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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1483&#44; Sandro Botticelli depicted what may be one of the earliest representations of juvenile idiopathic arthritis &#40;JIA&#41; in &#8220;Portrait of a Youth&#8221;&#44; in which he showed the swelling of the wrist&#44; metacarpophalangeal and proximal interphalangeal joints of one hand&#46; But it was in 1897 that George Frederic Still&#44; a paediatrician and pathologist at the Hospital for Sick Children at Great Ormond Street&#44; London&#44; published an article describing 22 children with chronic arthritis and highlighting that rheumatic manifestations in children differed from those in adults&#46; Some of these patients had what years later came to be known as Still&#8217;s disease and is currently known as systemic-onset JIA&#46; It was not until 1940 that the idea emerged again that children could have rheumatic diseases other than rheumatic fever&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Paediatric Rheumatology is a subspecialty of paediatrics focused on the diagnosis and management of a broad range of diseases&#58; musculoskeletal disorders such as JIA&#44; systemic autoimmune diseases such as systemic lupus erythematosus SLE&#44; juvenile dermatomyositis or juvenile scleroderma&#44; autoinflammatory diseases such as periodic fever&#44; aphthous stomatitis&#44; pharyngitis and cervical adenitis PFAPA syndrome or hereditary periodic fever syndromes&#44; disorders manifesting with increased pain such as fibromyalgia or chronic fatigue syndrome&#44; or secondary osteoporosis&#44; to name a few&#46; To further knowledge in this field&#44; in 1992 a group of paediatricians and rheumatologists in Spain created the Grupo Espa&#241;ol de Reumatolog&#237;a Pedi&#225;trica &#40;Spanish Group of Paediatric Rheumatology&#44; GERP&#41;&#44; which in 1995 became the Section of Paediatric Rheumatology of the Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a &#40;Spanish Association of Pediatrics&#44; AEP&#41; and in 1998 gave rise to the Sociedad Espa&#241;ola de Reumatolog&#237;a Pedi&#225;trica &#40;Spanish Society of Paediatric Rheumatology&#44; SERPE&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most frequent chronic rheumatic disease in the paediatric population is JIA&#44; formerly known as juvenile rheumatoid arthritis or juvenile chronic arthritis&#59; JIA ultimately is a consensus-based term that encompasses several subtypes of disease&#46; Few studies have been conducted in Spain to analyse its epidemiology&#44; and a study conducted in Catalonia reported an incidence of 6&#46;9 per 10 000 children aged less than 16 years and a prevalence of 39&#46;7 per 10 000 children aged less than 16 years&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other hand&#44; it is estimated that 20&#37; of cases of SLE have onset in childhood or adolescence&#44; and most autoinflammatory disorders have onset in childhood&#46; As physicians&#44; we are all familiar with the saying that &#8220;one only diagnoses what one knows&#8221;&#44; something that is particularly true in the field of paediatric rheumatology&#46; The study published by Udaondo Gasc&#243;n et al&#46; in the current issue of <span class="elsevierStyleItalic">Anales de Pediatr&#237;a</span> corroborates the perception that training in paediatric rheumatology must be improved at every level &#40;undergraduate and postgraduate&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is essential that training programmes for medical students&#44; residents in paediatrics and continuous education include not only information on this group of diseases but also on the evaluation of the musculoskeletal system&#46; Nobody would think that it is acceptable for paediatricians not to know how to examine an ear or perform auscultation of the chest&#44; but even the most recent evidence today shows that the physical examination often does not include a musculoskeletal evaluation and that many medical providers lack confidence in assessing joints&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Advances in imaging techniques along with the increased availability of ultrasound technicians in many clinics and in genetic diagnosis&#44; which guides the management of newly recognised autoinflammatory diseases&#44; combined with the development of new treatments&#44; are some of the factors that have contributed to improvements in the management of these diseases that we would not even have dreamt of until a few years ago&#46; Despite advances in treatment&#44; methotrexate&#44; which has been in use for more than 30 years&#44; continues to be the main systemic drug used for the management of diseases like JIA&#46; For this reason&#44; we consider that the work of Barral Mena et al&#46; analysing the factors associated with adverse reactions to methotrexate&#44; published in this issue of <span class="elsevierStyleItalic">Anales de Pediatr&#237;a</span>&#44; is certainly relevant&#46; It shows that despite its efficacy&#44; up to one third of patients need to discontinue methotrexate due to adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Fortunately&#44; alternative options are available today&#44; such as selective immunosuppressive agents &#40;biologic drugs&#41; or Janus kinase &#40;JAK&#41; inhibitors&#46; The days when children frequently ended up with significant limitations or physical sequelae&#44; or even dependent on a