1
|
Um IG, Woo JS, Lee YJ, Lee SY, Jeong HY, Na HS, Lee JS, Lee AR, Park SH, Cho ML. IL-21 drives skin and lung inflammation and fibrosis in a model for systemic sclerosis. Immunol Lett 2024; 270:106924. [PMID: 39260526 DOI: 10.1016/j.imlet.2024.106924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 09/05/2024] [Accepted: 09/08/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Systemic sclerosis (SSc) is an autoimmune disease characterized by vasculopathy, abnormal inflammation, and fibrosis of the skin and internal organs, notably the skin and lungs, significantly impairing quality of life. There is currently no cure for SSc, and its etiology remains largely unknown, presenting a primary barrier to effective treatment. We investigated the role of interleukin-21 (IL-21) in the pathogenesis of SSc. METHODS We assessed the expression levels of fibrosis-related genes in human dermal fibroblasts exposed to IL-21 and TGF beta. We also induced SSc in wild-type C57BL/6 mice and IL-21 knockout (KO) mice with a C57BL/6 background using bleomycin (Bleomycin). Histological analyses were conducted on skin and lung tissues from these mice. The distribution and expression levels of fibrosis-related proteins in the tissues were examined via immunohistochemistry and quantitative real-time PCR. Furthermore, we measured the frequency of Th1, Th2, and Th17 cells among splenocytes through flow cytometry. RESULTS IL-21 activation led to STAT3 phosphorylation more than TGF beta in dermal fibroblasts. In IL-21 KO mice with BLM-induced SSc, skin thickness and lung fibrosis were reduced. The absence of IL-21 in these mice resulted in suppressed expression of fibrosis-related genes, including Col1a1, Col1a2, Col3a1, CTGF, α-SMA, STAT3, and TGFβ, in the skin and lungs. It also led to a decreased frequency of Th1, Th2, and Th17 cells, as well as a lower Th17/Treg ratio among splenocytes, factors known to contribute to the development of SSc. CONCLUSIONS IL-21 contributes to the development of SSc by promoting the expression of fibrosis-related genes and modulating the levels of CD4+ T cells.
Collapse
Affiliation(s)
- In Gyu Um
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jin Seok Woo
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Young Joon Lee
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Seon-Yeong Lee
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Ha Yeon Jeong
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hun Sik Na
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jeong Su Lee
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - A Ram Lee
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; Department of Medical Life Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Mi-La Cho
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea; Lab of Translational ImmunoMedicine, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| |
Collapse
|
2
|
Abdel-Wahab N, Suarez-Almazor ME. Rheumatic adverse events of immune checkpoint inhibitors in cancer immunotherapy. Expert Rev Clin Immunol 2024; 20:873-893. [PMID: 38400840 PMCID: PMC11449381 DOI: 10.1080/1744666x.2024.2323966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION The advent of immune checkpoint inhibitors (ICIs) in cancer treatment has marked a transformative era, albeit tempered by immune-related adverse events (irAEs), including those impacting the musculoskeletal system. The lack of precise epidemiologic data on rheumatic irAEs is attributed to factors such as potential underrecognition, underreporting in clinical trials, and the tendency to overlook manifestations without immediate life-threatening implications, further complicating the determination of accurate incidence rates, while the complete understanding of the mechanisms driving rheumatic irAEs remains elusive. AREAS COVERED This literature review comprehensively examines rheumatic irAEs in cancer patients undergoing ICI therapy, encompassing epidemiology, risk factors, mechanisms, clinical manifestations, and current management guidance for prevalent conditions such as inflammatory arthritis, polymyalgia rheumatica, and myositis. Less frequent rheumatic and musculoskeletal irAEs are also explored, alongside insights into ongoing clinical trials testing therapeutic and preventive strategies for irAEs. A thorough literature search on Medline and the National Cancer Institute Clinical Trials Database was conducted up to October 2023 to compile relevant information. EXPERT OPINION In light of the evolving landscape of cancer immunotherapy, there is a compelling need for prospective longitudinal studies to enhance understanding and inform clinical management strategies for rheumatic irAEs.
