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This study was undertaken to assess the effects of a web-based program, MyLupusGuide, developed to facilitate self-management in systemic lupus erythematosus (SLE).In this randomized controlled online study, participants received either immediate access to the MyLupusGuide site or delayed access starting on month 3. The primary outcome was the patient activation measure (PAM) score. Secondary outcomes included measurements of health status, self-efficacy, coping, perceived patient-physician relationship, and medication adherence. Outcomes were measured at the baseline visit and at the 3-month and 6-month follow-up visits. We used linear mixed modeling to compare PAM scores between the 2 groups at months 3 and 6.There were 541 participants included in this study. The mean ± SE age was 50 ± 14 years; 93% were female and 74% were White. The mean ± SE disease duration was 17 ± 12 years, and 56% visited MyLupusGuide at least once. The baseline mean ± SE PAM score was 61.2 ± 13, with 36% scoring low for perceived self-management skills. After 3 months of exposure to MyLupusGuide, there were no differences in terms of PAM scores between groups. In exploratory analyses, we found significant improvement in PAM scores in those who had low PAM scores at baseline and in male individuals. We observed significant improvements in self-efficacy before and after access to MyLupusGuide and delayed improvements at month 6 compared to month 3 in terms of mental health and emotional coping.MyLupusGuide increases self-efficacy but not patient activation. A total of 56% of participants visited the MyLupusGuide site during the study period. Individuals with lupus need support to become activated toward self-management behaviors.

Cultivated Organic soils in Montreal's southwest plain are the most productive soils in the province of Quebec. After their initial drainage to enable farming, Organic soils are susceptible to many forms of degradation and soil loss. In this study, we characterized the physical, chemical, and pedological properties of 114 sites from five peatlands to form soil conservation management zones. We attempted to use the maximum peat thickness (MPT) as a soil degradation proxy. The MPT can be defined as the thickness of the layer of peat until coprogenous or mineral materials are reached. The latter are undesired growing media and are not considered in MPT calculation. A series of multivariate analysis of variance indicated that MPT was moderately related to soil degradation (optimal model's Pillai's trace = 0.495). Three soil degradation groups were defined, separated by two MPT thresholds: 60 and 100 cm. When looking at 17 different depth-property combinations, shallower sites (MPT < 60 cm) showed signs of soil degradation significantly higher than sites with an MPT above 60 cm. The second threshold was proposed for practical purposes. Then, these thresholds were used to separate the study area into spatially distinct management zones. Important spatial contrasts were found. This supports the theory that precision agriculture techniques are needed to target fields to optimize soil conservation interventions. The relationship between the MPT and soil degradation should be further explored to account for other degradation factors, and to better identify degraded soils and soils at risk.

Evaluate the efficacy of ultrasound-guided dry needling and open-release surgery in reducing pain and improving function in workers with lateral epicondylosis refractory to at least 6 months of nonsurgical management.We randomly assigned participants in a 1:1 ratio to receive dry needling or surgery. The primary outcome was the Patient Rated Tennis Elbow Evaluation (PRTEE) score at 6 months. Secondary outcome measures examined the impact of these techniques on professional activity, grip strength, and Global Rating of Change and Satisfaction scales. Statistical analyses included mixed-effects models and Fisher's exact tests.From October 2016 through June 2019, we enrolled 64 participants. Two participants were excluded, and data from 62 participants (48 ± 8 years, 33 men) with a mean duration of symptoms of 23 ± 21 months were analyzed. Baseline characteristics were similar in both groups. In the intention-to-treat analysis, no treatment-by-time interaction was observed (FUltrasound-guided dry needling resulted in comparable improvement in outcome scores on scales of pain, physical function, and global assessment of change and satisfaction than open-release surgery.ClinicalTrials.gov Identifier: NCT02710682 KEY POINTS: • In patients with chronic lateral epicondylosis, ultrasound-guided tendon dry needling provides comparable therapeutic efficacy to open-release surgery. • Ultrasound-guided tendon dry needling allows for an earlier return to work and may be less costly than open-release surgery. • Care management guidelines should recommend treatment by ultrasound-guided tendon dry needling before open-release surgery.

Objectives: This study aims to determine whether patients with active rheumatoid arthritis (RA), either starting on or changing biological or targeted synthetic disease-modifying antirheumatic drugs (DMARDs), demonstrate better self-management safety skills three months after receiving a multidisciplinary educational intervention compared to patients receiving usual care. Patients and methods: Between October 2015 and October 2018 , this open-label, randomized-controlled trial included a total of 107 RA patients (27 males, 80 females; mean age: 60.2±10.4 years; range, 54 to 71 years) who were on treatment or in whom treatment was changed with a biological or targeted synthetic DMARD. The patients were randomized into two groups: Group 1 (n=57) received additional intervention with educational DVD and one teleconference session and Group 2 (n=55) received usual care and were offered the intervention at three months. All patients underwent a final visit at six months. At each visit, the patients completed the BioSecure questionnaire measuring the self-care safety skills, a behavioral intention questionnaire, and the Beliefs about Medicines Questionnaire (BMQ). Results: No significant difference was observed in the Biosecure score at three months between the two groups (p=0.08). After pooling the first three-month data in Group 1 and the last three-month data in Group 2, the mean score of the BioSecure questionnaire increased to 7.10±0.92 in the group receiving educational intervention (p Conclusion: The development of an educational DVD followed by a teleconference seem to improve self-care safety skills of the patients in practical situations.

