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Nikolaidou A, Beis I, Dragoumi P, Zafeiriou D. Neuropsychiatric manifestations associated with Juvenile Systemic Lupus Erythematosus: An overview focusing on early diagnosis. Brain Dev 2024; 46:125-134. [PMID: 38061949 DOI: 10.1016/j.braindev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024]
Abstract
Juvenile systemic lupus erythematosus (jSLE) is a chronic multisystem inflammatory disease that manifests before the age of 16 years, following a remitting - relapsing course. The clinical presentation in children is multifaceted, most commonly including constitutional, hematological, cutaneous, renal, and neuropsychiatric symptoms. Neuropsychiatric manifestations range widely, affecting approximately 14-95 % of jSLE patients. They are associated with high morbidity and mortality, particularly at a younger age. Headaches, seizures, cognitive dysfunction, and mood disorders are the most frequent neuropsychiatric manifestations. The pathophysiological mechanism is quite complex and has not yet been fully investigated, with autoantibodies being the focus of research. The diagnosis of neuropsychiatric jSLE remains challenging and exclusionary. In this article we review the clinical neuropsychiatric manifestations associated with jSLE with the aim that early diagnosis and prompt treatment is achieved in children and adolescents with the disease.
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Affiliation(s)
- Anna Nikolaidou
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Beis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
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Natoli V, Charras A, Hahn G, Hedrich CM. Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus (jSLE). Mol Cell Pediatr 2023; 10:5. [PMID: 37556020 PMCID: PMC10412509 DOI: 10.1186/s40348-023-00161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a rare autoimmune/inflammatory disease with significant morbidity and mortality. Approximately 15-20% of SLE patients develop the disease during childhood or adolescence (juvenile-onset SLE/jSLE). Patients with jSLE exhibit more variable and severe disease when compared to patients with disease-onset during adulthood. Neuropsychiatric (NP) involvement is a clinically heterogenous and potentially severe complication. Published reports on the incidence and prevalence of NP-jSLE are scarce, and the exact pathophysiology is poorly understood.This manuscript provides a review of the existing literature, suggesting NP involvement in 13.5-51% of jSLE patients. Among patients with NP-jSLE affecting the CNS, we propose two main subgroups: (i) a chronic progressive, predominantly type 1 interferon-driven form that poorly responds to currently used treatments, and (ii) an acutely aggressive form that usually presents early during the disease that may be primarily mediated by auto-reactive effector lymphocytes. While this hypothesis requires to be tested in large collaborative international cohort studies, it may offer future patient stratification and individualised care.
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Affiliation(s)
- Valentina Natoli
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Amandine Charras
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gabriele Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Liu LH, Lee MD, Huang TH, Chu SH, Hsieh MY. Case report: Endovascular treatment of acute limb ischemia in an adolescent with newly diagnosed lupus. Front Cardiovasc Med 2023; 10:1152929. [PMID: 37324623 PMCID: PMC10267874 DOI: 10.3389/fcvm.2023.1152929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
We report a 14-year-old adolescent who presented with acute limb ischemia caused by systemic lupus erythematosus-related antiphospholipid syndrome (APS). In the pediatric population, acute limb ischemia is rare. This case is unique in that after the initial medical treatment failed, interventional devices for acute stroke intervention were utilized to salvage the limb in our patient with a small tibial artery vessel to achieve procedural success. To provide limb salvage, operators may combine peripheral and neuro-intervention devices to maximize procedure success.
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Affiliation(s)
- Lu-Hang Liu
- Division of Cardiology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Ming-Dar Lee
- Division of Nephrology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Ting-Huan Huang
- Division of Hematology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Szu-Hung Chu
- Division of Immunology, Department of Pediatrics, Mackay Memorial Hospital, Hsin-Chu, Taiwan
| | - Mu-Yang Hsieh
- Cardiovascular Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan
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Appenzeller S, Pereira DR, Julio PR, Reis F, Rittner L, Marini R. Neuropsychiatric manifestations in childhood-onset systemic lupus erythematosus. Lancet Child Adolesc Health 2022; 6:571-581. [PMID: 35841921 DOI: 10.1016/s2352-4642(22)00157-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Neuropsychiatric manifestations occur frequently and are challenging to diagnose in childhood-onset systemic lupus erythematosus (SLE). Most patients with childhood-onset SLE have neuropsychiatric events in the first 2 years of disease. 30-70% of patients present with more than one neuropsychiatric event during their disease course, with an average of 2-3 events per person. These symptoms are associated with disability and mortality. Serum, cerebrospinal fluid, and neuroimaging findings have been described in childhood-onset SLE; however, only a few have been validated as biomarkers for diagnosis, monitoring response to treatment, or prognosis. The aim of this Review is to describe the genetic risk, clinical and neuroimaging characteristics, and current treatment strategies of neuropsychiatric manifestations in childhood-onset SLE.
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Affiliation(s)
- Simone Appenzeller
- Department of Orthopedics, Rheumatology, and Traumatology, University of Campinas, Campinas, Brazil; Rheumatology Laboratory, University of Campinas, Campinas, Brazil.
| | - Danilo Rodrigues Pereira
- Rheumatology Laboratory, University of Campinas, Campinas, Brazil; Medical Physiopathology Graduate Program, University of Campinas, Campinas, Brazil
| | - Paulo Rogério Julio
- Rheumatology Laboratory, University of Campinas, Campinas, Brazil; Child and Adolescent Health Graduate Program, University of Campinas, Campinas, Brazil
| | - Fabiano Reis
- Department of Radiology, University of Campinas, Campinas, Brazil
| | - Leticia Rittner
- School of Medical Science; School of Electrical and Computer Engineering, University of Campinas, Campinas, Brazil
| | - Roberto Marini
- Pediatric Rheumatology Unit, Department of Pediatrics, University of Campinas, Campinas, Brazil
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5
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OUP accepted manuscript. Rheumatology (Oxford). [DOI: 10.1093/rheumatology/keac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/19/2022] [Indexed: 11/14/2022] Open
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Abstract
PURPOSE OF REVIEW Elucidating the pathogenic mechanisms mediated by antiphospholipid antibodies (aPL) might exert important clinical implications in pediatric antiphospholipid syndrome (APS). RECENT FINDINGS aPL are traditionally regarded as the main pathogenic players in APS, inducing thrombosis via the interaction with fluid-phase and cellular components of coagulation. Recent APS research has focused on the role of β2 glycoprotein I, which bridges innate immunity and coagulation. In pediatric populations, aPL should be screened in appropriate clinical settings, such as thrombosis, multiple-organ dysfunction, or concomitant systemic autoimmune diseases. Children positive for aPL tests often present non-thrombotic non-criteria manifestations or asymptomatic aPL positivity. In utero aPL exposure has been suggested to result in developmental disabilities, warranting long-term follow-up. The knowledge of the multifaceted nature of pediatric APS should be implemented to reduce the risk of underdiagnosing/undertreating this condition. Hopefully, recent pathogenic insights will open new windows of opportunity in the management of pediatric APS.