Collapse
Affiliation(s)
- Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine; and Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Maria E Suarez-Almazor
- Department of Health Services Research; and Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
3
|
Chandrashekara S. Pharmacokinetic review of janus kinase inhibitors and its clinical implications for the management of rheumatoid arthritis. Expert Opin Drug Metab Toxicol 2024:1-8. [PMID: 38916236 DOI: 10.1080/17425255.2024.2373092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/24/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION In the realm of autoimmune rheumatic diseases, understanding JAK inhibitors (JAKi) nuances is vital. Baricitinib, tofacitinib, upaacitinib, filgotinib, and peficitinib exhibit subtle yet impactful pharmacokinetic (PK) and pharmacodynamic (PD) variations. AREAS COVERED This narrative review critically assesses PK and PD distinctions among globally approved JAKi for rheumatoid arthritis, which primarily guide clinical decisions in autoimmune diseases, particularly rheumatoid arthritis. It explores the intricate JAK-STAT signaling pathway, offering insights into JAKs' roles in inflammation, hematopoiesis, and immune homeostasis. Emphasis on PK parameters, including absorption, distribution, metabolism, and excretion, along with CYP3A4 drug interactions, is highlighted. The review underscores integrating PK and PD properties, considering patient-specific factors like hepatic and renal clearance, for judicious JAKi selection in RA and related autoimmune conditions. The literature has been collected from all available databases based on the review question. EXPERT OPINION Integrating PK and PD properties with patient-specific factors is pivotal for judicious JAKi selection. Recognizing disparities in PK and PD across diseases, ethnicities, and environmental factors is crucial for personalized JAKi choices. This expert opinion underscores the significance of a second compartment analysis, elucidating the interplay between PK and PD and its impact on JAKi efficacy.
Collapse
Affiliation(s)
- S Chandrashekara
- Department of Clinical Immunology and Rheumatology, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
| |
Collapse
|
4
|
Decker RL, Steven Ernest C, Radtke DB, Wang R, Araújo J, Keller SY, Zhang X. A population pharmacokinetic model using allometric scaling for baricitinib in patients with juvenile idiopathic arthritis. CPT Pharmacometrics Syst Pharmacol 2024; 13:970-981. [PMID: 38532270 PMCID: PMC11179695 DOI: 10.1002/psp4.13131] [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: 01/18/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 03/28/2024] Open
Abstract
Baricitinib is approved for the treatment of rheumatoid arthritis (RA) in more than 70 countries, and juvenile idiopathic arthritis (JIA) in the European Union. Population pharmacokinetic (PK) models were developed in a phase 3 trial to characterize PK in pediatric patients with JIA and identify weight-based dosing regimens. The phase 3, randomized, double-blind, placebo-controlled withdrawal, efficacy and safety trial, JUVE-BASIS, enrolled patients (aged 2 to <18 years) with polyarticular course JIA. During a safety/PK period, baricitinib concentration data from age-based dose cohorts were compared to concentrations from adult patients receiving 4-mg QD. PK data were used to develop a population PK model with allometric scaling to determine a weight-based posology in pediatric patients with JIA that matched the adult 4-mg exposure. Baricitinib plasma concentrations from 217 pediatric patients were used to characterize PK. Based on the adult model, pediatric PK was best described using a 2-compartment model with allometric scaling on clearance and volume of distribution and renal function (estimated with glomerular filtration rate [GFR], a known covariate affecting PK of baricitinib) on clearance. The PK modeling suggested the optimal dosing regimen based on weight for pediatric patients as: 2-mg QD for patients 10 to <30 kg and 4-mg QD for patients ≥30 kg. The use of a population PK model of baricitinib treatment in adult patients with RA, with the addition of allometric scaling for weight on clearance and volume terms, was useful to predict exposures and identify weight-based dosing in pediatric patients with JIA.