ObjectiveIn a healthcare system with finite resources, hospital organisational factors may contribute to patient outcomes. We aimed to assess the association of nurse staffing and neonatal intensive care unit (NICU) occupancy with outcomes of preterm infants born DesignRetrospective cohort study.SettingFour level III NICUs.PatientsInfants born 23–32 weeks’ gestation 2015–2018.Main outcome measuresNursing provision ratios (nursing hours worked/recommended nursing hours based on patient acuity categories) and unit occupancy rates were averaged for the first shift, 24 hours and 7 days of admission of each infant. Primary outcome was mortality/morbidity (bronchopulmonary dysplasia, severe neurological injury, retinopathy of prematurity, necrotising enterocolitis and nosocomial infection). ORs for association of exposure with outcomes were estimated using generalised linear mixed models adjusted for confounders.ResultsAmong 1870 included infants, 823 (44%) had mortality/morbidity. Median nursing provision ratio was 1.03 (IQR 0.89–1.22) and median unit occupancy was 89% (IQR 82–94). In the first 24 hours of admission, higher nursing provision ratio was associated with lower odds of mortality/morbidity (OR 0.93, 95% CI 0.89 to 0.98), and higher unit occupancy was associated with higher odds of mortality/morbidity (OR 1.19, 95% CI 1.04 to 1.36). In causal mediation analysis, nursing provision ratios mediated 47% of the association between occupancy and outcomes.ConclusionsNICU occupancy is associated with mortality/morbidity among very preterm infants and may reflect lack of adequate resources in periods of high activity. Interventions aimed at reducing occupancy and maintaining adequate resources need to be considered as strategies to improve patient outcomes.

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy. This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy–guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0 years; SD 8.8 years; range 26–61 years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1 years; SD 11.2 years; range 29–72 years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models. During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p

In Canadian medicine faculties, an average of 2.3% of the medical curriculum is dedicated to musculoskeletal problems with a focus on orthopedic conditions. The goal of this descriptive study was to assess the educational preferences in rheumatology of family medicine residents and to identify their preferred methods of learning.From September 2017 to December 2017, two hundred and thirty-six first- and second-year family medicine residents from Université Laval were asked to complete an electronic anonymous survey assessing their confidence in doing different rheumatology tasks. They were also consulted on their favorite methods of learning and their preferred periods throughout their medical cursus to learn the different skills related to rheumatology.Eighty-five family medicine residents completed the survey. The residents were rather confident when evaluating mono-arthritis but less confident for oligo/polyarthritis and even less confident with connective tissue diseases. The family medicine residents mentioned preferring traditional lecture classes and clinical cases. They wanted to learn the majority of rheumatology education during medical school training. As residents, they wanted only small capsules, seminars, or memory aids. Interestingly, men preferred learning rheumatology skills during the residency, whereas women preferred learning it in medical school.The lack of confidence of family medicine residents when evaluating systemic inflammatory diseases compared to mechanical musculoskeletal problems highlights the importance of rheumatology teaching through general medical training and through family medicine residency. Key Points • Family medicine residents are less confident when evaluating systemic inflammatory diseases than musculoskeletal disorders. • Family medicine residents prefer traditional lecture classes and clinical cases. • Family medicine residents prefer learning rheumatology during medical school training.

53 páginas, 4 figuras, 2 tablas, Objective: Mitochondria are organelles that exhibit several bacterial features, such as a double-stranded genome with hypomethylated CpG islands, formylated proteins, and cardiolipin-containing membranes. In systemic lupus erythematosus (SLE), mitochondria and their inner components are released into the extracellular space, potentially eliciting a proinflammatory response from the immune system. While cardiolipin and mitochondrial DNA and RNA are confirmed targets of autoantibodies, other antigenic mitochondrial proteins in SLE remain to be identified. The present study was undertaken to characterize the protein repertoire recognized by antimitochondrial antibodies (AMAs) in patients with SLE. Methods: Using shotgun proteomic profiling, we identified 1,345 proteins, 431 of which were associated with the mitochondrial proteome. Immunoreactivities to several of these candidate proteins were assessed in serum samples from a local cohort (n = 30 healthy donors and 87 patients with SLE) using enzyme-linked immunosorbent assay, and further analyzed for associations with demographic and disease characteristics. Results: We determined that IgG antibodies to the complement component C1q binding protein were significantly elevated in the patients with SLE (P = 0.049) and were also associated with lupus anticoagulant positivity (P = 0.049). Elevated levels of IgG antibodies against mitochondrial protein mitofusin 1 (MFN-1) were promising predictors of SLE diagnosis in our cohort (adjusted odds ratio 2.99 [95% confidence interval 1.39-6.43], P = 0.0044). Moreover, increased levels of anti-MFN-1 were associated with the presence of antiphospholipids (P = 0.011) and anti-double-stranded DNA (P = 0.0005). Conclusion: In this study, we characterized the mitochondrial repertoire targeted by AMAs in the setting of SLE. Our results indicate that autoantibodies can recognize secreted and/or surface proteins of mitochondrial origin. Profiling of the AMA repertoire in large prospective cohorts may improve our knowledge of mitochondrial biomarkers and their usefulness for patient stratification., Supported by the Arthritis Society (grant 225638 to Dr. Fortin), the Canadian Institutes of Health Research (CIHR) (CIHR Foundation grant to Dr. Boilard and CIHR operating grant MOP-97916). Dr. Becker's work was supported by the Fonds de Recherche en Sante du Quebec (grant 282342) and the Arthritis Society (grant TGP-18-0257). Dr. Rubio's work was supported by the Secretaría de Estado de Investigación, Desarrollo e Innovación (grant BFU2017-84264-P) and by the Fundación Ramón Areces. Dr. Poirier's work was supported by the CIHR. Dr. Boilard's work was supported by the Fonds de Recherche en Sante du Quebec and the Canadian Donation and Transplantation Research Program

