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Black WR, Singleton J, Wang X, Harris JG, Jones JT. Effect of joint hypermobility on outcomes of children with juvenile idiopathic arthritis. Clin Rheumatol 2024:10.1007/s10067-024-07130-z. [PMID: 39227525 DOI: 10.1007/s10067-024-07130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is common in pediatric rheumatology. Despite treatment, many patients experience persistent disease activity. Joint hypermobility (JH), defined by an excessive range of motion across multiple joints, is prevalent in children and adolescents and may influence disease outcomes in JIA. OBJECTIVE This study examines the impact of JH on symptoms in youth and young adults with JIA. METHODS Data were obtained from the PR-COIN network and included patients under 21 years old with a diagnosis of JIA. Patients with JIA and JH were matched with those having JIA-only based on age, sex assigned at birth, JIA subtype, and medication exposure. Clinical data, including disease activity measures, patient well-being, and pain ratings, were collected at baseline and follow-up visits. RESULTS The sample included 420 patients with JIA + JH and 2100 with JIA only. The JIA + JH group exhibited higher disease activity at baseline, more active arthritis joints, elevated physician global assessment of disease activity scores, and worse patient-reported well-being. These differences persisted over time. The JIA + JH group had a 19-20% greater likelihood of maintaining high disease activity scores and worsening over subsequent visits, indicating a significant impact of JH on disease progression. CONCLUSION JH in youth with JIA is associated with higher and persistent disease activity, suggesting that JH significantly contributes to the disease burden in patients with JIA and should be considered in treatment strategies. Future research should further explore the mechanisms by which JH influences disease activity and investigate comprehensive management approaches to improve outcomes for this population. Key Points • Children with JIA and joint hypermobility (JH) exhibit significantly higher disease activity at baseline compared to those with JIA only, including more active arthritis joints and elevated physician global assessment scores. • The presence of JH in JIA patients is associated with poorer patient-reported well-being and higher overall disease activity scores, which persist over time despite treatment. • JIA + JH patients have a 19-20% greater likelihood of maintaining high disease activity and worsening over subsequent visits, indicating a significant impact of JH on disease progression. • The study suggests that JH should be considered an important clinical factor in the management of JIA, with targeted interventions needed to address the increased disease activity and improve overall patient outcomes.
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Affiliation(s)
- William R Black
- Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital, 700 Children's Drive, J West 3Rd Floor, Columbus, OH, 43205, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Jade Singleton
- Biostatistics Epidemiology and Analytics in Research (BEAR), Seattle Children's Research Institute, Seattle, WA, USA
| | - Xing Wang
- Biostatistics Epidemiology and Analytics in Research (BEAR), Seattle Children's Research Institute, Seattle, WA, USA
| | - Julia G Harris
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jordan T Jones
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Scagnellato L, Cozzi G, Prosepe I, Lorenzin M, Doria A, Martini G, Zulian F, Ramonda R. Relapses of juvenile idiopathic arthritis in adulthood: A monocentric experience. PLoS One 2024; 19:e0298679. [PMID: 38696444 PMCID: PMC11065285 DOI: 10.1371/journal.pone.0298679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/30/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Our aim was to describe a monocentric cohort of young adult patients with juvenile idiopathic arthritis (JIA), assessing the risk of relapse after transition to adult care. METHODS We conducted a retrospective study and collected clinical, serological, and demographic data of young adult patients (18-30 years old) referred to the Transition Clinic of a single Italian centre between January 2020 and March 2023. Patients with systemic-onset JIA were excluded. Primary outcome was disease relapse, defined by Wallace criteria. Risk factors were analysed by Cox proportional hazards regression. RESULTS Fifty patients with age 18-30 years old were enrolled in the study and followed for a median 30 months. The median disease duration at transition was 15 years. Twenty (40%) patients were on conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and 38 (76%) were on biological DMARDs through adulthood. Twenty-three patients relapsed after transitioning to adult care for a median 9-month follow-up (IQR 0-46.5). Most relapses involved the knees (69.6%). The univariate analysis identified monoarthritis (HR 4.67, CI 1.069-20.41, p value = 0.041) as the main risk factor for relapse within the first 36 months of follow-up. Early onset, ANA positivity, past and ongoing treatment with csDMARDs or bDMARDs, therapeutic withdrawal, and disease activity within 12 months before transition did not significantly influence the risk of relapse. CONCLUSION In JIA patients, the risk of relapse after transitioning to adult care remains high, irrespective of disease subtype and treatment. The main risk factor for the early occurrence of articular activity is monoarticular involvement.