wheelchair&#44; are behind us&#46; Today&#44; the vast majority of patients lead normal lives and participate in sports activities as do children of the same age&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; the follow-up of patients in specialty clinics has allowed participation in collaborative networks&#44; registers&#44; studies and clinical trials at the national and international levels&#46; Institutions such as the Pediatric Rheumatology Trials Organization &#40;PRINTO&#41;&#44; the Pediatric Rheumatology Society &#40;PReS&#41; or SERPE have invested on promoting research and the establishment of working groups to join efforts and progress in the field&#46; In 2013&#44; the Single Hub and Access point for paediatric Rheumatology in Europe &#40;SHARE&#41; initiative was launched with the participation of European paediatric rheumatology networks with the aim of describing current needs for the optimal management of children and youth with rheumatic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This initiative has given rise to numerous publications in recent years with recommendations for the management of the most common paediatric rheumatic diseases&#44; the performance of collaborative studies or the establishment of biobanks&#46; Particular emphasis has been placed on the needs of adolescents with chronic disease and how to facilitate transitioning to adult care&#44; which often involves a switch in the provider in charge of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We ought to highlight the important and novel role taken in recent years by patient organizations&#46; For instance&#44; since 2015 and with the support of the SERPE&#44; a yearly day-long &#8220;symposium for the families of children and adolescents with rheumatic diseases&#8221; is held simultaneously in several cities throughout Spain in collaboration with local patient organizations and the specialists that manage these patients&#46; In these symposiums&#44; health professionals&#44; parents and children share experiences&#44; questions and hopes&#46; Starting this year&#44; this symposium will be held on March to join the celebration in multiple countries of the World Young Rheumatic Diseases day &#40;WORD&#41;&#46; Furthermore&#44; some of these organizations make altruistic contributions to research in paediatric rheumatology&#44; offering research grants to further knowledge on these diseases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">However&#44; many challenges remain&#44; for instance at the educational level&#44; since&#44; as is the case in other paediatric subspecialties&#44; adequate training in the field needs to be guaranteed&#46; In 1992&#44; the American Board of Pediatrics held the first paediatric rheumatology subspecialty exam&#44; and in 1994&#44; specialist training was approved in the United Kingdom&#46; Since then&#44; numerous countries have recognised it as a specialty&#58; Germany&#44; the Netherlands&#44; Italy&#44; France&#44; Austria&#44; Sweden and Finland&#44; among others&#46; Furthermore&#44; the European Union of Medical Specialists &#40;UEMS&#41; and its paediatric section&#44; the European Academy of Paediatrics &#40;EAP&#41;&#44; have acknowledged this specialty and the specialty training curriculum at the European level&#46; Spain should promptly recognise paediatric subspecialties officially&#44; including paediatric rheumatology&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At the level of care delivery&#44; new communication technologies must be considered and applied to facilitate access of patients and their families to the providers involved in their care&#46; In this regard&#44; specialty nurses and case managers can play an essential role in contributing to the education&#44; self-care and follow-up of these patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When it comes to research objectives&#44; it is important to continue to develop new drugs and to conduct trials with those that already exist&#44; as well as to perform studies with the aim of identifying biomarkers &#40;genetic&#44; molecular&#44; indicative of disease recurrence or treatment response&#41; to aid prognosis and thus guide the selection of appropriate&#44; individualised and targeted treatment&#44; which not only would increase its effectiveness and decrease the probability of recurrence&#44; but also improve the adverse reaction profile&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As health care providers&#44; we must strive to ensure access to all patients to the best possible care&#44; to specialised care and to appropriate treatment for their disease&#46; As paediatricians&#44; we should be able to demand from our managers&#44; coordinators&#44; administrators and politicians that children with suspected non-infectious arthritis or autoimmune disease be assessed by a paediatric rheumatologist&#46; There is still a long way to go&#44; but the subspecialty of Paediatric Rheumatology is now a reality established on solid foundations&#46;</p></span>"
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Editorial
Paediatric Rheumatology: Where we are coming from and where we are going
Reumatología Pediátrica, de dónde venimos y a dónde vamos
Jordi Antóna, Marisol Camacho Lovillob,
Corresponding author
, Esmeralda Nuñez Cuadrosc
a Sección de Reumatología Pediátrica, Servicio de Pediatría, Hospital Sant Joan de Déu, Barcelona, Spain