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Affiliation(s)
- Silvia Rosina
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Immunology and Rheumatology Unit, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, Cusano Milanino, 20095, Milan, Italy.
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,University of Genoa, Genoa, Italy.,Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,RECAP_RD, University of Milan, Milan, Italy.,Pediatric Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
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Islabão AG, Mota LMH, Ribeiro MCM, Arabi TM, Cividatti GN, Queiroz LB, Andrade DC, Sakamoto AP, Trindade VC, Novak GV, Molinari BC, Campos LM, Aikawa NE, Pereira RMR, Terreri MT, Magalhães CS, Marini R, Gomes HR, Silva MF, Oliveira SK, Sztajnbok FR, Sacchetti SB, Bica BE, Sena EG, Moraes AP, Santos MC, Robazzi TC, Spelling PF, Scheibel IM, Cavalcanti AS, Naka EN, Guimarães LJ, Santos FP, Sampaio MC, Bonfá E, Silva CA. Childhood-onset systemic lupus erythematosus-related antiphospholipid syndrome: A multicenter study with 1519 patients. Autoimmun Rev 2020; 19:102693. [PMID: 33164791 DOI: 10.1016/j.autrev.2020.102693] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess childhood-onset systemic lupus erythematosus-related antiphospholipid syndrome(cSLE-APS) in a large Brazilian population. METHODS A retrospective observational cohort study was carried-out in 27 Pediatric Rheumatology university centers, including 1519 cSLE patients. RESULTS cSLE-APS was observed in 67/1519 (4%) and was diagnosed at disease onset in 39/67 (58%). The median disease duration was 4.9 (0-17) years. Thrombosis recurrences were evidenced in 18/67 (27%) cSLE-APS patients. The most frequent thrombosis sites in cSLE-APS patients were: venous thrombosis in 40/67 (60%), especially deep vein thrombosis in 29/40 (72%); arterial thrombosis in 35/67 (52%), particularly stroke; small vessels thrombosis in 9/67 (13%) and mixed thrombosis in 3/67 (4%). Pregnancy morbidity was observed in 1/67 (1%). Non-thrombotic manifestation associated to cSLE-APS occurred in 21/67 (31%), mainly livedo reticularis in 14/67 (21%), valvar thickening in 4/67 (6%) and valvar vegetations not related to infections in 2/67 (3%). None of them had catastrophic APS. Further analysis demonstrated that the median of SLICC/ACR-DI [1(0-5) vs. 0(0-7),p < 0.0001] was significantly higher in cSLE-APS patients compared to cSLE without APS. The frequencies of cerebrovascular disease (40% vs. 1%,p < 0.0001), polyneuropathy (9% vs. 1%,p < 0.0001), SLICC/ACR-DI ≥1 (57% vs. 27%, p < 0.0001) and intravenous cyclophosphamide use (59% vs. 37%, p < 0.0001) were significantly higher in the former group. CONCLUSIONS Our large multicenter study demonstrated that cSLE-APS was a rare condition, occurring during disease course with a high accrual damage. Central and peripheral neuropsychiatric involvements were distinctive features of this autoimmune thrombosis.
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Affiliation(s)
- Aline G Islabão
- Pediatric Rheumatology Unit, Hospital da Criança de Brasília Jose Alencar, Brasília, BR, Brazil; Post-graduation Program in Medical Science, University of Brasilia, Brasília, BR, Brazil.
| | - Licia M H Mota
- Post-graduation Program in Medical Science, University of Brasilia, Brasília, BR, Brazil; Rheumatology Unit, University of Brasilia, Brasília, BR, Brazil
| | | | - Tamima M Arabi
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Georgiana N Cividatti
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Ligia B Queiroz
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Danieli C Andrade
- Division of Rheumatology Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Ana P Sakamoto
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vitor C Trindade
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Glaucia V Novak
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Beatriz C Molinari
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Lucia M Campos
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Nádia E Aikawa
- Division of Rheumatology Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Rosa M R Pereira
- Division of Rheumatology Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Maria T Terreri
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Claudia S Magalhães
- Pediatric Rheumatology Division, Sao Paulo State University (UNESP), Botucatu, BR, Brazil
| | - Roberto Marini
- Pediatric Rheumatology Unit, University of Campinas (UNICAMP), Campinas, BR, Brazil
| | - Hugo R Gomes
- Pediatric Rheumatology Unit, Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, BR, Brazil
| | - Marco F Silva
- Pediatric Rheumatology Unit, Hospital Geral de Fortaleza, Fortaleza, BR, Brazil
| | - Sheila K Oliveira
- Pediatric Rheumatology Unit, Rio de Janeiro Federal University (IPPMG-UFRJ), Rio de Janeiro, BR, Brazil
| | - Flavio R Sztajnbok
- Pediatric Rheumatology Unit, Pedro Ernesto University Hospital, Rio de Janeiro, BR, Brazil
| | - Silvana B Sacchetti
- Pediatric Rheumatology Unit, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, BR, Brazil
| | - Blanca E Bica
- Rheumatology Division - Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, BR, Brazil
| | - Evaldo G Sena
- Pediatric Rheumatology Unit, Lauro Vanderley University Hospital, João Pessoa, BR, Brazil
| | - Ana P Moraes
- Pediatric Rheumatology Unit, Federal University of Pará, Belém, BR, Brazil
| | - Maria C Santos
- Pediatric Rheumatology Unit, Hospital Darcy Vargas, São Paulo, BR, Brazil
| | - Teresa C Robazzi
- Pediatric Rheumatology Unit, Federal University of Bahia, Salvador, BR, Brazil
| | - Paulo F Spelling
- Pediatric Rheumatology Unit, Hospital Evangélico de Curitiba, Curitiba, BR, Brazil
| | - Iloite M Scheibel
- Pediatric Rheumatology Unit, Hospital Criança Conceição, Porto Alegre, BR, Brazil
| | - Andre S Cavalcanti
- Pediatric Rheumatology Unit, Federal University of Pernambuco, Recife, BR, Brazil
| | - Erica N Naka
- Pediatric Rheumatology Unit, Federal University of Mato Grosso do Sul, Campo Grande, BR, Brazil
| | | | - Flavia P Santos
- Pediatric Rheumatology Unit, Federal University of Minas Gerais, Belo Horizonte, BR, Brazil
| | - Magda C Sampaio
- Pediatric Immunology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Eloisa Bonfá
- Division of Rheumatology Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, BR, Brazil
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Sarecka-Hujar B, Kopyta I. Antiphospholipid syndrome and its role in pediatric cerebrovascular diseases: A literature review. World J Clin Cases 2020; 8:1806-1817. [PMID: 32518771 PMCID: PMC7262698 DOI: 10.12998/wjcc.v8.i10.1806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 02/05/2023] Open
Abstract
Antiphospholipid syndrome (APS) or Hughes syndrome is an acquired thromboinflammatory disorder. Clinical criteria of APS diagnosis are large- and small-vessel thrombosis as well as obstetric problems; laboratory criteria are the presence of antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein-1). The presence of at least 1 clinical and 1 laboratory criterion allows definitive diagnosis of APS. Primary APS is diagnosed in patients without features of connective tissue disease; secondary APS is diagnosed in patients with clinical signs of autoimmune disease. A high frequency of catastrophic APS as well as a high tendency to evolve from primary APS to secondary syndrome during the course of lupus and lupus-like disease is a feature of pediatric APS. The most characteristic clinical presentation of APS in the pediatric population is venous thrombosis, mainly in the lower limbs, and arterial thrombosis causing ischemic brain stroke. Currently, no diagnostic criteria for pediatric APS exist, which probably results in an underestimation of the problem. Similarly, no therapeutic procedures for APS specific for children have yet been established. In the present literature review, we discussed data concerning APS in children and its role in cerebrovascular diseases, including pediatric arterial ischemic stroke, migraine and cerebral venous thrombosis.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
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Abstract
Despite its potential to cause significant morbidity in children, pediatric antiphospholipid syndrome (APS) is an understudied condition. In this review, we will cover what is known about pediatric APS epidemiology and how the clinician might approach the diagnosis of pediatric APS. We will highlight similarities and differences with the adult disease, both for primary APS and in the context of lupus. Clinical manifestations beyond thrombosis, especially neurologic and hematologic in nature, will be discussed. We will also consider what unique implications antiphospholipid antibody-positivity may have for children with lupus and for neonates born to mothers with APS. The approach to treatment will be covered, including the unique impact of APS medications on children as compared with adults. Finally, the importance of future mechanistic research is emphasized as physicians endeavor to provide the personalized care that children with APS clearly deserve.