International audience; Nearly half of choroidal melanomas progress to the metastatic stage at 15 years. The purpose of our study was to evaluate the prognostic value of tumour-height regression rate in medium-sized choroidal melanomas treated with iodine-125 brachytherapy. A retrospective cohort study was performed on 128 patients with medium-sized choroidal melanoma who were treated with iodine-125 brachytherapy. Tumour characteristics including tumour apical height at baseline and after irradiation, recurrence, metastasis and mortality were collected from patients' records. Regression rate was defined in mm/month or in percentage of baseline apical height. Patients were statistically stratified in three groups of regression rate at 6 months using the Ward's method and Euclidian distance (slow, medium and fast regression groups). Mean initial apical height was of 5.71±1.79 mm. At 6 months, the average regression rate was 0.02±0.12 mm/month in the slow group (n=60), 0.32±0.11 mm/month in the medium group (n=52) and 0.67±0.21 mm/month in the fast group (n=16). Cox regression analysis for the recurrence, metastasis and mortality rates according to the three groups did not show any statistically significant difference. Sensitivity analyses with the regression rates at 12 months showed similar associations. Exudative retinal detachment resolved with treatment at 5.9±4.0 months, and it was more common at presentation in the fast regression rate group. The regression rate at 6 and 12 months after iodine-125 brachytherapy is not associated with a higher metastatic rate in medium-sized choroidal melanoma.

BACKGROUND Whereas platelet transfusion is a common medical procedure, inflammation still occurs in a fraction of transfused individuals despite the absence of any apparent infectious agents. Platelets can shed membrane vesicles, called extracellular vesicles (EVs), some of which contain mitochondria (mito+EV). With its content of damage-associated molecular pattern (DAMP), the mitochondrion can stimulate the innate immune system. Mitochondrial DNA (mtDNA) is a recognized DAMP detected in the extracellular milieu in numerous inflammatory conditions and in platelet concentrates. We hypothesized that platelet-derived mitochondria encapsulated in EVs may represent a reservoir of mtDNA. STUDY DESIGN AND METHODS Herein, we explored the implication of mito+EVs in the occurrence of mtDNA quantified in platelet concentrate supernatants that induced or did not induce transfusion adverse reactions. RESULTS We observed that EVs were abundant in platelet concentrates, and platelet-derived mito+EVs were more abundant in platelet concentrates that induced adverse reactions. A significant correlation (rs = 0.73; p

Background: To evaluate the quality of an organized mammography screening program based on the perception of screened women, we developed and validated the French-language Mammography Satisfaction Instrument (MSI). The study objective was to confirm the validity and reliability of the MSI. Methods: A confirmatory study was conducted among 529 women who had had a recent screening mammography under the Quebec Breast Cancer Screening Program (PQDCS). Eligible women from the Quebec City region completed the online MSI between January 14 and May 23, 2016. The MSI originally included 14 items evaluating 4 factors: satisfaction with (1) the technician’s skills; (2) the physical environment; (3) the staff’s communication skills; and (4) the information provided under the program. A fifth factor with 2 items, evaluating mammography accessibility, was added. A confirmatory factor analysis (CFA) was done and goodness of fit indices were generated (SRMR, CFI, RMSEA with its 90% CI). Item reliability and composite reliability were estimated. Variance extract estimates (VEEs) were generated to assess the amount of variance explained by the factors. Multivariate logistic regressions were done to test the sensitivity of each scale to identify subgroups of unsatisfied women. Odds ratios (OR) and their 95% CI were estimated. Results: Most women (62.0%) were aged 55–64, and 32.9% had university level education. The CFA demonstrated that the 5 factors fitted the data well (SRMR=0.044; CFI=0.969; RMSEA=0.055 with its 90% CI: 0.047–0.063). Item reliabilities (≥0.55) and composite reliabilities (≥0.87) were high. All VEEs were also high (≥0.70). Pain during compression, anxiety before the mammography, perception of not having an excellent health, and the radiologic centers were the factors the most consistently and significantly associated with the 5 scales of satisfaction. In addition, women with university level education were less satisfied with the staff’s communication skills (OR=0.64; 95% CI: 0.43–0.97) and those having had less than 10 lifetime mammograms were less satisfied with the physical environment (OR=0.52; 95% CI: 0.33–0.83) and the accessibility (OR=0.53; 95% CI: 0.31–0.92). Conclusions: This confirmatory study showed the good reliability and validity of the construct of the 16-item MSI with 5 factors. The MSI is useful to detect unsatisfied women and to improve the quality of organized breast cancer screening programs.

