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Biomedical subjects

James N Jarvis

Publications and source records attributed to James N Jarvis.

At least 19 recordsLinked to original sources

Defining three dimensional chromatin structures of pediatric and adolescent B cells using primary B cell and EBV-immortalized B cell reference genomes.

BACKGROUND/PURPOSE: Knowledge of the 3D genome is essential to elucidate genetic mechanisms driving autoimmune diseases. The 3D genome is distinct for each cell type, and it is uncertain whether cell lines faithfully recapitulate the 3D architecture of primary human cells or whether developmental aspects of the pediatric immune system require use of pediatric samples. We undertook a systematic analysis of B cells and B cell lines to compare 3D genomic features encompassing risk loci for juvenile idiopathic arthritis (JIA), systemic lupus (SLE), and type 1 diabetes (T1D). METHODS: We isolated B cells from four healthy individuals, ages 9-17. HiChIP was performed using a CTCF antibody, and CTCF peaks were called within each sample separately. Peaks observed in all four samples were identified. CTCF loops were called within the pediatric samples using three CTCF peak datasets: 1) self-called CTCF consensus peaks called within the pediatric samples, 2) ENCODE's publicly available GM12878 CTCF ChIP-seq peaks, and 3) ENCODE's primary B cell CTCF ChIP-seq peaks from two adult females. Differential looping was assessed within the pediatric samples and each of the three peak datasets. RESULTS: The number of consensus peaks called in the pediatric samples was similar to that identified in ENCODE's GM12878 and primary B cell datasets. We observed&#x2009;<&#x2009;1% of loops that demonstrated significantly differential looping between peaks called within the pediatric samples themselves and when called using ENCODE GM12878 peaks. Significant looping differences were even fewer when comparing loops of the pediatric called peaks to those of the ENCODE primary B cell peaks. When querying loops found in juvenile idiopathic arthritis, type 1 diabetes, or systemic lupus erythematosus risk haplotypes, we observed significant differences in only 2.2%, 1.0%, and 1.3% loops, respectively, when comparing peaks called within the pediatric samples and ENCODE GM12878 dataset. The differences were even less apparent when comparing loops called with the pediatric vs ENCODE adult primary B cell peak datasets. CONCLUSION: The 3D chromatin architecture in B cells is similar across pediatric, adult, and EBV-transformed cell lines. This conservation of 3D structure includes regions encompassing autoimmune risk haplotypes. Thus, even for pediatric autoimmune diseases, publicly available adult B cell and cell line datasets may be sufficient for assessing effects exerted in the 3D genomic space.

Humans↗

A systematic strategy for identifying causal single nucleotide polymorphisms and their target genes on Juvenile arthritis risk haplotypes.

BACKGROUND: Although genome-wide association studies (GWAS) have identified multiple regions conferring genetic risk for juvenile idiopathic arthritis (JIA), we are still faced with the task of identifying the single nucleotide polymorphisms (SNPs) on the disease haplotypes that exert the biological effects that confer risk. Until we identify the risk-driving variants, identifying the genes influenced by these variants, and therefore translating genetic information to improved clinical care, will remain an insurmountable task. We used a function-based approach for identifying causal variant candidates and the target genes on JIA risk haplotypes. METHODS: We used a massively parallel reporter assay (MPRA) in myeloid K562 cells to query the effects of 5,226 SNPs in non-coding regions on JIA risk haplotypes for their ability to alter gene expression when compared to the common allele. The assay relies on 180&#xa0;bp oligonucleotide reporters ("oligos") in which the allele of interest is flanked by its cognate genomic sequence. Barcodes were added randomly by PCR to each oligo to achieve&#x2009;>&#x2009;20 barcodes per oligo to provide a quantitative read-out of gene expression for each allele. Assays were performed in both unstimulated K562 cells and cells stimulated overnight with interferon gamma (IFNg). As proof of concept, we then used CRISPRi to demonstrate the feasibility of identifying the genes regulated by enhancers harboring expression-altering SNPs. RESULTS: We identified 553 expression-altering SNPs in unstimulated K562 cells and an additional 490 in cells stimulated with IFNg. We further filtered the SNPs to identify those plausibly situated within functional chromatin, using open chromatin and H3K27ac ChIPseq peaks in unstimulated cells and open chromatin plus H3K4me1 in stimulated cells. These procedures yielded 42 unique SNPs (total&#x2009;=&#x2009;84) for each set. Using CRISPRi, we demonstrated that enhancers harboring MPRA-screened variants in the TRAF1 and LNPEP/ERAP2 loci regulated multiple genes, suggesting complex influences of disease-driving variants. CONCLUSION: Using MPRA and CRISPRi, JIA risk haplotypes can be queried to identify plausible candidates for disease-driving variants. Once these candidate variants are identified, target genes can be identified using CRISPRi informed by the 3D chromatin structures that encompass the risk haplotypes.