b Servicio de Infectología, Reumatología e Inmunología Pediátrica, Hospital Universitario Virgen del Rocío, Sevilla, Spain
c Unidad Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1483&#44; Sandro Botticelli depicted what may be one of the earliest representations of juvenile idiopathic arthritis &#40;JIA&#41; in &#8220;Portrait of a Youth&#8221;&#44; in which he showed the swelling of the wrist&#44; metacarpophalangeal and proximal interphalangeal joints of one hand&#46; But it was in 1897 that George Frederic Still&#44; a paediatrician and pathologist at the Hospital for Sick Children at Great Ormond Street&#44; London&#44; published an article describing 22 children with chronic arthritis and highlighting that rheumatic manifestations in children differed from those in adults&#46; Some of these patients had what years later came to be known as Still&#8217;s disease and is currently known as systemic-onset JIA&#46; It was not until 1940 that the idea emerged again that children could have rheumatic diseases other than rheumatic fever&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Paediatric Rheumatology is a subspecialty of paediatrics focused on the diagnosis and management of a broad range of diseases&#58; musculoskeletal disorders such as JIA&#44; systemic autoimmune diseases such as systemic lupus erythematosus SLE&#44; juvenile dermatomyositis or juvenile scleroderma&#44; autoinflammatory diseases such as periodic fever&#44; aphthous stomatitis&#44; pharyngitis and cervical adenitis PFAPA syndrome or hereditary periodic fever syndromes&#44; disorders manifesting with increased pain such as fibromyalgia or chronic fatigue syndrome&#44; or secondary osteoporosis&#44; to name a few&#46; To further knowledge in this field&#44; in 1992 a group of paediatricians and rheumatologists in Spain created the Grupo Espa&#241;ol de Reumatolog&#237;a Pedi&#225;trica &#40;Spanish Group of Paediatric Rheumatology&#44; GERP&#41;&#44; which in 1995 became the Section of Paediatric Rheumatology of the Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a &#40;Spanish Association of Pediatrics&#44; AEP&#41; and in 1998 gave rise to the Sociedad Espa&#241;ola de Reumatolog&#237;a Pedi&#225;trica &#40;Spanish Society of Paediatric Rheumatology&#44; SERPE&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most frequent chronic rheumatic disease in the paediatric population is JIA&#44; formerly known as juvenile rheumatoid arthritis or juvenile chronic arthritis&#59; JIA ultimately is a consensus-based term that encompasses several subtypes of disease&#46; Few studies have been conducted in Spain to analyse its epidemiology&#44; and a study conducted in Catalonia reported an incidence of 6&#46;9 per 10 000 children aged less than 16 years and a prevalence of 39&#46;7 per 10 000 children aged less than 16 years&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other hand&#44; it is estimated that 20&#37; of cases of SLE have onset in childhood or adolescence&#44; and most autoinflammatory disorders have onset in childhood&#46; As physicians&#44; we are all familiar with the saying that &#8220;one only diagnoses what one knows&#8221;&#44; something that is particularly true in the field of paediatric rheumatology&#46; The study published by Udaondo Gasc&#243;n et al&#46; in the current issue of <span class="elsevierStyleItalic">Anales de Pediatr&#237;a</span> corroborates the perception that training in paediatric rheumatology must be improved at every level &#40;undergraduate and postgraduate&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is essential that training programmes for medical students&#44; residents in paediatrics and continuous education include not only information on this group of diseases but also on the evaluation of the musculoskeletal system&#46; Nobody would think that it is acceptable for paediatricians not to know how to examine an ear or perform auscultation of the chest&#44; but even the most recent evidence today shows that the physical examination often does not include a musculoskeletal evaluation and that many medical providers lack confidence in assessing joints&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Advances in imaging techniques along with the increased availability of ultrasound technicians in many clinics and in genetic diagnosis&#44; which guides the management of newly recognised autoinflammatory diseases&#44; combined with the development of new treatments&#44; are some of the factors that have contributed to improvements in the management of these diseases that we would not even have dreamt of until a few years ago&#46; Despite advances in treatment&#44; methotrexate&#44; which has been in use for more than 30 years&#44; continues to be the main systemic drug used for the management of diseases like JIA&#46; For this reason&#44; we consider that the work of Barral Mena et al&#46; analysing the factors associated with adverse reactions to methotrexate&#44; published in this issue of <span class="elsevierStyleItalic">Anales de Pediatr&#237;a</span>&#44; is certainly relevant&#46; It shows that despite its efficacy&#44; up to one third of patients need to discontinue methotrexate due to adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Fortunately&#44; alternative options are available today&#44; such as selective immunosuppressive agents &#40;biologic drugs&#41; or Janus kinase &#40;JAK&#41; inhibitors&#46; The days when children frequently ended up with significant limitations or physical