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Renaudineau Y, Charras A, Natoli V, Fusaro M, Smith EMD, Beresford MW, Hedrich CM. Type I interferon associated epistasis may contribute to early disease-onset and high disease activity in juvenile-onset lupus. Clin Immunol 2024; 262:110194. [PMID: 38508295 DOI: 10.1016/j.clim.2024.110194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/01/2024] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
Pathologic type I interferon (T1IFN) expression is a key feature in systemic lupus erythematosus (SLE) that associates with disease activity. When compared to adult-onset disease, juvenile-onset (j)SLE is characterized by increased disease activity and damage, which likely relates to increased genetic burden. To identify T1IFN-associated gene polymorphisms (TLR7, IRAK1, miR-3142/miR-146a, IRF5, IRF7, IFIH1, IRF8, TYK2, STAT4), identify long-range linkage disequilibrium and gene:gene interrelations, 319 jSLE patients were genotyped using panel sequencing. Coupling phenotypic quantitative trait loci (QTL) analysis identified 10 jSLE QTL that associated with young age at onset (<12 years; IRAK1 [rs1059702], TLR7 [rs3853839], IFIH1 [rs11891191, rs1990760, rs3747517], STAT4 [rs3021866], TYK2 [rs280501], IRF8 [rs1568391, rs6638]), global disease activity (SLEDAI-2 K >10; IFIH1 [rs1990760], STAT4 [rs3021866], IRF8 [rs903202, rs1568391, rs6638]), and mucocutaneous involvement (TLR7 [rs3853839], IFIH1 [rs11891191, rs1990760]). This study suggests T1IFN-associated polymorphisms and gene:gene interrelations in jSLE. Genotyping of jSLE patients may allow for individualized treatment and care.
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Affiliation(s)
- Yves Renaudineau
- Immunology Department Laboratory, Referral Medical Biology Laboratory, Institut Fédératif de Biologie, Toulouse University Hospital Center, France; INFINITy, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse III, Toulouse, France
| | - Amandine Charras
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK
| | - Valentina Natoli
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Università degli Studi di Genova, Dipartimento di Neuroscienze, riabilitazione, oftalmologia, genetica e scienze materno-infantili, DINOGMI, Genoa, Italy
| | - Mathieu Fusaro
- Immunology Department Laboratory, Referral Medical Biology Laboratory, Institut Fédératif de Biologie, Toulouse University Hospital Center, France; INFINITy, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse III, Toulouse, France
| | - Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Natoli V, Charras A, Hahn G, Hedrich CM. Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus ( jSLE). Mol Cell Pediatr 2023; 10:5. [PMID: 37556020 PMCID: PMC10412509 DOI: 10.1186/s40348-023-00161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a rare autoimmune/inflammatory disease with significant morbidity and mortality. Approximately 15-20% of SLE patients develop the disease during childhood or adolescence (juvenile-onset SLE/jSLE). Patients with jSLE exhibit more variable and severe disease when compared to patients with disease-onset during adulthood. Neuropsychiatric (NP) involvement is a clinically heterogenous and potentially severe complication. Published reports on the incidence and prevalence of NP-jSLE are scarce, and the exact pathophysiology is poorly understood.This manuscript provides a review of the existing literature, suggesting NP involvement in 13.5-51% of jSLE patients. Among patients with NP-jSLE affecting the CNS, we propose two main subgroups: (i) a chronic progressive, predominantly type 1 interferon-driven form that poorly responds to currently used treatments, and (ii) an acutely aggressive form that usually presents early during the disease that may be primarily mediated by auto-reactive effector lymphocytes. While this hypothesis requires to be tested in large collaborative international cohort studies, it may offer future patient stratification and individualised care.