Humans↗

Neonatal-onset multisystem inflammatory disease responsive to interleukin-1beta inhibition.

BACKGROUND: Neonatal-onset multisystem inflammatory disease is characterized by fever, urticarial rash, aseptic meningitis, deforming arthropathy, hearing loss, and mental retardation. Many patients have mutations in the cold-induced autoinflammatory syndrome 1 (CIAS1) gene, encoding cryopyrin, a protein that regulates inflammation. METHODS: We selected 18 patients with neonatal-onset multisystem inflammatory disease (12 with identifiable CIAS1 mutations) to receive anakinra, an interleukin-1-receptor antagonist (1 to 2 mg per kilogram of body weight per day subcutaneously). In 11 patients, anakinra was withdrawn at three months until a flare occurred. The primary end points included changes in scores in a daily diary of symptoms, serum levels of amyloid A and C-reactive protein, and the erythrocyte sedimentation rate from baseline to month 3 and from month 3 until a disease flare. RESULTS: All 18 patients had a rapid response to anakinra, with disappearance of rash. Diary scores improved (P<0.001) and serum amyloid A (from a median of 174 mg to 8 mg per liter), C-reactive protein (from a median of 5.29 mg to 0.34 mg per deciliter), and the erythrocyte sedimentation rate decreased at month 3 (all P<0.001), and remained low at month 6. Magnetic resonance imaging showed improvement in cochlear and leptomeningeal lesions as compared with baseline. Withdrawal of anakinra uniformly resulted in relapse within days; retreatment led to rapid improvement. There were no drug-related serious adverse events. CONCLUSIONS: Daily injections of anakinra markedly improved clinical and laboratory manifestations in patients with neonatal-onset multisystem inflammatory disease, with or without CIAS1 mutations. (ClinicalTrials.gov number, NCT00069329 [ClinicalTrials.gov].).

Adolescent↗

Learned helplessness in children and adolescents with juvenile rheumatic disease.

OBJECTIVE: To examine a learned helplessness conceptualization of psychological sequela in children and adolescents with juvenile rheumatic diseases (JRD) via an experimental procedure utilizing behavior-outcome contingent and noncontingent feedback. METHODS: Thirty-eight children and adolescents with JRD completed measures of transient affect, self-efficacy for functional ability, and causal attributions prior to and immediately following a computerized learned helplessness induction procedure. RESULTS: Children across contingent and noncontingent feedback conditions experienced decreased positive affect with a slightly more pronounced decline in the noncontingent condition. Noncontingent feedback resulted in poorer internalization of success for problem solving, while contingent feedback resulted in greater internalization of success for problem solving. Additionally, posttreatment control self-efficacy was significantly greater for children in the contingent condition that initially endorsed higher levels of internal task attributions. CONCLUSIONS: Children with JRD who experience behavior-outcome contingency in their environment may develop increased perceptions of control over functional ability. Furthermore, environmental noncontingency may result in poorer internalization of success, whereas contingent reinforcement may enhance cognitive appraisal mechanisms (i.e., causal attributions) associated with favorable disease outcome. Despite a modest decline in positive affect for children in the noncontingent condition, mood dysfunction is not entirely explicable within the context of noncontingent reinforcement.

Adolescent↗

Evidence for chronic, peripheral activation of neutrophils in polyarticular juvenile rheumatoid arthritis.

