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Objective: To explore the trajectory of scleroderma disease activity in women who experienced a pregnancy after systemic sclerosis diagnosis compared to nulliparous women. Methods: We analyzed data from the Canadian Scleroderma Research Group registry by identifying nulliparous women and women with ⩾1 pregnancy after systemic sclerosis diagnosis. Patient characteristics were compared between groups at registry entry. Controlling for age, smoking, and time since systemic sclerosis diagnosis, generalized estimating equations tested the effect of pregnancy on force vital capacity, diffusing capacity of the lungs for carbon monoxide, right ventricular systolic pressure, glomerular filtration rate, antibody status, active digital ulcers, physician global assessment of activity, and severity over 9 years. Results: At registry entry, numbers of women in the nulliparous and pregnancy after systemic sclerosis diagnosis groups were 153 and 45, respectively. Corresponding numbers at 6 and 9 years were 48 and 21, and 18 and 9, respectively. The prevalence of anti-topoisomerase positivity was 18.3% in nulliparous and 12.5% in pregnancy after systemic sclerosis diagnosis. Baseline differences included mean (Standard deviation) age of diagnosis (nulliparous: 38.8 (14.0), pregnancy after systemic sclerosis diagnosis: 22.6 (6.8) years, p Conclusion: Results demonstrated that having ⩾1 pregnancy after systemic sclerosis diagnosis did not appear to significantly impact long-term renal, respiratory, or global function outcomes. While this offers a hopeful message to systemic sclerosis patients planning a pregnancy, physicians and patients should remain vigilant for potential post-partum complications.

Objective The COVID-19 pandemic has disrupted healthcare delivery and clinical research worldwide, with data from areas most affected demonstrating an impact on rheumatology care. This study aimed to characterize the impact of the pandemic on the initial presentation of JIA and JIA-related research in Canada. Methods Data collected from the Canadian Alliance of Pediatric Rheumatology Investigators JIA Registry from the year pre-pandemic (11 March 2019 to 10 March 2020) was compared with data collected during the first year of the pandemic (11 March 2020 to 10 March 2021). Outcomes included time from symptom onset to first assessment, disease severity at presentation and registry recruitment. Proportions and medians were used to describe categorical and continuous variables, respectively. Results The median time from symptom onset to first assessment was 138 (IQR 64–365) days pre-pandemic vs 146 (IQR 83–359) days during the pandemic. The JIA category frequencies remained overall stable (44% oligoarticular JIA pre-pandemic, 46.8% pandemic), except for systemic JIA (12 cases pre-pandemic, 1 pandemic). Clinical features, disease activity (cJADAS10), disability (CHAQ) and quality of life (JAQQ) scores were similar between the two cohorts. Pre-pandemic, 225 patients were enrolled, compared with 111 in the pandemic year, with the greatest decrease from March to June 2020. Conclusions We did not observe the anticipated delay in time to presentation or increased severity at presentation, suggesting that, within Canada, care adapted well to provide support to new patient consults without negative impacts. The COVID-19 pandemic was associated with an initial 50% decrease in registry enrolment but has since improved.

There is a paucity of information about the epidemiology, pathophysiology, and treatment of patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). A retrospective chart review was performed of patients at McMaster Children's Hospital with a diagnosis of either IBD or CRMO, to identify those with the dual diagnosis over a 10-year period. A dual diagnosis was identified in seven patients. Most patients (6/7) had a diagnosis of IBD first and were subsequently diagnosed with CRMO. At the time of CRMO diagnosis, IBD treatment regimens included one or more of, sulfasalazine (1/6), infliximab (3/6), adalimumab (1/6), or no treatment (1/6). Although the etiology of the link remains unknown, there does not seem to be an association to a specific IBD subtype, age, or treatment. Our patient population demonstrated a response to biologic agents, specifically tumor necrosis factor-α inhibitors, as treatment for both conditions.