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Affiliation(s)
- Laura Scagnellato
- Rheumatology Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - Giacomo Cozzi
- Rheumatology Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - Ilaria Prosepe
- Biomedical Data Science Department, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mariagrazia Lorenzin
- Rheumatology Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
| | - Giorgia Martini
- Paediatric Rheumatology Unit, Department of Women’s and Children’s Health, Padova University Hospital, Padova, Italy
| | - Francesco Zulian
- Paediatric Rheumatology Unit, Department of Women’s and Children’s Health, Padova University Hospital, Padova, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine DIMED, Padova University Hospital, Padova, Italy
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Zulian F, Pierobon B, Zannin ME, Politi C, Vittadello F, Meneghel A, Tirelli F, Martini G. Monoarticular juvenile idiopathic arthritis as a distinct clinical entity A proof-of-concept study. Pediatr Rheumatol Online J 2023; 21:81. [PMID: 37563674 PMCID: PMC10416450 DOI: 10.1186/s12969-023-00869-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Currently, monoarticular Juvenile Idiopathic Arthritis (monoJIA) is included in the ILAR classification as oligoarticular subtype although various aspects, from clinical practice, suggest it as a separate entity. OBJECTIVES To describe the clinical characteristics of persistent monoJIA. METHODS Patients with oligoJIA and with at least two years follow-up entered the study. Those with monoarticular onset and persistent monoarticular course were compared with those with oligoJIA. Variables considered were: sex, age at onset, presence of benign joint hypermobility (BJH), ANA, uveitis, therapy and outcome. Patients who had not undergone clinical follow-up for more than 12 months were contacted by structured telephone interview. RESULTS Of 347 patients with oligoJIA, 196 with monoarticular onset entered the study and 118 (60.2%), identified as persistent monoJIA, were compared with 229 oligoJIA. The mean follow-up was 11.4 years. The switch from monoarticular onset to oligoarticular course of 78 patients (38.8%) occurred by the first three years from onset. In comparison with oligoJIA, the most significant features of monoJIA were later age at onset (6.1 vs. 4.7 years), lower female prevalence (70.3 vs. 83.4%), higher frequency of BJH (61.9 vs. 46.3%), lower frequency of uveitis (14.4 vs. 34.1%) and ANA+ (68.6 vs. 89.5%) and better long-term outcome. CONCLUSIONS MonoJIA, defined as persistent arthritis of unknown origin of a single joint for at least three years, seems to be a separate clinical entity from oligoJIA. This evidence may be taken into consideration for its possible inclusion into the new classification criteria for JIA and open new therapeutic perspectives.
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Affiliation(s)
- Francesco Zulian
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy.
| | - Beatrice Pierobon
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Maria Elisabetta Zannin
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Caterina Politi
- Legal Medicine, Caterina Politi, University of Padova, Padua, MD, Italy
| | | | - Alessandra Meneghel
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Francesca Tirelli
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Giorgia Martini
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
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Tofts LJ, Simmonds J, Schwartz SB, Richheimer RM, O'Connor C, Elias E, Engelbert R, Cleary K, Tinkle BT, Kline AD, Hakim AJ, van Rossum MAJ, Pacey V. Pediatric joint hypermobility: a diagnostic framework and narrative review. Orphanet J Rare Dis 2023; 18:104. [PMID: 37143135 PMCID: PMC10157984 DOI: 10.1186/s13023-023-02717-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/30/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are debilitating conditions. Diagnosis is currently clinical in the absence of biomarkers, and criteria developed for adults are difficult to use in children and biologically immature adolescents. Generalized joint hypermobility (GJH) is a prerequisite for hEDS and generalized HSD. Current literature identifies a large proportion of children as hypermobile using a Beighton score ≥ 4 or 5/9, the cut off for GJH in adults. Other phenotypic features from the 2017 hEDS criteria can arise over time. Finally, many comorbidities described in hEDS/HSD are also seen in the general pediatric and adolescent population. Therefore, pediatric specific criteria are needed. The Paediatric Working Group of the International Consortium on EDS and HSD has developed a pediatric diagnostic framework presented here. The work was informed by a review of the published evidence. OBSERVATIONS The framework has 4 components, GJH, skin and tissue abnormalities, musculoskeletal complications, and core comorbidities. A Beighton score of ≥ 6/9 best identifies children with GJH at 2 standard deviations above average, based on published general population data. Skin and soft tissue changes include soft skin, stretchy skin, atrophic scars, stretch marks, piezogenic papules, and recurrent hernias. Two symptomatic groups were agreed: musculoskeletal and systemic. Emerging comorbid relationships are discussed. The framework generates 8 subgroups, 4 pediatric GJH, and 4 pediatric generalized hypermobility spectrum disorders. hEDS is reserved for biologically mature adolescents who meet the 2017 criteria, which also covers even rarer types of Ehlers-Danlos syndrome at any age. CONCLUSIONS This framework allows hypermobile children to be categorized into a group describing their phenotypic and symptomatic presentation. It clarifies the recommendation that comorbidities should be defined using their current internationally accepted frameworks. This provides a foundation for improving clinical care and research quality in this population.
