID category and JIS correlation. JIS was not significantly associated with the CID category but did correlate with the physician decision. No significant association was found between clinical decision and CID category. The JIS area under the ROC curve (AUC) was 0.80 (95% CI 0.62-0.99) with a score ≥ 8 to predict an escalation. JIS sensitivity and specificity were both 78% with accuracy of 78%, compared to only 67%, 46% and 49%, respectively, for the CID criteria. Clinical criteria alone are not sufficient to assess disease activity status. Clinical decision trends correlated to MRI findings but not PRINTO CID criteria. Multi centre prospective studies are needed to replicate our findings and establish how to best use MRI as a biomarker of disease activity.
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Affiliation(s)
- Kapil Gargh
- Childhood Arthritis and Rheumatic Diseases Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, West Midlands, UK
| | - Eslam Al-Abadi
- Childhood Arthritis and Rheumatic Diseases Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, West Midlands, UK.
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, West Midlands, UK.
| | - Samantha Low
- Radiology Department, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, West Midlands, UK
| | - Kathryn Harrison
- Childhood Arthritis and Rheumatic Diseases Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, West Midlands, UK
| | - William Coles
- Childhood Arthritis and Rheumatic Diseases Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, West Midlands, UK
| | - Penny Davis
- Childhood Arthritis and Rheumatic Diseases Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, West Midlands, UK
| | - Karl Johnson
- Radiology Department, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, West Midlands, UK
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Pachman LM, Nolan BE, DeRanieri D, Khojah AM. Juvenile Dermatomyositis: New Clues to Diagnosis and Therapy. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021; 7:39-62. [PMID: 34354904 PMCID: PMC8336914 DOI: 10.1007/s40674-020-00168-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To identify clues to disease activity and discuss therapy options. RECENT FINDINGS The diagnostic evaluation includes documenting symmetrical proximal muscle damage by exam and MRI, as well as elevated muscle enzymes-aldolase, creatine phosphokinase, LDH, and SGOT-which often normalize with a longer duration of untreated disease. Ultrasound identifies persistent, occult muscle inflammation. The myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) are associated with specific disease course variations. Anti-NXP-2 is found in younger children and is associated with calcinosis; anti-TIF-1γ+ juvenile dermatomyositis has a longer disease course. The diagnostic rash-involving the eyelids, hands, knees, face, and upper chest-is the most persistent symptom and is associated with microvascular compromise, reflected by loss of nailfold (periungual) end row capillaries. This loss is associated with decreased bioavailability of oral prednisone; the bioavailability of other orally administered medications should also be considered. At diagnosis, at least 3 days of intravenous methyl prednisolone may help control the HLA-restricted and type 1/2 interferon-driven inflammatory process. The requirement for avoidance of ultraviolet light exposure mandates vitamin D supplementation. SUMMARY This often chronic illness targets the cardiovascular system; mortality has decreased from 30 to 1-2% with corticosteroids. New serological biomarkers indicate occult inflammation: ↑CXCL-10 predicts a longer disease course. Some biologic therapies appear promising.
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Affiliation(s)
- Lauren M. Pachman
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Cure JM Center of Excellence in Juvenile Myositis Research and Care, The Stanley Manne Research Center for Children, Chicago, IL, USA
| | - Brian E. Nolan
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Deidre DeRanieri
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Amer M. Khojah
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Division of Allergy/Immunology, Chicago, IL, USA, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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Tawalbeh SM, Marin W, Morgan GA, Dang UJ, Hathout Y, Pachman LM. Serum protein biomarkers for juvenile dermatomyositis: a pilot study. BMC Rheumatol 2020; 4:52. [PMID: 33015544 PMCID: PMC7528471 DOI: 10.1186/s41927-020-00150-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Blood accessible biomarkers to assess disease activity and their response to therapies in Juvenile Dermatomyositis (JDM) are urgently needed. This pilot study aims to identify serum protein biomarkers associated with clinical disease activity in untreated JDM and their response to medical therapy. METHODS SomaScan® technology screened JDM patients for 1305 proteins at three points: 1) before start of treatment, 2) while on therapy, and 3) after treatment tapering when patients were clinically inactive. To define disease associated biomarkers, SomaScan® data from untreated JDM patients (n = 8) were compared to SomaScan® data from an independent age-matched healthy control group (n = 12). Longitudinal analysis defined treatment responsive proteins at three time points: untreated (7 samples), treated (7 samples), and clinically inactive (6 samples). To confirm the SomaScan® data, a subset of nine candidate proteins (CXCL11, IL-17B, IL-17D, IL-22, CXCL10, MCP-1, ANGPT2, MIF, IL-23) were tested by ELISA after adding 2 JDM (one untreated, one clinically inactive) serum samples to the same group of JDM girls (8 untreated, 7 treated; 7 clinically inactive) as well as with 17 age, gender, matched healthy controls. RESULTS Comparison of untreated JDM versus healthy controls identified 202 elevated and 49 decreased serum proteins in JDM patients with an adjusted p-value < 0.001. Only 82 out of 251 identified biomarker candidates responded to treatment while 12 out of these 82 proteins returned to their original untreated disease levels upon therapy tapering. The ELISA testing of the untreated samples for nine candidate proteins confirmed previously known biomarkers (CXCL10 or IP-10, CXCL11 or I-TAC and MCP-1) and identified novel biomarkers including IL-22, Angiopoetin-2, and IL-17B in a cross-sectional analysis comparing 8 untreated JDM and 17 age/gender matched controls. The subsequent longitudinal data by ELISA were not concordant for some biomarkers (IL-22 and IL-17B), but the other biomarkers either normalized or rebounded concordantly. CONCLUSIONS Blood accessible protein biomarkers reflecting JDM pathophysiology were identified; some of them rebounded after therapy was tapered. Further studies bridging these biomarkers to specific clinical features of JDM are required to confirm the clinical utility of these serum protein biomarkers.