Although strong epidemiologic evidence suggests an important role for adaptive immunity in the pathogenesis of polyarticular juvenile rheumatoid arthritis (JRA), there remain many aspects of the disease that suggest equally important contributions of the innate immune system. We used gene expression arrays and computer modeling to examine the function in neutrophils of 25 children with polyarticular JRA. Computer analysis identified 712 genes that were differentially expressed between patients and healthy controls. Computer-assisted analysis of the differentially expressed genes demonstrated functional connections linked to both interleukin (IL)-8- and interferon-gamma (IFN-gamma)-regulated processes. Of special note is that the gene expression fingerprint of children with active JRA remained essentially unchanged even after they had responded to therapy. This result differed markedly from our previously reported work, in which gene expression profiles in buffy coats of children with polyarticular JRA reverted to normal after disease control was achieved pharmacologically. These findings suggest that JRA neutrophils remain in an activated state even during disease quiescence. Computer modeling of array data further demonstrated disruption of gene regulatory networks in clusters of genes modulated by IFN-gamma and IL-8. These cytokines have previously been shown to independently regulate the frequency (IFN-gamma) and amplitude (IL-8) of the oscillations of key metabolites in neutrophils, including nicotinamide adenine dinucleotide (phosphate) (NAD(P)H) and superoxide ion. Using real-time, high-speed, single-cell photoimaging, we observed that 6/6 JRA patients displayed a characteristic defect in 12% to 23% of the neutrophils tested. Reagents known to induce only frequency fluctuations of NAD(P)H and superoxide ion induced both frequency and amplitude fluctuations in JRA neutrophils. This is a novel finding that was observed in children with both active (n = 4) and inactive (n = 2) JRA. A subpopulation of polyarticular JRA neutrophils are in a chronic, activated state, a state that persists when the disease is well controlled pharmacologically. Furthermore, polyarticular JRA neutrophils exhibit an intrinsic defect in the regulation of metabolic oscillations and superoxide ion production. Our data are consistent with the hypothesis that neutrophils play an essential role in the pathogenesis of polyarticular JRA.

Adolescent↗

Gene expression profiling in pediatric rheumatic disease: what have we learned? What can we learn?

PURPOSE OF THIS REVIEW: Gene expression profiling is emerging as a promising methodology in pediatric rheumatology research. There is considerable interest in using this technology as the basis for diagnostic assays. This review will summarize the new knowledge. RECENT FINDINGS: Most gene expression studies of children have been exploratory in nature. However, preliminary gene expression studies in juvenile dermatomyositis, systemic lupus erythematosus, and chronic forms of arthritis demonstrate both the promise and limits of this technology. It seems likely that gene expression profiling will significantly enhance our understanding of the immunopathology of childhood-onset rheumatic diseases; however, considerable impediments must be overcome before these assays move into the clinical arena. SUMMARY: Gene expression profiling carries considerable potential to provide novel insights into the rheumatic diseases of childhood. Future developments will determine whether these technologies provide new clinical diagnostic or prognostic tools.

Child↗

Diagnostic and prognostic potential of gene microarrays in rheumatoid arthritis.

Rheumatoid arthritis and juvenile rheumatoid arthritis are histopathologically similar diseases characterized by chronic inflammation of the synovium. The pathogenesis of these diseases is unknown, but the emergence of gene expression profiling provides considerable promise that some of the complex, interconnected immunopathologic events underlying these diseases will soon be better understood. This review will summarize the potential use of gene expression profiling as a diagnostic or prognostic modality, and the potential benefits or limits of such uses. It will conclude with a short discussion of the potential for using gene expression profiling to identify novel targets of therapy in rheumatoid arthritis and related diseases.

Arthritis, Rheumatoid↗

Hypervariable genes--experimental error or hidden dynamics.

In a homogeneous group of samples, not all genes of high variability stem from experimental errors in microarray experiments. These expression variations can be attributed to many factors including natural biological oscillations or metabolic processes. The behavior of these genes can tease out important clues about naturally occurring dynamic processes in the organism or experimental system under study. We developed a statistical procedure for the selection of genes with high variability denoted hypervariable (HV) genes. After the exclusion of low expressed genes and a stabilizing log-transformation, the majority of genes have comparable residual variability. Based on an F-test, HV genes are selected as having a statistically significant difference from the majority of variability stabilized genes measured by the 'reference group'. A novel F-test clustering technique, further noted as 'F-means clustering', groups HV genes with similar variability patterns, presumably from their participation in a common dynamic biological process. F-means clustering establishes, for the first time, groups of co-expressed HV genes and is illustrated with microarray data from patients with juvenile rheumatoid arthritis and healthy controls.