Background The transition of patients with a chronic rheumatic disease from pediatric to adult care has been characterized by poor medical and patient-centered outcomes due to the lack of comprehensive transition programs and the paucity of evidence to guide practitioners. We describe a multidisciplinary transition program, data assessing patients’ preparedness for transition and perception of care providers, and the association between these outcomes. Content Patients aged 14–19 with childhood-onset systemic lupus erythematosus (cSLE) or juvenile idiopathic arthritis (JIA) were recruited from Rheumatology Transition Clinics and Young Adult Clinics at a single institution. Participants completed the TRANSITION-Q, which assesses healthcare self-management skills as a proxy for transition readiness, and the Consultation and Relational Empathy Scale (CARE) questionnaire, which measures patients’ perception of their providers’ care and empathy. Summary Among 63 participants, 87% had JIA (mean age 16.5 years). Age was the only patient characteristic positively associated with TRANSITION-Q scores. CARE scores revealed overwhelmingly positive interactions between patients and healthcare team members. TRANSITION-Q and CARE scores were positively correlated. Outlook The transition from pediatric to adult rheumatology care should be recognized as an opportunity to impact the trajectories of patients entering adult care where the patient-provider relationship may play an important role.

Development of coastal New England has led to the replacement of up to 37% of salt marshes with degraded freshwater wetlands, primarily through tidal restrictions. Removing these restrictions to restore salt marsh ecology would improve water quality, increase flood and storm protection, nutrient filtration, erosion control, and carbon sequestration. However, such restorations replace functional freshwater wetlands and could potentially impact freshwater species. Freshwater-dependent wildlife species such as the spotted turtle (Clemmys guttata), may be especially vulnerable to rapid changes in habitat resulting from tidal reintroduction due to their high site fidelity and limited ability to disperse quickly. Conservation of genetically and physically isolated spotted turtle populations as well as the restoration of salt marshes to mitigate climate change impacts are both high priorities on Nantucket Island. These two priorities conflicted in a project to restore tidal hydrology to an impounded freshwater marsh known to host a robust spotted turtle population. We evaluated changes to spotted turtle home range size and location and habitat use in response to salt marsh restoration over eight years. Home range size did not change but the location of home ranges shifted into bordering wetlands landward of the tidal salt water influence. Spotted turtles selected remaining freshwater marshes and shrub swamps while avoiding developed land and areas of establishing salt marsh within areas that had previously been high quality habitat. This study suggests prioritizing conservation of wetlands adjacent to planned salt marsh restoration to provide habitat for freshwater species to migrate.

Objectives Imaging modalities have become common in evaluating patients for a possible diagnosis of GCA. This study seeks to contextualize how temporal arterial magnetic resonance angiography (TA-MRA) can be used in facilitating the diagnosis of GCA. Methods A retrospective cohort study was performed on patients who had been previously referred to a rheumatologist for evaluation of possible GCA in Hamilton, Ontario, Canada. Data including clinical features, inflammatory markers, imaging, and biopsy results were extracted. Multivariable logistic regression model to predict the diagnosis of GCA. Using these models, the utility of TA-MRA in series with or in parallel to clinical evaluation was demonstrated across the cohort as well as in subgroups defined by biopsy and imaging status. Results In total 268 patients had complete data. Those diagnosed with biopsy- and/or imaging-positive GCA were more likely to demonstrate classic features including jaw claudication and vision loss. Clinical multivariable modelling allowed for fair discriminability [receiver operating characteristic (ROC) 0.759, 95% CI: 0.703, 0.815] for diagnosing GCA; there was excellent discriminability in facilitating the diagnosis of biopsy-positive GCA (ROC 0.949, 0.898–1.000). When used in those with a pre-test probability of 50% or higher, TA-MRA had a positive predictive value of 93.0%; in those with a pre-test probability of 25% or less TA-MRA had a negative predictive value of 89.5%. Conclusion In those with high disease probability, TA-MRA can effectively rule in disease (and replace temporal artery biopsy). In those with low to medium probability, TA-MRA can help rule out the disease, but this continues to be a challenging diagnostic population.