sequelae&#44; or even dependent on a wheelchair&#44; are behind us&#46; Today&#44; the vast majority of patients lead normal lives and participate in sports activities as do children of the same age&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; the follow-up of patients in specialty clinics has allowed participation in collaborative networks&#44; registers&#44; studies and clinical trials at the national and international levels&#46; Institutions such as the Pediatric Rheumatology Trials Organization &#40;PRINTO&#41;&#44; the Pediatric Rheumatology Society &#40;PReS&#41; or SERPE have invested on promoting research and the establishment of working groups to join efforts and progress in the field&#46; In 2013&#44; the Single Hub and Access point for paediatric Rheumatology in Europe &#40;SHARE&#41; initiative was launched with the participation of European paediatric rheumatology networks with the aim of describing current needs for the optimal management of children and youth with rheumatic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This initiative has given rise to numerous publications in recent years with recommendations for the management of the most common paediatric rheumatic diseases&#44; the performance of collaborative studies or the establishment of biobanks&#46; Particular emphasis has been placed on the needs of adolescents with chronic disease and how to facilitate transitioning to adult care&#44; which often involves a switch in the provider in charge of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We ought to highlight the important and novel role taken in recent years by patient organizations&#46; For instance&#44; since 2015 and with the support of the SERPE&#44; a yearly day-long &#8220;symposium for the families of children and adolescents with rheumatic diseases&#8221; is held simultaneously in several cities throughout Spain in collaboration with local patient organizations and the specialists that manage these patients&#46; In these symposiums&#44; health professionals&#44; parents and children share experiences&#44; questions and hopes&#46; Starting this year&#44; this symposium will be held on March to join the celebration in multiple countries of the World Young Rheumatic Diseases day &#40;WORD&#41;&#46; Furthermore&#44; some of these organizations make altruistic contributions to research in paediatric rheumatology&#44; offering research grants to further knowledge on these diseases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">However&#44; many challenges remain&#44; for instance at the educational level&#44; since&#44; as is the case in other paediatric subspecialties&#44; adequate training in the field needs to be guaranteed&#46; In 1992&#44; the American Board of Pediatrics held the first paediatric rheumatology subspecialty exam&#44; and in 1994&#44; specialist training was approved in the United Kingdom&#46; Since then&#44; numerous countries have recognised it as a specialty&#58; Germany&#44; the Netherlands&#44; Italy&#44; France&#44; Austria&#44; Sweden and Finland&#44; among others&#46; Furthermore&#44; the European Union of Medical Specialists &#40;UEMS&#41; and its paediatric section&#44; the European Academy of Paediatrics &#40;EAP&#41;&#44; have acknowledged this specialty and the specialty training curriculum at the European level&#46; Spain should promptly recognise paediatric subspecialties officially&#44; including paediatric rheumatology&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At the level of care delivery&#44; new communication technologies must be considered and applied to facilitate access of patients and their families to the providers involved in their care&#46; In this regard&#44; specialty nurses and case managers can play an essential role in contributing to the education&#44; self-care and follow-up of these patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When it comes to research objectives&#44; it is important to continue to develop new drugs and to conduct trials with those that already exist&#44; as well as to perform studies with the aim of identifying biomarkers &#40;genetic&#44; molecular&#44; indicative of disease recurrence or treatment response&#41; to aid prognosis and thus guide the selection of appropriate&#44; individualised and targeted treatment&#44; which not only would increase its effectiveness and decrease the probability of recurrence&#44; but also improve the adverse reaction profile&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As health care providers&#44; we must strive to ensure access to all patients to the best possible care&#44; to specialised care and to appropriate treatment for their disease&#46; As paediatricians&#44; we should be able to demand from our managers&#44; coordinators&#44; administrators and politicians that children with suspected non-infectious arthritis or autoimmune disease be assessed by a paediatric rheumatologist&#46; There is still a long way to go&#44; but the subspecialty of Paediatric Rheumatology is now a reality established on solid foundations&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ant&#243;n J&#44; Camacho Lovillo M&#44; Nu&#241;ez Cuadros E&#46; Reumatolog&#237;a Pedi&#225;trica&#44; de d&#243;nde venimos y a d&#243;nde vamos&#46; An Pediatr &#40;Barc&#41;&#46; 2020&#59;92&#58;121&#8211;123&#46;</p>"
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ISSN: 23412879
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