Adolescent↗

Chronic arthritis in children and adolescents in two Indian health service user populations.

BACKGROUND: High prevalence rates for rheumatoid arthritis, spondyloarthopathies, and systemic lupus erythematosus have been described in American Indian and Alaskan Native adults. The impact of these diseases on American Indian children has not been investigated. METHODS: We used International Classification of Diseases-9 (ICD-9) codes to search two Indian Health Service (IHS) patient registration databases over the years 1998-2000, searching for individuals 19 years of age or younger with specific ICD-9-specified diagnoses. Crude estimates for disease prevalence were made based on the number of individuals identified with these diagnoses within the database. RESULTS: Rheumatoid arthritis (RA) / juvenile rheumatoid arthritis (JRA) was the most frequent diagnosis given. The prevalence rate for JRA in the Oklahoma City Area was estimated as 53 per 100,000 individuals at risk, while in the Billings Area, the estimated prevalence was nearly twice that, at 115 per 100,000. These rates are considerably higher than those reported in the most recent European studies. CONCLUSION: Chronic arthritis in childhood represents an important, though unrecognized, chronic health challenge within the American Indian population living in the United States.

Adolescent↗

Clinical utility of antinuclear antibody tests in children.

BACKGROUND: Antinuclear antibody (ANA) tests are frequently used to screen children for chronic inflammatory diseases such as systemic lupus erythematosus (SLE). However, the diagnostic utility of this test is limited because of the large number of healthy children who have low-titer positive tests. We sought to determine the clinical utility of ANA tests in screening children for rheumatic disease and to determine whether there are specific signs or symptoms that enhance the clinical utility of ANA tests in children. METHODS: We undertook a retrospective analysis of 509 new patient referrals. Charts of patients referred because of results of ANA testing were selected for further analysis. Children with JRA, SLE, and other conditions were compared using demographic data, chief complaints at the time of presentation, and ANA titers. RESULTS: One hundred ten patients were referred because of an ANA test interpreted as positive. Ten patients were subsequently diagnosed with SLE. In addition, we identified one patient with mixed connective tissue disease, and an additional child with idiopathic Raynaud's phenomenon. Eighteen children of the children referred for a positive ANA test had juvenile rheumatoid arthritis (JRA). Another 80 children with positive ANA tests were identified, the majority of whom (n = 39, 49%) had musculoskeletal pain syndromes. Neither the presence nor the titer of ANA served to distinguish children with JRA from children with other musculoskeletal conditions. Children with JRA were readily identified on the basis of the history and physical examination. Children with SLE were therefore compared with children with positive ANA tests who did not have JRA, designated the "comparison group." Non-urticarial rash was more common in children with SLE than in children without chronic inflammatory disease (p = 0.007). Children with SLE were also older (mean +/- sd = 14.2 +/- 2.5 years) than the comparison group (11.0 +/- 3.6 years; p = 0.001). ANA titer was also a significant discriminator between children with SLE and children without chronic inflammatory disease. The median ANA titer in children with SLE was 1: 1,080 compared with 1:160 for other children (p < 0.0001). ANA titers of >/=1,080 had a positive predictive value for SLE of 1.0 while titers of </=1: 360 had a negative predictive value for lupus of 0.84. CONCLUSION: Age and ANA titer assist in discriminating children with SLE from children with other conditions. ANA tests are of no diagnostic utility in either making or excluding the diagnosis of JRA.

Age Factors↗

Cord blood and adult T cells show different responses to C1q-bearing immune complexes.