Background: Current international guidelines recommend annual screening for pulmonary arterial hypertension with transthoracic echocardiogram and pulmonary function testing in all patients with scleroderma (systemic sclerosis). Our objectives were to determine Canadian rheumatologists’ screening practices for pulmonary arterial hypertension in patients with systemic sclerosis and identify reasons why current guideline recommendations may not be followed. Methods: A survey was emailed to all Canadian Rheumatology Association members. They self-identified as systemic sclerosis experts or non-experts and provided basic demographic data. Participants were asked how frequently they screened with transthoracic echocardiogram and pulmonary function testing and, if applicable, why they did not adhere to recommendations. Results: A total of 71 rheumatologists participated, of whom 43 identified as non-experts. Overall, 81.4% ordered annual transthoracic echocardiogram and 77.6% annual pulmonary function testing. Rates of annual transthoracic echocardiogram testing were similar between experts and non-experts, whereas experts ordered annual pulmonary function testing more often. Clinicians with a higher proportion of systemic sclerosis patients in their practice were more likely to follow guidelines. There was an inverse relationship between years in practice and adherence to screening guidelines. The most common reason for not following screening guidelines was disagreement with recommendations, followed by unfamiliarity with guidelines. Conclusions: Pulmonary arterial hypertension screening rates remain sub-optimal in Canada but have improved since 2012. Failure to adopt guidelines is due to rheumatologists disagreeing with or not knowing current recommendations. Future studies should examine why rheumatologists disagree with guidelines and how to improve awareness.

ObjectiveTo investigate the mental health of children and adolescents admitted to neonatal intensive/special care units (NICUs) in infancy.MethodsThis cross-sectional study used a provincially representative cohort from the 2014 Ontario Child Health Study. Parents provided data on psychiatric disorders using the MINI International Neuropsychiatric Interview for Children and Adolescents in 3141 children aged 4–11 years (NICU n=389; control n=2752) and in 2379 children aged 12–17 years (NICU n=298; control n=2081). Additionally, 2235 adolescents aged 12–17 years completed the interview themselves (NICU n=285; control n=1950). Odds of psychiatric disorder were compared in those admitted and controls.ResultsBased on parent reports, NICU graduates aged 4–11 years had increased adjusted ORs (95% CI) of 1.78 (1.39 to 2.28) for any psychiatric disorder, with a marginal prevalence of 32.4% in NICU participants and 27.6% in controls. At this age, NICU graduates also had increased ORs of 1.74 (1.25 to 2.40) for psychiatric comorbidity, 1.48 (1.04 to 2.11) for oppositional defiant disorder, 1.61 (1.19 to 2.19) for attention-deficit hyperactivity disorder, 4.11 (2.33 to 7.25) for separation anxiety disorder and 2.13 (1.37 to 3.31) for specific phobia. At 12–17 years, 40.5% and 30.5% of NICU graduates and 30.6% and 17.9% of controls had any psychiatric disorder as reported by parents and self-report, respectively. Parents and adolescents, respectively, reported increased adjusted ORs (95% CI) of 1.63 (1.18 to 2.26) and 1.55 (1.13 to 2.11) for any disorder, 1.64 (1.06 to 2.54) and 1.74 (1.11 to 2.73) for psychiatric comorbidity, and 1.89 (1.22 to 2.93) and 3.17 (2.03 to 4.95) for oppositional defiant disorder.ConclusionsNICU graduates are at increased risk for psychiatric disorders during childhood and adolescence.

Compared with clinical examination (CE), ultrasonography (US) provides additional and more accurate assessment of inflammation and visualization of structural damage. To better understand the effectiveness of US in metatarsophalangeal joints (MTPJs), we compared disease activity in MTPJs 2–5 assessed by CE and US, with magnetic resonance imaging (MRI) as reference standard. Treatment-naive adult patients with early RA (ACR criteria, disease duration

