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Fukui S, Kawaai S, Sawada H, Kishimoto M. Upadacitinib for the treatment of adults with active non-radiographic axial spondyloarthritis (nr-axSpA). Expert Rev Clin Immunol 2024; 20:141-153. [PMID: 37955181 DOI: 10.1080/1744666x.2023.2282696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Non-radiographic axial spondyloarthritis (nr-axSpA) is a chronic inflammatory condition with axial and peripheral musculoskeletal involvement, fulfilling criteria of axSpA in the absence of advanced radiographic sacroiliitis. While appropriate treatment is required for chronic pain and disability resulting from disease progression, the limited availability of treatment options becomes evident. Upadacitinib, an oral selective Janus kinase 1 inhibitor, was approved in Europe, the United States, and other countries for management of nr-axSpA with inadequate response to existing therapies. AREA COVERED This review summarizes essential drug profiles, efficacy, and safety of upadacitinib for nr-axSpA in conjunction with data pertaining to radiographic axSpA. EXPERT OPINION In a phase 3 trial, upadacitinib exhibited efficacy for patients with nr-axSpA, irrespective of prior exposures to biological disease-modifying antirheumatic drugs (bDMARDs). The safety profiles of upadacitinib in nr-axSpA mirrored those in other indications, underscoring its potential as a promising treatment option for nr-axSpA. Concurrently, physicians should be aware of the absence of real-world data, longitudinal efficacy and safety, direct comparative studies between upadacitinib and bDMARDs in nr-axSpA, and evidence for precision medicine to identify patients who may optimally benefit from upadacitinib over bDMARDs. Future research is imperative to facilitate the effective utilization of upadacitinib in daily clinical practice.
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Affiliation(s)
- Sho Fukui
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Emergency and General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Satoshi Kawaai
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Haruki Sawada
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
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Yurt EF, Biçer C, Serdar MA, Akan S, Erten Ş. Accelerated kynurenine pathway downregulates immune activation in patients with axial spondyloarthritis. Cytokine 2023; 169:156247. [PMID: 37295242 DOI: 10.1016/j.cyto.2023.156247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/27/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
Various studies reported that the kynurenine (Kyn) pathway plays a pivotal role in regulating the balance between activation and inhibition of the immune system. Proinflammatory cytokines can accelerate the Kyn pathway by altering indoleamine (2, 3)- dioxygenase (IDO) allosteric enzyme activity. Excessive cytokine release and immune system activation have essential roles in the pathogenesis of axial spondyloarthritis (axSpA). We aimed to investigate the relationship of the Kyn pathway with proinflammatory cytokines and with the severity of the disease in patients with axSpA. The study included 104 patients with axSpA and 54 healthy volunteers. The severity of the disease was determined by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The Kyn pathway was evaluated by IDO activity calculated with Kyn/Tryptophan (Trp) ratio. Plasma Trp and Kyn concentrations were measured with tandem mass spectrometry. Serum IL 17/23 and IFN-γ concentrations were measured with ELISA. These groups were compared in terms of IDO, IL-17, IL-23, IFN-γ, and BASDAI. Plasma IDO activity was significantly increased, however, serum IL-17, IL-23, and IFN-γ levels were significantly decreased in patients compared to healthy volunteers. While IFN-γ was positively correlated with the severity of the disease (p = 0.02), it also had a significant inverse correlation with IDO activity (p < 0.001). However, these correlations are weak. As a result of this study, the Kyn pathway is accelerated and proinflammatory cytokine levels are decreased in patients with axSpA. All of these results with an indirect weak negative association between high IDO and low disease activity suggest that an accelerated Kyn pathway may limit the immune system activation in axSpA disease.
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Affiliation(s)
- Emine Feyza Yurt
- Medical Biochemistry, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Türkiye.