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Affiliation(s)
- Valentina Natoli
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Amandine Charras
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gabriele Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Shaaban Y, El-Marsafawy H, El-Farahaty RM, El-Ziny S, El-Refaey AM. Aquaporin-4 IgG antibodies: predictors of positivity and their relationship with neuropsychiatric disorders and white matter lesions in Juvenile systemic lupus erythematosus. Pediatr Rheumatol Online J 2023; 21:47. [PMID: 37208665 DOI: 10.1186/s12969-023-00827-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/25/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND This study aimed to describe the prevalence of the various clinical features and severity of juvenile systemic lupus erythematosus (jSLE) and to assess predictors of AQP4-Ab positivity in jSLE. In addition, we assessed the relationship of AQP4-Abs with neuropsychiatric disorders and white matter lesions in jSLE. METHOD For 90 patients with jSLE, demographic data, clinical manifestations, and treatments received were recorded, and all of the patients were underwent clinical examinations, including assessments for the neurological manifestations of jSLE and neuropsychiatric disorders; Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score evaluations; laboratory investigations, including serum AQP4-Ab assays; and 1.5 Tesla brain MRI. Echocardiography and renal biopsy were performed for the indicated patients. RESULT Fifty-six patients (62.2%) tested positive for AQP4-Abs. These patients were more likely to have higher disease activity scores (p < 0.001); discoid lesions (p = 0.039); neurological disorders (p = 0.001), mainly psychosis and seizures (p = 0.009 and p = 0.032, respectively); renal and cardiac involvement (p = 0.004 and p = 0.013, respectively); lower C3 levels (p = 0.006); white matter hyperintensities (p = 0.008); and white matter atrophy (p = 0.03) than patients who were negative for AQP4-Abs. Furthermore, AQP4-Ab-positive patients were more likely to have received cyclophosphamide (p = 0.028), antiepileptic drugs (p = 0.032) and plasma exchange therapy (p = 0.049). CONCLUSION jSLE patients with higher severity scores, neurological disorders, or white matter lesions could develop antibodies against AQP4. We recommend more studies for systematic screening of AQP4-Ab positivity in jSLE patients to confirm its relationship with neurological disorders.
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Affiliation(s)
- Yasmeen Shaaban
- Department of Paediatrics, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Hala El-Marsafawy
- Department of Paediatrics, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Reham M El-Farahaty
- Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Ahmed M El-Refaey
- Department of Paediatrics, Mansoura University Children's Hospital, Mansoura, Egypt.
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Charras A, Haldenby S, Smith EMD, Egbivwie N, Olohan L, Kenny JG, Schwarz K, Roberts C, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Modgil G, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Beresford MW, Hedrich CM. Panel sequencing links rare, likely damaging gene variants with distinct clinical phenotypes and outcomes in juvenile-onset SLE. Rheumatology (Oxford) 2023; 62:SI210-SI225. [PMID: 35532072 PMCID: PMC9949710 DOI: 10.1093/rheumatology/keac275] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Juvenile-onset systemic lupus erythematosus (jSLE) affects 15-20% of lupus patients. Clinical heterogeneity between racial groups, age groups and individual patients suggests variable pathophysiology. This study aimed to identify highly penetrant damaging mutations in genes associated with SLE/SLE-like disease in a large national cohort (UK JSLE Cohort Study) and compare demographic, clinical and laboratory features in patient sub-cohorts with 'genetic' SLE vs remaining SLE patients. METHODS Based on a sequencing panel designed in 2018, target enrichment and next-generation sequencing were performed in 348 patients to identify damaging gene variants. Findings were integrated with demographic, clinical and treatment related datasets. RESULTS Damaging gene variants were identified in ∼3.5% of jSLE patients. When compared with the remaining cohort, 'genetic' SLE affected younger children and more Black African/Caribbean patients. 'Genetic' SLE patients exhibited less organ involvement and damage, and neuropsychiatric involvement developed over time. Less aggressive first line treatment was chosen in 'genetic' SLE patients, but more second and third line agents were used. 'Genetic' SLE associated with anti-dsDNA antibody positivity at diagnosis and reduced ANA, anti-LA and anti-Sm antibody positivity at last visit. CONCLUSION Approximately 3.5% of jSLE patients present damaging gene variants associated with younger age at onset, and distinct clinical features. As less commonly observed after treatment induction, in 'genetic' SLE, autoantibody positivity may be the result of tissue damage and explain reduced immune complex-mediated renal and haematological involvement. Routine sequencing could allow for patient stratification, risk assessment and target-directed treatment, thereby increasing efficacy and reducing toxicity.
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Affiliation(s)
- Amandine Charras
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
| | - Sam Haldenby
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Naomi Egbivwie
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Lisa Olohan
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - John G Kenny
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
- Teagasc Food Research Centre, Moorepark, Cork, Ireland
| | - Klaus Schwarz
- Institut for Transfusion Medicine, University Ulm, Ulm
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service Baden-Württemberg—Hessen, Ulm, Germany
| | - Carla Roberts
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children’s Hospital, Birmingham
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children’s Hospital, Sheffield
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children’s Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne
| | - Gita Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton
| | | | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham
| | - Phil Riley
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester
| | - Arani Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences
- Centre for Genomic Research, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool
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Alexander T, Hedrich CM. Systemic lupus erythematosus - Are children miniature adults? Clin Immunol 2021; 234:108907. [PMID: 34890808 DOI: 10.1016/j.clim.2021.108907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 12/13/2022]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune/inflammatory disease that can affect any organ system and cause significant damage and organ failure. Disease-onset during childhood (juvenile-onset SLE) is associated with less typical autoantibody patterns, diffuse organ involvement, more damage already at diagnoses, and a higher need of immunomodulating treatment, including corticosteroids, when compared to adult-onset SLE. Differences in the molecular pathophysiology within SLE, and over-representation of patients with "genetic SLE" contribute to differences in clinical presentation and treatment responses between children and adults. This manuscript summarizes currently available literature focusing on parallels and differences between clinical pictures, known pathomechanisms, and available treatment options in juvenile- versus adult-onset SLE.
