A decade of progress in juvenile idiopathic athritis treatments and outcomes in Canada: results from ReACCh-Out and the CAPRI registry.

OBJECTIVE: To assess changes in juvenile idiopathic arthritis (JIA) treatments and outcomes in Canada, comparing a 2005-2010 and a 2017-2021 inception cohorts. METHODS: Patients enrolled within three months of diagnosis in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) and the Canadian Alliance of Pediatric Rheumatology Investigators Registry (CAPRI) cohorts were included. Cumulative incidences of drug starts and outcome attainment within 70 weeks of diagnosis were compared with Kaplan Meier survival analysis and multivariable Cox regression. RESULTS: The 2005-2010 and 2017-2021 cohorts included 1128 and 721 patients, respectively. JIA category distribution and baseline clinical juvenile idiopathic arthritis disease activity (cJADAS10) scores at enrolment were comparable. By 70 weeks, 6% of patients (95% CI 5, 7) in the 2005-2010 and 26% (23, 30) in the 2017-2021 cohort had started a biologic DMARD (bDMARD), and 43% (40, 47) and 60% (56, 64) had started a conventional DMARD (cDMARD), respectively. Outcome attainment was 64% (61, 67) and 83% (80, 86) for Inactive disease (Wallace criteria), 69% (66, 72) and 84% (81, 87) for minimally active disease (cJADAS10 criteria), 57% (54, 61) and 63% (59, 68) for pain control (<1/10), and 52% (47, 56) and 54% (48, 60) for a good health-related quality of life. CONCLUSION: Although baseline disease characteristics were comparable in the 2005-2010 and 2017-2021 cohorts, cDMARD and bDMARD use increased with a concurrent increase in minimally active and inactive disease. Improvements in parent and patient reported outcomes were smaller than improvements in disease activity.

Functional Limitations in Individuals With Long COVID.

OBJECTIVES: To examine the extent of long-term functional deficits experienced by individuals hospitalized for coronavirus disease 2019 (COVID-19). Specific objectives were to (1) describe changes in perceived global health, mobility, participation in daily activities, and employment status from pre-COVID-19 to ≥2 months after infection and (2) evaluate factors associated with change in function. DESIGN: We conducted a telephone survey (at least 2 months postinfection). SETTING: Population-based study of adults living at home. PARTICIPANTS: Adult residents in Laval, Quebec (n=121), who were discharged home posthospitalization for COVID-19. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants responded to a standard questionnaire (COVID-19 Yorkshire Rehabilitation Screen) regarding persistent symptoms and limitations in daily functioning. We calculated the prevalence of changes in perceived global health, mobility, personal care, participation in daily activities, and employment, and evaluated associated factors using bivariate analysis and multivariable logistic regression. RESULTS: Almost all participants (94%) were more fatigued and reported deterioration of their global health status (90%) at least 3 months after infection. The majority were more short of breath and experienced pain and anxiety. The change in outcomes indicates a substantial reduction in those reporting "good" health status, mobility, personal care, and daily activities and less employment. Time since diagnosis was significantly associated with global health, mobility, and participation in daily activities. CONCLUSIONS: This population-based study suggests that individuals hospitalized for COVID-19 infection have symptoms that affect daily functional activities many months after infection. It is imperative that the effect of infection be better understood so that those affected long term can receive the needed services.

Use of IMMPACT Recommendations to Explore Pain Phenotypes in People with Knee Osteoarthritis.