The myeloid inhibitory receptor CLEC12A negatively regulates inflammation. Reduced CLEC12A expression enhances inflammation in CLEC12A knock-out mice with collagen antibody-induced arthritis. Moreover, CLEC12A internalisation augments human neutrophil activation. We thus postulated that CLEC12A expression on circulating myeloid cells of rheumatoid arthritis patients is associated with disease manifestations. Cell-surface, CLEC12A receptor expression was determined on circulating neutrophils and monocytes of eRA patients and of healthy donors. Generalized estimating equations model, Student’s t-test and Spearman’s correlations were performed to compare CLEC12A expression between groups and test its association with disease activity and clinical parameters. Plasma cytokines were measured by multiplex immunoassay. Patients with reduced neutrophil or monocyte CLEC12A expression at baseline and at 3 months have an increased simple disease activity index. Low baseline CLEC12A expression also correlates with a higher SDAI at 6 months. In contrast, positive correlations were observed between baseline CLEC12A expression and several cytokines. Moreover, neutrophil and monocyte CLEC12A expression is significantly higher in early rheumatoid arthritis patients at baseline than healthy controls. Circulating neutrophil and monocyte CLEC12A expression correlates with disease activity at baseline and is predictive of SDAI at later stages of the disease indicative of a regulatory role for CLEC12A in RA.

Primary Subject area Neonatal-Perinatal Medicine Background In a health care system with limited resources, hospital organizational factors such as unit occupancy and nurse-to-patient ratios may contribute to patient outcomes. Objectives We aimed to assess the association of NICU occupancy and nurse staffing with outcomes of very preterm infants born < 33 weeks gestational age (GA). Design/Methods This was a multicenter retrospective cohort study of infants born 23-32 weeks GA without major congenital anomaly, admitted within 2 days after birth to one of four Level 3 NICUs in Quebec, Canada (2015-2018). For each 8 h shift, data on unit occupancy were obtained from a central provincial database (SiteNeo) and linked to the hospital nursing hours database (Logibec). Unit occupancy rates and nursing provision ratios (nursing hours/recommended nursing hours based on patient dependency categories) were pooled for the first shift, 24 h, and 7 days of admission for each infant. Patient data were obtained from the Canadian Neonatal Network database. Primary outcome was mortality and/or morbidity (severe neurological injury, bronchopulmonary dysplasia, necrotizing enterocolitis, and late-onset sepsis, severe retinopathy of prematurity). Adjusted odds ratios (AOR) for association of exposure with outcomes were estimated using generalized linear mixed models with a random effect for center, while adjusting for confounders (gestational age, small for gestational age, sex, outborn, Score for Neonatal Acute Physiology version 2, mode of delivery, and the other organizational variables). Results Among 1870 infants included in analyses, 796 (43%) had mortality/morbidity. Median occupancy was 89% (IQR 82-94) and median nursing provision was 1.13 (IQR 0.97-1.37). Overall higher NICU occupancy on shift of admission, first 24 h, and 7 days were associated with higher odds of mortality/morbidity (Figure 1) but nursing provision was not (Figure 2). Subgroup analysis by GA (< 29 and 29-32 weeks) yielded similar results (not shown). Generalized linear mixed model analyses showed that a 5% reduction in occupancy in the first 24 h of admission was associated with a 6% reduction in mortality/morbidity. Conclusion NICU occupancy is associated with mortality/morbidity among very preterm infants and may reflect lack of adequate resources in periods of high activity. Interventions aimed at reducing occupancy and maintaining adequate resources need to be considered as strategies to improve patient outcomes.

Supplemental material, sj-pdf-3-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-5-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-1-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-8-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-2-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-7-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-6-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

Supplemental material, sj-pdf-4-mdm-10.1177_0272989X20984134 for User Involvement in the Design and Development of Patient Decision Aids and Other Personal Health Tools: A Systematic Review by Gratianne Vaisson, Thierry Provencher, Michèle Dugas, Marie-Ève Trottier, Selma Chipenda Dansokho, Heather Colquhoun, Angela Fagerlin, Anik M. C. Giguere, Hina Hakim, Lynne Haslett, Aubri S. Hoffman, Noah M. Ivers, Anne-Sophie Julien, France Légaré, Jean-Sébastien Renaud, Dawn Stacey, Robert J. Volk and Holly O. Witteman in Medical Decision Making