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Affiliation(s)
- Tobias Alexander
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and the Berlin Institute of Health, 10117 Berlin, Germany; Deutsches Rheuma-Forschungszentrum (DRFZ Berlin), ein Leibniz Institute, 10117 Berlin, Germany
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Live Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Eissa E, Morcos B, Abdelkawy RFM, Ahmed HH, Kholoussi NM. Association of microRNA-125a with the clinical features, disease activity and inflammatory cytokines of juvenile-onset lupus patients. Lupus 2021; 30:1180-1187. [PMID: 33866896 DOI: 10.1177/09612033211010328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with marked variation in its clinical presentation. Juvenile-onset SLE (jSLE) exhibits an aggressive clinical phenotype and severe complications. Dysregulated expression of microRNAs (miRs) in immune cells from patients with SLE has been found. We aim to evaluate the association of miR-125a with the clinical and laboratory characteristics, disease activity and inflammatory cytokines of jSLE patients. METHODS 60 jSLE patients and 25 normal controls were involved in the study. The expression pattern of miR-125a was determined in plasma of all subjects using qRT-PCR. In addition, plasma levels of IL-17 and IFN-γ were examined using ELISA. The correlation of miR-125a expression with the clinical manifestations and disease activity of jSLE patients was analyzed. Also, its association with the inflammatory cytokines was investigated in jSLE patients. RESULTS Our findings showed that miR-125a expression levels were significantly reduced in jSLE patients compared to normal controls (p < 0.01) and these expression levels differed based on the clinical variability of patients. In addition, plasma levels of IL-17 and IFN-γ in jSLE patients were significantly higher than healthy controls (p < 0.01). Finally, miR-125a expression had significant negative associations with each of SLEDAI-2K (p < 0.01), SLICC (p < 0.01), ESR (p < 0.05), proteinuria (p < 0.01) and IL-17 levels (p < 0.01) in jSLE patients. CONCLUSION Our findings postulate that miR-125a could act as a candidate therapeutic target for its possible regulation of inflammation in jSLE patients.
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Affiliation(s)
- Eman Eissa
- Human Genetics and Genome Research Division, Immunogenetics Department, National Research Centre, Giza, Egypt
| | - Botros Morcos
- Human Genetics and Genome Research Division, Immunogenetics Department, National Research Centre, Giza, Egypt
| | | | - Hanan H Ahmed
- Department of Rheumatology and Rehabilitation, Al Kasr Alainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Naglaa M Kholoussi
- Human Genetics and Genome Research Division, Immunogenetics Department, National Research Centre, Giza, Egypt
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Massias JS, Smith EM, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Beresford MW, Hedrich CM. Clinical and laboratory phenotypes in juvenile-onset Systemic Lupus Erythematosus across ethnicities in the UK. Lupus 2021; 30:597-607. [PMID: 33413005 PMCID: PMC7967896 DOI: 10.1177/0961203320984251] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune/inflammatory disease. Patients diagnosed with juvenile-onset SLE (jSLE), when compared to individuals with adult-onset SLE, develop more severe organ involvement, increased disease activity and greater tissue and organ damage. In adult-onset SLE, clinical characteristics, pathomechanisms, disease progression and outcomes do not only vary between individuals and age groups, but also ethnicities. However, in children and young people, the influence of ethnicity on disease onset, phenotype and outcome has not been investigated in detail. In this study, we investigated clinical and laboratory characteristics in pediatric SLE patients from different ethnic backgrounds (White Caucasian, Asian, Black African/Caribbean) accessing data from a national cohort of jSLE patients (the UK JSLE Cohort Study). Among jSLE patients in the UK, ethnicity affects both the disease’s clinical course and outcomes. At diagnosis, Black African/Caribbean jSLE patients show more “classical” laboratory and clinical features when compared to White Caucasian or Asian patients. Black African/Caribbean jSLE patients exhibit more renal involvement and more frequently receive cyclophosphamide and rituximab. Studies targeting ethnicity-specific contributors to disease expression and phenotypes are necessary to improve our pathophysiological understanding, diagnosis and treatment of jSLE.
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Affiliation(s)
| | - Eve Md Smith
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | - Joyce Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Dan P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Devesh Mewar
- Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK
| | - Gita Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Robert Moots
- Department of Rheumatology, University Hospital Aintree, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Phil Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Arani Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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