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Affiliation(s)
- Jacqueline A. Madison
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Ritchey AK, O’brien SH, Keller FG. Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Rumsey DG, Myones B, Massicotte P. Diagnosis and treatment of antiphospholipid syndrome in childhood: A review. Blood Cells Mol Dis 2017; 67:34-40. [PMID: 28283251 DOI: 10.1016/j.bcmd.2017.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/23/2017] [Accepted: 02/26/2017] [Indexed: 01/14/2023]
Abstract
The antiphospholipid syndrome (APS) is a multisystem autoimmune disease characterized by recurrent fetal loss and thromboembolic events associated with the presence of elevated titres of antiphospholipid antibodies (aPL). The purpose of this review is to summarize what is currently known about the diagnosis and treatment of pediatric APS, to highlight key differences between APS presenting in adults versus children throughout, and to identify areas where future research is needed.
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Affiliation(s)
- Dax G Rumsey
- Department of Pediatrics, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
| | - Barry Myones
- Pediatric Rheumatology, 2119 Plantation Bend Drive, Sugar Land, TX 77478, USA
| | - Patti Massicotte
- Department of Pediatrics, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada
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Abstract
In systemic lupus erythematosus renal involvement is more frequent in children than in adults. Overall, 60-80% of children with systemic lupus erythematosus have urinary or renal function abnormalities early in the disease course. In 90% of patients, renal disease occurs within two years from disease onset. Clinically significant renal involvement ranges from asymptomatic urinary findings to nephrotic syndrome and renal failure. Long-term prognosis is similar to that observed in adults. Treatment aspects that are peculiar to children include drug side-effects, such as growth inhibition induced by steroids, the need to consider morbidity-related issues with respect to the very long life expectancy of patients and the problems related to the impact of disease in adolescents. The recent availability of a childhood SLE definition of improvement and the presence of large international paediatric rheumatology networks should, in the future, facilitate the implementation of controlled clinical trials devoted to paediatric SLE.
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Affiliation(s)
- F Perfumo
- Nephrology Unit, University of Genoa, Istituto G. Gaslini, Genoa, Italy
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14
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Abstract
Neuropsychiatric (NP) manifestations are found in approximately 25% of children and adolescents with pediatric SLE (pSLE). In 70% of those, NP involvement will occur within the first year from the time of diagnosis. Headaches (66%), psychosis (36%), cognitive dysfunction (27%) and cerebrovascular disease (24%) are the most common presentations. The support of a psychiatrist is often required. Anti-phospholipid antibodies are associated with distinct NP disease entities and may be implicated in the pathogenesis of several manifestations of NP-pSLE including chorea, cerebrovascular disease and seizures. The role of novel auto-antibodies and imaging modalities is currently explored. The treatment of NP-pSLE is not based on prospective studies; however, an immunosuppressive combination therapy consisting of high doses of prednisone and a second line agent such as cyclophosphamide or azathioprine is commonly suggested for children with NP-pSLE. The role of novel therapies is currently studied. The outcome of children with NP-pSLE is relatively good. The overall survival is 95—97%, 20% of children experience a disease flare during childhood and 25% have evidence of permanent neuropsychiatric damage. Lupus (2007) 16, 564—571.
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Affiliation(s)
- S M Benseler
- Divisions of Rheumatology, Department of Paediatrics and Immunology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Aviña-Zubieta JA, Vostretsova K, De Vera MA, Sayre EC, Choi HK. The risk of pulmonary embolism and deep venous thrombosis in systemic lupus erythematosus: A general population-based study. Semin Arthritis Rheum 2015; 45:195-201. [PMID: 26364556 DOI: 10.1016/j.semarthrit.2015.05.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 03/19/2015] [Accepted: 05/14/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To estimate the future risk and time trends of newly diagnosed venous thromboembolism (VTE) in individuals with incident systemic lupus erythematosus (SLE) in the general population. METHODS Using a population-based database that includes all residents of British Columbia, Canada we conducted a study cohort of all patients with incident SLE and up to 10 age-, sex-, and entry-time-matched individuals from the general population. We compared incidence rates of pulmonary embolism (PE), deep venous thrombosis (DVT), and VTE between the two groups according to SLE disease duration. We calculated hazards ratios (HR), adjusting for confounders. RESULTS Among 4863 individuals with SLE (86% female; mean age, 48.9 years), the incidence rates (IRs) of PE, DVT, and VTE were 2.58, 3.33, and 5.32 per 1000 person-years, respectively, whereas the corresponding rates in the comparison cohort were 0.67, 0.57, and 1.11 per 1000 person-years. Compared with non-SLE individuals, the multivariable HRs among SLE patients were 3.04 (95% CI: 2.08-4.45), 4.46 (95% CI: 3.11-6.41), and 3.55 (95% CI: 2.69-4.69), respectively. The age-, sex-, and entry-time-matched HRs for PE, DVT, and VTE were highest during the first year after SLE diagnosis [13.57 (95% CI: 7.66-24.02), 11.13 (95% CI: 6.55-18.90), and 12.89 (95% CI: 8.56-19.41), respectively]. CONCLUSION These findings provide population-based evidence that patients with SLE have a substantially increased risk of VTE, especially in the first year after SLE diagnosis. Awareness and increased vigilance of this potentially fatal, but preventable, complication is recommended.