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Affiliation(s)
- Shefa M. Tawalbeh
- Biomedical Engineering Department, State University of New York at Binghamton, Binghamton, New York USA
- School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Binghamton, Johnson City, New York USA
| | - Wilfredo Marin
- Department of Pediatrics, Northwestern’s Feinberg School of Medicine, Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children’s Hospital; Cure JM Program of Excellence in Juvenile Myositis Research, Stanley Manne Children’s Research Institute of Chicago, Chicago, IL USA
| | - Gabrielle A. Morgan
- Department of Pediatrics, Northwestern’s Feinberg School of Medicine, Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children’s Hospital; Cure JM Program of Excellence in Juvenile Myositis Research, Stanley Manne Children’s Research Institute of Chicago, Chicago, IL USA
| | - Utkarsh J. Dang
- School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Binghamton, Johnson City, New York USA
| | - Yetrib Hathout
- School of Pharmacy and Pharmaceutical Sciences, State University of New York at Binghamton, Binghamton, Johnson City, New York USA
| | - Lauren M. Pachman
- Department of Pediatrics, Northwestern’s Feinberg School of Medicine, Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children’s Hospital; Cure JM Program of Excellence in Juvenile Myositis Research, Stanley Manne Children’s Research Institute of Chicago, Chicago, IL USA
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Wienke J, Pachman LM, Morgan GA, Yeo JG, Amoruso MC, Hans V, Kamphuis SSM, Hoppenreijs EPAH, Armbrust W, van den Berg JM, Hissink Muller PCE, Gelderman KA, Arkachaisri T, van Wijk F, van Royen-Kerkhof A. Endothelial and Inflammation Biomarker Profiles at Diagnosis Reflecting Clinical Heterogeneity and Serving as a Prognostic Tool for Treatment Response in Two Independent Cohorts of Patients With Juvenile Dermatomyositis. Arthritis Rheumatol 2020; 72:1214-1226. [PMID: 32103637 PMCID: PMC7329617 DOI: 10.1002/art.41236] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 02/06/2020] [Indexed: 12/22/2022]
Abstract
Objective Juvenile dermatomyositis (DM) is a heterogeneous systemic immune‐mediated vasculopathy. This study was undertaken to 1) identify inflammation/endothelial dysfunction–related biomarker profiles reflecting disease severity at diagnosis, and 2) establish whether such biomarker profiles could be used for predicting the response to treatment in patients with juvenile DM. Methods In total, 39 biomarkers related to activation of endothelial cells, endothelial dysfunction, and inflammation were measured using multiplex technology in serum samples from treatment‐naive patients with juvenile DM from 2 independent cohorts (n = 30 and n = 29). Data were analyzed by unsupervised hierarchical clustering, nonparametric tests with correction for multiple comparisons, and Kaplan‐Meier tests with Cox proportional hazards models for analysis of treatment duration. Myositis‐specific antibodies (MSAs) were measured in the patients’ serum using line blot assays. Results Severe vasculopathy in patients with juvenile DM was associated with low serum levels of intercellular adhesion molecule 1 (Spearman's rho [rs] = 0.465, P = 0.0111) and high serum levels of endoglin (rs = −0.67, P < 0.0001). In the discovery cohort, unsupervised hierarchical clustering analysis of the biomarker profiles yielded 2 distinct patient clusters, of which the smaller cluster (cluster 1; n = 8) exhibited high serum levels of CXCL13, CCL19, galectin‐9, CXCL10, tumor necrosis factor receptor type II (TNFRII), and galectin‐1 (false discovery rate <0.0001), and this cluster had greater severity of muscle disease and global disease activity (each P < 0.05 versus cluster 2). In the validation cohort, correlations between the serum levels of galectin‐9, CXCL10, TNFRII, and galectin‐1 and the severity of global disease activity were confirmed (rs = 0.40–0.52, P < 0.05). Stratification of patients according to the 4 confirmed biomarkers identified a cluster of patients with severe symptoms (comprising 64.7% of patients) who were considered at high risk of requiring more intensive treatment in the first 3 months after diagnosis (P = 0.0437 versus other cluster). Moreover, high serum levels of galectin‐9, CXCL10, and TNFRII were predictive of a longer total treatment duration (P < 0.05). The biomarker‐based clusters were not evidently correlated with patients’ MSA serotypes. Conclusion Results of this study confirm the heterogeneity of new‐onset juvenile DM based on serum biomarker profiles. Patients with high serum levels of galectin‐9, CXCL10, TNFRII, and galectin‐1 may respond suboptimally to conventional treatment, and may therefore benefit from more intensive monitoring and/or treatment.