| | - Cemile Biçer
- Medical Biochemistry, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Türkiye
| | - Muhittin A Serdar
- Medical Biochemistry, Faculty of Medicine, Acıbadem University, Türkiye
| | - Selçuk Akan
- Rheumatology, Ankara City Hospital, Ankara, Türkiye
| | - Şükran Erten
- Rheumatology, Ankara City Hospital, Ankara, Türkiye; Rheumatology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Türkiye
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Braun J, Blanco R, Marzo-Ortega H, Gensler LS, Van den Bosch F, Hall S, Kameda H, Poddubnyy D, van de Sande M, van der Heijde D, Zhuang T, Stefanska A, Readie A, Richards HB, Deodhar A. Two-year imaging outcomes from a phase 3 randomized trial of secukinumab in patients with non-radiographic axial spondyloarthritis. Arthritis Res Ther 2023; 25:80. [PMID: 37194094 DOI: 10.1186/s13075-023-03051-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/13/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Radiographic progression and course of inflammation over 2 years in patients with non-radiographic axial spondyloarthritis (nr-axSpA) from the phase 3, randomized, PREVENT study are reported here. METHODS In the PREVENT study, adult patients fulfilling the Assessment of SpondyloArthritis International Society classification criteria for nr-axSpA with elevated CRP and/or MRI inflammation received secukinumab 150 mg or placebo. All patients received open-label secukinumab from week 52 onward. Sacroiliac (SI) joint and spinal radiographs were scored using the modified New York (mNY) grading (total sacroiliitis score; range, 0-8) and modified Stoke Ankylosing Spondylitis Spine Score (mSASSS; range, 0-72), respectively. SI joint bone marrow edema (BME) was assessed using the Berlin Active Inflammatory Lesions Scoring (0-24) and spinal MRI using the Berlin modification of the AS spine MRI (ASspiMRI) scoring (0-69). RESULTS Overall, 78.9% (438/555) of patients completed week 104 of the study. Over 2 years, minimal changes were observed in total radiographic SI joint scores (mean [SD] change, - 0.04 [0.49] and 0.04 [0.36]) and mSASSS scores (0.04 [0.47] and 0.07 [0.36]) in the secukinumab and placebo-secukinumab groups. Most of the patients showed no structural progression (increase ≤ smallest detectable change) in SI joint score (87.7% and 85.6%) and mSASSS score (97.5% and 97.1%) in the secukinumab and placebo-secukinumab groups. Only 3.3% (n = 7) and 2.9% (n = 3) of patients in the secukinumab and placebo-secukinumab groups, respectively, who were mNY-negative at baseline were scored as mNY-positive at week 104. Overall, 1.7% and 3.4% of patients with no syndesmophytes at baseline in the secukinumab and placebo-secukinumab group, respectively, developed ≥ 1 new syndesmophyte over 2 years. Reduction in SI joint BME observed at week 16 with secukinumab (mean [SD], - 1.23 [2.81] vs - 0.37 [1.90] with placebo) was sustained through week 104 (- 1.73 [3.49]). Spinal inflammation on MRI was low at baseline (mean score, 0.82 and 1.07 in the secukinumab and placebo groups, respectively) and remained low (mean score, 0.56 at week 104). CONCLUSION Structural damage was low at baseline and most patients showed no radiographic progression in SI joints and spine over 2 years in the secukinumab and placebo-secukinumab groups. Secukinumab reduced SI joint inflammation, which was sustained over 2 years. TRIAL REGISTRATION ClinicalTrials.gov, NCT02696031.
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Affiliation(s)
- Juergen Braun
- Department of Rheumatology, Ruhr-University Bochum, Bochum, Germany.
- Rheuma Praxis, Berlin, Germany.
| | - Ricardo Blanco
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, LIRMM, University of Leeds, Leeds, UK
| | | | - Filip Van den Bosch
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- VIB Center for Inflammation Research, Ghent, Belgium
| | - Stephen Hall
- Department of Medicine, Monash University, Melbourne, Australia
| | | | - Denis Poddubnyy
- German Rheumatism Research Centre, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marleen van de Sande
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | | | | | - Aimee Readie
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Atul Deodhar
- Oregon Health & Science University, Division of Arthritis and Rheumatic Diseases, Portland, USA
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Ohta R, Sano C. Differentiating Between Undifferentiated Peripheral Spondyloarthritis From Septic Arthritis: A Case Report. Cureus 2023; 15:e37742. [PMID: 37213946 PMCID: PMC10192946 DOI: 10.7759/cureus.37742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
Undifferentiated peripheral spondyloarthritis (SpA) and septic arthritis are two distinct differential diagnoses for patients with acute-onset monoarthritis. Effective history-taking and thorough physical examination are essential to differentiate between these two diseases. Precise follow-up can be critical for diagnosing undifferentiated peripheral SpA. Herein, we report our experience with two cases that required differentiation between undifferentiated peripheral SpA and septic arthritis. This case series shows the importance of ruling out septic arthritis promptly and considering the possibility of undifferentiated peripheral PsA based on clinical findings and imaging tests.
