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Trang KB, Sharma P, Cook L, Mount Z, Thomas RM, Kulkarni NN, Pahl MC, Pippin JA, Su C, Kaestner KH, O'Brien JM, Wagley Y, Hankenson KD, Jermusyk A, Hoskins JW, Amundadottir LT, Xu M, Brown KM, Anderson SA, Yang W, Titchenell PM, Seale P, Zemel BS, Chesi A, Romberg N, Levings MK, Grant SFA, Wells AD. 3D chromatin-based variant-to-gene maps across 57 human cell types reveal the cellular and genetic architecture of autoimmune disease susceptibility. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.12.24311676. [PMID: 39185517 PMCID: PMC11343244 DOI: 10.1101/2024.08.12.24311676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
A portion of the genetic basis for many common autoimmune disorders has been uncovered by genome-wide association studies (GWAS), but GWAS do not reveal causal variants, effector genes, or the cell types impacted by disease-associated variation. We have generated 3D genomic datasets consisting of promoter-focused Capture-C, Hi-C, ATAC-seq, and RNA-seq and integrated these data with GWAS of 16 autoimmune traits to physically map disease-associated variants to the effector genes they likely regulate in 57 human cell types. These 3D maps of gene cis-regulatory architecture are highly powered to identify the cell types most likely impacted by disease-associated genetic variation compared to 1D genomic features, and tend to implicate different effector genes than eQTL approaches in the same cell types. Most of the variants implicated by these cis-regulatory architectures are highly trait-specific, but nearly half of the target genes connected to these variants are shared across multiple autoimmune disorders in multiple cell types, suggesting a high level of genetic diversity and complexity among autoimmune diseases that nonetheless converge at the level of target gene and cell type. Substantial effector gene sharing led to the common enrichment of similar biological networks across disease and cell types. However, trait-specific pathways representing potential areas for disease-specific intervention were identified. To test this, we pharmacologically validated squalene synthase, a cholesterol biosynthetic enzyme encoded by the FDFT1 gene implicated by our approach in MS and SLE, as a novel immunomodulatory drug target controlling inflammatory cytokine production by human T cells. These data represent a comprehensive resource for basic discovery of gene cis-regulatory mechanisms, and the analyses reported reveal mechanisms by which autoimmune-associated variants act to regulate gene expression, function, and pathology across multiple, distinct tissues and cell types.
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Affiliation(s)
- Khanh B Trang
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Prabhat Sharma
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura Cook
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zachary Mount
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rajan M Thomas
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nikhil N Kulkarni
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew C Pahl
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James A Pippin
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chun Su
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Klaus H Kaestner
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joan M O'Brien
- Scheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, PA, USA
- Penn Medicine Center for Ophthalmic Genetics in Complex Disease
| | - Yadav Wagley
- Department of Orthopedic Surgery University of Michigan Medical School Ann Arbor, MI, USA
| | - Kurt D Hankenson
- Department of Orthopedic Surgery University of Michigan Medical School Ann Arbor, MI, USA
| | - Ashley Jermusyk
- Laboratory of Translational Genomics, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Jason W Hoskins
- Laboratory of Translational Genomics, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Laufey T Amundadottir
- Laboratory of Translational Genomics, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Mai Xu
- Laboratory of Translational Genomics, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Kevin M Brown
- Laboratory of Translational Genomics, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Stewart A Anderson
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wenli Yang
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul M Titchenell
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Seale
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alessandra Chesi
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Neil Romberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Institute for Immunology and Immune Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Megan K Levings
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Struan F A Grant
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew D Wells
- Center for Spatial and Functional Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Institute for Immunology and Immune Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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2
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Gruca M, Zamojska J, Niewiadomska-Jarosik K, Wosiak A, Stasiak A, Sikorska K, Stańczyk J, Smolewska E. Assessment of Cardiovascular Risk Factors in Patients with Juvenile Idiopathic Arthritis. Nutrients 2023; 15:nu15071700. [PMID: 37049540 PMCID: PMC10096608 DOI: 10.3390/nu15071700] [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: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction: The aim of this study was to assess the exposure to cardiovascular disease (CVD) risk factors in patients with juvenile idiopathic arthritis (JIA). Intima–media complex thickness (IMT), selected metabolic parameters and health behaviors were assessed in the course of the study. Methods: The study included study group, which consisted of 45 patients with JIA and 37 healthy age- and sex-matched children in the control group. Analyses in both groups included anthropometric parameters, laboratory tests, IMT and a questionnaire on exposure to modifiable CVD risk factors. Results: The study confirmed that CVD risk factors were present in both groups of patients. Significantly more children with JIA had abnormal BMI (p = 0.006) compared to the control group. Children in the study group were more likely to consume fruit regularly (p = 0.021) and less likely to consume fast food (p = 0.011) and sweetened beverages (p = 0.042) than children in the control group. Only 1 patient with JIA met criteria for ideal cardiovascular health. Dietary habits were not associated with IMT values, BMI, presence of joint pain or biochemical parameters in the study group. Conclusions: Patients with JIA are exposed to cardiovascular risk factors equally to their healthy peers. Ideal cardiovascular health should be pursued in the pediatric population with particular attention paid to patients with chronic diseases (i.e., JIA). The application of carotid artery IMT measurement in the assessment of CVD risk requires studies on a larger group of patients.
