BackgroundThis study aimed to describe the proportion of patients with juvenile idiopathic arthritis (JIA) who had experienced an unsuccessful transfer from a pediatric rheumatology team to an adult rheumatologist and to compare the characteristics of those who achieved successful transfer to those who did not.MethodsWe conducted a systematic chart review of all patients with JIA who attended their final Montreal Children's Hospital JIA clinic appointment between 1992 and 2005. We tracked these patients for the two years after transfer to an adult rheumatologist. We then compared characteristics of patients with successful and unsuccessful transfers of care. Variables pertaining to disease characteristics, disease severity and psychosocial factors were examined. Univariate analyses were performed to determine if any single factor was associated with the outcome of unsuccessful transfer of care.Results52% of patients fulfilled our criteria for unsuccessful transfer. Of the variables tested, an active joint count (AJC) of zero at last visit was associated with the outcome of unsuccessful transfer (OR = 2.67 (CI 1.16-6.16; p = 0.0199)).ConclusionsDespite the presence of a coordinated process of transfer from pediatric to adult health care for the majority of the patients in this study, there was a high rate of unsuccessful transfer and/or sustained follow up which is disheartening. We found that patients with less active disease at the time of transfer, as indicated by a lower AJC, were more likely to be lost to follow up. Recent literature suggests that even in the least severe categories of JIA, 50% of patients persist with active disease into adulthood. Thus educating all JIA patients about the possibility of disease flare in adulthood may improve their adherence to recommendations for sustained follow-up in the adult milieu. This may lead to improvement of longitudinal outcomes for all JIA patients.

Objective.To assess vaccination coverage and predictors of vaccination among a Canadian population of rheumatology patients in routine clinical care.Methods.In this cross-sectional study, consecutive adult patients presenting to a tertiary rheumatology clinic at the McGill University Health Center between May and September 2015 were asked to fill a survey on vaccination. Patients self-identified as having rheumatoid arthritis (RA), systemic autoimmune rheumatic diseases (SARD), spondyloarthropathies (SpA), or other diseases (OD). Multivariate logistical regression analyses were performed to evaluate patient and physician factors associated with various vaccinations [for influenza, pneumococcus, and hepatitis B virus (HBV)]. Published Quebec general population influenza and pneumococcal vaccination rates in those aged ≥ 65 years were used as comparative baseline rates.Results.Three hundred fifty-two patients were included in the analysis (RA: 136, SARD: 113, SpA: 47, OD: 56). Vaccination rates were reported as follows: (1) influenza: RA 48.5%, SARD 42.0%, SpA 31.9%, OD 88.9%, Quebec general population 58.5%; (2) pneumococcal: RA 42.0%, SARD 37.8%, SpA 29.7%, OD 33.3%, Quebec general population 53.2%; (3) HBV: RA 33.6%, SARD 55.6%, SpA 73.5%, OD 36.8%; and (4) herpes zoster: RA 5.6%, SARD 28.6%, SpA 25.0%, OD 16.7%. Physician recommendation was the strongest independent predictor of vaccination across all vaccine types (influenza: OR 8.56, 95% CI 2.80–26.2, p < 0.001; pneumococcal: OR 314, 95% CI 73.0–1353, p < 0.001; HBV: OR 12.8, 95% CI 5.27–31.1, p < 0.001). Disease group, disease duration, comorbidities, treatment type, and being followed by a primary care physician were not significantly associated with vaccination.Conclusion.There is suboptimal immunization coverage among ambulatory rheumatology patients. An important role for patient and physician education is highlighted in our study, especially because physician recommendation of vaccination was strongly predictive of vaccine uptake.