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Affiliation(s)
| | - Jane Simmonds
- Great Ormond Street Institute of Child Health, University College London, London, UK
- London Hypermobility Unit, Central Health Physiotherapy, London, UK
| | - Sarah B Schwartz
- Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Roberto M Richheimer
- Centro Médico ABC, Carlos Graef Fernández 154-1A, Col. Tlaxala, Alc. Cuajimalpa de Morelos, 05300, Mexico City, CDMX, Mexico
| | - Constance O'Connor
- Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Ellen Elias
- University of Colorado School of Medicine, Denver, USA
- Ehlers-Danlos Center for Excellence and Special Care Clinic, Children's Hospital Colorado Special Care Clinic, Aurora, CO, USA
| | - Raoul Engelbert
- Department of Rehabilitation Medicine, Amsterdam University Medical Center (AMC), Meiberg Dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Katie Cleary
- Ocean Kids Physio, Unit 1/2-8 Peninsula Blvd, Seaford, VIC, 3198, Australia
| | - Brad T Tinkle
- Peyton Manning Children's Hospital, 8402 Harcourt Rd, Ste 300, Indianapolis, IN, 46260, USA
| | - Antonie D Kline
- Greater Baltimore Medical Center, Harvey Institute for Human Genetics, 6701 N. Charles St., Suite 2326, Baltimore, MD, 21204, USA
| | - Alan J Hakim
- The Harley Street Clinic, HCA Healthcare, 16 Devonshire Street, London, UK.
| | | | - Verity Pacey
- Macquarie University, 75 Talavera Rd, Sydney, NSW, 2109, Australia
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Maleki A, Anesi SD, Look-Why S, Manhapra A, Foster CS. Pediatric uveitis: A comprehensive review. Surv Ophthalmol 2021; 67:510-529. [PMID: 34181974 DOI: 10.1016/j.survophthal.2021.06.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Pediatric uveitis accounts for 5-10% of all uveitis. Uveitis in children differs from adult uveitis in that it is commonly asymptomatic and can become chronic and cause damage to ocular structures. The diagnosis might be delayed for multiple reasons, including the preverbal age and difficulties in examining young children. Pediatric uveitis may be infectious or noninfectious in etiology. The etiology of noninfectious uveitis is presumed to be autoimmune or autoinflammatory. The most common causes of uveitis in this age group are idiopathic and juvenile idiopathic arthritis-associated uveitis. The stepladder approach for the treatment of pediatric uveitis is based on expert opinion and algorithms proposed by multidisciplinary panels. Uveitis morbidities in pediatric patients include cataract, glaucoma, and amblyopia. Pediatric patients with uveitis should be frequently examined until remission is achieved. Once in remission, the interval between follow-up visits can be extended; however, it is recommended that even after remission the child should be seen every 8-12 weeks depending on the history of uveitis and the medications used. Close follow up is also necessary as uveitis can flare up during immunomodulatory therapy. It is crucial to measure the impact of uveitis, its treatment, and its complications on the child and the child's family. Visual acuity can be considered as an acceptable criterion for assessing visual function. Additionally, the number of cells in the anterior chamber can be a measure of disease activity. We review different aspects of pediatric uveitis. We discuss the mechanisms of noninfectious uveitis, including autoimmune and autoinflammatory etiologies, and the risks of developing uveitis in children with systemic rheumatologic diseases. We address the risk factors for developing morbidities, the Standardization of Uveitis Nomenclature (SUN) criteria for timing and anatomical classifications, and describe a stepladder approach in the treatment of pediatric uveitis based on expert opinion and algorithms proposed by multi-disciplinary panels. In this review article, We describe the most common entities for each type of anatomical classification and complications of uveitis for the pediatric population. Additionally, we address monitoring of children with uveitis and evaluation of Quality of Life.