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Affiliation(s)
- Marta Gruca
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
- Correspondence:
| | - Justyna Zamojska
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
| | | | - Agnieszka Wosiak
- Institute of Information Technology, Lodz University of Technology, 91-738 Lodz, Poland
| | - Aleksandra Stasiak
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
| | - Karolina Sikorska
- Paediatric Department, Independent Public Health Care Complex in Minsk Mazowiecki, Szpitalna 37, 05-300 Warsaw, Poland
| | - Jerzy Stańczyk
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
| | - Elżbieta Smolewska
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738 Lodz, Poland
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Zhang RD, Chen C, Wang P, Fang Y, Jiang LQ, Fang X, Zhao Y, Ni J, Wang DG, Pan HF. Air pollution exposure and auto-inflammatory and autoimmune diseases of the musculoskeletal system: a review of epidemiologic and mechanistic evidence. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2023:10.1007/s10653-023-01495-x. [PMID: 36735155 DOI: 10.1007/s10653-023-01495-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
Auto-inflammatory and autoimmune diseases of the musculoskeletal system can be perceived as a spectrum of rheumatic diseases, with the joints and connective tissues are eroded severely that progressively develop chronic inflammation and lesion. A wide range of risk factors represented by genetic and environmental factors have been uncovered by population-based surveys and experimental studies. Lately, the exposure to air pollution has been found to be potentially involved in the mechanisms of occurrence or development of such diseases, principally manifest in oxidative stress, local and systemic inflammation, and epigenetic modifications, as well as the mitochondrial dysfunction, which has been reported to participate in the intermediate links. The lungs might serve as a starting area of air pollutants, which would cause oxidative stress-induced bronchial-associated lymphoid tissue (iBALT) to further to influence T, B cells, and the secretion of pro-inflammatory cytokines. The binding of aromatic hydrocarbon receptor (AhR) to the corresponding contaminant ligands tends to regulate the reaction of Th17 and Tregs. Furthermore, air pollution components might spur on immune and inflammatory responses by damaging mitochondria that could interact with and exacerbate oxidative stress and pro-inflammatory cytokines. In this review, we focused on the association between air pollution and typical auto-inflammatory and autoimmune diseases of the musculoskeletal system, mainly including osteoarthritis (OA), rheumatoid arthritis (RA), spondyloarthritis (SpA) and juvenile idiopathic arthritis (JIA), and aim to collate the mechanisms involved and the potential channels. A complete summary and in-depth understanding of the autoimmune and inflammatory effects of air pollution exposure should hopefully contribute new perspectives on how to formulate better public health policies to alleviate the adverse health effects of air pollutants.
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Affiliation(s)
- Ruo-Di Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Cong Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Peng Wang
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
- Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Yang Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Ling-Qiong Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Xi Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Yan Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Jing Ni
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - De-Guang Wang
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
- Department of Nephrology, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China.
- Institute of Kidney Disease, Inflammation and Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, Hefei, 230032, Anhui, People's Republic of China.