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Affiliation(s)
- J Antonio Aviña-Zubieta
- Division of Rheumatology, Department of Medicine, Arthritis Research Canada, University of British Columbia, Richmond, British Columbia, Canada; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Kateryna Vostretsova
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A De Vera
- Division of Rheumatology, Department of Medicine, Arthritis Research Canada, University of British Columbia, Richmond, British Columbia, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric C Sayre
- Division of Rheumatology, Department of Medicine, Arthritis Research Canada, University of British Columbia, Richmond, British Columbia, Canada
| | - Hyon K Choi
- Division of Rheumatology, Department of Medicine, Arthritis Research Canada, University of British Columbia, Richmond, British Columbia, Canada; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Berkun Y, Simchen MJ, Strauss T, Menashcu S, Padeh S, Kenet G. Antiphospholipid antibodies in neonates with stroke--a unique entity or variant of antiphospholipid syndrome? Lupus 2014; 23:986-93. [PMID: 24729280 DOI: 10.1177/0961203314531842] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE YB current affiliation: Department of Pediatrics, Hadassah-Hebrew University Medical Center, Mount Scopus, Israel YB and MJS contributed equally to the study and should be regarded as joint first authors on this manuscript. Antiphospholipid syndrome (APS) may present with thrombosis and persistently elevated titers of antiphospholipid antibodies (aPL) in the neonatal period. Our aim was to investigate the course and impact of elevated titers of aPL in a cohort of infants presenting with either perinatal arterial ischemic stroke (PAS) or cerebral sinus vein thrombosis (CSVT) during the perinatal period. STUDY DESIGN Sixty-two infants with clinically and radiologically confirmed PAS or CSVT presenting in the neonatal period underwent thrombophilia workup that included Factor V Leiden (FVL), PII20210A mutation, MTHFR 677T polymorphism, protein C, protein S, aPL namely either circulating lupus anticoagulant (CLA), anticardiolipin antibodies (aCL) or anti-β2-glycoprotein-1 (β2GP1). Mothers also underwent thrombophilia workup. RESULTS Twelve infants with persistently elevated aPL were prospectively followed. Infants with positive aPL showed no concordance with presence of maternal aPL. All children were followed for a median of 3.5 years (range: nine months to 19 years) with repeated aPL testing every three to six months. Anticoagulant therapy initiation and therapy duration varied at the physician's discretion. In 10/12 cases aPL decreased to normal range within 2.5 years; one female with complex thrombophilia risk factors required indefinite prolonged anticoagulation. None of the infants showed recurrent thrombosis or any other APS manifestations, despite lack of prolonged anticoagulation. CONCLUSIONS The presence of aPL may be important in the pathogenesis of cerebral thrombosis in neonates. Nevertheless, the nature of thrombophilia interactions in this period and their therapeutic impact warrants further investigation.
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Affiliation(s)
- Y Berkun
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - M J Simchen
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - T Strauss
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - S Menashcu
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - S Padeh
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - G Kenet
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Cabrejas Lalmolda A, Orden Rueda C, García Iñiguez J, Madurga Revilla P, Janer Subías E, Justa Roldán M. Tromboembolismo pulmonar en paciente afectado de nefropatía lúpica. An Pediatr (Barc) 2013; 78:348-9. [DOI: 10.1016/j.anpedi.2012.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 11/13/2012] [Accepted: 11/14/2012] [Indexed: 10/27/2022] Open
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Ahluwalia J, Singh S, Naseem S, Suri D, Rawat A, Gupta A, Masih J, Bose S. Antiphospholipid antibodies in children with systemic lupus erythematosus: a long-term clinical and laboratory follow-up status study from northwest India. Rheumatol Int 2014; 34:669-73. [PMID: 23563494 DOI: 10.1007/s00296-013-2736-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 03/24/2013] [Indexed: 10/27/2022]
Abstract
We have previously shown that children with pediatric systemic lupus erythematosus (pSLE) have high incidence of anti-phospholipid antibodies (APLA) and reports suggest that presence of APLA can modify disease expression. While the frequency of APLA has been studied previously in adults with SLE, there is paucity of literature in children especially with regard to long-term follow-up. In the earlier study, we analyzed 27 pSLE patients for the prevalence of APLA; in the present study, we further reviewed the APLA status and its relation with clinical outcome of this cohort of patients over a further 7 year follow-up period. Out of the initial cohort of 27 patients, follow-up APLA testing was available in 21 patients who were tested for APLA at least once during this time. Seven (33.3 %) of these 21 patients were never positive for any of the APLA; 1 (4.8 %) was persistently positive; and 13 (61.9 %) were positive for APLA intermittently or at least once. Overall, APLA positivity for IgG, IgM anticardiolipin antibodies (ACA) and lupus anticoagulant (LA) was comparable, with positivity seen in 10 (47.6 %), 9 (42.9 %) and 9 (42.9 %) cases, respectively. Anti-β2 GP1 antibodies were tested in 11 patients on follow-up, of which 3 (27.3 %) showed positivity. In all, 10 (47.6 %) patients showed positivity for more than 1 APLA. Two (9.5 %) patients showed varying degrees of positivity for LA, ACA, and anti-β2 GP1 antibodies at different times, thereby showing the importance of checking for all APLAs at each time of testing. Out of these 21 patients, 3 (14.3 %) patients had thrombosis, and all 3 patients were positive for APLA. There were 2 (9.5 %) fatalities-both of these had thrombosis and were positive for APLA. Our study shows that pSLE patients on treatment frequently test positive for APLA. Thrombosis was infrequent in this cohort. However, when present it was associated with APLA positivity and high fatality in our experience. On the other hand, presence or persistence of these antibodies was not always associated with thrombosis. Our study suggests that pSLE children should be tested routinely for APLA, as this would identify patients with an increased risk of thrombotic complications. However, the frequency of repeat testing for APLA in those who test negative initially needs to be determined on a case-to-case basis.
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Abstract
Systemic disorders with possible involvement of the nervous system include a variety of diseases with presumed inflammatory and autoimmune pathomechanisms, among them Behçet disease, sarcoidosis, systemic lupus erythematosus, juvenile idiopathic arthritis, scleroderma, and Sjögren syndrome. This disease group encompasses systemic inflammatory disorders with a genetically defined dysregulation of the innate immune system as well as systemic autoimmune disorders characterized by alterations of the adaptive immunity such as autoantibodies and autoreactive T cells. Although more commonly diagnosed in adults, all of these diseases can manifest in childhood and some as early as infancy. Neurological involvement may represent the initial manifestation, and nearly every neurological symptom can be caused by inflammatory/autoimmune diseases. In a child with (sub)acute onset of otherwise unexplained neurological findings, consideration of inflammatory/autoimmune disorders may be of crucial therapeutic and prognostic importance. In the absence of disease-specific clinical features, the initial diagnostic workup is broad. Basic blood tests include inflammatory markers and autoantibodies. Cerebral magnetic resonance imaging and a lumbar puncture with measurement of opening pressure as well as cerebrospinal fluid analysis are indicated in most patients with central nervous system (CNS) involvement. Skin, muscle, or organ biopsies (e.g., renal) may provide additional information. Especially in patients with isolated CNS involvement, a brain biopsy may be indicated. Timely recognition and treatment of CNS inflammation may improve or even reverse clinical symptoms and prevent secondary brain injury.