UNLABELLED: We have previously shown that T cells can be activated through cell-surface C1q receptors, resulting in secretion of interferon-gamma (IFN-gamma) and tumor necrosis factor alpha (TNFalpha), further demonstrating the intimate linkage between innate and adaptive immunity. In this current report, we sought to determine whether: (1) T cell responses to C1q-bearing immune complexes are dependent on the maturational status of the T cells and (2) whether signaling through the C1q receptor on T cells modulates conventional activation mediated through the conventional T cell receptor (TCR)/CD3 signaling complex. We first examined the capacity of neonatal T cells to respond to C1q-bearing immune complexes using IFNgamma, IL-2, and MIF secretion as measures of activation (MIF was chosen because of its crucial role in coordinating innate and adaptive immunity). Neonatal T cells produced significantly less IFNgamma but not IL-2, when stimulated by C1q immune complexes compared with adult T cells. MIF levels did not exceed background levels in these experiments. Next, we examined the capacity of C1q-bearing immune complexes to regulate signaling through the conventional TCR/CD3 signaling complex. Pre-incubating adult T cells with C1q-bearing immune complexes significantly reduced IFNgamma secretion when those same cells were subsequently stimulated with anti-CD3 and anti-CD28 monoclonal antibodies. Pre-incubation of neonatal T-cells with C1q-bearing immune complexes had no effect on IFNgamma secretion, although IFNgamma secretion was lower than that found in adult T cells for each experimental condition. We speculate that reduced IFNgamma secretion after pre-incubation with C1q immune complexes may be due to IL-10 secretion, which was observed in C1q-stimulated adult (but not neonatal) T cells. CONCLUSIONS: C1q-bearing immune complexes exert complex effects on mature T cells that include both pro- and anti-inflammatory responses. Immunologic maturation is required for these effects, as cord blood T cells are relatively hyporesponsive to C1q-bearing immune complexes compared with adult T cells.

Antigen-Antibody Complex↗

Gene expression arrays reveal a rapid return to normal homeostasis in immunologically-challenged trophoblast-like JAR cells.

The immunologic adaptations of pregnancy have come under increasing scrutiny in the past 15 years. Existing experimental evidence clearly demonstrates that placental trophoblasts play an important role in regulating immunologic/inflammatory responses at the maternal-fetal interface. We used a well-developed gene expression array to examine in greater detail the physiologic response of trophoblast-like choriocarcinoma cells to a model immunologic 'challenge.' We co-cultured PHA-activated or resting peripheral blood mononuclear cells (PBMC) with the human choriocarcinoma cell line JAR for time periods ranging from 2 to 18 h. Messenger RNA expression in the JAR cells was then assessed using a 21,329-gene microarray and novel biostatistical analyses that we have previously published. Patterns of differential gene expression were assessed using a commercial pathway analysis software program. Differences in gene expression between JAR cells cultured with activated PBMC (experimental samples) and JAR cells cultured with resting PBMC (control samples) were seen only at the 2h time point. That is, multiple genes were transcribed in JAR cells in response to activated PBMC, but expression levels of the genes had all returned to baseline by 6h. Molecular modeling demonstrated that the differentially expressed genes were largely associated with cell growth and differentiation. This model was confirmed by noting a two-fold increase in CD10/neutral endopeptidase expression (a marker for cell differentiation) in JAR cells incubated with media from activated PBMC compared with JAR cells incubated with resting PBMC. These findings support the hypothesis that there is a delicate immunologic milieu at the maternal-fetal interface that must be maintained. Immunologic/inflammatory challenge at the maternal-fetal interface is compensated by cellular mechanisms that work to reduce inflammation and rapidly restore immunologic balance.

Biomarkers↗

Novel approaches to gene expression analysis of active polyarticular juvenile rheumatoid arthritis.

Juvenile rheumatoid arthritis (JRA) has a complex, poorly characterized pathophysiology. Modeling of transcriptosome behavior in pathologic specimens using microarrays allows molecular dissection of complex autoimmune diseases. However, conventional analyses rely on identifying statistically significant differences in gene expression distributions between patients and controls. Since the principal aspects of disease pathophysiology vary significantly among patients, these analyses are biased. Genes with highly variable expression, those most likely to regulate and affect pathologic processes, are excluded from selection, as their distribution among healthy and affected individuals may overlap significantly. Here we describe a novel method for analyzing microarray data that assesses statistically significant changes in gene behavior at the population level. This method was applied to expression profiles of peripheral blood leukocytes from a group of children with polyarticular JRA and healthy control subjects. Results from this method are compared with those from a conventional analysis of differential gene expression and shown to identify discrete subsets of functionally related genes relevant to disease pathophysiology. These results reveal the complex action of the innate and adaptive immune responses in patients and specifically underscore the role of IFN-gamma in disease pathophysiology. Discriminant function analysis of data from a cohort of patients treated with conventional therapy identified additional subsets of functionally related genes; the results may predict treatment outcomes. While data from only 9 patients and 12 healthy controls was used, this preliminary investigation of the inflammatory genomics of JRA illustrates the significant potential of utilizing complementary sets of bioinformatics tools to maximize the clinical relevance of microarray data from patients with autoimmune disease, even in small cohorts.