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4
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Farhat SCL, Ejnisman C, Alves AGF, Goulart MFG, Lichtenfels AJDFC, Braga ALF, Pereira LAA, Maluf Elias A, Silva CA. Air pollution influence on serum inflammatory interleukins: A prospective study in childhood-onset systemic lupus erythematous patients. Lupus 2021; 30:2268-2275. [PMID: 34879788 DOI: 10.1177/09612033211061479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effect of individual exposure, in real-time, to traffic-related pollutants on serum interleukin levels of childhood-onset lupus erythematous systemic (c-SLE) patients. METHODS A longitudinal and observational design was conducted in 12 repeated measures of serum samples and clinical evaluations (totaling 108 measurements) of c-SLE patients over 30 consecutive months. Real-time, individual exposure to fine particles (PM2.5) and nitrogen dioxide (NO2) was measured with portable monitors. Generalized estimating equation was used to evaluate the association between exposure to PM2.5 and NO2 and the following serum cytokine levels on the 7 days preceding clinical assessment and serum collection: MCP1, IL-6, IL-8, IL-10, IL-17, IFN-alpha, and TNF-alpha. Disease activity and other risk factors were also controlled. RESULTS An interquartile range (IQR) increase in PM2.5 daily concentration was significantly associated with increased levels of TNF-alpha on the third, fourth, and seventh day after exposure; IL-10 on the third and fourth day after exposure; IL-17 on the third and seventh day after exposure; and INF-alpha on the third day after exposure (p < 0.05). An IQR increase in 7-day moving average of PM2.5 was associated with a 6.2 pg/mL (95% CI: 0.5; 11.8; p = 0.04) increase in serum IFN-alpha level. An unexpected significant association was observed between an IQR increase in NO27-day cumulative concentration and a decrease of 1.6 pg/mL (95% CI: -2.6; -0.7; p < 0.001) in serum IL-17. CONCLUSION Real-time exposure to PM2.5 prospectively associated with increased serum TNF-alpha, INF-alpha, IL-10, and IL-17 levels in c-SLE patients.
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Affiliation(s)
- Sylvia Costa Lima Farhat
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratory of Experimental Air Pollution, LIM05, Faculdade de Medicina FMUSP, 37884Universidade de Sao Paulo, São Paulo, Brazil.,Pediatric Department Hospital das Clinicas HCFMUSP, Faculdade de Medicina, 37884Universidade de Sao Paulo, São Paulo, Brazil
| | - Carolina Ejnisman
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,428062Universidade de Santo Amaro, Sao Paulo, Brazil
| | - Andressa Guariento Ferreira Alves
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Fernanda Giacomin Goulart
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Alfésio Luis Ferreira Braga
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratory of Experimental Air Pollution, LIM05, Faculdade de Medicina FMUSP, 37884Universidade de Sao Paulo, São Paulo, Brazil.,Environmental Exposure and Risk Assessment Group, Collective Health Post-graduation Program, 67888Universidade Catolica de Santos, Santos, Brazil
| | - Luiz Alberto Amador Pereira
- Environmental Epidemiology Study Group, Laboratory of Experimental Air Pollution, 37884Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratory of Experimental Air Pollution, LIM05, Faculdade de Medicina FMUSP, 37884Universidade de Sao Paulo, São Paulo, Brazil
| | - Adriana Maluf Elias
- Pediatric Department Hospital das Clinicas HCFMUSP, Faculdade de Medicina, 37884Universidade de Sao Paulo, São Paulo, Brazil.,Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, 28133Universidade de Sao Paulo, São Paulo, Brazil
| | - Clovis A Silva
- Pediatric Department Hospital das Clinicas HCFMUSP, Faculdade de Medicina, 37884Universidade de Sao Paulo, São Paulo, Brazil.,Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, 28133Universidade de Sao Paulo, São Paulo, Brazil.,Division of Rheumatology, Faculdade de Medicina FMUSP, 37884Universidade de Sao Paulo, São Paulo, Brazil
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5
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Vasques Dantas Landim JI, da Rocha LN, Silva MF, Dos Santos Brasil LT, Lima Rocha HA, Junior CNR, Rocha FAC. Parental Smoking Influence in Disease Activity in a Low-Income Juvenile Idiopathic Arthritis Cohort. J Clin Rheumatol 2021; 27:e596-e598. [PMID: 31977651 DOI: 10.1097/rhu.0000000000001299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
Studying environmental risk factors for pediatric rheumatic diseases (PRD) is important because the identification of these factors may lead to strategies to prevent disease, and to new insights into pathogenesis and therapeutic targets. Compared with other chronic diseases, there are few environmental epidemiology studies in PRD. Although strong risk factors common to all PRDs have not been identified, some exposures including infection, smoke exposure, and ultraviolet radiation have been associated with several of them. High-technology studies, especially of microbiomics and metabolomics, are increasing and will likely lead to new understandings of the complex interplay between environment, genetics, and disease.
