Use of administrative claims data in observational studies of antirheumatic medication effects on pregnancy outcomes: a scoping review protocol.

OBJECTIVE: The primary objective of this review is to examine which disease-modifying antirheumatic drugs (DMARDs) and biologics used to treat pregnant individuals with rheumatic conditions have been reported in observational studies using population-based health administrative data. The secondary objective is to describe which adverse pregnancy outcomes (both maternal and neonatal) have been reported, their definitions, and corresponding diagnostic and/or procedural codes. INTRODUCTION: Pregnant individuals are typically excluded from drug trials due to unknown potential risks to both the pregnant person and fetus, leaving most antirheumatic drugs understudied for use in pregnancy. Despite these substantial knowledge gaps, most pregnant individuals continue to be maintained on antirheumatic medications due to the benefits generally outweighing the risks. In contrast to previous systematic reviews of findings from randomized trials, our scoping review aims to leverage this real-world data to generate real-world evidence of antirheumatic drug safety during pregnancy. INCLUSION CRITERIA: Articles must report on observational studies using population-based health administrative data from pregnant individuals with rheumatic conditions (rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and psoriatic arthritis) receiving antirheumatic drug therapy (DMARDs and biologics). Randomized trials, reviews, case studies, opinion pieces, and abstracts will be excluded. METHODS: Electronic databases (MEDLINE [Ovid], Embase [Ovid], CINAHL [EBSCOhost]) and gray literature (OpenGrey, Health Services Research Projects in Progress, World Health Organization Library, and Google Scholar) will be searched for relevant evidence. Search terms will combine 4 concepts: rheumatic diseases, drug therapy, pregnancy, and health care administrative data. Identified articles will be independently screened, selected, and extracted by 2 researchers. Data will be analyzed descriptively and presented in tables. REVIEW REGISTRATION: Open Science Framework https://osf.io/5e6tp.

Factors influencing rheumatology residents' decision on future practice location.

BACKGROUND: There are regional disparities in the distribution of Canadian rheumatologists. The objective of this study was to identify factors impacting rheumatology residents' postgraduate practice decisions to inform Canadian Rheumatology Association workforce recommendations. METHODS: An online survey was developed, and invitations were sent to all current Canadian rheumatology residents in 2019 (n = 67). Differences between subgroups of respondents were examined using the Pearson χ2 test. RESULTS: A total of 34 of 67 residents completed the survey. Seventy-three percent of residents planned to practice in the same province as their rheumatology training. The majority of residents (80%) ranked proximity to friends and family as the most important factor in planning. Half of participants had exposure to alternative modes of care delivery (e.g. telehealth) during their rheumatology training with fifteen completing a community rheumatology elective (44%). CONCLUSIONS: The majority of rheumatology residents report plans to practice in the same province as they trained, and close to home. Gaps in training include limited exposure to community electives in smaller centers, and training in telehealth and travelling clinics for underserviced populations. Our findings highlight the need for strategies to increase exposure of rheumatology trainees to underserved areas to help address the maldistribution of rheumatologists.

CONTEXTE: Au Canada, il existe des disparités régionales dans la répartition des rhumatologues. La présente étude recense les facteurs qui influencent les choix des résidents en rhumatologie concernant leur lieu d'exercice futur afin de guider les recommandations de Société canadienne de rhumatologie relatives aux effectifs. MÉTHODES: Après l'élaboration d'un sondage en ligne, une invitation a été envoyée à tous les résidents en rhumatologie au Canada en 2019 (n = 67). Les différences entre les groupes ont été examinées à l'aide du test Pearson χ2. RÉSULTATS: Trente-quatre des 67 résidents contactés ont répondu au sondage. Soixante-treize pour cent des répondants prévoyaient d'exercer dans la province où ils avaient fait leur formation en rhumatologie. La majorité des résidents (80 %) ont classé la proximité des amis et de la famille comme le facteur le plus important dans leur choix de lieu d'exercice. La moitié des participants s'étaient familiarisés avec d'autres modes de prestation de soins (par exemple, la télésanté) pendant leur formation en rhumatologie et 15 d'entre eux (44 %) avaient fait un stage en rhumatologie communautaire. CONCLUSIONS: La majorité des résidents en rhumatologie déclarent avoir l'intention d'exercer près de chez eux, dans la province où ils ont fait leurs études. Les lacunes dans la formation comportent l'exposition limitée à des stages dans les petits centres en milieu communautaire, en télésanté et dans les cliniques mobiles ciblant les populations mal desservies. Nos conclusions soulignent le besoin de stratégies visant à augmenter l'exposition des résidents en rhumatologie à des zones mal desservies afin de remédier à la mauvaise répartition géographique des rhumatologues.