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Affiliation(s)
- Daniela Pohl
- Department of Neurology, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
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Affiliation(s)
- S Habibi
- Department of Rheumatology, Nizams Institute of Medical Sciences, Hyderabad, India
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Abstract
Unlike in adults, pulmonary embolism (PE) is an infrequent event in children. It has a marked bimodal distribution during the paediatric years, occurring predominantly in neonates and adolescents. The most important predisposing factors to PE in children are the presence of a central venous line (CVL), infection, and congenital heart disease. Clinical signs of PE are non-specific in children or can be masked by underlying conditions. Diagnostic testing is necessary in children, especially with the lack of clinical prediction rules. Recommendations for tests are derived from adult studies with ventilation/perfusion (V/Q) scintigraphy being well established. There exists an increasing role for computerised tomography pulmonary angiography (CTPA) and magnetic resonance pulmonary angiography (MRPA). Thrombotic events in children are initially treated with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For the extended anticoagulant therapy LMWH or vitamin K antagonists can be used with duration of treatment recommendations extrapolated from adult data. Mortality rates for PE in children are reported to be around 10%, with death usually related to the underlying disease processes. Exact data about recurrence risk in children is unknown. Because of the difference in aetiology, presentation, diagnostic methods and treatment between adults and children further research is necessary to assess the validity of recommendations for children.
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Affiliation(s)
- F Nicole Dijk
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 939] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Abstract
In children, laboratory evaluations can assist in the screening of patients for inflammatory disorders, confirm diagnoses, allow for monitoring of disease activity and response to therapy, and suggest prognoses and risk of morbidities associated with rheumatic diseases. This review provides an overview of the usefulness and interpretation of both the commonly ordered tests ordered by the general pediatrician as well as those frequently used in the pediatric rheumatology clinic for diagnosis and disease monitoring. Studies discussed include the complete blood count, acute phase reactants, autoantibodies, serum complement, urinalysis, streptococcal antibody tests, and commonly used genetic studies.
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Affiliation(s)
- Jay Mehta
- Division of Pediatric Rheumatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY 10467, USA.
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Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of disease manifestations that can involve any organ system, and can lead to significant morbidity and even mortality. This article reviews the epidemiology, common clinical features, and complications of the disease, and briefly discusses the available treatment options. In addition, important medical and psychosocial issues relevant to the pediatrician caring for children and adolescents with SLE are discussed.
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Affiliation(s)
- Deborah M. Levy
- Assistant Professor, Pediatrics, University of Toronto Staff Rheumatologist, Hospital for Sick Children
| | - Sylvia Kamphuis
- Pediatric rheumatologist/immunologist, Sophia Children’s Hospital, Erasmus University MC, SP 3429, PO Box 2060, 3000 CB Rotterdam, tel: 0031-10-7036104 (secr), fax: 0031-10-7036943,
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Abstract
In neonates and infants with idiopathic venous thrombosis (VTE) and in pediatric populations in which thromboses were associated with medical diseases, inherited thrombophilia (IT) have been described as risk factors. Follow-up data for VTE recurrence in neonates suggest a recurrence rate between 3% in provoked and 21% in idiopathic VTE. Apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE have shown significant associations between factor V G1691A, factor II G20210A, and deficiencies of protein C, protein S and antithrombin, even more pronounced when combined IT were involved. Independent from the age at first VTE onset, the pooled odds ratios (OR: single IT) for VTE ranged from 2.4 for the factor II G20210A mutation to 9.4 in neonates and infants with antithrombin deficiency. The pooled OR for persistent antiphospholipid antibodies/lupus anticoagulants was 4.9 for pediatric patients with venous VTE. The factor II G20210A mutation (OR: 2.1), and deficiencies of protein C (OR: 2.4), S (OR: 3.1) and antithrombin (OR: 3.0) also played a significant role at recurrence. Based on these data, screening and treatment algorithms must be discussed.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Department of Coagulation and Hemostasis, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, Building 17, Campus Kiel, D-24105 Kiel, Germany.
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Skalova S, Minxova L, Lukes A, Dedek P, Tousovska K, Podhola M. Renal vein thrombosis with pulmonary embolism: first manifestation of lupus nephritis. J Paediatr Child Health 2011; 47:315-6. [PMID: 21599786 DOI: 10.1111/j.1440-1754.2011.02091.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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García-Peña P, Boixadera H, Barber I, Toran N, Lucaya J, Enríquez G. Thoracic Findings of Systemic Diseases at High-Resolution CT in Children. Radiographics 2011; 31:465-82. [DOI: 10.1148/rg.312095160] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bhat MA, Qureshi UA, Ali SW, Bhat JI, Din N, Robbani I. Pulmonary thromboembolism as the initial manifestation in a child with antiphospholipid syndrome in the emergency department. Pediatr Emerg Care 2011; 27:205-7. [PMID: 21378521 DOI: 10.1097/PEC.0b013e31820d8dd4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Antiphospholipid syndrome is characterized by recurrent arterial or venous thrombosis at any level of the vascular tree and the presence of circulating antiphospholipid antibodies. The syndrome may be idiopathic or secondary to an underlying autoimmune disorder. The disease is uncommon in children, and manifestations are diverse and underreported. We report the case of a 10-year-old boy who presented with features of pulmonary thromboembolism in the emergency department. Subsequently, he proved to have systemic lupus erythematosus with circulating antiphospholipid antibodies. He had no signs of systemic lupus erythematosus at presentation. In conclusion, antiphospholipid syndrome should also be kept as a possibility in children presenting for the first time with pulmonary thromboembolism in the emergency department.
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Abstract
UNLABELLED There is still a significant morbidity and mortality associated with childhood-onset systemic lupus erythematosus (SLE), despite an increasing armamentarium of immunosuppressive agents. The ideal therapeutic strategy for children and adolescents with SLE should provide the right amount of treatment to allow normal growth, development and fertility while reducing the disease activity and damage that can be accrued over the years. Each patient should have individualized treatments tailored to their organ involvement, disease severity and history of flares together with recent clinical, haematological and immunological parameters to avoid further flares of disease activity and side-effects of treatment, especially severe infections and future malignancies. The most commonly cited side-effects of medications include Cushingoid features of corticosteroids, infective complications of cyclophosphamide and gastrointestinal side-effects of mycophenolate mofetil. There is increasing evidence to support the use of oral mycophenolate mofetil as opposed to cyclophosphamide for both induction and maintenance therapies in many children with SLE with or without lupus nephritis (LN). Recently, case series utilizing B-lymphocyte depletion therapies with rituximab look promising for patients with severe or refractory disease activity. In this article, we explore current evidence to effectively treat children and adolescents with SLE with or without LN. CONCLUSION Modern therapeutic strategies include reduced doses and use of corticosteroids and intravenous cyclophosphamide respectively, with increased use of azathioprine, MMF and rituximab.
