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To evaluate the impact of concomitant use of conventional synthetic DMARDs (csCMARD) on adherence, switching and dose of biologic disease modifying antirheumatic drugs (bDMARD) in rheumatoid arthritis (RA) patients treated with bDMARDs. This was a population-based cohort study conducted in five provinces of Canada (Alberta, Manitoba, Ontario, Quebec, and Saskatchewan), and one American database (IBM® MarketScan® Databases). Adult RA patients entered the study after a 3-month initiation period of bDMARDs between 1 January 2007, and 30 March 2014. Concomitant csDMARD exposure was compared to non-csDMARD exposure on the following outcomes: discontinuation of bDMARD therapy, switching of bDMARDs, and percent change in dose of bDMARD compared to initial dose. The effect of the time-varying changes in csDMARD exposure was analyzed using marginal structural models. Dose change was analyzed using linear regression. Results from each participating site were combined using likelihood ratio meta-analysis. The study population comprised 20,221 new users of bDMARDs: adalimumab (7609), etanercept (9809), abatacept (1024), infliximab (1779). Concomitant use of csDMARD therapy was not significantly associated with reduced discontinuation of bDMARD treatment (hazard ratio 0.90, 95% intrinsic confidence interval 0.79 to 1.02) or reduced switching of bDMARDs (hazard ratio 0.95, 95% intrinsic confidence interval 0.80 to 1.11), but was associated with a small increase in bDMARD dose compared to the mean dose over the first three months of treatment (mean percentage change in dose +0.56% mg/day, 95% intrinsic confidence interval +0.14% to +0.97%). In this large study of RA patients using bDMARDs in Canada and the United States, we found no clear evidence that patients who received concomitant csDMARD therapy were less likely to discontinue, switch or increase their dose of bDMARD. [ABSTRACT FROM AUTHOR]

Abstract Introduction Anticentromere antibodies have been associated with peripheral vascular occlusive disease, most frequently accompanied by sclerodactyly in the context of a connective tissue disorder. We report a case of digital gangrene with no other clinical associations except positive anticentromere antibodies. Case presentation Our patient, a 53-year-old Caucasian woman, non-smoker, presented with progressive pain and blackening of the distal right third finger over the preceding five weeks. No sclerodactyly was evident. She was anticentromere antibody positive at greater than 100 U/mL. Angiography revealed diffuse distal vasculopathy in both upper extremities. Other investigations were unremarkable. Conclusions It is rare for anticentromere antibody-associated digital necrosis to develop without concomitant sclerodactyly. However, this patient's case illustrates the need to consider an autoimmune contribution to the pathogenesis of digital ischemia even in the absence of a recognizable connective tissue disease.

Agricultural workers have physically demanding occupations. In this study of Saskatchewan farmers, the authors examined (1) self-reported prevalence of physician-diagnosed rheumatoid arthritis and osteoarthritis; and (2) the impact of these chronic arthridities on engagement in physical tasks related to farming. This study was conducted through a cross-sectional analysis of baseline data from the Saskatchewan Farm Injury Cohort Study in which 2,473 adult residents upon 1,216 farms participated. Collected survey data included demographic and health information; regional musculoskeletal symptoms for each participant assessed via the Standard Nordic Questionnaire; and engagement in various specific physical tasks or activities associated with mixed farming practices. Of the 2,473 respondents, 13% reported chronic arthritic diagnoses (10% osteoarthritis, 4% rheumatoid arthritis, with 1% from each category overlapping with both forms of arthritis). Participants reporting arthritis were more likely to also report disabling musculoskeletal symptoms involving their shoulders, elbows, hands, lower back, hips, knees, and ankles. Farmers with arthritis reported less participation in all physical farming activities studied, including various machinery operations, herd maintenance and veterinary activities, overhead work, shoveling/pitchfork work, and lifting/carrying. When adjusted for age, gender, and comorbidities, operation of combines and shoveling/pitchfork work continued to be significantly less engaged in by farmers with arthritis. The overall prevalence of arthritis was consistent with general population prevalence, although the category of rheumatoid arthritis was overrepresented. Farmers with arthritis were significantly less likely to participate in combine operation and shoveling/pitchfork chores compared with their counterparts without arthritis. [ABSTRACT FROM AUTHOR]