OBJECTIVE: Knee osteoarthritis (OA) is a disease of multiple phenotypes of which a chronic pain phenotype (PP) is known. Previous PP studies have focused on one domain of pain and included heterogenous variables. We sought to identify multidimensional PPs using the IMMPACT recommendations and their relationship to clinical outcomes. METHODS: Participants >40 years of age with knee OA having a first-time orthopedic consultation at five university affiliated hospitals in Montreal, Quebec, and Hamilton (Canada) were recruited. Latent profile analysis was used to determine PPs (classes) using variables recommended by IMMPACT. This included pain variability, intensity and qualities, somatization, anxiodepressive symptoms, sleep, fatigue, pain catastrophizing, neuropathic pain, and quantitative sensory tests. We used MANOVA and χ2 tests to assess differences in participant characteristics across the classes and linear and Poisson regression to evaluate the association of classes to outcomes of physical performance tests, self-reported function and provincial healthcare data. RESULTS: In total, 343 participants were included (mean age 64 years, 64% female). Three classes were identified with increasing pain burden (class3 > class1), characterized by significant differences across most self-report measures and temporal summation, and differed in terms of female sex, younger age, lower optimism and pain self-efficacy. Participants in class2 and class3 had significantly worse self-reported function, stair climb and 40 m walk tests, and higher rates of healthcare usage compared to those in class1. CONCLUSIONS: Three distinct PPs guided by IMMPACT recommendations were identified, predominated by self-report measures and temporal summation. Using this standardized approach may improve PP study variability and comparison.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission.

BACKGROUND: Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic. METHODS: In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed. RESULTS: Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies. CONCLUSIONS: The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Evaluating a new referral pathway from physical therapists to rheumatologists: A qualitative study.

Early referral to rheumatology of people with suspected inflammatory arthritis is associated with better outcomes. Typically, these individuals are seen by a family physician who would assess the need for rheumatology referral. However, some may first consult a physical therapist where no physician referral is required. New interprofessional referral pathways, such as direct referral from a physical therapist to a rheumatologist, could enhance early access to a rheumatologist. Our objective was to explore perceptions of clinicians and people with inflammatory arthritis regarding physical therapists referring directly to rheumatologists. We used purposive and snowball sampling to recruit participants for five focus groups: rheumatologists, family physicians, physical therapists, people with inflammatory arthritis, and a mixed group of physical therapists and people with inflammatory arthritis. Thematic analysis revealed four core themes: difficulties accessing care, reluctance of family physicians and rheumatologists toward the new pathway, interprofessional relationships (or lack thereof), and opportunities along the referral pathway. The conclusions are that care must be optimized by ensuring swift referral for those who require it; and that there is a need for knowledge translation to all actors on the advantages of this new pathway.

National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care Survey.

OBJECTIVES: To portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments. STUDY DESIGN: Using nationally representative data of ambulatory physician office visits (2007-2015 United States National Ambulatory Medical Care Survey), we identified and cross-sectionally analyzed visits by persons <25 years of age diagnosed with a chronic musculoskeletal pain condition. RESULTS: There were 28.6 million visits over the 9-year period for chronic musculoskeletal pain for persons <25 years of age, (average 3.2 million visits/year). There were more visits among older age groups, female persons, non-Hispanic White ethnicity/race, and those with more medical visits in the past year. Nonopioid medications were the most frequent treatments in all age groups (range 38.5%-48.8%). Opioids were rarely prescribed for children and adolescents but were prescribed in 23% of visits among young adults (18-24 years of age). Health education and counseling were consistently prescribed at 20% of visits and physical therapy (range 9.5%-23.7%) and other treatments were less frequently prescribed. Age, sex, payment source, and physician specialty were associated with various treatments. CONCLUSION: There were over 3 million annual visits for chronic musculoskeletal pain in young Americans; these increased with age. Pharmacologic treatment is used more than nonpharmacologic approaches, and opioid prescribing in the 18- to 24-year-old age group approaches estimates in adults with musculoskeletal pain.

The burden of waiting to access pain clinic services: perceptions and experiences of patients with rheumatic conditions.