BackgroundExtracellular vesicles (EVs) released by blood cells have proinflammation and procoagulant action. Patients with systemic lupus erythematosus (SLE) present high vascular inflammation and are prone to develop cardiovascular diseases. Therefore, we postulated that the EV populations found in blood, including platelet EVs (PEVs) and red blood cell EVs (REVs), are associated with SLE disease activity and SLE-associated cardiovascular accidents.MethodWe assessed autotaxin (ATX) plasma levels by ELISA, the platelet activation markers PAC1 and CD62P, ATX bound to platelets and the amounts of plasma PEVs and REVs by flow cytometry in a cohort of 102 patients with SLE, including 29 incident cases of SLE and 30 controls. Correlation analyses explored the associations with the clinical parameters.ResultPlatelet activation markers were increased in patients with SLE compared with healthy control, with the marker CD62P associated with the SLE disease activity index (SLEDAI). The incident cases show additional associations between platelet markers (CD62P/ATX and PAC1/CD62P) and the SLEDAI. Compared with controls, patients with SLE presented higher levels of PEVs, phosphatidylserine positive (PS+) PEVs, REVs and PS+REVs, but there is no association with disease activity. When stratified according to the plasma level of PS+REVs, the group of patients with SLE with a high level of PS+REVs presented a higher number of past thrombosis events and higher ATX levels.ConclusionIncident and prevalent forms of SLE cases present similar levels of platelet activation markers, with CD62P correlating with disease activity. Though EVs are not associated with disease activity, the incidence of past thrombotic events is higher in patients with a high level of PS+REVs.

Objective Nursing workload assessment tools are widely used to determine nurse staffing requirements in the neonatal intensive care unit (NICU). We aimed to compare three existing workload assessment tools and assess their association with mortality or morbidity among very preterm infants. Study Design Single-center retrospective cohort study of infants born Results Median number of nurses required per shift using the WANNNT was 25.0 (interquartile range [IQR]: 23.1–26.7). Correlation between WANNNT and QPNNR was high (r = 0.92, p Conclusion Lower nursing provision ratio calculated using the WANNNT and CNRU during the first 7 days of admission is associated with an increased risk of mortality/morbidity in very preterm infants. Key Points

Objective Systemic lupus erythematosus is a chronic autoimmune disease with varied and unpredictable levels of disease activity. The ability to self-manage lupus is important in controlling disease activity. Our objective was to determine levels of patient activation toward self-management in lupus. Methods We used baseline results from the MyLupusGuideTM study that had recruited 541 lupus patients from ten centers. We used the Patient Activation Measure (PAM), a validated self-reported tool designed to measure activation towards self-management ability, as our primary variable and examined its association with demographic, disease-related, patient-provider communication and psychosocial variables captured in our study protocol. Univariable and multivariable linear regressions were performed using linear mixed models, with a random effect for centers. Results The average age was 50±14 years, 93% were female, 74% were Caucasian and the average disease duration was 17±12 years. The mean PAM score was 61.2±13.5 with 36% of participants scoring in the two lower levels, indicating low activation. Variables associated with low activation included being single, lower physical health status, lower self-reported disease activity, lower self-efficacy, use of more emotional coping and less distraction and instrumental coping strategies, and perceived lack of clarity in patient-doctor communication. Conclusion Low patient activation was observed in more than one third of lupus patients indicating a large proportion of patients perceived that they are lacking in lupus self-management skills. These results highlight a modifiable gap in perceived self-management ability among patients with lupus.

Background Mitochondria are intracellular organelles of bacterial origin capable of stimulating the immune system when released into the extracellular milieu. We previously reported the expression of anti-mitochondrial antibodies (AMA) targeting whole organelles (AwMA), mitochondrial DNA (AmtDNA) or mitochondrial RNA (AmtRNA) in patients with systemic lupus erythematosus (SLE). Antiphospholipid syndrome (APS) is an autoimmune condition that may be independent of, or associated with, other diseases, usually SLE. This study aimed to detect AMA in patients with APS and to explore the association with clinical features of APS. Methods AwMA-, AmtDNA- and AmtRNA-IgG and -IgM were detected in a pilot study (healthy controls n = 30 and APS patients n = 24) by direct ELISA, and their levels were associated with demographic and disease characteristics. Results AmtDNA-IgM and AmtRNA-IgG and IgM were elevated in APS compared to healthy controls ( p = 0.009, p = 0.0005 and p = 0.01, respectively). AwMA-IgG were increased in patients positive for lupus anticoagulant (median ± interquartile range = 0.36 ± 0.31 vs. 0.14 ± 0.08, p = 0.008), and optical density values for AwMA-IgM were correlated with titres of IgM against cardiolipin ( rs = 0.51, p = 0.01). An increment of 0.1 unit of AmtDNA-IgM levels was associated with reduced prior reporting of arterial events (odds ratio = 0.86; 95% confidence interval 0.74–1.00; p = 0.047). Conclusion Our pilot study suggests that AMA are represented within the autoantibody repertoire in APS and may display different associations with the clinical manifestations of the disease. Further studies should focus on reproducing these preliminary results by following AMA levels through time in larger prospective cohorts.