Coastal sandplains provide habitat for a suite of rare and endangered plant and wildlife species in the northeastern United States. These early successional plant communities were maintained by natural and anthropogenic disturbances including salt spray, fire, and livestock grazing, but over the last 150 years, a decrease in anthropogenic disturbance frequency and intensity has resulted in a shift towards woody shrub dominance at the expense of herbaceous taxa. This study quantified the effects of more than a decade of dormant season disturbance-based vegetation management (mowing and prescribed fire) on coastal sandplain plant community composition on Nantucket Island, Massachusetts, USA. We used time-series plant cover data from two similar sites to evaluate the effectiveness of disturbance management for restoring herbaceous species cover and reducing woody shrub dominance. Our results indicate that applying management outside of the peak of the growing season has not been effective in maintaining or increasing the cover of herbaceous species. While management activities resulted in significant (P

Despite erosions being as prevalent in feet as in hands in patients with rheumatoid arthritis (RA), their development in relation to synovitis and bone marrow edema (BME) have mainly been studied in hands. This study examines the prevalence and longitudinal trajectory of erosions, BME, and synovitis in metatarsophalangeal joints (MTPJs) in patients with early RA over 2 years of treatment. We also describe correlations between erosions, synovitis, and BME at the joint level. Magnetic resonance imaging (MRI) of the most symptomatic forefoot was acquired at baseline, year 1, and ≥ 2 years. Metatarsophalangeal joints 2-5 were scored by a radiologist for erosions, synovitis, and BME according to OMERACT guidelines. Patients were treated per standard of care. Thirty-two patients with early RA were included. Significant reductions in overall synovitis scores, MTPJ2, and MTPJ3 synovitis scores were seen between year 1 and ≥ 2 years. Overall BME scores improved in year 1 and were sustained at ≥ 2 years. BME improved in MTPJ2, MTPJ3, and MTPJ4. Overall erosions did not significantly change. Positive correlations were seen between changes in synovitis and BME in MTPJ2 and MTPJ5. In patients with early RA, standard of care was associated with overall reductions in synovitis by year 2, BME by year 1, and no progression in overall erosion scores on MRI. MTPJ2 and MTPJ3 appeared to be the most active joints. Improvements in synovitis were noted in MTPJ2 and MTPJ3 and reductions in BME in MTPJ2, MTPJ3, and MTPJ4, while other MTPJs did not progress. Key Points • This is one of the few MRI studies that examined longitudinal changes in imaging outcomes in early RA at the joint level in feet. • Erosions, synovitis, and bone marrow edema (BME) visualized on magnetic resonance imaging were most prevalent in metatarsophalangeal joints (MTPJ) 2 and 3 in patients with early rheumatoid arthritis (RA). • Standard of care was associated with improvements in synovitis in MTPJ2 and MTPJ3 and improvements in BME in MTPJ2, MTPJ3, and MTPJ4 over 2 years of treatment.

Objective The transition from pediatric to adult rheumatology care represents a particularly vulnerable time for patients with juvenile idiopathic arthritis (JIA) and childhood-onset systemic lupus erythematosus (cSLE). Improving self-management skills is important in optimizing health care transition. The study's objectives were to 1) examine variability in transition readiness of adolescents and young adults within and between different ages, sexes, and disease types; 2) determine the association between age and transition readiness; and 3) identify specific challenges to transition readiness for adolescents. Methods Over 1 year, patients 14 to 20 years of age with JIA or cSLE were recruited from pediatric transition and young adult clinics at a single academic institution. Participants completed the 14-item Transition-Q at a single time point. Total scores range from 0 to 100; higher scores indicate greater health care self-management skills as a proxy for transition readiness. Descriptive statistics summarized patient characteristics and Transition-Q scores for the population. Regression analyses determined the association between age, sex, and disease type and Transition-Q score. Results Among 70 participants, 61 had JIA and 9 cSLE (mean disease duration 4.6 years). The mean (SD) total Transition-Q score was 59.8 (14.9). Age was significantly associated with Transition-Q score (standardized β = 0.372l P = 0.002). The most commonly reported challenges were seeing the physician alone (without parents), making one's own appointments, picking up prescriptions, and independent transportation for appointments. Conclusion Transition readiness appears to increase with patient age. There is significant variability in Transition-Q scores between patients of the same age, suggesting that an individualized approach to improving self-management skills is necessary.