BACKGROUND: Extensive waiting times before receiving services is a major barrier to adequate pain management. Waiting times may have a detrimental impact on patients' conditions and quality of life. However, there remains a lack of knowledge on the actual experiences of patients waiting to receive services, especially for those with rheumatic conditions. The present study aimed to gain an in-depth understanding of perceptions and experiences of patients with rheumatic conditions regarding access to pain clinic services. The secondary objective was to identify possible solutions to improve this access according to patients' perspectives. METHODS: This qualitative study based on semi-structured interviews was conducted with adults with rheumatic conditions waiting to access pain clinics in the province of Quebec, Canada. Interviews were transcribed verbatim and analyzed using thematic content analysis. RESULTS: Twenty-six participants were interviewed (22 women and 4 men; mean age 54 ± 10 years). Four main themes were identified: 1) the perception that waiting time is unacceptably long; 2) how the lack of information affects patients' experiences of waiting; 3) patients' various expectations towards the pain clinic, from high hopes to disillusionment and 4) carrying an emotional, physical and financial burden resulting from the wait. Participants reported several solutions to improve the experience of waiting, including providing information to patients, increasing resources, improving prioritization processes and care coordination, and providing alternative interventions to patients during the wait. CONCLUSIONS: For patients with rheumatic conditions, access to pain clinic services is challenging due to extensive waiting times. The burden it imposes on them adds to the existing challenge of living with a chronic rheumatic condition. The solutions identified by participants could serve as building blocks to develop and implement measures to improve patients' experience of accessing pain-related services.

Determining the Effect of Group Flower Arranging Sessions on Caregiver Self-Efficacy and Stress Levels in an In-Patient Hospice.

This study was designed to promote enhanced self-efficacy and decreased stress levels for family caregivers at a hospice care hospital, thus increasing their quality of life. This is achieved through group flower arranging sessions. The objectives are to (a) enhance self-efficacy scores for family caregivers of Calvary patients, (b) decrease stress levels for family caregivers of Calvary patients, and (c) disseminate results to other hospices. The results show that the flower arranging sessions resulted in significantly increased self-efficacy and decreased stress and associated problems for the caregiver participants. Implications and suggestions for future research are discussed.

Tensions Living Out Professional Values for Physical Therapists Treating Injured Workers.

Health care services provided by workers' compensation systems aim to facilitate recovery for injured workers. However, some features of these systems pose barriers to high quality care and challenge health care professionals in their everyday work. We used interpretive description methodology to explore ethical tensions experienced by physical therapists caring for patients with musculoskeletal injuries compensated by Workers' Compensation Boards. We conducted in-depth interviews with 40 physical therapists and leaders in the physical therapy and workers' compensation fields from three Canadian provinces and analyzed transcripts using concurrent and constant comparative techniques. Through our analysis, we developed inductive themes reflecting significant challenges experienced by participants in upholding three core professional values: equity, competence, and autonomy. These challenges illustrate multiple facets of physical therapists' struggles to uphold moral commitments and preserve their sense of professional integrity while providing care to injured workers within a complex health service system.

The effectiveness of the Pathways and Resources for Engagement and Participation (PREP) intervention: improving participation of adolescents with physical disabilities.

AIM: This study examined the effectiveness of the Pathways and Resources for Engagement and Participation (PREP) intervention in improving the participation of adolescents in community-based activities. METHOD: Twenty-eight adolescents (14 males, 14 females), aged 12 to 18 years (mean 14y 6mo, SD 21.6mo) with moderate physical disabilities participated in a 12-week PREP intervention. An interrupted time series design with multiple baselines was employed, replicating the intervention effect across three chosen activities and all participants. An occupational therapist worked individually with adolescents and parents to identify and implement strategies to remove environmental barriers that impede participation in selected activities. Activity performance was repeatedly measured using the Canadian Occupational Performance Measure (COPM) at baseline, intervention, and follow-up (20wks). For each activity, the trajectory representing change in performance was analyzed descriptively. Segmented regression combined with a mixed-effects modeling approach was used to statistically estimate the overall effectiveness of the intervention within and across 79 activities. RESULTS: A statistically significant improvement (B=2.08, p<0.001) was observed across all activities, 59 per cent of which also indicated a clinically significant change of more than 2 points on the COPM scale. Levels of performance were maintained during follow-up with an additional increase of 0.66 points on the COPM scale (t=3.04, p=0.004). Intervention was most effective for males and those with a higher number of functional issues. INTERPRETATION: Findings illustrate that participation can be improved by changing the environment only. Such evidence further supports emerging therapeutic approaches that are activity-based, goal-oriented, and ecological in nature. WHAT THIS PAPER ADDS: Environment-based intervention strategies, guided by the Pathways and Resources for Engagement and Participation, are effective in improving and maintaining adolescent participation. Intervention was most effective for males and those with a higher number of functional issues. The study design serves as an example for future pragmatic studies accounting for individual-based changes and contexts.