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Affiliation(s)
- Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Mina R, Brunner HI. Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus? Rheum Dis Clin North Am 2010; 36:53-80, vii-viii. [PMID: 20202591 DOI: 10.1016/j.rdc.2009.12.012] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.
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Affiliation(s)
- Rina Mina
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA
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Mok CC, Ho LY, Yu KL, To CH. Venous thromboembolism in southern Chinese patients with systemic lupus erythematosus. Clin Rheumatol 2010; 29:599-604. [DOI: 10.1007/s10067-009-1364-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 12/20/2009] [Accepted: 12/22/2009] [Indexed: 11/24/2022]
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Nowak-Göttl U, Bidlingmaier C, Kurnik K. Thromboembolische Erkrankungen bei Neugeborenen und Kindern. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Abstract
In recent years, antiphospholipid syndrome (APS) has been increasingly recognised in various paediatric autoimmune and nonautoimmune diseases, but the relatively low prevalence and heterogeneity of APS in childhood made it very difficult to study in a systematic way. The project of an international registry of paediatric patients with APS (the Ped-APS Registry) was initiated in 2004 to foster and conduct multicentre, controlled studies with large number of paediatric APS patients. The Ped-APS Registry is organised as a collaborative project of the European Forum on Antiphospholipid Antibodies and Juvenile Systemic Lupus Erythematosus Working Group of the Paediatric Rheumatology European Society. Currently, it documents a standardised clinical, laboratory and therapeutic data of 133 children with antiphospholipid antibodies (aPL)-related thrombosis from 14 countries. The priority projects for future research of the Ped-APS Registry include prospective enrollment of new patients with aPL-related thrombosis, assessment of differences between the paediatric and adult APS, evaluation of proinflammatory genotype as a risk factor for APS manifestations in childhood and evaluation of patients with isolated nonthrombotic aPL-related manifestations.
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Affiliation(s)
- T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Ljubljana, Slovenia.
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Hobbs DJ, Barletta GM, Rajpal JS, Rajpal MN, Weismantel DP, Birmingham JD, Bunchman TE. Severe paediatric systemic lupus erythematosus nephritis--a single-centre experience. Nephrol Dial Transplant 2009; 25:457-63. [PMID: 19755473 DOI: 10.1093/ndt/gfp481] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Paediatric patients with systemic lupus erythematosus (SLE) often have severe presentations including lupus nephritis (LN). Few paediatric studies have evaluated the anticardiolipin antibody (aCL) and renal histology. The purpose of this study was to evaluate clinicopathologic features, including aCL, short-term clinical and renal histologic outcomes of paediatric patients with new-onset SLE nephritis. METHODS We conducted a single centre, retrospective inception cohort study. Charts were reviewed at presentation (initial renal biopsy), 6-month (follow-up biopsy) and 12-month follow-up. RESULTS The population consisted of 21 patients (median age, 14.5 years): 19/21 were female, 6/21 African American, 3/21 Asian, 9/21 Caucasian and 3/21 Hispanic. At presentation, 19/21 had elevated aCL, 15/21 hypertensive, 12/21 nephrotic and 7/21 required haemodialysis (HD)-2/7 HD patients had thrombotic microangiopathy, 1/7 crescentic glomerulonephritis. Two patients had thromboembolism: both had aCL, were taking oral contraceptives and required HD, one was nephrotic and the other had elevated lupus anticoagulant. Initial biopsies revealed 6/21 ISN/RPS class II nephritis, 3/21 class III, 7/21 class IV and 5/21 class V. Treatment consisted of methylprednisolone, corticosteroids, cyclophosphamide or mycophenolate mofetil. Follow-up biopsies revealed 12/13 to have improved histology. Indication for a follow-up biopsy was severe illness at presentation. At 12-month follow-up, no patients were nephrotic (P < 0.001) or required HD (P < 0.001), and 3/14 had elevated aCL (P < 0.001). CONCLUSION Elevated aCL, hypertension, nephrotic syndrome and need for HD were common presentations among our paediatric SLE nephritis population. Renal histology and aCL were helpful in the therapeutic management.
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Affiliation(s)
- David J Hobbs
- Pediatric Nephrology, Helen DeVos Children's Hospital and Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Salah S, Lotfy HM, Sabry SM, El Hamshary A, Taher H. Systemic lupus erythematosus in Egyptian children. Rheumatol Int 2009; 29:1463-8. [PMID: 19301009 DOI: 10.1007/s00296-009-0888-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 03/04/2009] [Indexed: 11/26/2022]
Abstract
The aim of the study was to study the characteristics of systemic lupus erythematosus (SLE) in the Egyptian population, comparing it to other populations. We retrospectively studied 207 patients with SLE diagnosed between 1990 and 2005. We obtained clinical features and laboratory data and analyzed them statistically. We studied 151 female and 56 male SLE patients. The female to male ratio was 2.7 to 1 and the mean age at presentation was 10 +/- 2.7 years (range 2-16). The mean disease duration was 6.47 +/- 3.74 years. At diagnosis, musculoskeletal, constitutional and mucocutaneous manifestations were the commonest features. During follow-up, the prevalence of nephritis (67%), hematological manifestations (44.9%), photosensitivity (44%), arthritis (39%), malar rash (38.2%), serositis (32.9%) and neuropsychiatric manifestations (24.25%) increased significantly. Those whose age of onset of the disease was <or=5 years (nine patients) had significantly more common hematological affection (P value = 0.0005). The characteristics of SLE in Egyptian patients show some similarities to other series of Middle Eastern countries, but with a lower female to male ratio. Disease onset below 5 years is extremely rare (4.35%), commonly presenting with hematological manifestations. The kidney was the commonest major internal organ involved, and also an important cause of death.