Objectives While the transition period can be a difficult time for adolescents with chronic health conditions, parents also face challenges in understanding their changing role and how to support their children. To date, minimal interventions have focused on supporting and empowering parents during this period. Methods We co-created a toolkit with and for parents to help prepare them for their child’s transition to adult care. The toolkit was created using an iterative process of reviewing existing resources with integrating feedback from rheumatology patients and parents. Input was sought from the Family and Youth Advisory Councils at McMaster Children’s Hospital in Hamilton, Canada. Results The two components of the toolkit include a Transition Road Map and a Parent Guide to Transition. Five domains of transition readiness were established as pillars of the Road Map. Within each domain, a checklist to achieve self-management was established. The Parent Guide was developed to highlight important information including defining transition, outlining differences between pediatric and adult care, and providing tips on helping and supporting adolescents. Conclusions A Parent Toolkit directed at the Transition from Pediatric to Adult Rheumatology Care was developed and underwent extensive review with multiple stakeholders. Ongoing research on its impact on transition readiness is underway.

Introduction: Gastrointestinal manifestations of systemic sclerosis affect up to 90% of patients, with symptoms including diarrhea and constipation. Small intestinal bacterial overgrowth is a condition associated with increased numbers of pathogenic bacteria in the small bowel. While currently unknown, it has been suggested that dysregulation of the fecal microbiota may play a role in the development of systemic sclerosis and small intestinal bacterial overgrowth. Objectives: Our study aimed to describe the fecal microbiota of patients with systemic sclerosis and compare it between those with and without a diagnosis of small intestinal bacterial overgrowth. We also compared the fecal microbiota of systemic sclerosis patients with that of healthy controls to understand the association between particular bacterial taxa and clinical gastrointestinal manifestations of systemic sclerosis. Methods: A total of 29 patients with systemic sclerosis underwent breath testing to assess for small intestinal bacterial overgrowth, provided stool samples to determine taxonomic assignments, and completed the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0, which details symptoms and quality-of-life factors. Stool samples were compared between systemic sclerosis patients with and without small intestinal bacterial overgrowth, and between patients with systemic sclerosis and a healthy control cohort (n = 20), aged 18–80 years. Results: Fecal microbiome analyses demonstrated differences between systemic sclerosis patients with and without small intestinal bacterial overgrowth and differences in the diversity of species between healthy controls and patients with systemic sclerosis. Trends were also observed in anticentromere antibody systemic sclerosis patients, including higher Alistipies indistincus spp. levels associated with increased methane levels of breath gas testing and higher Slakia spp. levels associated with increased rates of fecal soiling. Conclusions: Our results suggest that changes to the fecal microbiome occur in patients with small intestinal bacterial overgrowth and systemic sclerosis when compared to healthy controls. As a cross-sectional study, the potential pathophysiologic role of an altered microbiome in the development of systemic sclerosis was not considered and hence needs to be further investigated.

Sandplain grassland and coastal heathland are globally rare communities threatened by succession, development, and shoreline change. Restricted mainly to coastal plains of the Northeast, they provide vital habitat for many state and regionally rare species, highlighting their importance for conservation and restoration. Brush-cutting and prescribed fire have been successful in maintaining these communities but have proven ineffective in converting overgrown shrubland to an earlier successional state. Previous research has established that the soil seed bank in overgrown shrubland lacks key dominant grassland species, and that while small-scale soil disturbance leads to short-term increases in grasses and forbs, woody species rapidly resume dominance. We examined whether applying larger-scale soil disturbance in an area previously treated with annual brush-cutting could more effectively impede woody regrowth while providing an extensive mineral soil seed bed to recruit desired vegetation. We evaluated the effectiveness of harrowing, harrowing plus seeding, and seeding alone, compared to untreated plots and to existing sandplain grassland and coastal heathland reference sites. Harrowing stimulated seed bank germination of varied native disturbance-associated species, including four Massachusetts state-listed rare species that recruited only within the harrowed area, and indicated that the seed bank lacked key grassland dominants. Comparison to reference grassland and heathland sites suggested that harrowing plus seeding more closely approached the desired restoration outcome than any other treatment. Our results suggest that larger-scale soil disturbance can enhance biodiversity by stimulating germination of native early successional plants from the seed bank while providing germination sites for sown target species.