Differences in Waiting List Prioritization Preferences of Occupational Therapists, Elderly People, and Persons With Disabilities: A Discrete Choice Experiment.

OBJECTIVE: To compare the preferences of occupational therapists, elderly people, and adults with disabilities regarding prioritization criteria for occupational therapy waiting lists in home care. DESIGN: Discrete choice experiment survey. SETTING: Survey mailed to occupational therapists working in home care and community-dwelling elderly or disabled persons. PARTICIPANTS: A sample (N=714) of home-based occupational therapists (n=241), elderly persons from a bank of research participants (n=226), and adults with physical disabilities recruited through community organizations (n=247). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The dependent variable was whether the referral scenario was prioritized or not in each question. The results were analyzed through logistic regression using conditional logit models. RESULTS: Prioritization preferences differed between groups (P<.001). Occupational therapists most strongly prioritized people who had a few falls (odds ratio vs no falls, 48.7), whereas elderly people and adults with disabilities most strongly prioritized people who were unable to enter and exit the home (odds ratio vs no difficulty entering and exiting the home, 30.8 for elderly people and 16.8 for persons with disabilities.) CONCLUSIONS: Our results highlight the gap between the priorities of home-based occupational therapists and their target clientele. Although further inquiry is needed to inform priority setting, the findings emphasize the importance of public or patient involvement in decisions on waiting list prioritization.

Validity of Combining History Elements and Physical Examination Tests to Diagnose Patellofemoral Pain.

OBJECTIVE: To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude patellofemoral pain (PFP). DESIGN: Prospective diagnostic study. SETTINGS: Orthopedic outpatient clinics, family medicine clinics, and community-dwelling. PARTICIPANTS: Consecutive patients (N=279) consulting one of the participating orthopedic surgeons (n=3) or sport medicine physicians (n=2) for any knee complaint. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: History elements and physical examination tests were obtained by a trained physiotherapist blinded to the reference standard: a composite diagnosis including both physical examination tests and imaging results interpretation performed by an expert physician. Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of PFP, and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios with associated 95% confidence intervals (CIs) were calculated. RESULTS: Two hundred seventy-nine participants were evaluated, and 75 had a diagnosis of PFP (26.9%). Different combinations of history elements and physical examination tests including the age of participants, knee pain location, difficulty descending stairs, patellar facet palpation, and passive knee extension range of motion were associated with a diagnosis of PFP and used in clusters to accurately discriminate between individuals with PFP and individuals without PFP. Two diagnostic clusters developed to confirm the presence of PFP yielded a positive likelihood ratio of 8.7 (95% CI, 5.2-14.6) and 3 clusters to exclude PFP yielded a negative likelihood ratio of .12 (95% CI, .06-.27). CONCLUSIONS: Diagnostic clusters combining common history elements and physical examination tests that can accurately diagnose or exclude PFP compared to various knee disorders were developed. External validation is required before clinical use.

Physiotherapy for injured workers in Canada: are insurers' and clinics' policies threatening good quality and equity of care? Results of a qualitative study.

BACKGROUND: In recent years, significant efforts have been made to improve the provision of care for compensated injured workers internationally. However, despite increasing efforts at implementing best practices in this field, some studies show that policies overseeing the organisation of care for injured workers can have perverse influences on healthcare providers' practices and can prevent workers from receiving the best care possible. The influence of these policies on physiotherapists' practices has yet to be investigated. Our objectives were thus to explore the influence of 1) workers' compensation boards' and 2) physiotherapy clinics' policies on the care physiotherapists provide to workers with musculoskeletal injuries in three large Canadian provinces. METHODS: The Interpretive Description framework, a qualitative methodological approach, guided this inquiry. Forty participants (30 physiotherapists and 10 leaders and administrators from physiotherapy professional groups and workers' compensation boards) were recruited in British Columbia, Ontario and Quebec to participate in an in-depth interview. Inductive analysis was conducted using constant comparative techniques. RESULTS: Narratives from participants show that policies of workers' compensation boards and individual physiotherapy clinics have significant impacts on physiotherapists' clinical practices. Policies found at both levels often place physiotherapists in uncomfortable positions where they cannot always do what they believe to be best for their patients. Because of these policies, treatments provided to compensated injured workers markedly differ from those provided to other patients receiving physiotherapy care at the same clinic. Workers' compensation board policies such as reimbursement rates, end points for treatment and communication mechanisms, and clinic policies such as physiotherapists' remuneration schemes and restrictions on the choice of professionals had negative influences on care. Policies that were viewed as positive were board policies that recognize, promote and support physiotherapists' duties and clinics that provide organisational support for administrative tasks. CONCLUSION: In Canada, workers' compensation play a significant role in financing physiotherapy care for people injured at work. Despite the best intentions in promoting evidence-based guidelines and procedures regarding rehabilitation care for injured workers, complex policy factors currently limit the application of these recommendations in practice. Research that targets these policies could contribute to significant changes in clinical settings.