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Affiliation(s)
- Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Sydney Look-Why
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Ambika Manhapra
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA; Harvard Medical School, Department of Ophthalmology, Boston, MA, USA.
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Rustad AM, Nolan BE, Ollech A, Boctor MJ, Paller AS. Incorporating joint pain screening into the pediatric dermatologic examination. Pediatr Dermatol 2021; 38:92-97. [PMID: 33275304 DOI: 10.1111/pde.14454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Joint manifestations are a feature of many pediatric skin disorders, among them psoriasis, autoimmune and autoinflammatory diseases, hypermobility disorders, and as an adverse effect of certain medications. Identifying joint disease early is important for intervention and prevention of chronic damage. However, pediatric musculoskeletal complaints are common and determining whether symptoms warrant a rheumatology referral for arthritis can be challenging. METHODS Pediatric dermatologists were surveyed for their comfort in screening for joint disease. Through literature review and interviews with three pediatric rheumatologists, key joints involved in disorders with skin manifestations and arthritis were identified and the essential evaluations were determined. RESULTS Of 100 surveyed practicing board-certified pediatric dermatologists, 79% did not feel confident in their ability to perform a joint-focused physical examination, a key step in screening for joint disease. A rapid joint examination technique (R-JET) was developed, along with an accompanying three-question survey and body diagram for patient self-report of symptoms. A video demonstration of the R-JET was created as a teaching tool. CONCLUSIONS Teaching and incorporation of a rapid screening examination for arthritis by pediatric dermatologists has the potential to identify pediatric arthritis earlier, facilitate referral, and reduce the risk of progressive joint disease. These instruments can easily be incorporated into a pediatric dermatology office visit.
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Affiliation(s)
- Andrea M Rustad
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian E Nolan
- Departments of Pediatrics/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ayelet Ollech
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Departments of Pediatrics/Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Boctor
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Departments of Pediatrics/Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Jari M, Shiari R, Salehpour O, Rahmani K. Epidemiological and advanced therapeutic approaches to treatment of uveitis in pediatric rheumatic diseases: a systematic review and meta-analysis. Orphanet J Rare Dis 2020; 15:41. [PMID: 32019589 PMCID: PMC7001204 DOI: 10.1186/s13023-020-1324-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Despite the low prevalence of uveitis in pediatric rheumatic diseases, potential problems as well as high disease burden can complicate its management. In this review, we systematically assessed the epidemiological, etiological, and managerial aspects of uveitis in pediatric rheumatic diseases. Methods This current study was conducted in accordance with the established methods and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). We searched the manuscript databases, including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane for all eligible studies in line with the considered keywords. We also conducted the statistical analysis using the Stata software. Results Considering studies focusing on uveitis in Juvenile Idiopathic Arthritis (JIA) yielded a pooled prevalence of 11.8% (95%CI: 11.2 to 12.4%) for uveitis following JIA. In this regard, the prevalence rate of uveitis related to Behçet,s disease and Systemic Lupus Erythematosus (SLE( was estimated to be 15.0 and 0.8%, respectively. The pooled response rate to Adalimumab and Infliximab was estimated to be 68.0% (95%CI: 65.4 to 70.6%), 64.7% (95%CI: 59.8 to 69.3%), respectively. The documents for the systematical assessment of other biological medications (e.g. Tocilizumab, Daclizumab and Rituximab) were inadequate; however, the mean response rate for these drugs was 59, 75 and 80%, respectively. Our meta-analysis showed a pooled response rate of 40.0% (95%CI, 36.0% to 44.2) to Methotrexate. Significant heterogeneity and significant diffusion bias were demonstrated by reviewing studies. Conclusions The pooled prevalence of uveitis in pediatric rheumatic diseases widely varied based on the underlying disease requiring more investigations in different subtypes of rheumatic diseases. The biologic medications, especially Adalimumab are the most effective treatments for uveitis in pediatric rheumatic diseases; however, a combination of the safe, available alternatives is preferred to achieve the most desirable treatment response.
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Affiliation(s)
- Mohsen Jari
- Department of Pediatric Rheumatology, Imam Hossein Children's Hospital. Isfahan University of Medical Sciences, Isfahan, Iran. .,Child Growth and Development Research Center, Research Institute for Primordial prevention of non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Reza Shiari
- Department of Pediatric Rheumatology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Salehpour
- Negah Specialty Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khosro Rahmani
- Department of Pediatric Rheumatology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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