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

Objectives: (1) To assess the evolution of prepalatoplasty sleep oximetry (PRESO) and postpalatoplasty sleep oximetry (POSSO) in cleft patients and (2) to evaluate the impact of the size of the nasopharynx on PRESO and POSSO values. Study Design: Retrospective cohort study. Patients and Methods: In 81 patients with cleft palate and/or cleft lip, the following data were prospectively collected: patient demographics and prepalatoplasty cleft palate measurements. All the patients had at least 1 PRESO and POSSO. A Kaplan-Meier curve was obtained from all the sleep oximetry results. Transverse nasopharyngeal area (TNA) pre- and postvalues were compared for each group with paired t tests, while analysis of variance was used to compare TNA pre- and postscores between the groups with a Bonferroni correction for multiple comparisons. Results: POSSO results were normal or showed mild desaturations in most patients in the few weeks following palatoplasty. For the cohort, no statistically significant changes were found between PRESO and POSSO values. A 2-fold variation in the area of the TNA was found before palatoplasty within identical cleft malformation cases. No statistically significant association was found between the TNA or the a/30 − b 1 parameter values and the sleep study scores. Conclusions: The patients with the smaller nasopharyngeal areas presented identical PRESO and POSSO results when compared to those with larger nasopharyngeal sizes. Future studies should address the possible association between prepalatoplasty and postpalatoplasty TNAs and the occurrence of velopharyngeal deficiency later in life.

Key decision-makers among experts in a given field can sometimes be identified based on their role and responsibilities. The aim of the study is to compare perceptual-cognitive skills of experts with decisional responsibilities (setters in volleyball) with that of other volleyball experts. Eighty-two participants (26 setters, 36 other players and 20 controls) viewed 50 volleyball video sequences. Sequences stopped 120 ms before ball contact and participants, whose eye movements were recorded, had to predict the ball direction. Generalized Estimating Equations analysis revealed that setters and controls made more but shorter fixations than other players. However, both expert groups made better predictions than controls. Dynamics analyses of eye movements over time show that, right before ball contact, opposing players’ upper body is a most relevant attentional cue in all game situations. Results are discussed in terms of decision-making responsibilities to identify key decision-makers in volleyball and in general. They point towards specific perceptual-cognitive abilities found in setters and support the idea that they constitute a subgroup of experts, but that they are not “better” than other players in anticipating the game.

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy.This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy-guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0 years; SD 8.8 years; range 26-61 years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1 years; SD 11.2 years; range 29-72 years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models.During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p .001) space was a predictor of therapeutic efficacy but not in the foraminal (p = .54), epidural (p = .89), or retrodural (p = .75) space.TFSI and IFSI led to preferential extraforaminal and retrodural injectate spread, respectively. Targeting the extraforaminal or juxta-articular facet space improved the clinical efficacy of steroid injections when treating cervical radiculopathy.• During intra-articular facet injection, the injectate spreads from the facet joint to the retrodural space and rarely reaches the epidural and/or foraminal spaces. • Epidural spread of the injectate during an anterolateral transforaminal steroid injection is the least effective for pain relief in patients with cervical radiculopathy. • Injection techniques targeting the extraforaminal or juxta-articular facet space are safer than transforaminal injections and effectively relieve pain in patients with cervical radiculopathy.

Supplemental material, Appendix4_online_supp for What Helps People Make Values-Congruent Medical Decisions? Eleven Strategies Tested across 6 Studies by Holly O. Witteman, Anne-Sophie Julien, Ruth Ndjaboue, Nicole L. Exe, Valerie C. Kahn, Angela (Angie) Fagerlin and Brian J. Zikmund-Fisher in Medical Decision Making

To assess the dental class occlusion and lateral cephalometry of children with conservatively treated Pierre Robin sequence (PRS) and to identify associations between these findings and prepalatoplasty cleft palate measurements.Retrospective cohort study.Among 22 patients with PRS, the following data were prospectively collected: demographics and preoperative cleft palate measurements. After patients reached age 6 years, an orthodontist assessed dental occlusion class and performed a lateral cephalometric analysis. PRS cephalometric data were compared with reference population values. Bivariate logistic regression was used to test the association with malocclusion class. Results are presented as odds ratios with 95% profile likelihood confidence intervals. The association between cleft measurements and cephalometric parameters was tested with Spearman's correlation ( rAll 22 patients had bimaxillary hypoplasia and were prone to hyperdivergency, with a 41% rate of dental class III malocclusion. An increased anterior growth of the still retrusive mandible mostly accounts for the occurrence of the class III malocclusion in PRS (class II SNB = 74.3° vs class III SNB = 77.6°, P = .04). A larger cleft at the time of the cleft repair (mean, 11 months) was associated with increased mandibular retrusion (smaller SNB angle, rThe 41% rate of class III malocclusion among these conservatively treated patients needs to be considered in the choice of the initial airway approach. The future impact of early mandibular advancement will have to be determined.