The impact of a specialized spinal cord injury center as compared with non-specialized centers on the acute respiratory management of patients with complete tetraplegia: an observational study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To compare the proportion of tracheostomy placement and duration of mechanical ventilation (MV) in patients with a complete cervical spinal cord injury (SCI) that were managed early or lately in a specialized acute SCI-center. The second objective was to determine the impact of the timing of admission to the SCI-center on the MV support duration. SETTING: A single Level-1 trauma center specialized in SCI care in Quebec (Canada). METHODS: A cohort of 81 individuals with complete tetraplegia over a 6-years period was included. Group 1 (N = 57- early group-) was admitted before surgical management in one specialized acute SCI-center, whereas Group 2 (N = 24 -late group-) was surgically managed in a non-specialized center and transferred to the SCI-center for post-operative management only. The proportion of tracheostomy placement and MV duration were compared. Multivariate regression analysis was used to assess the impact of the timing of admission to the SCI-center on the MV duration during the SCI-center stay. RESULTS: Patients in Group 2 had a higher proportion of tracheostomy (70.8 vs. 35.1%, p = 0.004) and a higher mean duration of MV support (68.0 ± 64.2 days vs. 21.8 ± 29.7 days, p = 0.006) despite similar age, trauma severity (ISS), neurological level of injury and proportion of pneumonia. Later transfer to the specialized acute SCI-center was the main predictive factor of longer MV duration, with a strong impact factor (s = 946.7, p < 0.001). CONCLUSIONS: Early admission to a specialized acute SCI-center for surgical and peri-operative management after a complete tetraplegia is associated with lower occurrence of tracheostomy and shorter mechanical ventilation duration support. SPONSORSHIP: MENTOR Program of the Canadian Institute of Health Research and US Department of Defense Spinal Cord Injury Research Program.

The acceptance of the clinical photographic posture assessment tool (CPPAT).

BACKGROUND: There is a lack of evidence-based quantitative clinical methods to adequately assess posture. Our team developed a clinical photographic posture assessment tool (CPPAT) and implemented this tool in clinical practice to standardize posture assessment. The objectives were to determine the level of acceptance of the CPPAT and to document predictors as well as facilitators of and barriers to the acceptance of this tool by clinicians doing posture re-education. METHODS: This is a prospective study focussing on technology acceptance. Thirty-two clinician participants (physical therapists and sport therapists) received a 3-5 h training workshop explaining how to use the CPPAT. Over a three-month trial, they recorded time-on-task for a complete posture evaluation (photo - and photo-processing). Subsequently, participants rated their acceptance of the tool and commented on facilitators and barriers of the clinical method. RESULTS: Twenty-three clinician participants completed the trial. They took 22 (mean) ± 10 min (SD) for photo acquisition and 36 min ± 19 min for photo-processing. Acceptance of the CPPAT was high. Perceived ease of use was an indirect predictor of intention to use, mediated by perceived usefulness. Analysis time was an indirect predictor, mediated by perceived usefulness, and a marginally significant direct predictor. Principal facilitators were objective measurements, visualization, utility, and ease of use. Barriers were time to do a complete analysis of posture, quality of human-computer interaction, non-automation of posture index calculation and photo transfer, and lack of versatility. CONCLUSION: The CPPAT is perceived as useful and easy to use by clinicians and may facilitate the quantitative analysis of posture. Adapting the user-interface and functionality to quantify posture may facilitate a wider adoption of the tool.