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Jurencák R, Fritzler M, Tyrrell P, Hiraki L, Benseler S, Silverman E. Autoantibodies in pediatric systemic lupus erythematosus: ethnic grouping, cluster analysis, and clinical correlations. J Rheumatol 2009; 36:416-21. [PMID: 19208567 DOI: 10.3899/jrheum.080588] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE (1) To evaluate the spectrum of serum autoantibodies in pediatric-onset systemic lupus erythematosus (pSLE) with a focus on ethnic differences; (2) using cluster analysis, to identify patients with similar autoantibody patterns and to determine their clinical associations. METHODS A single-center cohort study of all patients with newly diagnosed pSLE seen over an 8-year period was performed. Ethnicity, clinical, and serological data were prospectively collected from 156/169 patients (92%). The frequencies of 10 selected autoantibodies among ethnic groups were compared. Cluster analysis identified groups of patients with similar autoantibody profiles. Associations of these groups with clinical and laboratory features of pSLE were examined. RESULTS Among our 5 ethnic groups, there were differences only in the prevalence of anti-U1RNP and anti-Sm antibodies, which occurred more frequently in non-Caucasian patients (p < 0.0001, p < 0.01, respectively). Cluster analysis revealed 3 autoantibody clusters. Cluster 1 consisted of anti-dsDNA antibodies. Cluster 2 consisted of anti-dsDNA, antichromatin, antiribosomal P, anti-U1RNP, anti-Sm, anti-Ro and anti-La autoantibody. Cluster 3 consisted of anti-dsDNA, anti-RNP, and anti-Sm autoantibody. The highest proportion of Caucasians was in cluster 1 (p < 0.05), which was characterized by a mild disease with infrequent major organ involvement compared to cluster 2, which had the highest frequency of nephritis, renal failure, serositis, and hemolytic anemia, or cluster 3, which was characterized by frequent neuropsychiatric disease and nephritis. CONCLUSION We observed ethnic differences in autoantibody profiles in pSLE. Autoantibodies tended to cluster together and these clusters were associated with different clinical courses.
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Affiliation(s)
- Roman Jurencák
- Division of Rheumatology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8
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Young G, Albisetti M, Bonduel M, Brandao L, Chan A, Friedrichs F, Goldenberg NA, Grabowski E, Heller C, Journeycake J, Kenet G, Krümpel A, Kurnik K, Lubetsky A, Male C, Manco-Johnson M, Mathew P, Monagle P, van Ommen H, Simioni P, Svirin P, Tormene D, Nowak-Göttl U. Impact of Inherited Thrombophilia on Venous Thromboembolism in Children. Circulation 2008; 118:1373-82. [DOI: 10.1161/circulationaha.108.789008] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background—
The aim of the present study was to estimate the impact of inherited thrombophilia (IT) on the risk of venous thromboembolism (VTE) onset and recurrence in children by a meta-analysis of published observational studies.
Methods and Results—
A systematic search of electronic databases (Medline, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2007 was conducted using key words in combination as both MeSH terms and text words. Citations were independently screened by 2 authors, and those meeting the inclusion criteria defined a priori were retained. Data on year of publication, study design, country of origin, number of patients/controls, ethnicity, VTE type, and frequency of recurrence were abstracted. Heterogeneity across studies was evaluated, and summary odds ratios and 95% CIs were calculated with both fixed-effects and random-effects models. Thirty-five of 50 studies met inclusion criteria. No significant heterogeneity was discerned across studies. Although >70% of patients had at least 1 clinical risk factor for VTE, a statistically significant association with VTE onset was demonstrated for each IT trait evaluated (and for combined IT traits), with summary odds ratios ranging from 2.63 (95% CI, 1.61 to 4.29) for the factor II variant to 9.44 (95% CI, 3.34 to 26.66) for antithrombin deficiency. Furthermore, a significant association with recurrent VTE was found for all IT traits except the factor V variant and elevated lipoprotein(a).
Conclusions—
The present meta-analysis indicates that detection of IT is clinically meaningful in children with, or at risk for, VTE and underscores the importance of pediatric thrombophilia screening programs.
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Affiliation(s)
- Guy Young
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Manuela Albisetti
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Mariana Bonduel
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Leonardo Brandao
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Anthony Chan
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Frauke Friedrichs
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Neil A. Goldenberg
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Eric Grabowski
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Christine Heller
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Janna Journeycake
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Gili Kenet
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Anne Krümpel
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Karin Kurnik
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Aaron Lubetsky
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Christoph Male
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Marilyn Manco-Johnson
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Prasad Mathew
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Paul Monagle
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Heleen van Ommen
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Paolo Simioni
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Pavel Svirin
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Daniela Tormene
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
| | - Ulrike Nowak-Göttl
- From the Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, Calif (G.Y.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Servicio de Hematolgía y Oncología, Hospital de Pediatría “Prof. Dr. J.P. Garrahan,” Buenos Aires, Argentina (M.B.); Hospital for Sick Children, Toronto, Canada (L.B.); McMaster University, Hamilton, Canada (A.C.); Leibniz Institute for Arteriosclerosis Research, University of Münster, Münster, Germany (F.F.)
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Hiraki LT, Benseler SM, Tyrrell PN, Hebert D, Harvey E, Silverman ED. Clinical and laboratory characteristics and long-term outcome of pediatric systemic lupus erythematosus: a longitudinal study. J Pediatr 2008; 152:550-6. [PMID: 18346514 DOI: 10.1016/j.jpeds.2007.09.019] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/13/2007] [Accepted: 09/10/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the frequency and characteristics of clinical signs, symptoms, laboratory findings, and medication use in children with pediatric systemic lupus erythematosus (pSLE) at presentation and during the course of the disease, and to examine correlations among disease manifestations, disease activity, and damage over time. STUDY DESIGN The study involved an analysis of medical records and the SLE database of an inception cohort of 256 patients with pSLE (female:male ratio, 4.7:1). RESULTS The most common clinical manifestations were arthritis (67%), malar rash (66%), nephritis (55%), and central nervous system (CNS) disease (27%). At diagnosis, patients with both renal and CNS disease had the highest SLE Disease Activity Index (SLEDAI) scores (P < .0001), but these scores were similar to those of the total group at 1 year (P = .11). Patients who developed renal and CNS disease more than 1 year after diagnosis had higher SLEDAI scores at disease onset. Some 34% of patients had Systemic Lupus International Collaborative Clinics Damage Index (SLICC-DI) scores >1 at a mean follow-up of 3.5 years. A greater proportion of patients with renal and CNS disease had SLICC-DI scores of >1, and these patients had higher mean scores compared with patients without major organ involvement (70% vs 11% [P < .0001] and 1.4 vs 0.1 [P < .0001], respectively). CONCLUSIONS Most of the patients in our cohort exhibited major organ involvement. These patients had the highest SLEDAI scores at diagnosis, which normalized at 1 year but preceded development of renal and CNS disease. The average SLICC-DI score was lower than that previously reported in patients with pSLE.
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Affiliation(s)
- Linda T Hiraki
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Abstract
The antiphospholipid syndrome (APS) is recognized increasingly as the most common acquired hypercoagulation state of autoimmune etiology and may occur as an isolated clinical entity (primary APS) or in association with an underlying systemic disease, particularly systemic lupus erythematosus (SLE). The major differences between pediatric and adult APS include absence of common acquired risk factors for thrombosis, absence of pregnancy-related morbidity, increased incidence of infection-induced antibodies, differences in cut-off values for determination of aPL and specific factors regarding long-term therapy in children. APS in children has been largely reported in patients with arterial or venous thromboses and less frequently in association with neurological or hematological manifestations. The presence of aPL in pediatric SLE can modify the disease expression and may be an important predictor of the development of irreversible organ damage. Two recently established international registries of neonates and children with APS provide a good opportunity to conduct large, prospective studies on the clinical significance of aPL and long-term outcome of pediatric APS.