Collapse
Affiliation(s)
| | | | | | - Rona Wang
- Eli Lilly and CompanyIndianapolisIndianaUSA
| | | | | | - Xin Zhang
- Eli Lilly and CompanyIndianapolisIndianaUSA
| |
Collapse
|
5
|
Calvo-Garcia A, Ramírez Herráiz E, Llorente Cubas IM, Varas De Dios B, Benedí González J, Morell Baladrón A, García-Vicuña R. The Real-World Effectiveness, Persistence, Adherence, and Safety of Janus Kinase Inhibitor Baricitinib in Rheumatoid Arthritis: A Long-Term Study. J Clin Med 2024; 13:2517. [PMID: 38731045 PMCID: PMC11084207 DOI: 10.3390/jcm13092517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Aim: Baricitinib (BAR) is the first oral selective Janus kinase inhibitor approved in Europe for rheumatoid arthritis (RA). Real-world data are still needed to clarify its long-term benefits/risk profile. This study aimed to evaluate the effectiveness, persistence, adherence, and safety of BAR in a real-world setting. Methods: An ambispective study was conducted between October 2017 and December 2021 in RA patients starting BAR. The effectiveness was evaluated, assessing changes from the baseline of the Disease Activity Score using 28-joint counts-C reactive protein (DAS28CRP), and the achievement of low disease activity/remission. Drug persistence was evaluated using Kaplan-Meier analysis. Adherence was estimated using the medication possession ratio (MPR) and the 5-item Compliance Questionnaire for Rheumatology. Safety was assessed determining global incidence proportion and adverse event adjusted incidence rates. Results: In total, 61/64 recruited patients were finally analyzed, 83.6% were female, 78.7% were seropositive, the mean age was 58.1 (15.4) years, and the disease duration was 13.9 (8.3) years. A total of 32.8% of patients were naïve to biologics and 16.4% received BAR as monotherapy. The median exposure to BAR was 12.4 (6.6-31.2) months (range 3.1-51.4). A significant change in DAS28CRP was observed after treatment (difference -1.2, p = 0.000). 70.5% and 60.7% of patients achieved low disease activity or remission, respectively, and 50.8% (31/61) remained on BAR throughout the follow-up, with a median persistence of 31.2 (9.3-53.1) months. The average MPR was 0.96 (0.08) and all patients exhibited "good adherence" according to the questionnaire. In total, 21.3% of patients discontinued baricitinib due to toxicity. Conclusions: In our real-world practice, BAR demonstrated effectiveness, large persistence, high adherence to treatment, and an acceptable safety profile.
Collapse
Affiliation(s)
- Alberto Calvo-Garcia
- Pharmacy Service, Hospital Universitario La Princesa, IIS-Princesa, 28006 Madrid, Spain; (A.C.-G.); (E.R.H.); (A.M.B.)
| | - Esther Ramírez Herráiz
- Pharmacy Service, Hospital Universitario La Princesa, IIS-Princesa, 28006 Madrid, Spain; (A.C.-G.); (E.R.H.); (A.M.B.)
| | | | - Blanca Varas De Dios
- Rheumatology Service, Hospital Universitario Santa Cristina, 28006 Madrid, Spain;
| | - Juana Benedí González
- Pharmacology, Pharmacognosy and Botany Department, Pharmacy Faculty, Complutense University of Madrid, 28040 Madrid, Spain;
| | - Alberto Morell Baladrón
- Pharmacy Service, Hospital Universitario La Princesa, IIS-Princesa, 28006 Madrid, Spain; (A.C.-G.); (E.R.H.); (A.M.B.)
| | - Rosario García-Vicuña
- Rheumatology Service, Hospital Universitario La Princesa, IIS-Princesa, 28006 Madrid, Spain;
- Department of Medicine, Faculty of Medicine, Autonomous University of Madrid, 28049 Madrid, Spain
| |
Collapse
|
6
|
Wei XH, Liu YY. Potential applications of JAK inhibitors, clinically approved drugs against autoimmune diseases, in cancer therapy. Front Pharmacol 2024; 14:1326281. [PMID: 38235120 PMCID: PMC10792058 DOI: 10.3389/fphar.2023.1326281] [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] [Received: 10/23/2023] [Accepted: 12/12/2023] [Indexed: 01/19/2024] Open
Abstract
Disturbances in immunoregulation may lead to both cancer and autoimmune diseases. Many therapeutic drugs for autoimmune diseases also display anti-tumor efficacy. The Janus kinase/signal transducer and activator of transcription signaling pathways are involved in the secretion of more than 50 distinct cytokines, which have critical roles in inducing autoimmune diseases and tumorigenesis. Thus, Janus kinases have become classical immunotherapeutic targets for immune disease. More than 70 Janus kinase inhibitors have been approved as immunomodulatory drugs for clinical use, of which 12 are used in the treatment of autoimmune diseases. This systematic review aims to elucidate the anti-tumor role of clinically approved Janus kinase inhibitors that were primarily designed for the treatment of autoimmune diseases and their potential for clinical translation as cancer treatments.