Supporting ethics educators in Canadian occupational therapy and physical therapy programs: A national interprofessional knowledge exchange project.

Ethics education is the cornerstone of professional practice, fostering knowledge and respect for core ethical values among healthcare professionals. Ethics is also a subject well-suited for interprofessional education and collaboration. However, there are few initiatives to gather experiences and share resources among ethics educators in rehabilitation. We thus undertook a knowledge exchange project to: 1) share knowledge about ethics training across Canadian occupational and physical therapy programs, and 2) build a community of educators dedicated to improving ethics education. The objectives of this paper are to describe this interprofessional knowledge exchange project involving ethics educators (with a diversity of professional and disciplinary backgrounds) from Canadian occupational and physical therapy programs as well as analyze its outcomes based on participants' experiences/perceptions. Two knowledge exchange strategies were employed: an interactive one-day workshop and a wiki platform. An immediate post-workshop questionnaire evaluated the degree to which participants' expectations were met. Structured telephone interviews 9-10 months after the workshop collected participants' perceptions on whether (and if so, how) the project influenced their teaching or led to further interprofessional collaborations. Open-ended questions from the post-workshop questionnaires and individual interviews were analyzed using qualitative methods. Of 40 ethics educators contacted, 23 participated in the workshop and 17 in the follow-up interview. Only 6 participants logged into the wiki from its launch to the end of data collection. Five themes emerged from the qualitative analysis: 1) belonging and networking; 2) sharing and collaborating; 3) changing (or not) ways of teaching ethics; 4) sustaining the network; and 5) envisioning the future of ethics education. The project attained many of its goals, despite encountering some challenges. While the wiki platform proved to be of limited benefit in advancing the project goals, the interactive format and collaborative nature of the one-day workshop were described as rewarding and effective in bringing together occupational therapy and physical therapy educators to meet, network, and share knowledge.

Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study.

Objective: The aim was to evaluate the prevalence of postpartum complications, including depression, in new mothers who had juvenile idiopathic arthritis (JIA) and to assess whether these differ from mothers who never had JIA. Methods: Our cohort study used data from physician billing and hospitalizations covering Quebec, Canada. We identified females with JIA with a first-time birth between 1 January 1983 and 31 December 2010 and assembled a control cohort of first-time mothers without JIA from the same administrative data, matching 4:1 for date of first birth, maternal age and area of residence. We compared the following postpartum complications: major puerperal infection, anaesthetic complications, postpartum haemorrhage, thromboembolism, obstetrical trauma, complications of obstetrical surgical wounds and maternal depression in the first year after delivery, in the JIA vs non-JIA groups, using bivariate analysis and multiple logistic regression. Results: The mean age at delivery was 24.7 years in the JIA group (n = 1681) and 25.0 years for the non-JIA group (n = 6724). Mothers with JIA were more likely to experience complications attributable to anaesthetic [adjusted risk ratio (aRR) 2.17, 95% CI; 1.05, 4.48], postpartum haemorrhage (aRR = 2.75, 95% CI: 2.42, 3.11) and thromboembolism (aRR = 5.27, 95% CI: 1.83, 15.17) but were at lower risk for obstetrical trauma (aRR = 0.78, 95% CI: 0.64, 0.95) or newly to develop depression in the first year postpartum (aRR = 0.52, 95% CI: 0.40, 0.68). Conclusion: Mothers with JIA appear to be at higher risk for complications attributable to anaesthesia, postpartum haemorrhage and thromboembolism. Prevention strategies for postpartum haemorrhage and thromboembolism may be especially important in this population.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Structured Physical Activity in the Management of Juvenile Idiopathic Arthritis.