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Objective: The aim of this study was to explore association between hypermobility and osteoarthritis (OA) at the first carpometacarpal (CMC) joint, using magnetic resonance imaging (MRI) to identify early change in women at high risk of developing OA but without yet established diagnoses., Methods: For this observational study, 33 women (aged 30-50 years) with self-reported history of maternal hand OA but without personal diagnoses of OA were recruited. Participants completed a 5-point hypermobility questionnaire. The 20 participants with 2 or more positive responses were categorized with "high hypermobility scores." The remaining 13 were categorized with "low hypermobility scores." Data collection included functional index, hand pain measure, parity, smoking status, and body mass index. Each participant underwent dominant hand radiographic and MRI examination. Imaging studies were interpreted by assessors blinded to hypermobility score categorization., Results: No significant differences in age, body mass index, parity, functional index, or pain scores were observed between higher and lower hypermobility score groups. Similarly, there were no significant differences between groups for radiographic changes. However, significantly higher proportions of women with higher hypermobility scores were observed on MRI to have abnormalities of trapezium cartilage (75% vs. 38%), metacarpal cartilage (80% vs. 38%), and trapezium bone (70% vs. 31%); p < 0.05 for all., Conclusions: First CMC joint structural abnormalities were more frequently observed in women with higher hypermobility scores. Identification of early preradiographic changes in this group supports the concept that early-life joint laxity may contribute to future OA predisposition. Magnetic resonance imaging may be a preferred imaging test for detection of early cartilage changes in people at high risk of CMC joint OA., Competing Interests: Conflicts of Interest: The authors (RTG, BN, JAL, HO, DL) declare no conflicts of interest in the conduct of this research., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify discrete clusters comprising clinical features and inflammatory biomarkers in children with JIA and to determine cluster alignment with JIA categories., Methods: A Canadian prospective inception cohort comprising 150 children with JIA was evaluated at baseline (visit 1) and after six months (visit 2). Data included clinical manifestations and inflammation-related biomarkers. Probabilistic principal component analysis identified sets of composite variables, or principal components, from 191 original variables. To discern new clinical-biomarker clusters (clusters), Gaussian mixture models were fit to the data. Newly-defined clusters and JIA categories were compared. Agreement between the two was assessed using Kruskal-Wallis analyses and contingency plots., Results: Three principal components recovered 35% (three clusters) and 40% (five clusters) of the variance in patient profiles in visits 1 and 2, respectively. None of the clusters aligned precisely with any of the seven JIA categories but rather spanned multiple categories. Results demonstrated that the newly defined clinical-biomarker lustres are more homogeneous than JIA categories., Conclusion: Applying unsupervised data mining to clinical and inflammatory biomarker data discerns discrete clusters that intersect multiple JIA categories. Results suggest that certain groups of patients within different JIA categories are more aligned pathobiologically than their separate clinical categorizations suggest. Applying data mining analyses to complex datasets can generate insights into JIA pathogenesis and could contribute to biologically based refinements in JIA classification., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Sleep health questionnaires are often employed as a first assessment step for sleep pathology. The Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI) are two commonly employed questionnaire instruments. Aspects of sleep health may be measured differently depending on choice of instrument., Objectives: In a patient population at high risk for sleep disorders, referred for polysomnography (PSG), we evaluated the level of association between results from these two instruments. Questionnaire results were also compared with measured PSG parameters., Methods: Records of patients undergoing overnight PSG in the sleep laboratory between February-June 2011 were retrospectively reviewed for eligibility. Inclusion criteria were met by 236 patients. PSQI and ESS scores, demographic information, and PSG data were extracted from each record for analysis. Four subgroups based on normal/abnormal values for ESS and PSQI were evaluated for between-group differences., Results: Of 236 adult participants, 72.5% were male, the mean age was 52.9 years (13.9), mean body mass index (BMI) 34.4 kg/m(2) (8.3), mean ESS 9.0 (4.8; range: 0-22), PSQI mean 8.6 (4.2; range: 2-19). The Pearson correlation coefficient was r = 0.13 (P = 0.05) for association between ESS and PSQI. Participants with an abnormal ESS were more likely to have an abnormal PSQI score (odds ratio 1.9 [1.1-3.6]; P = 0.03). Those with an abnormal ESS had higher BMI (P = 0.008) and higher apnea-hypopnea indexes (AHI) (P = 0.05). Differences between the four subgroups were observed for BMI and sex proportions, but not for AHI., Conclusions: We observed limited association between these two commonly used questionnaire instruments, the ESS and the PSQI. These two questionnaires appear to evaluate different aspects of sleep. In terms of clinical application, for global assessment of patients with sleep problems, care should be taken to include instruments measuring different facets of sleep health.