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Affiliation(s)
| | - Chiaki Sano
- Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
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Kameda H, Kishimoto M, Kobayashi S, Tomita T, Morita A, Yamamura M. Axial Spondyloarthritis in Japan. Curr Rheumatol Rep 2022; 24:149-155. [PMID: 35380380 DOI: 10.1007/s11926-022-01068-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The differences in the epidemiology and management of patients with axial spondyloarthritis (axSpA) among regions and countries largely depend on the positivity of human leukocyte antigen (HLA)-B27 and the health care system. This review article focused on axSpA in Japan, where the prevalence of HLA-B27 is extremely low (0.3%) and the universal health insurance system typically provides a 70% or more copayment by the government. RECENT FINDINGS A nationwide survey was conducted in Japan in 2018, which estimated that there were 3200 patients (95% confidence interval [CI]: 2400-3900) with ankylosing spondylitis (AS), a term interchangeable with radiographic axSpA (r-axSpA), and 800 patients (95% CI: 530-1100) had non-radiographic (nr)-axSpA. These data indicate a prevalence of 2.6/100,000 or 0.0026% for AS and 0.6/100,000 or 0.0006% for nr-axSpA. Patients with AS, but not those with nr-axSpA, are designated as suffering from intractable diseases in Japan; thus, their medical expenses are reduced by grant under the Act on Medical Care for Patients with Intractable Diseases. As of February 2022, infliximab, adalimumab, secukinumab, ixekizumab, and brodalumab have been approved for AS, and secukinumab, ixekizumab, and brodalumab have been approved for nr-axSpA. An algorithm for nr-axSpA in Japan has been developed for the proper diagnosis and use of these therapeutic agents. A low prevalence of axSpA, especially that of nr-axSpA, was found in Japan. Early referral and the resultant diagnosis and appropriate treatment of these patients by rheumatologists are crucial issues in Japan, as in other countries.
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Affiliation(s)
- Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University (Ohashi Medical Center), 2-22-36 Ohashi, Meguro-ku, Tokyo, Japan.
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Shigeto Kobayashi
- Department of Internal Medicine and Rheumatology, Juntendo University Koshigaya Hospital, Saitama, Japan
| | - Tetsuya Tomita
- Department of Orthopedic Biomaterial Science, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Yamamura
- Center for Rheumatology, Okayama Saiseikai General Hospital, Okayama, Japan
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Interobserver Reliability of Magnetic Resonance Imaging of Sacroiliac Joints in Axial Spondyloarthritis. Life (Basel) 2022; 12:life12040470. [PMID: 35454961 PMCID: PMC9032207 DOI: 10.3390/life12040470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction: Axial spondyloarthritis (axSpA) is characterized by damage to the axial skeleton and entheses, and is often associated with extra-articular manifestations, in the presence of the human leukocyte antigen (HLA) B27. The aim of our study is to assess the performance of rheumatologists in interpreting the inflammatory and structural damage to sacroiliac joints, in comparison to radiologists. Material and Methods: The present study included a total of 34 patients diagnosed with axSpA, according to the Assessment of SpondyloArthritis International Society (ASAS) criteria for axSpA, examined from January 2021 to November 2021 in the Departments of Rheumatology and Radiology and Medical Imaging of the University of Medicine and Pharmacy of Craiova. All patients underwent physical examination, laboratory tests, and magnetic resonance imaging (MRI) of the sacroiliac joints. The images were interpreted by a senior radiologist (SR), a junior radiologist (JR), a senior rheumatologist (SRh), and a junior rheumatologist (JRh), who were blinded to the clinical and paraclinical data. Results: The overall κ was 0.7 for the JR (substantial agreement), 0.707 for the SRh (substantial agreement), and 0.601 for the JRh (moderate agreement), in comparison with the SR. Regarding the overall inflammatory changes, the SRh and JR were proven to have substantial agreement (κ = 0.708 and 0.742, respectively) with the SR, while the JRh was proven to have moderate agreement (κ = 0.607). The structural damage observed by the JR showed substantial agreement (κ = 0.676) with the SR, while the SRh and JRh had substantial and moderate agreement (κ = 0.705 and 0.596, respectively) with the SR. Conclusions: Our study showed substantial agreement between the senior radiologist, senior rheumatologist, and junior radiologist, and moderate agreement with the junior rheumatologist.