Medical residency is an important time in the development of physician professionalism, as residents’ identities and medical responsibilities shift from student-learners to practitioner-leaders. During this transition time, many residents struggle with stress due to the unique pressures of their post-graduate training. This, in turn, can potentially hinder successful professional identity development. In response, the Royal College of Physicians and Surgeons of Canada (RCPSC) has incorporated physician health into its CanMEDS professional competency framework.Although this framework identifies enabling self-care professional competencies (e.g., capacity for self-regulation and resilience for sustainable practice), it does not specify the types of educational strategies best suited to teach and assess these competencies. To support the prevention and rehabilitation of resident health issues, residency training programs are faced with the complex challenge of developing socially accountable curricula that successfully foster self-care competencies. Duoethnography, a dialogic and collaborative form of curriculum inquiry, is presented as a pedagogical model for resident professionalism and self-care education. Merits of duoethnography centers on its: 1) capability to foster self-reflexive and transformative learning; 2) versatility to accommodate learner diversity; and 3) adaptability for use in different social, situational, and ethical contexts.

In Canada, little is known about residents' self-confidence to diagnose/treat musculoskeletal (MSK) disease and factors affecting pursuit of a rheumatology career. Our study explored these factors. An online survey (descriptive cross-sectional design) was distributed to Canadian postgraduate year (PGY) 1 and 2 internal medicine (IM) residents. Questions probed self-confidence in rheumatology and factors influencing subspecialty career choice. Frequencies were determined and responses compared between PGY-1 and PGY-2 using univariate statistical analyses. Fifty-four IM residents completed the survey. PGY-2 residents were statistically more certain in subspecialty decidedness and had higher levels of self-confidence to diagnose/treat MSK disease and perform a physical exam. "Quality of life" was the most encouraging factor for a rheumatology career choice followed by "job opportunities" and "previous clinical exposure." Although 50% of PGY-1 residents had completed a rheumatology clinical rotation, 76% indicated that increased knowledge would affect rheumatology career choice. Only 38% were interested in novel rheumatology education. No difference in rheumatology exposure, rheumatology clinical rotation completion year, or rheumatology career choice was observed. Our research confirms findings from similar United States (US) and United Kingdom (UK) studies that suggest that increased MSK knowledge positively influences residents' confidence to diagnose/treat MSK disease. Our study differs with Canadian PGY-1 and PGY-2 IM residents by evaluating self-confidence to diagnose/treat MSK disease separately from self-confidence to perform a physical exam. Significant differences between first and second year trainees suggest types/quality of rheumatology experiences (e.g., case complexity, diagnostic problem-solving competency) may affect self-confidence to diagnose/treat MSK disease factors and rheumatology career choice.

The Medouie Creek wetland complex on Nantucket Island, MA was historically one contiguous salt marsh. Diking in the 1930s caused tidal restriction, creating a freshwater wetland colonized by Phragmites australis. To restore salt marsh habitat, the tidal restriction was removed and tidal salt water hydrology reestablished. Soil pore water salinity increased rapidly through the site with the majority of the marsh exhibiting salt marsh hydrology and higher salinities (25-30 ppt) eight years post-restoration. Extensive dieback of freshwater vegetation facilitated fairly rapid colonization by salt marsh vegetation, particularly adjacent to the culvert and marsh ditches. A non-metric multidimensional scaling (nMDS) analysis demonstrated that vegetation community composition was driven primarily by soil pore water salinity and marsh surface elevation. Eight years post-restoration, areas under 4 m elevation were dominated by salt marsh species while areas over 4 m retained freshwater vegetation. Unlike some other salt marsh restoration projects, salt marsh vegetation communities successfully established at Medouie primarily due to hydrological alteration and without the need for active revegetation or other restoration methods. P. australis stands were also significantly decreased. Given appropriate marsh conditions, altering hydrology alone to mimic functioning salt marsh hydrology may effectively drive vegetation succession and lead to ecologically functional salt marshes.