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis.

OBJECTIVE:: To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis. METHODS:: A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05). RESULTS:: Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength. CONCLUSION:: Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

Immunology for rheumatology residents: working toward a Canadian national curriculum consensus.

BACKGROUND: Immunologic mechanisms play an integral role in understanding the pathogenesis and management of rheumatic conditions. Currently, there is limited access to formal instruction in immunology for rheumatology trainees across Canada. AIM: The aims of this study were (1) to describe current immunology curricula among adult rheumatology training programs across Canada and (2) to compare the perceived learning needs of rheumatology trainees from the perspective of program directors and trainees to help develop a focused nationwide immunology curriculum. METHODS: Rheumatology trainees and program directors from adult rheumatology programs across Canada completed an online questionnaire and were asked to rank a comprehensive list of immunology topics. A modified Delphi approach was implemented to obtain consensus on immunology topics. RESULTS: Only 42% of program directors and 31% of trainees felt the current method of teaching immunology was effective. Results illustrate concordance between program directors and trainees for the highest-ranked immunology topics including innate immunity, adaptive immunity, and cells and tissues of the immune system. However, there was discordance among other topics, such as diagnostic laboratory immunology and therapeutics. CONCLUSIONS: There is a need to improve immunology teaching in rheumatology training programs. Results show high concordance between the basic immunology topics. This study provides the groundwork for development of future immunology curricula.

Analysis of the effect of the oral contraceptive pill on clinical outcomes in women with ankylosing spondylitis.

OBJECTIVE: There are unexplained sex-specific changes in the clinical expression of ankylosing spondylitis (AS). We sought to examine the potential effect of exogenous estrogen in the form of oral contraceptive pills (OCP) on AS initiation and severity. METHODS: This cross-sectional study consisted of women with AS from the membership of the Spondylitis Association of America. Measures of disease severity included use of biological agents and hip replacement surgery, while Bath AS Functional Index (BASFI) scores served as a surrogate marker of disability. Information was obtained using a patient questionnaire on patient demographics, OCP use, pregnancy history, AS duration, medication use, and hip replacement. RESULTS: There were 571 women with AS who participated in our study, consisting of 448 OCP ever-users and 123 non-OCP users. The mean age of OCP users was 42.7 yrs (± 11.5) and of non-OCP users, 48.4 yrs (± 12.1). No difference was noted in the age at initial onset of back pain. However, OCP users were significantly younger at the time of diagnosis of AS (36.5 yrs vs 39.1 yrs, p = 0.02). There were no significant differences between the 2 groups in tumor necrosis factor inhibitor or opioid use, BASFI scores, pregnancy complications, or hip surgery. CONCLUSION: The use of exogenous estrogens in the form of OCP is not associated with a measurable effect on initiation or severity of AS. Biologic and social factors may contribute to earlier diagnosis of AS in OCP users. This is the largest study to date investigating the potential effect of exogenous estrogens in women with AS.

Fertility and pregnancy in vasculitis.

Despite the rarity of vasculitides, fertility and pregnancy outcome in the setting of vasculitis have become a major topic of interest within the past decade. The potential impact of vasculitis therapies, particularly cyclophosphamide, has been examined to some extent, but data are limited on the possible impact of the disease itself on fertility. Ideally, pregnancy should be planned when the vasculitis is in remission. The outcome for mothers and newborns is usually good when vasculitis is known before the pregnancy and is in remission, but every pregnant woman must be monitored by a specialised health-care team consisting of obstetricians specialised in high-risk births and internists/rheumatologists with expertise in managing these rare conditions. Most maternal complications during pregnancy are indeed due to vasculitis damage: hypertension in Takayasu arteritis (TAK) or granulomatosis with polyangiitis (GPA)/microscopic polyangiitis (MPA) with renal insufficiency, asthma or cardiac damage in eosinophilic granulomatosis with polyangiitis (EGPA) and subglottic and/or bronchial stenosis(es) in GPA. Pregnancy loss can occur in about 10% of cases in GPA, up to 20% in EGPA, 20-30% in Behçet's disease and up to 25% in TAK, and several studies found high rates of preterm births, at least with some vasculitides. Vasculitis manifestations in newborns from mothers with known vasculitis are very rare and usually transient.