Collapse
Affiliation(s)
- Xiao-Huan Wei
- Respiratory and Critical Care Department, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
- Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Oncology Department, People’s Hospital of Peixian, Xuzhou, Jiangsu, China
| | - Yuan-Yuan Liu
- Respiratory and Critical Care Department, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
- Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, Jiangsu, China
| |
Collapse
|
7
|
Sarapultsev A, Gusev E, Komelkova M, Utepova I, Luo S, Hu D. JAK-STAT signaling in inflammation and stress-related diseases: implications for therapeutic interventions. MOLECULAR BIOMEDICINE 2023; 4:40. [PMID: 37938494 PMCID: PMC10632324 DOI: 10.1186/s43556-023-00151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
The Janus kinase-signal transducer and transcription activator pathway (JAK-STAT) serves as a cornerstone in cellular signaling, regulating physiological and pathological processes such as inflammation and stress. Dysregulation in this pathway can lead to severe immunodeficiencies and malignancies, and its role extends to neurotransduction and pro-inflammatory signaling mechanisms. Although JAK inhibitors (Jakinibs) have successfully treated immunological and inflammatory disorders, their application has generally been limited to diseases with similar pathogenic features. Despite the modest expression of JAK-STAT in the CNS, it is crucial for functions in the cortex, hippocampus, and cerebellum, making it relevant in conditions like Parkinson's disease and other neuroinflammatory disorders. Furthermore, the influence of the pathway on serotonin receptors and phospholipase C has implications for stress and mood disorders. This review expands the understanding of JAK-STAT, moving beyond traditional immunological contexts to explore its role in stress-related disorders and CNS function. Recent findings, such as the effectiveness of Jakinibs in chronic conditions such as rheumatoid arthritis, expand their therapeutic applicability. Advances in isoform-specific inhibitors, including filgotinib and upadacitinib, promise greater specificity with fewer off-target effects. Combination therapies, involving Jakinibs and monoclonal antibodies, aiming to enhance therapeutic specificity and efficacy also give great hope. Overall, this review bridges the gap between basic science and clinical application, elucidating the complex influence of the JAK-STAT pathway on human health and guiding future interventions.
Collapse
Affiliation(s)
- Alexey Sarapultsev
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, 454080, Chelyabinsk, Russia.
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049, Ekaterinburg, Russia.
| | - Evgenii Gusev
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, 454080, Chelyabinsk, Russia
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049, Ekaterinburg, Russia
| | - Maria Komelkova
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, 454080, Chelyabinsk, Russia
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049, Ekaterinburg, Russia
| | - Irina Utepova
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049, Ekaterinburg, Russia
- Department of Organic and Biomolecular Chemistry, Ural Federal University, 620002, Ekaterinburg, Russian Federation
| | - Shanshan Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Desheng Hu
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, 430022, China
- Clinical Research Center of Cancer Immunotherapy, Hubei Wuhan, 430022, China
| |
Collapse
|
8
|
Tokareva K, Reid P, Yang V, Liew D, Peterson AC, Baraff A, Giles J, Singh N. JAK inhibitors and black box warnings: what is the future for JAK inhibitors? Expert Rev Clin Immunol 2023; 19:1385-1397. [PMID: 37596779 PMCID: PMC10615860 DOI: 10.1080/1744666x.2023.2249237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Janus kinase inhibitors (JAKi) have dramatically improved the treatment of various autoimmune and myeloproliferative disorders. Recently, concern has arisen regarding their safety in patients with rheumatoid arthritis. AREAS COVERED Here, we provide a comprehensive summary of the major current and emerging JAKi and their indications, address recent studies on comparative safety, and provide insight into their future and use. We emphasize that the application of the research findings on a case-by-case basis should consider a patient's age, comorbidities, disease for which JAKi is being considered, disease activity, the JAKi target(s), alternate treatment options available for the patient, and the planned duration of JAKi. EXPERT OPINION Rheumatologists are used to prescribing therapies in which a risk-to-benefit assessment is required as well as to screening and monitoring the safety of medications. Thus, rheumatologists are already practiced in applying specific criteria to effectively screen and monitor patients who are candidates for JAKi therapy. Ongoing research will help to clarify any mechanisms underlying differential safety signals between JAK and other therapies, what the balance between risk and efficacy is, who the susceptible subpopulations are, and whether safety signals are shared between different JAKis and across indications.
Collapse
Affiliation(s)
- Kate Tokareva
- Medical Student, University of Washington, Seattle, WA, USA
| | - Pankti Reid
- Division of Rheumatology and Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Victor Yang
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
| | - David Liew
- Department of Rheumatology, Austin Health, Melbourne, Victoria, Australia
- Department of Clinical Pharmacology and Therapeutics, Austin Health, Melbourne, Victoria, Australia
| | | | - Aaron Baraff
- VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Jon Giles
- Columbia University, New York, NY, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|