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7
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Abstract
Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.
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8
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Clarke SLN, Mageean KS, Maccora I, Harrison S, Simonini G, Sharp GC, Relton CL, Ramanan AV. Moving from nature to nurture: a systematic review and meta-analysis of environmental factors associated with juvenile idiopathic arthritis. Rheumatology (Oxford) 2021; 61:514-530. [PMID: 34382060 PMCID: PMC8824412 DOI: 10.1093/rheumatology/keab627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/10/2021] [Accepted: 07/21/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives JIA is the most common paediatric rheumatic disease, thought to be influenced by both genetics and the environment. Identifying environmental factors associated with disease risk will improve knowledge of disease mechanism and ultimately benefit patients. This review aimed to collate and synthesize the current evidence of environmental factors associated with JIA. Methods Four databases (MEDLINE, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature) were searched from inception to January 2020. Study quality was rated using the Newcastle-Ottawa Scale. Pooled estimates for each environmental factor were generated using a random-effects, inverse-variance method, where possible. The remaining environmental factors were synthesized in narrative form. Results This review includes 66 environmental factors from 39 studies (11 cohort and 28 case-control studies) over 45 years. Study sample sizes ranged from 41 to 1.9 million participants. Eight environmental factors from ten studies were meta-analysed. Caesarean section delivery was associated with increased JIA risk [pooled odds ratio (OR) 1.11, 95% CI: 1.01, 1.22]. Conversely, presence (vs absence) of siblings (pooled OR 0.60, 95% CI: 0.44, 0.81) and maternal prenatal smoking (pooled OR 0.70, 95% CI: 0.58, 0.84) were associated with decreased JIA risk. Conclusion This review identifies several environmental factors associated with JIA and demonstrates the huge breadth of environmental research undertaken over five decades. We also highlight the challenges of combining data collected over this period due to limited between study comparability, evolution in healthcare and social practices, and changing environment, which warrant consideration when planning future studies.
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Affiliation(s)
- Sarah L N Clarke
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katie S Mageean
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ilaria Maccora
- Rheumatology Unit, A Meyer Children Hospital, NEUROFARBA Department, University of Florence, Florence, Italy
| | - Sean Harrison
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gabriele Simonini
- Rheumatology Unit, A Meyer Children Hospital, NEUROFARBA Department, University of Florence, Florence, Italy
| | - Gemma C Sharp
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caroline L Relton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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9
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Rubinstein TB, Bullock DR, Ardalan K, Mowrey WB, Brown NM, Bauman LJ, Stein REK. Adverse Childhood Experiences Are Associated with Childhood-Onset Arthritis in a National Sample of US Youth: An Analysis of the 2016 National Survey of Children's Health. J Pediatr 2020; 226:243-250.e2. [PMID: 32553837 DOI: 10.1016/j.jpeds.2020.06.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine whether there is an association between adverse childhood experiences (ACEs) and childhood-onset arthritis, comparing youth with arthritis to both healthy youth and youth with other acquired chronic physical diseases (OCPD); and to examine whether ACEs are associated with disease-related characteristics among children with arthritis. STUDY DESIGN In a cross-sectional analysis of data from the 2016 National Survey of Children's Health we examined whether ACEs were associated with having arthritis vs either being healthy or having a nonrheumatologic OCPD. ACE scores were categorized as 0, 1, 2-3, ≥4 ACEs. Multinomial logistic regression models examined associations between ACEs and health status while adjusting for age, sex, race/ethnicity, and poverty status. Among children with arthritis, associations between ACEs and disease-related characteristics were assessed by Pearson χ2 analyses. RESULTS Compared with children with no ACEs, children with 1, 2-3, and ≥4 ACEs had an increased odds of having arthritis vs being healthy (adjusted OR for ≥4 ACEs, 9.4; 95% CI, 4.0-22.1) and vs OCPD (adjusted OR for ≥4 ACEs, 3.7; 95% CI-1.7, 8.1). Among children with arthritis, ACEs were associated with worse physical impairment. CONCLUSIONS Children with higher numbers of ACEs are more likely to have arthritis, when arthritis status is compared either with being healthy or with having OCPD. Further studies are needed to determine the direction of the association between ACEs and childhood arthritis, its impact on disease course, and potential intervention targets that might mitigate these effects.