OBJECTIVE: To create guidelines focused on the use of structured physical activity (PA) in the management of juvenile idiopathic arthritis (JIA). DATA SOURCES: A systematic literature search was conducted using the electronic databases Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), EMBASE (Ovid), and Physiotherapy Evidence Database for all studies related to PA programs for JIA from January 1966 until December 2014, and was updated in May 2015. STUDY SELECTION: Study selection was completed independently by 2 reviewers. Studies were included if they involved individuals aged ≤21 years diagnosed with JIA who were taking part in therapeutic exercise or other PA interventions for which effects of various disease-related outcomes were compared with a control group (eg, no PA program or activity of lower intensity). DATA EXTRACTION: Two reviewers independently extracted information on interventions, comparators, outcomes, time period, and study design. The statistical analysis was reported using the Cochrane Collaboration methods. The quality of the included studies was assessed according to the Physiotherapy Evidence Database Scale. DATA SYNTHESIS: Five randomized controlled trials (RCTs) fit the selection criteria; of these, 4 were high-quality RCTs. The following recommendations were developed: (1) Pilates for improving quality of life, pain, functional ability, and range of motion (ROM) (grade A); (2) home exercise program for improving quality of life and functional ability (grade A); (3) aquatic aerobic fitness for decreasing the number of active joints (grade A); and (4) and cardio-karate aerobic exercise for improving ROM and number of active joints (grade C+). CONCLUSIONS: The Ottawa Panel recommends the following structured exercises and physical activities for the management of JIA: Pilates, cardio-karate, home and aquatic exercises. Pilates showed improvement in a higher number of outcomes.

What can organizations do to improve family physicians' interprofessional collaboration? Results of a survey of primary care in Quebec.

OBJECTIVE: To assess the degree of collaboration in primary health care organizations between FPs and other health care professionals; and to identify organizational factors associated with such collaboration. DESIGN: Cross-sectional survey. SETTING: Primary health care organizations in the Montreal and Monteregie regions of Quebec. PARTICIPANTS: Physicians or administrative managers from 376 organizations. MAIN OUTCOME MEASURES: Degree of collaboration between FPs and other specialists and between FPs and nonphysician health professionals. RESULTS: Almost half (47.1%) of organizations reported a high degree of collaboration between FPs and other specialists, but a high degree of collaboration was considerably less common between FPs and nonphysician professionals (16.5%). Clinic collaboration with a hospital and having more patients with at least 1 chronic disease were associated with higher FP collaboration with other specialists. The proportion of patients with at least 1 chronic disease was the only factor associated with collaboration between FPs and nonphysician professionals. CONCLUSION: There is room for improvement regarding interprofessional collaboration in primary health care, especially between FPs and nonphysician professionals. Organizations that manage patients with more chronic diseases collaborate more with both non-FP specialists and nonphysician professionals.

The risk and nature of flares in juvenile idiopathic arthritis: results from the ReACCh-Out cohort.

OBJECTIVE: To describe probabilities and characteristics of disease flares in children with juvenile idiopathic arthritis (JIA) and to identify clinical features associated with an increased risk of flare. METHODS: We studied children in the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) prospective inception cohort. A flare was defined as a recurrence of disease manifestations after attaining inactive disease and was called significant if it required intensification of treatment. Probability of first flare was calculated with Kaplan-Meier methods, and associated features were identified using Cox regression. RESULTS: 1146 children were followed up a median of 24 months after attaining inactive disease. We observed 627 first flares (54.7% of patients) with median active joint count of 1, physician global assessment (PGA) of 12 mm and duration of 27 weeks. Within a year after attaining inactive disease, the probability of flare was 42.5% (95% CI 39% to 46%) for any flare and 26.6% (24% to 30%) for a significant flare. Within a year after stopping treatment, it was 31.7% (28% to 36%) and 25.0% (21% to 29%), respectively. A maximum PGA >30 mm, maximum active joint count >4, rheumatoid factor (RF)-positive polyarthritis, antinuclear antibodies (ANA) and receiving disease-modifying antirheumatic drugs (DMARDs) or biological agents before attaining inactive disease were associated with increased risk of flare. Systemic JIA was associated with the lowest risk of flare. CONCLUSIONS: In this real-practice JIA cohort, flares were frequent, usually involved a few swollen joints for an average of 6 months and 60% led to treatment intensification. Children with a severe disease course had an increased risk of flare.