Biliopancreatic diversion with duodenal switch (BPD-DS) decreases vitamin D and calcium absorption, which may result in secondary hyperparathyroidism. This study aimed at evaluating the prevalence of vitamin D deficiency and secondary hyperparathyroidism before and after BPD-DS. A retrospective analysis of patients who had undergone BPD-DS at a tertiary bariatric center between 2003 and 2010 and for whom simultaneous measurements of serum 25-hydroxyvitamin D and parathyroid hormone were available within 5 years post-op was performed. The prevalence of vitamin D deficiency ( 65 pg/mL) at different time points was calculated. Included were 1436 patients (mean ± SD, age 42.7 ± 10.4 years; BMI 51.5 ± 8.6 kg/m2; 69.8% women). Prevalence of vitamin D deficiency decreased up to 6–12 months after surgery (from 35.8% at baseline down to 6–9%) then rose progressively, plateauing at 15.5% after 36 months. Prevalence of hyperparathyroidism was 28.5% before surgery and rose progressively after surgery, reaching 68.6% at 5 years. Mean serum corrected calcium increased from 0 to 6 months then decreased up to 36 months. Preoperatively, the prevalence of hypocalcemia was 7.3%. It increased after 12 months, attaining 26.9% at 48 months. Prevalence of vitamin D deficiency and secondary hyperparathyroidism is high before BPD-DS. Despite a low prevalence of vitamin D deficiency after surgery, prevalence of hyperparathyroidism increased steadily 1 year after surgery, preceded by a decrease in serum calcium. Factors explaining the high prevalence of secondary hyperparathyroidism after BPD-DS and its long-term impact on bone health should be addressed.

Objective We examined clinicians’ attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations. Methods We randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary). Results 132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26 ± 12%; equipoise 28 ± 11%; vaccine-hesitancy 22 ± 11%; p = 0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p = 0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p = 0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent’s views (all ps Conclusion Clinicians’ attitudes may impact conversations when patients question evidence-based recommendations. Practice implications Clinicians should consider ways to discuss evidence and clarify patients’ values to optimize health without damaging patient-clinician relationships.

The duration of hemodialysis (HD) sessions for the treatment of acute ethylene glycol poisoning is dependent on concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. Ethylene glycol assays are not readily available, potentially leading to undue extension or premature termination of HD. We report a prediction model for the duration of high-efficiency HD sessions based retrospectively on a cohort study of 26 cases of acute ethylene glycol poisoning in 24 individuals treated by alcohol dehydrogenase competitive inhibitors, cofactors and HD. Two patients required HD for more than 14 days, and two died. In 19 cases, the mean ethylene glycol elimination half-life during high-efficiency HD was 165 minutes (95% confidence interval of 151-180 minutes). In a training set of 12 patients with acute ethylene glycol poisoning, using the 90th percentile half-life (195 minutes) and a target ethylene glycol concentration of 2 mmol/l (12.4 mg/dl) allowed all cases to reach a safe ethylene glycol under 3 mmol/l (18.6 mg/dl). The prediction model was then validated in a set of seven acute ethylene glycol poisonings. Thus, the HD session time in hours can be estimated using 4.7 x (Ln [the initial ethylene glycol concentration (mmol/l)/2]), provided that metabolic acidosis is corrected.

Background Minimally invasive surfactant therapy (MIST) is a new strategy to avoid mechanical ventilation (MV) in respiratory distress syndrome. The primary aim of this study was to test MIST as a means of avoiding MV exposure and pneumothorax occurrence in moderate and late preterm infants (32 to 36 weeks' gestational age). Methods This was a randomized controlled trial including three Canadian centres. Patients were randomized to standard management or to the intervention if they required nasal continuous positive airway pressure of 6 cm H2O and 35% FiO2 in the first 24 hours of life. Patients from the intervention group received MIST immediately after inclusion. The primary outcome was either need for MV or development of a pneumothorax requiring a chest tube. To ensure that clinicians were not biased toward delaying intubation in the intervention group, clinical failure criteria were also used as a primary outcome. The primary outcome was analyzed using bivariate and multivariate logistic regressions. Results Among 45 randomized patients, 24 were assigned to MIST and 21 to standard management. Eight infants (33%) from the intervention group met the primary outcome criteria versus 19 (90%) in the control group (absolute risk reduction 0.57, 95% confidence interval 0.54 to 0.60). One patient in each group reached the primary outcome because of pneumothorax occurrence. The other patients were exposed to MV. None of the patients reached the clinical failure criteria. Conclusion MIST for respiratory distress syndrome management in moderate and late preterm infants was associated with a significant reduction of MV exposure and pneumothorax occurrence.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.

Background: Multiple guidelines recommend involving patients and stakeholders in developing patient decision aids; however, best practices have yet to be identified. User-centered design is a well-established approach for engaging users in developing tools. We aimed to compile reports of patient decision aid development, using a user-centered design framework to synthesize evidence of existing practices and identify potential opportunities for improvement.Methods: We conducted searches in MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Library, the ACM library, IEEE Xplore and Google Scholar. We included articles describing (1) at least one development step of a patient decision aid, (2) at least one development step of user- or human-centered design of another patient-centered tool, and/or (3) evaluation of included decision aids and other patient-centered tools. Two analysts independently screened for inclusion, assessed study quality, and extracted data.Results: We included 623 articles describing 390 projects: 325 patient decision aid projects and 65 user-centered design projects. Fifty percent of patient decision aid projects reported involving users in at least one development step for understanding users, 35% in at least one development step for developing/refining the prototype and 84% in at least one development step for directly or indirectly observing prospective users’ interaction with the prototype. User-centered design projects reported 91%, 49% and 92%, respectively. Seventy-four percent of patient decision aid projects reported iterative development processes with median 3 development cycles (interquartile range 2-4); 92% of user-centered design projects reported iterativity, with median 3 development cycles (interquartile range 2-3). Sixty-six percent of patient decision aid projects and 89% of user-centered design projects reported preliminary evaluations such as usability testing or feasibility testing.Conclusions: We identified 3 key opportunities for improving the user-centeredness of patient decision aid development: involving users earlier to understand their needs, goals, strengths, limitations, context and intuitive processes; asking about and observing users’ interactions with developing versions of the decision aid; and reporting changes between iterative cycles. Additionally, developers of patient decision aids and other patient-centered tools may wish to more often involve patients, clinicians and other users in co-design of prototypes and in formal advisory or partnership roles.