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Affiliation(s)
- Tamar B Rubinstein
- Division of Pediatric Rheumatology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Bronx, NY.
| | - Danielle R Bullock
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Kaveh Ardalan
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC; Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Wenzhu B Mowrey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Nicole M Brown
- Albert Einstein College of Medicine, Bronx, NY; Strong Children Wellness Medical Group Jamaica, NY
| | - Laurie J Bauman
- Division of Academic General Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Department of Psychiatry and Behavioral Science, Albert Einstein College of Medicine, Bronx, NY
| | - Ruth E K Stein
- Division of Developmental Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Division of Developmental Medicine, Children's Hospital at Montefiore, Bronx, NY
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10
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Inhaled ultrafine particles, epigenetics and systemic autoimmune rheumatic diseases. Autoimmun Rev 2020; 19:102640. [PMID: 32801038 DOI: 10.1016/j.autrev.2020.102640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023]
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11
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Wang CM, Jung CR, Chen WT, Hwang BF. Exposure to fine particulate matter (PM 2.5) and pediatric rheumatic diseases. ENVIRONMENT INTERNATIONAL 2020; 138:105602. [PMID: 32120057 DOI: 10.1016/j.envint.2020.105602] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 06/10/2023]
Abstract
Few studies have assessed the association between fine particulate matter (PM2.5) exposure during pregnancy and infancy and pediatric rheumatic diseases (PRDs). The goal of this study was to investigate the association of PM2.5 with PRDs, and to explore sensitive windows of exposure. Therefore, we conducted a cohort-based case-control study to investigate the association between weekly exposure to PM2.5 and PRDs in Taiwan. Our birth cohort consisted of infants born in 2004-2014 (n = 1,991,592) who were followed from conception to the end of 2015. There were 2363 cases of incident PRDs in children, and 23,630 children served as controls using density matching (1:10) based on date of birth, gender, and gestational week. We used a linear mixed effect (LME) model to incorporate the aerosol optical depth (AOD), meteorological variables, and land-use data to predict daily PM2.5 concentrations. We also performed conditional logistic regression with distributed lag non-linear models (DLNMs) to assess the effects of weekly average PM2.5 on PRDs, as well as dose-response relationships. In DLNMs, exposure to PM2.5 during pregnancy (11-40 weeks) or infancy (1-14 weeks after birth) was associated with incident PRDs adjusting for potential confounding factors, and for carbon monoxide and sulfur dioxide. In the dose-response association, the odds ratios of PRDs were significantly increased for PM2.5 exposures between 26 and 54 μg/m3. In addition, exposure to PM2.5 above 81 μg/m3 dramatically increased the risk of PRDs. In conclusions, our study provides new data to suggest that PM2.5 exposure from 11-40 gestational weeks to 1-14 weeks after birth can increase the risk for PRDs in a non-linear dose-response fashion.
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Affiliation(s)
- Chi-Min Wang
- Department of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan.
| | - Chau-Ren Jung
- Department of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan; Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, Tsukuba, Japan.
| | - Wei-Ting Chen
- Department of Atmospheric Sciences, National Taiwan University, Taipei, Taiwan.
| | - Bing-Fang Hwang
- Department of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Occupational Therapy, College of Medical and Health Science, Asia University, Taichung, Taiwan.