On Nantucket Island, MA, the present range of coastal sandplain grasslands is primarily attributed to intense and prolonged historic sheep grazing following European settlement. The maintenance of this early successional habitat (ranked S-1 or “critically imperiled” in Massachusetts) relies on disturbance-based land-management tools. Habitat management efforts have focused primarily on mechanical and prescribed fire treatments, with limited emphasis on re-introducing sheep. This study examined and compared the impacts of repeated growing-season grazing, repeated growing-season mowing, and no management on vegetation community composition in a previously managed grassland. Sheep grazing effectively controlled and reduced clonal and vining woody plant coverage while increasing available bare ground for grassland species seed recruitment. However, grazing and mowing treatments resulted in an increase in weedy agricultural plant species, which may be an inherent side effect of management that results...

Patients with systemic sclerosis (SSc) are at increased risk of pulmonary arterial hypertension (PAH). Guidelines recommend annual screening with pulmonary function testing (PFT) and transthoracic echocardiogram (TTE). Through auditing the charts of 11 rheumatologists associated with McMaster University, we evaluated the proportion of SSc patients without PAH or pulmonary fibrosis who receive annual TTE, PFT, and dyspnea screening. Screening rates between self-identified SSc experts and non-experts were compared. In cases where screening tests were abnormal, charts were reviewed for evidence of cardiologist or respirologist referral. In total, 136 patients’ charts were included. Annual screening for dyspnea was very common (88% of patients, 119/134). Annual PAH screening via TTE (74%, 100/135) and PFT (79%, 107/136) was less common. Annual dyspnea screening, TTE, and PFT were more commonly performed by SSc experts than by non-experts (94% vs. 83%, p = 0.03; 85% vs. 61%, p = 0.002; 93% vs. 62%, p

This study aimed to determine the extent to which changes over 2.5 years in medial knee cartilage thickness and volume were predicted by: (1) Peak values of the knee adduction (KAM) and flexion moments; and (2) KAM impulse and loading frequency, representing cumulative load, after controlling for age, sex and body mass index (BMI). Adults with clinical knee osteoarthritis participated. At baseline and approximately 2.5 years follow-up, cartilage thickness and volume of the medial tibia and femur were segmented from magnetic resonance imaging scans. Gait kinematics and kinetics, and daily knee loading frequency were also collected at baseline. Multiple linear regressions predicted changes in cartilage morphology from baseline gait mechanics. Data were collected from 52 participants (41 women) [age 61.0 (6.9) y; BMI 28.5 (5.7) kg/m2 ] over 2.56 (0.51) years. There were significant KAM peak-by-BMI (p = 0.023) and KAM impulse-by-BMI (p = 0.034) interactions, which revealed that larger joint loads in those with higher BMIs were associated with greater loss of medial tibial cartilage volume. In conclusion, with adjustments for age, sex, and cartilage measurement at baseline, large magnitude KAM peak and KAM impulse each interacted with BMI to predict loss of cartilage volume of the medial tibia over 2.5 years among individuals with knee osteoarthritis. These data suggest that, in clinical knee osteoarthritis, exposure to large KAMs may be detrimental to cartilage in those with larger BMIs. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2476-2483, 2017.