Objective Immunization is an essential component of rheumatoid arthritis (RA) care. Nevertheless, vaccine coverage in RA is suboptimal. Contextual, individual, and vaccine-related factors influence vaccine acceptance. However, barriers and facilitators of vaccination in RA are not well defined. The aim of this study was to assess perspectives of RA patients and health care professionals (HCPs) involved in RA care of barriers and facilitators regarding influenza and pneumococcal vaccines. Methods Eight focus groups (4 with RA patients and 4 with HCPs), and eight semi-structured open-ended individual interviews with vaccine hesitant RA patients were conducted. Data were audio-recorded, transcribed verbatim, and imported to the MAXQDA software. Analysis using the framework of vaccine hesitancy proposed by the Strategic Advisory Group of Experts (SAGE) on Immunization was conducted. Results RA patients and HCPs reported common and specific barriers and facilitators to influenza vaccination that included contextual, individual and/or group, and vaccine and/or vaccination specific factors. A key contextual influence on vaccination was patients’ perception of the media, pharmaceutical industry, authorities, scientists, and the medical community at large. Among the individual-related influences, experiences with vaccination, knowledge/awareness, and beliefs about health and disease prevention were considered to impact vaccine-acceptance. Vaccine-related factors including concerns of vaccine side effects such as RA flares, safety of new formulations, mechanism of action, access to vaccines and costs associated with vaccination were identified as actionable barriers. Conclusion Acknowledging RA patients' perceived barriers to influenza and pneumococcal vaccination and implementing specific strategies to address them might increase vaccination coverage in this population.

A convincing body of evidence points to an early window of opportunity for the treatment of rheumatoid arthritis. However, data indicate that in many cases, this window of opportunity is missed. Once a patient does present to their primary care provider, important additional delays in rheumatology assessment can occur. To report the results of our study assessing referral letters to rheumatologists, we examined referral letters received over a one-year period by one full-time rheumatologist practicing at a tertiary-care center. We found only a small percentage of referral letters made mention of the pattern of joint involvement. Just 17% of consults indicated symptom duration. Only 2% mentioned any circadian rhythm of symptoms (such as morning stiffness), and only 6% provided information about functional status. Almost two-thirds (62%) of consults specified only 'joint pain' in the referral letter. We provide objective evidence that referral letters sent to rheumatologists are often lacking in key elements of the medical history. This lack of information means that appropriate triage of referrals by rheumatologists is very difficult. As a response to this, we have developed, with family physicians and rheumatologists, a standardized referral template which is being pilot-tested. Our ultimate goal is to improve wait times for patients with urgent conditions such as inflammatory arthritis.

Objective. Ehlers-Danlos syndrome (EDS) is a group of genetic disorders affecting connective tissue. Symptoms include joint and ligament laxity. The objectives of this study were to compare muscle activation, joint angles, and spatiotemporal parameters during gait, and to compare isometric strength between participants with EDS (hypermobility and classical subtypes) and healthy adults. Methods. Participants with EDS (n = 14) and healthy adults (n = 14) were recruited for this cross-sectional study. Lower extremity muscle activation, sagittal joint angles, and spatiotemporal parameters during gait were measured using surface electromyography (EMG), motion capture, and force plates. Isometric strength of the lower extremity joints was measured with an isokinetic dynamometer. Important characteristics (principal components [PCs]) were determined from EMG and angle waveforms using PC analysis; relationships between PC scores and groups were examined using multilevel linear models after accounting for gait speed. Spatiotemporal parameters and strength were compared using independent t-tests and effect sizes (Cohen's d). Results. The EDS group was associated with delayed vastus lateralis (b = 16.69) and medialis activation (b = 11.33), higher rectus femoris (b = 28.34) and tensor fascia latae activation (b =-11.06), prolonged gluteus medius activation (b =-32.78), and lower medial gastrocnemius activation (b =-27.18). Joint angles were similar between the EDS and healthy groups. The EDS group had slower gait speeds, shorter stride lengths, and a greater percentage of time in stance (d =-1.05 to 0.96). The EDS group had weaker hip and ankle muscles (d =-0.83 to-0.97). Conclusion. Alterations in muscle activation and spatiotemporal parameters during gait in patients with EDS may be a result of impaired proprioception and balance and muscle weakness. Interventions should target these deficits.