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12
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Qian X, Liu YX, Ye X, Zheng W, Lv S, Mo M, Lin J, Wang W, Wang W, Zhang X, Lu M. Gut microbiota in children with juvenile idiopathic arthritis: characteristics, biomarker identification, and usefulness in clinical prediction. BMC Genomics 2020; 21:286. [PMID: 32264859 PMCID: PMC7137182 DOI: 10.1186/s12864-020-6703-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Background Recent studies have suggested that the gut microbiota is altered in children with juvenile idiopathic arthritis (JIA). However, age, sex, and body mass index (BMI) were not matched in the previous studies, and the results are inconsistent. We conducted an age-, sex-, and BMI-matched cross-sectional study to characterize the gut microbiota in children with JIA, and evaluate its potential in clinical prediction. Methods A total of 40 patients with JIA and 42 healthy controls, ranging from 1 to 16 years, were enrolled in this study. Fecal samples were collected for 16S rDNA sequencing. The data were analyzed using QIIME software and R packages. Specifically, the random forest model was used to identify biomarkers, and the receiver operating characteristic curve and the decision curve analysis were used to evaluate model performance. Results A total of 39 fecal samples from patients with JIA, and 42 fecal samples from healthy controls were sequenced successfully. The Chao 1 and Shannon–Wiener index in the JIA group were significantly lower than those in the control group, and the Bray-Curtis dissimilarity also differed significantly between the two groups. The relative abundance of 4 genera, Anaerostipes, Dialister, Lachnospira, and Roseburia, decreased significantly in the JIA group compared to those in the control group. The 4 genera included microbes that produce short-chain fatty acids (SCFAs) and were negatively correlated with some rheumatic indices. Moreover, 12 genera were identified as potential biomarkers by using the nested cross-validation function of the random forest. A random forest model constructed using these genera was able to differentiate the patients with JIA from the healthy controls, and the area under the receiver operating characteristic curve was 0.7975. The decision curve analysis indicated that the model had usefulness in clinical practice. Conclusions The gut microbiota in patients with JIA is altered and characterized by a decreased abundance of 4 SCFA-producing genera. The decreases in the 4 genera correlated with more serious clinical indices. Twelve genera could be used as biomarkers and predictors in clinical practice. Trial registration The study is registered online at the Chinese Clinical Trial Registry on 11 May 2018 (registration number: ChiCTR1800016110).
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Affiliation(s)
- Xubo Qian
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yong-Xin Liu
- State Key Laboratory of Plant Genomics, Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, Beijing, China
| | - Xiaohong Ye
- Department of Scientific Research Management and Medical Education, Jinhua Hospital of Traditional Chinese Medicine, Jinhua, Zhejiang Province, China
| | - Wenjie Zheng
- Department of Paediatric Rheumatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Shaoxia Lv
- Nursing Department, Jiangnan Community Healthcare Center, Jinhua, Zhejiang Province, China
| | - Miaojun Mo
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Jinjing Lin
- Department of Pediatrics, Shaoxing People's Hospital, Shaoxing Hospital, Zhejiang University School of Medicine, Shaoxing, Zhejiang Province, China
| | - Wenqin Wang
- Department of Rheumatology Immunology, Jinhua Municipal People's Hospital, Jinhua, Zhejiang Province, China
| | - Weihan Wang
- Department of Scientific Research Management and Medical Education, Jinhua Hospital of Traditional Chinese Medicine, Jinhua, Zhejiang Province, China
| | - Xianning Zhang
- Department of Genetics, Institute of Genetics, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
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13
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Horton DB, Shenoi S. Review of environmental factors and juvenile idiopathic arthritis. Open Access Rheumatol 2019; 11:253-267. [PMID: 31807094 PMCID: PMC6842741 DOI: 10.2147/oarrr.s165916] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022] Open
Abstract
Juvenile idiopathic arthritis is a common rheumatic disease that presents as chronic childhood arthritis. JIA is considered a multifactorial disease that may result from diverse genetic and environmental risk factors. A minority of the population-attributable risk of JIA is estimated to be due to familial factors. Thus, non-genetic or environmental factors likely account for a majority of the risk of developing JIA. Yet, while substantial data have linked environmental factors to the development of rheumatoid arthritis, similar evidence regarding JIA is sparse. This narrative review provides updates on recent literature about environmental factors that might influence the risk of developing JIA, including studies about potentially beneficial and harmful influences as well as factors with unclear effects.