Background Predictors of poor outcome in systemic lupus erythematosus (SLE) may lead to the identification of high-risk patients at the onset of disease (incident cases) and/or when we first assess them in our clinics (prevalent cases). We tested whether the Lupus Severity Index (LSI) can help characterize high versus low risk lupus patients. Methods Population: Patients from six lupus centers were recruited according to a standard data collection protocol. We characterized incident cases and prevalent cases as those with a diagnosis made within or after the previous 15 months. Data collected: Demographic, socioeconomic, disease specific and medication data were collected at baseline and annually. We collected: the American College of Rheumatology (ACR) and the Systemic Lupus International Collaborating Clinics (SLICC) classification criteria, the SLE Disease Activity Index (SLEDAI), the Systemic Lupus Activity Questionnaire (SLAQ), and the SLICC Damage Index (SDI). The LSI was derived from the ACR classification criteria and used as a predictor variable. Statistical analyses: Kruskal-Wallis test and Spearman correlations were used to see the association of LSI with categorical and continuous variables respectively. The baseline LSI was used to predict outcomes at follow-ups using logistic regressions and Spearman correlations for dichotomous and continuous variables respectively. Results We enrolled 639 lupus patients and 440, 324 and 168 were re-evaluated at 1, 2 and 3 years. Baseline characteristics (table 1) [median (IQR)] were: age=49.0 (36.8–58.5) years, female=92%, Caucasian=74%, disease duration=10.1 (2.7–20.6) years. We had 129 (20%) incident cases and 471 (74%) prevalent cases with missing information in 39 (6%). Twelve patients died during follow-up. Table 1 summarizes baseline associations between LSI and several characteristics for the incident and prevalent cases. We found that age, sex, ethnicity (Asian worse LSI), SLICC classification criteria, SLEDAI, prednisone use and daily dose were associated with LSI in both incident and prevalent groups while the SDI and the use of immunosuppressors drugs was associated with LSI only in the prevalent cases. In follow-up, baseline LSI predicted SDI in prevalent cases (p=0.02) with a trend in incident cases (p=0.07). LSI predicted death in the prevalent group. Conclusions The LSI is easy to derive from the ACR classification criteria and a useful measure of severity in lupus. The LSI is associated with baseline characteristics, some of them - like disease activity and prednisone dose - modifiable. LSI can predict adverse outcome such as damage or death over time. Funding Source(s): Lupus Canada.

Background Systemic Lupus Erythematosus (SLE) is an unpredictable multisystem chronic disease that leads to insecurity, requires life-style adaptations, work accommodations and longterm medication use. We previously reported that a web-based interactive navigator named MyLupusGuide (MLG) was well accepted by lupus patients and met with their informational needs. When used without reinforcement however MLG did not change patient activation towards self-management. We performed additional analyses to test if subgroups of patients were more likely to become activated than others in a large lupus population. Methods Population and recruitment strategy: Patients from ten lupus centers were randomized to either immediate access to MLG (NOW) or usual care (LATER). Partial cross-over occurred at three months and there was a final assessment at six months. Data collected: Demographic and socioeconomic data were collected at baseline. The 13-item Patient Activation Measure (PAM) was used to assess patient`s healthcare engagement. Higher PAM score relates to greater engagement. Additional self-reported measures for self-efficacy (Lupus Self-Efficacy Scale - LSES) and coping strategies (Coping with Health Injuries and Problems - CHIP) were obtained at baseline, 3 and 6 months. Statistical analyses: Linear mixed models were used to test the evolution of PAM over time between groups. This abstract reports on the following subanalyses: analyses of the subgroup with low PAM score at baseline and of being male or female, and analyses of other outcomes such as LSES and CHIP. Results A total of 541 of 1920 (28%) lupus patients responded at baseline, 399 at 3 months and 355 at 6 months. At baseline, mean (sd) age=50.1 (14.2) years, female=93%, Caucasian=74%, disease duration=16.9 (11.9) years and PAM score=61.1 (13.5). The following subanalyses (table 1) showed a beneficial effect of MLG on activation after three months in the subgroup of patients with low PAM at baseline, as well as for men. A significant improvement in LSES was also observed after 3 months of exposure to MLG but there was no change in CHIP. Conclusions At 3 months, access to MLG improved activation in patients with a low activation at baseline and in men. Self-efficacy also improved significantly without changes in coping strategies. The MLG is a unique web-based resource that provides reliable information for patients with lupus to assist them with disease management and lifestyle adaptations. Funding Source(s): A Knowledge-to-Action Canadian Institute for Health Research grant. Dr. Fortin holds a Canada Research Chair.