Objectives: There is little information regarding the reliability of repeat tuberculin skin tests (TSTs) and interferon gamma release assays (IGRAs) in detecting latent tuberculosis infection (LTBI) in people on anti-tumour necrosis factor (TNF) medication., Methods: We conducted a prospective, observational study of patients referred to the Saskatoon Tuberculosis (TB) Clinic prior to starting anti-TNF medication. A chest x-ray (CXR), 2-step TST and IGRA (QuantiFERON-TB Gold In-Tube Method) were performed at baseline. Those patients with a baseline TST ≥10 mm and/or a positive IGRA were followed with a clinic visit, CXR, TST and IGRA at 3 and 6 months after starting anti-TNF medication., Results: Of 106 potential patients, 91 consented to participate. Twenty-six patients had a positive (≥ 10 mm) TST or IGRA at baseline; twelve started and stayed on anti-TNF medication through the 6-month follow-up and completed both planned follow-up visits. The baseline mean TST measurement for the 12 participants was 13.9 mm (SD 11.4), increasing to a mean of 16.8 mm (SD 9.3) post-booster. At 3 months post-anti-TNF initiation, there was an overall decrease in TST measurement (mean=10.0 mm; SD 9.3; p=0.013), with measurements <5 mm in 3 of the 12 patients. By the 6-month TST, a response recovery was observed with a mean TST measurement of 14.5 mm (SD 7.7), with 11/12 ≥5 mm. The IGRA was unchanged throughout the study period in all patients. The overall agreement between TST and IGRA was poor (kappa coefficient = 0.180, p=0.020)., Conclusions: We demonstrated a transient but significant decrease in TST response in the first six months of anti-TNF therapy.

Objectives: There is increasing awareness of the importance of sleep in health maintenance. Our primary objective was to evaluate prevalence of excess daytime sleepiness in a rheumatic disease patient population. Secondary objectives included evaluation of prevalence of abnormal sleep quality and primary sleep disorders., Methods: Consecutive Rheumatology clinic patients were invited to participate in a self-administered questionnaire study. Included were measures for pain, fatigue, and global functioning, modified Health Assessment Questionnaire, Epworth Sleepiness Score (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin Score, diagnostic criteria for restless legs syndrome (RLS), Centre for Epidemiologic Studies Depression score (CES-D), stress scores, and the short form-36 quality of life instrument., Results: Of 507 consecutive patients invited to participate, 423 agreed. Mean age was 52.1 years; 26% were male. Prevalence of excessive sleepiness (ESS >10) was 25.7%, abnormal sleep quality (PSQI >5) was 67.3%, high risk for obstructive sleep apnea Berlin scores were present in 35.2% and 24% of participants met criteria for RLS. Significantly worse pain, fatigue, global function, short form-36 summary scores, modified Health Assessment Questionnaire, depression, and stress scores were present in patients with higher ESS and PSQI scores. No significant differences in sleep assessment scores were observed between specific rheumatic disease groups., Conclusions: Our findings suggest a high prevalence of unrecognized hypersomnolence, poor sleep quality, and primary sleep disorders in rheumatology patients. We suggest evaluation of sleep health be incorporated into standard clinical assessments of all rheumatology patients. We would recommend this evaluation include the ESS and the criteria for RLS.