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Hay CA, Packham J, Ryan S, Mallen CD, Chatzixenitidis A, Prior JA. Diagnostic delay in axial spondyloarthritis: a systematic review. Clin Rheumatol 2022; 41:1939-1950. [PMID: 35182270 PMCID: PMC9187558 DOI: 10.1007/s10067-022-06100-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/01/2022] [Accepted: 02/13/2022] [Indexed: 12/23/2022]
Abstract
Identification of axial spondyloarthritis (axSpA) remains challenging, frequently resulting in a diagnostic delay for patients. Current benchmarks of delay are usually reported as mean data, which are typically skewed and therefore may be overestimating delay. Our aim was to determine the extent of median delay patients’ experience in receiving a diagnosis of axSpA and examine whether specific factors are associated with the presence of such delay. We conducted a systematic review across five literature databases (from inception to November 2021), with studies reporting the average time period of diagnostic delay in patients with axSpA being included. Any additional information examining associations between specific factors and delay were also extracted. A narrative synthesis was used to report the median range of diagnostic delay experienced by patients with axSpA and summarise which factors have a role in the delay. From an initial 11,995 articles, 69 reported an average time period of diagnostic delay, with 25 of these providing a median delay from symptom onset to diagnosis. Across these studies, delay ranged from 0.67 to 8 years, with over three-quarters reporting a median of between 2 years and 6 years. A third of all studies reported median delay data ranging from just 2 to 2.3 years. Of seven variables reported with sufficient frequency to evaluate, only ‘gender’ and ‘family history of axSpA’ had sufficient concordant data to draw any conclusion on their role, neither influenced the extent of the delay. Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay and this remains an extensive worldwide problem. This is further compounded by a mixed picture of the disease, patient and healthcare-related factors influencing delay.Key points • Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay. • Median diagnostic delay typically ranges from 2 to 6 years globally. • Neither ‘gender’ nor ‘family history of axSpA’ influenced the extent of diagnostic delay experienced. • Diagnostic delay based on mean, rather than median, data influences the interpretation of the delay time period and consistently reports a longer delay period. |
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Affiliation(s)
- Charles A Hay
- School of Medicine, Keele University, Keele, ST5 5BG, UK
| | - Jon Packham
- School of Medicine, Keele University, Keele, ST5 5BG, UK.,Academic Unit of Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,Midlands Partnership NHS Foundation Trust, Stafford, UK
| | - Sarah Ryan
- Midlands Partnership NHS Foundation Trust, Stafford, UK.,School of Nursing and Midwifery, Keele University, Keele, ST5 5BG, UK
| | - Christian D Mallen
- School of Medicine, Keele University, Keele, ST5 5BG, UK.,Midlands Partnership NHS Foundation Trust, Stafford, UK
| | | | - James A Prior
- School of Medicine, Keele University, Keele, ST5 5BG, UK. .,Midlands Partnership NHS Foundation Trust, Stafford, UK.
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Matsubara Y, Nakamura Y, Tamura N, Kameda H, Otomo K, Kishimoto M, Kadono Y, Tsuji S, Atsumi T, Matsuno H, Takagi M, Kobayashi S, Fujio K, Nishimoto N, Okamoto N, Nakajima A, Matsui K, Yamamura M, Nakashima Y, Kawakami A, Mori M, Tomita T. A Nationwide Questionnaire Survey on the Prevalence of Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis in Japan. Mod Rheumatol 2021; 32:960-967. [PMID: 34755187 DOI: 10.1093/mr/roab096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/17/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This nationwide study aimed to reveal the prevalence of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-ax SpA), and the positive rate of human leukocyte antigen (HLA) among these patients in Japan. METHODS The first survey was conducted in 2221 randomly selected facilities (26.3%) in September, 2018, where the patients with AS/nr-ax SpA were taken care of from January to December, 2017. We estimated the total number of these patients using response and extraction rate. A second survey was conducted in 117 facilities (49.8%) to assess for HLA-B 27 positivity rate and clinical features. RESULTS The estimated total number of the patients with AS and nr-ax SpA were 3200 (95% confidence interval [CI]: 2400-3900) and 800 (530-1100), suggesting that the prevalence of AS and nr-ax SpA in general population were 2.6/100,000 (0.0026%) and 0.6/100,000 (0.0006%), respectively. Although 55.5 % (76/137) of patients with AS were HLA-B27 positive, those whose age of onset was estimated to be over 50 years tended to undergo less HLA-B27 testing. CONCLUSION This study revealed the lower prevalence of AS/nr-ax SpA in Japan, compared to those in other countries. Further studies are required to reveal the association of HLA-B27 with the clinical features.
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Affiliation(s)
- Yuri Matsubara
- Department of Public Health, Jichi Medical University, Tochigi, Japan
| | - Yosikazu Nakamura
- Department of Public Health, Jichi Medical University, Tochigi, Japan
| | - Naoto Tamura
- Department of Rheumatology and Internal Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Kotaro Otomo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Yuho Kadono
- Department of Orthopaedic Surgery, Saitama Medical University, Saitama, Japan
| | - Shigeyoshi Tsuji
- Department of Orthopaedics and Rheumatology, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Hokkaido, Japan
| | | | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Shigeto Kobayashi
- Department of Internal Medicine and Rheumatology, Juntendo University Koshigaya Hospital, Saitama, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Nishimoto
- Department of Molecular Regulation for Intractable Diseases, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan.,Osaka Rheumatology Clinic, Osaka, Japan
| | - Nami Okamoto
- Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
| | - Kiyoshi Matsui
- Division of Diabetes, Endocrinology and Clinical Immunology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Masahiro Yamamura
- Center for Rheumatology, Okayama Saiseikai General Hospital, Okayama, Japan
| | | | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, Osaka, Japan
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