Journal Article↗

Rheumatic disease in Native American children: opportunities and challenge.

Rheumatic diseases are prevalent in Native American adults at rates five to seven times higher than those seen in the Caucasian population. Little, however, has been published concerning rheumatic diseases in Native American children. The authors' work in Oklahoma and with tribes on the northern Great Plains demonstrates high rates of childhood-onset rheumatic disease in this population. Familial disease is common, and large, multiplex kindreds showing strong founder effects are likely found within specific Native American tribes. However, a deeper understanding of the genetic and environmental triggers of rheumatic disease in Native Americans will require a respect and appreciation for the specific and unique cultural and social issues that impinge on research with Native Americans and other indigenous people.

Adolescent↗

Activated peripheral blood mononuclear cells induce p44/42 mitogen-activated protein kinase phosphorylation in trophoblast-like JAR cells.

Mammalian pregnancy bears many similarities to transplantation, since the fetus is semi-allogenic to mother. Thus, mammals have developed numerous mechanisms to protect the developing fetus from maternal immunologic recognition and attack. We have previously shown that human choriocarcinoma JAR cells, which resemble first trimester trophoblasts, regulate several important mRNAs in activated peripheral blood mononuclear cells (PBMC). We now provide further evidence that communication between maternal and fetal tissues is bi-directional, and that activation of PBMC leads to activation of specific signaling pathways in JAR cells. Activated PBMC were co-cultured with JAR cells for specific time intervals, after which JAR cells were lysed and subjected to western blotting for activated forms of the JNK, Erk 1-2, and p38 mitogen-activated protein kinases (MAPK). Phosphorylation of Erk 1-2, but not JNK or p38, was induced in co-cultures of PBMC and JAR cells. These results were also obtained when JAR cells were incubated with conditioned medium from activated, but not resting, PBMC. Results were confirmed using specific MAPK reporter constructs, using luciferase activity as a measure of Elk-1 phosphorylation. Erk 1-2 phosphorylation was not required for JAR cells to inhibit IL-2 production in activated PBMC. Addition of the specific MAPK inhibitor UO126 to JAR cells prior to the addition of activated PBMC to the cultures did not abolish the capacity of JAR cells to inhibit IL-2 mRNA expression in PBMC. We conclude that there is likely to be significant bi-directional signaling between leukocytes and trophoblasts at the maternal-fetal interface. We propose the existence of a delicate maternal-fetal immunologic homeostasis based on these experimental results.

Base Sequence↗

Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children.

OBJECTIVE: To examine complaints for which children were referred to a pediatric rheumatology service and to determine whether there are specific complaints that are more likely to indicate the presence of chronic arthritis or chronic, systemic inflammatory disease. METHODS: A retrospective chart review of 414 children referred to the pediatric rheumatology service at the Children's Hospital of Oklahoma from April 1998 to July 2001. RESULTS: Musculoskeletal pain was the most common complaint for which children were referred (n = 226). Of these, 111 had musculoskeletal pain as an isolated complaint. One of these children had a chronic inflammatory disease. Another 115 children had pain as 1 of several reasons for seeking a rheumatology consultation, including positive results on laboratory tests (antinuclear antibody, erythrocyte sedimentation rate, and rheumatoid factor). Nineteen of these children had a chronic inflammatory disease, including 12 with juvenile rheumatoid arthritis (JRA). Thus, musculoskeletal pain as a presenting complaint had a strong negative predictive value for the presence of either JRA (0.95) or any other chronic inflammatory disease that might be characterized by arthritis. Children who were referred, in part, because of positive antinuclear antibody and/or rheumatoid factor tests were no more likely to have a chronic inflammatory disease than children who did not include such results as a reason for referral. Joint swelling, in contrast, was the most likely complaint to be associated with a diagnosis of JRA. CONCLUSIONS: Musculoskeletal pain was the most common reason for referral to our pediatric rheumatology clinic. However, isolated musculoskeletal pain, in the absence of other signs or symptoms, is almost never a presenting complaint of children with chronic forms of arthritis. Children with arthritis more commonly present with complaints of joint swelling and/or gait disturbance. Neither ANA nor rheumatoid factor evaluations were useful in evaluating children with musculoskeletal complaints.

Adolescent↗