Objective: To evaluate the diagnostic utility of nerve conduction studies (NCSs) by examining a population with a high pretest probability of carpal tunnel syndrome (CTS), including bilaterally and unilaterally symptomatic patients., Design: Comparison of the results of NCSs with the results of prospective, pre-NCS, self-administered questionnaires of patients with clinical diagnoses of CTS referred for confirmatory NCSs., Setting: A tertiary care hospital neuro-electrophysiology laboratory., Participants: The study population consisted of 211 patients, 156 (73.9%) of whom were female. Population mean (range) age was 46.7 (21 to 88) years. Mean (range) symptom duration was 29.3 (1 to 300) months., Main Outcome Measures: Patient-reported symptom localization and NCS results., Results: Results of NCSs were normal in 83 (39.3%) patients, were consistent with CTS in 121 (57.3%) patients, and suggested non-CTS abnormalities in 7 (3.3%) patients. Bilateral symptoms were reported by 139 (65.9%) patients, and isolated unilateral symptoms were reported by 72 (34.1%) patients. Those reporting bilateral symptoms had the highest agreement with NCS results at 38.8%. Unilateral NCS abnormalities were seen in 18.0% of those reporting bilateral hand symptoms. Discordant findings, either bilateral or opposite-side neuropathies, were seen in 25.6% of those reporting isolated right-sided symptoms, and in 55.2% of those reporting isolated left-sided symptoms. Based on these data the sensitivity of the NCS results was 49.1%, with a specificity of 62.5%. The positive predictive value was 86.4%, and the negative predictive value was 20.2%. Overall accuracy was 51.4%. Likelihood ratios were 1.3 with positive results, and 0.8 with negative results., Conclusion: In our study population NCS results did little to alter the pretest probability of CTS. Physicians using NCSs for verification of clinical diagnosis should be aware of potential limitations.

Objective: To use the 2003 International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria and to evaluate restless legs syndrome (RLS) prevalence in a rheumatoid arthritis (RA) and osteoarthritis (OA) population. Further, we wished to evaluate physician awareness of this disorder by as reflected in prevalence of preexisting diagnoses of RLS in these populations., Methods: This was a questionnaire study of Saskatchewan RA and OA patients enrolled in a longitudinal database study. A data collection instrument, including the 2003 IRLSSG criteria for RLS was distributed to the patients enrolled., Results: Of the 193 respondents, 158 (81.9%) were women. The population consisted of 148 RA and 45 OA patients. RA patients were younger (mean age, 65.8 years) in comparison with those in the OA group (mean age, 72.8 years; P < 0.001). All criteria for RLS were met by 27.7% of RA patients and by 24.4% of OA patients. A previous diagnosis of RLS was reported by 2.6% of patients., Conclusions: A quarter of all our patients met the 2003 IRLSSG criteria, in both RA and OA groups; however, only 2.6% of study patients reported a previous diagnosis of RLS. As RLS can significantly affect quality of life, increased awareness with improvement in surveillance, recognition, and treatment would be beneficial to patient care. We advocate screening for symptoms of sleep disorders to be incorporated into the routine rheumatologic history for all patients with RA and OA.

Objective: To determine how frequently treatments had been offered to patients with suspected diagnoses of carpal tunnel syndrome (CTS) who had been referred for confirmatory nerve conduction studies (NCSs) and to identify potential predictors of such treatment. A follow-up survey was conducted to determine the effect of NCS results on subsequent treatment., Design: Self-administered survey questionnaire and follow-up telephone survey., Setting: Royal University Hospital at the University of Saskatchewan in Saskatoon., Participants: Two hundred eleven patients with clinically suspected CTS who had been referred for confirmatory NCS., Main Outcome Measures: Results of NCSs, number of patients prescribed wrist splints or nonsteroidal anti-inflammatory drugs (NSAIDs) before and after NCSs, patient characteristics associated with being prescribed therapy, and reporting benefit of therapy., Results: Nerve conduction studies confirmed CTS in 121 (57.3%) of the 211 study patients. Before NCSs, wrist splints and NSAIDs had been prescribed to 33.2% and 38.8% of patients, respectively. Splints and NSAIDs were reported to alleviate symptoms by 78.3% and 74% of patients, respectively, who received such treatments. No significant differences in age, sex, body mass index, symptom duration, symptom or function scores, or subsequent NCS results were noted between patients who were and were not prescribed these therapies or between those who did or did not report improvement in symptoms. Results of the follow-up survey indicated that the number of recommendations for splints and NSAIDs had doubled after NCSs were completed and that surgical intervention had been at least discussed in most cases. Treatment recommendations, including surgery, however, were not associated with identifiable patient factors, including patients' NCS results., Conclusion: Some patients were prescribed conservative treatments before NCSs. Following NCSs, prescriptions for wrist splints or NSAIDs approximately doubled. Interestingly, NCS results did not appear to influence subsequent therapeutic decision-making for either conservative treatment or surgical options. We think these findings suggest a lack of confidence in electrodiagnostic study results. It would be interesting to evaluate a larger population of primary care patients prospectively to examine further the use of NCSs in current clinical decision-making.