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Affiliation(s)
- T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Ljubljana, Slovenia.
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Avčin T, Benseler SM, Tyrrell PN, Čučnik S, Silverman ED. A followup study of antiphospholipid antibodies and associated neuropsychiatric manifestations in 137 children with systemic lupus erythematosus. ACTA ACUST UNITED AC 2008; 59:206-13. [DOI: 10.1002/art.23334] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
APS is recognized increasingly as a leading cause of vascular thrombosis in the pediatric population. With the obvious exception of pregnancy morbidity, most of the clinical features that may occur in adults with APS have been described also in children. Because the coincident prothrombotic factors that are common in adults have little or no impact in children, pediatric patients with APS constitute a suitable sample to investigate the relationship of aPL with the associated clinical manifestations, such as thrombocytopenia, hemolytic anemia, chorea, and livedo reticularis, and the specificities of aPL that are more linked to thrombosis. On the other hand, because of the high frequency of infectious processes in early life, children may have a greater prevalence of nonpathogenic and transient aPL. For these reasons, the diagnostic and therapeutic approach to APS in childhood may be different from that for adults. Because of the rarity of aPL-related thrombosis in children, the natural history and optimal management can be defined only through large, multicenter, controlled studies. A internet-based registry for pediatric patients with APS (Ped-APS Register) has been recently established as part of the activities of the Euro-aPL Forum and the Lupus Working Group of the Pediatric Rheumatology European Society. This registry is aimed to obtain information on APS in childhood, particularly regarding association of aPL with clinical manifestations, specificity of aPL, impact of treatment and long-term outcome (http://www.med.ub.es/MIMMUN/FORUM/PEDIATRIC.HTM).
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Affiliation(s)
- Angelo Ravelli
- Pediatria II, Istituto di Ricovero e Cura a Carattere Scientifico G. Gaslini, Largo G. Gaslini, 5, 16147, Genoa, Italy.
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Cheunsuchon B, Rungkaew P, Chawanasuntorapoj R, Pattaragarn A, Parichatikanond P. Prevalence and clinicopathologic findings of antiphospholipid syndrome nephropathy in Thai systemic lupus erythematosus patients who underwent renal biopsies. Nephrology (Carlton) 2007; 12:474-80. [PMID: 17803471 DOI: 10.1111/j.1440-1797.2007.00792.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To determine the prevalence of antiphospholipid syndrome nephropathy (APSN) in Thai systemic lupus erythematosus (SLE) patients who underwent renal biopsy and to compare the relationship of renal histopathology and other significant clinical parameters between SLE patients with and without APSN. METHODS A retrospective analysis was undertaken in systemic lupus erythematosus patients (n = 150, 44 <15 years old, 106 0e;15 years old) who underwent renal biopsy. The specimens were evaluated for histological features of APSN and other significant clinical parameters. The result of antiphospholipid antibodies, clinical course, and renal function from chart review were analysed. RESULTS The prevalence of APSN in systemic lupus erythematosus patients who underwent renal biopsies was 34% (16% in <15-year-old group, 41.5% in > or =15-year-old group). APSN was associated with more severe hypertension (P = 0.002 for systolic and P = 0.004 for diastolic blood pressure), acute renal failure (P = 0.003), persistent heavy proteinuria (P < 0.001 for 4+ proteinuria), severe lupus nephritis (class III and IV, P = 0.014, high activity and chronicity indices, P < 0.001) and a tendency to progress to end-stage renal disease. CONCLUSION Systemic lupus erythematosus patients who underwent renal biopsies in our institute showed a prevalence of APSN comparable to those in western countries. The presence of APSN was significantly higher in the adult than in the paediatric population. Its association with poor prognostic indicators suggests poor renal outcome. Clinicians should be aware of this condition in order to give proper care to systemic lupus erythematosus patients.
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Affiliation(s)
- Boonyarit Cheunsuchon
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Abstract
OBJECTIVES Thromboembolic episodes are frequent manifestations of systemic lupus erythematosus (SLE). Although the presence of anti-phospholipid antibodies (aPL) is known to contribute to thromboembolism (TE), the relative contribution of other TE risk factors is unknown. The aim of this study was to determine the prevalence of TE in a Caucasian SLE population, to identify the risk factors of highest importance, and to assess the clinical value of thrombophilia screening among SLE patients. METHODS Samples from 105 patients were analysed with a screen including aPL, activated protein C resistance, factor V Leiden (FVL) and prothrombin G20210A mutations; protein C, protein S and antithrombin activity; factor VIII (FVIII) and von Willebrand factor (vWF), and homocysteine (Hcy) levels. RESULTS The annual incidence of arterial and venous TE events in our SLE population was 5.4 and 12.4 per 1000, respectively. The highest risk of thrombosis was carried by the simultaneous presence of lupus anticoagulant (LA) and anti-cardiolipin (aCL) [relative risk (RR) = 4.03, 95% confidence interval (CI) 2.06-7.86] or anti-beta2-glycoprotein I antibodies (abeta2-GPI) (RR = 5.10, 95% CI 2.58-10.1). Positivity for the individual aPL tests all carried an elevated TE risk. The presence of other risk factors seemed to be of less importance. CONCLUSIONS In SLE patients, the presence of aPL is a more significant risk factor for the development of thrombosis than the known inherited deficiencies. Based on these data, routine screening for additional hereditary risk factors seems to be unwarranted.
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Affiliation(s)
- K K Sallai
- Central Laboratory of Immunology, Semmelweis University Medical School, Budapest, Hungary.
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Abstract
APS is rare in the pediatric age, but it represents an interesting phenomenon because most of the known "second hit" risk factors such as atherosclerosis, smoking, hypertension, contraceptive hormonal treatment, and pregnancy are not present in childhood. This could also be the reason for the prevalence of some clinical manifestations rather than others in PAPS. On the other hand, the increased frequency of infectious processes in the childhood age is likely responsible for the relatively high prevalence of non-pathogenic and transient aPL. Such points raise the problem of a different diagnosis or monitoring approach in pediatric APS. Of particular interest is the special entity of neonatal APS, which represents an in vivo model of acquired autoimmune disease, in which transplacentally acquired aPL cause thrombosis in the newborn. International registries for pediatric and neonatal APS are currently in place; epidemiologic, clinical, and laboratory re-search will help to shed light on all the still obscure aspects of this fascinating but rare disorder in the very young. Finally, treatment is less aggressive overall in pediatric APS, given the reluctance to anticoagulate children over the long term. Studies on the outcome of pediatric APS and the relative risks of prolonged anticoagulation in children are necessary to determine the type and duration of anticoagulation therapy.
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Affiliation(s)
- Rolando Cimaz
- Département de Pédiatrie, Pavillon S, Hopital Edouard Herriot, 69437, Lyon, France.
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. EAEB, . AMAAA, . HM, . EAEG, . IS. Antithrombin-III in Pediatric Systemic Lupus Erythematosus. J of Medical Sciences 2006. [DOI: 10.3923/jms.2006.779.785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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