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Affiliation(s)
- Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA.,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Pediatric Rheumatology, Seattle Children's Hospital and Research Center and University of Washington, Seattle, WA, USA
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14
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Sperling CD, Kjaer SK, Hargreave M, Jensen A. Risk of juvenile idiopathic arthritis among children conceived after fertility treatment: a nationwide registry-based cohort study. Hum Reprod 2019; 34:1139-1145. [PMID: 30927428 DOI: 10.1093/humrep/dez035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/15/2019] [Accepted: 02/25/2019] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Is the risk of juvenile idiopathic arthritis (JIA) increased in children conceived after fertility treatment, and is an observed association caused by specific types of fertility treatment or by factors associated with the underlying infertility? SUMMARY ANSWER The risk of JIA in children conceived after fertility treatment (any and specific types of fertility treatment) was not convincingly affected when compared with children born to fertile women. WHAT IS KNOWN ALREADY It has been suggested that fertility treatment may affect the development of the immune system and thereby increase the risk of developing autoimmune diseases, including JIA. STUDY DESIGN, SIZE, DURATION This retrospective population-based cohort study included all live-born children in Denmark between 1 January 1996 and 31 December 2012 (n = 1 084 184). The study population was followed from date of birth until first diagnosis of JIA as registered in the Danish National Patient Registry, date of 16th birthday, date of emigration, date of death or end of follow-up (31 December 2014), whichever occurred first. PARTICIPANTS/MATERIALS, SETTING, METHODS The study cohort was linked to the Danish Infertility Cohort in order to identify children born to women with fertility problems (n = 174 702) and fertility treatment (n = 89 931). Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for potential confounders. MAIN RESULTS AND THE ROLE OF CHANCE During a median follow-up period of 10.3 years, 2237 children were diagnosed with JIA. Children born to women with fertility problems had an increased risk of JIA (HR 1.18, 95% CI 1.05-1.32) compared with children born to fertile women. However, the risk was not increased in children conceived after any fertility treatment (HR 1.11; 95% CI 0.95-1.29), or after specific types of fertility treatment being ART (HR 1.05; 95% CI 0.83-1.33), IVF (HR 1.01; 95% CI 0.73-1.38), ICSI (HR 0.98; 95% CI 0.64-1.50) or any fertility drugs (HR 1.10; 95% CI 0.94-1.28) compared with children born to fertile women. The associations between fertility treatment and JIA were also assessed by using children born to women with fertility problems without fertility treatment in the index pregnancy as a reference group, however, the findings did not change substantially. LIMITATIONS REASONS FOR CAUTION Despite a large study population, the statistical precision in some subgroup analyses may be affected due to the low number of JIA cases. There may be some misclassification of fertility problems, as some women have undiagnosed fertility problems and are therefore not included in the Danish Infertility Cohort; potentially leading to slight attenuation of the association between fertility problems and JIA. WIDER IMPLICATIONS OF THE FINDINGS The results are based on national data and our findings can therefore be applied to other similar populations. Our results indicate that fertility treatment per se do not increase the risk of JIA but merely that the increased risk of JIA observed among children born to women with fertility problems may be due to underlying factors related to both infertility and JIA. However, as this is the first large study in this field, further studies are needed to confirm our findings. STUDY FUNDING/COMPETING INTEREST(S) The study was supported by grants from the Jascha Foundation, the Aase and Ejner Danielsens Foundation and The Danish Rheumatism Association. All authors report no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- C D Sperling
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - S K Kjaer
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - M Hargreave
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - A Jensen
- Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
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15
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Evaluation of disease activity in a low-income juvenile idiopathic arthritis cohort. Rheumatol Int 2018; 39:67-71. [PMID: 30101369 DOI: 10.1007/s00296-018-4128-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
Determine disease activity in a low income juvenile idiopathic arthritis (JIA) cohort. 164 JIA patients from families with less than US$ 4500.00/capita mean annual income followed in Fortaleza-CE, Brazil, were cross-sectionally evaluated between May 2015-April 2016. Mean age was 14 ± 5.1 years (95 female) with 10.31 ± 3.7 years disease duration. Polyarticular category predominated, with 63 (38.4%) patients, followed by 40 (24%) enthesitis-related (ERA), and 36 (22%) oligoarticular. All but 1 out of 84 parents declared less than US$ 10,000.00 annual family income. Eighty-eight (60.7%) were receiving methotrexate and 19 (13%) leflunomide including 12 (63%) using both; 46 (28%) were on biologic DMARD including 20 (43.5%) adalimumab, 17 (41.5) etanercept, 5 (10.8%) tocilizumab, 2 (4.2%) abatacept, and 1 (2.1%) each on infliximab and canakinumab. Mean CHAQ and JADAS27 were 0.36 ± 0.55 and 5.31 ± 8.5, respectively. Thirty-two (20%) out of 159 patients had deformities. A bivariate analysis revealed that polyarticular had more deformities than oligoarticular patients (p = 0.002; OR = 2.389; 95% CI 1.37-4.14). Logistic regression showed no association between high JADAS and family income (p = 0.339; OR = 1.45; 95% CI 0.67-3.31). A general linear model showed significantly lower CHAQ score in patients from families earning more as compared to those earning less than 300.00 US$ monthly (p = 0.002). This study reports JIA disease activity in a low income population. Low income apparently did not influence prognosis given the low mean JADAS27 and CHAQ scores vis-à-vis data from other cohorts.
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