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Affiliation(s)
- Judith Wienke
- University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Lauren M Pachman
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, and the Cure JM Center of Excellence, Chicago, Illinois
| | - Gabrielle A Morgan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, and the Cure JM Center of Excellence, Chicago, Illinois
| | - Joo Guan Yeo
- KK Women's and Children's Hospital, and Duke-NUS Medical School, Singapore, Singapore
| | - Maria C Amoruso
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, and the Cure JM Center of Excellence, Chicago, Illinois
| | - Victoria Hans
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, and the Cure JM Center of Excellence, Chicago, Illinois
| | - Sylvia S M Kamphuis
- Sophia Children's Hospital and Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Wineke Armbrust
- Beatrix Children's Hospital and University Medical Centre Groningen, Groningen, The Netherlands
| | - J Merlijn van den Berg
- Emma Children's Hospital and Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Petra C E Hissink Muller
- Sophia Children's Hospital and Erasmus University Medical Centre, Rotterdam, The Netherlands, and Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Femke van Wijk
- University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
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Bellutti Enders F, Bader-Meunier B, Baildam E, Constantin T, Dolezalova P, Feldman BM, Lahdenne P, Magnusson B, Nistala K, Ozen S, Pilkington C, Ravelli A, Russo R, Uziel Y, van Brussel M, van der Net J, Vastert S, Wedderburn LR, Wulffraat N, McCann LJ, van Royen-Kerkhof A. Consensus-based recommendations for the management of juvenile dermatomyositis. Ann Rheum Dis 2016; 76:329-340. [PMID: 27515057 PMCID: PMC5284351 DOI: 10.1136/annrheumdis-2016-209247] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/09/2016] [Accepted: 05/17/2016] [Indexed: 12/17/2022]
Abstract
Background In 2012, a European initiative called Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases. Juvenile dermatomyositis (JDM) is a rare disease within the group of paediatric rheumatic diseases (PRDs) and can lead to significant morbidity. Evidence-based guidelines are sparse and management is mostly based on physicians' experience. Consequently, treatment regimens differ throughout Europe. Objectives To provide recommendations for diagnosis and treatment of JDM. Methods Recommendations were developed by an evidence-informed consensus process using the European League Against Rheumatism standard operating procedures. A committee was constituted, consisting of 19 experienced paediatric rheumatologists and 2 experts in paediatric exercise physiology and physical therapy, mainly from Europe. Recommendations derived from a validated systematic literature review were evaluated by an online survey and subsequently discussed at two consensus meetings using nominal group technique. Recommendations were accepted if >80% agreement was reached. Results In total, 7 overarching principles, 33 recommendations on diagnosis and 19 recommendations on therapy were accepted with >80% agreement among experts. Topics covered include assessment of skin, muscle and major organ involvement and suggested treatment pathways. Conclusions The SHARE initiative aims to identify best practices for treatment of patients suffering from PRD. Within this remit, recommendations for the diagnosis and treatment of JDM have been formulated by an evidence-informed consensus process to produce a standard of care for patients with JDM throughout Europe.
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Affiliation(s)
- Felicitas Bellutti Enders
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.,Division of Allergology, Immunology and Rheumatology, Department of Pediatrics, University Hospital, Lausanne, Switzerland
| | - Brigitte Bader-Meunier
- Department for Immunology, Hematology and Pediatric Rheumatology, Necker Hospital, APHP, Institut IMAGINE, Paris, France
| | - Eileen Baildam
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Tamas Constantin
- 2nd Department of Pediatrics, Semmelweis Hospital, Budapest, Hungary
| | - Pavla Dolezalova
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Brian M Feldman
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Pekka Lahdenne
- Department of Pediatric Rheumatology, Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Bo Magnusson
- Paediatric Rheumatology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital Stockholm, Sweden
| | - Kiran Nistala
- Centre for Adolescent Rheumatology, Institute of Child Health University College London, London, UK
| | - Seza Ozen
- Department of Paediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Clarissa Pilkington
- Centre for Adolescent Rheumatology, Institute of Child Health University College London, London, UK
| | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | - Ricardo Russo
- Service of Immunology and Rheumatology, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Yosef Uziel
- Department of Paediatrics, Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marco van Brussel
- Division of Pediatrics, Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janjaap van der Net
- Division of Pediatrics, Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sebastiaan Vastert
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Lucy R Wedderburn
- Centre for Adolescent Rheumatology, Institute of Child Health University College London, London, UK
| | - Nicolaas Wulffraat
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Liza J McCann
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Annet van Royen-Kerkhof
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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