Background Thigh lean muscle and intramuscular fat have been implicated in the impairment of physical function observed in people with knee osteoarthritis. We investigated the relationships of quadriceps and hamstrings intramuscular fat fraction and lean muscle volume with muscle power and strength, controlling for neuromuscular activation, and physical performance in women with knee OA. Methods Women (n = 20) 55 years or older with symptomatic, radiographic knee osteoarthritis underwent a 3.0T magnetic resonance imaging scan of the thigh of their most symptomatic knee. Axial fat-separated images were analyzed using software to quantify intramuscular fat and lean muscle volumes of the quadriceps and hamstrings. To quantify strength and power of the knee extensors and flexors, participants performed maximum voluntary isometric contraction and isotonic knee extensions and flexions, respectively. Electromyography of the quadriceps and hamstrings was measured. Participants also completed five physical performance tests. Findings Quadriceps and hamstrings lean muscle volumes were related to isotonic knee extensor (B = 0.624; p = 0.017) and flexor (B = 1.518; p = 0.032) power, but not knee extensor (B = 0.001; p = 0.615) or flexor (B = 0.001; p = 0.564) isometric strength. Intramuscular fat fractions were not related to isotonic knee extensor or flexor power, nor isometric strength. No relationships were found between intramuscular fat or lean muscle volume and physical performance. Interpretation Muscle power may be more sensitive than strength to lean muscle mass in women with knee osteoarthritis. Thigh lean muscle mass, but neither intramuscular nor intermuscular fat, is related to knee extensor and flexor power in women with knee osteoarthritis.

Small intestinal bacterial overgrowth (SIBO) is common in patients with systemic sclerosis (SSc) yet often goes underrecognized in clinical practice. In patients with SSc, untreated SIBO may result in marked morbidity and possible mortality. The pathogenesis of SIBO is multifactorial and relates to immune dysregulation, vasculopathy, and dysmotility. This article reviews various diagnostic approaches and therapeutic options for SIBO. Treatment modalities mainly include prokinetics, probiotics, and antibiotics.

Purpose: This study determined the extent to which modifiable risk factors (balance, muscle strength, and physical activity [PA]) explained variability in bone mineral density (BMD) among people with a recent distal radius fracture (DRF). Method: This cross-sectional study included 190 patients, aged 50–80 years, with a DRF. Participants were assessed for balance, muscle strength, PA, fracture-specific pain, and disability. Areal BMD at the femoral neck (BMD-FN) and total hip (BMD-TH) was assessed. Correlation and multiple linear regression was used to determine the contribution of modifiable risk factors to BMD. Results: Balance, handgrip strength, knee extension strength, and plantar-flexion strength had significant bivariate associations with BMD-FN. There was a weak to moderate correlation ( r = 0.25–0.40; p < 0.05) of balance and grip strength with BMD. Grip strength independently ( p < 0.05) explained 17% and 12% of the variability in BMD-FN ( n = 81) and BMD-TH ( n = 82), respectively. Stratified by age, balance ( R2 = 0.10; p = 0.04) and grip strength ( R2 = 0.32; p = 0.003) were independent significant predictors of BMD-FN among women aged 50–64 years and 65–80 years, respectively. Conclusions: Grip strength of the unaffected hand is independently associated with BMD-FN and BMD-TH in people with recent DRF. It may act as a surrogate for general bone health, frailty, or overall muscle strength rather than as a direct target for intervention.

Compared with clinical examination (CE), ultrasonography (US) provides additional and more accurate assessment of inflammation and visualization of structural damage. To better understand the effectiveness of US in metatarsophalangeal joints (MTPJs), we compared disease activity in MTPJs 2-5 assessed by CE and US, with magnetic resonance imaging (MRI) as reference standard.Treatment-naïve adult patients with early RA (ACR criteria, disease duration 2 years) were consecutively recruited. MTPJs 2-5 were assessed for swelling and tenderness, and imaged by US (Esaote MyLab70). The most symptomatic foot was imaged by peripheral MRI (1.0 Tesla). US was semiquantitatively graded for synovial thickening (ST) and power Doppler (PD) (0-3), and erosions (yes/no). MRI was semiquantitatively graded for bone marrow edema (BME), synovitis, and erosions (OMERACT). Kappa agreement, sensitivity, specificity, and predictive values were analyzed using cut-offs at ST ≥ 2, PD ≥ 1, and MRI synovitis and BME at both ≥ 1 and ≥ 2.This study included 39 patients (85% female, mean (SD) age = 51.6 (10.3)). Using MRI synovitis and BME grade ≥ 2 as the reference, PD had superior sensitivity (82%) and kappa agreement (k = 0.43) than swollen joint count (55%, k = 0.20), but similar high specificity (88%, 83%). ST and PD were often observed in clinically asymptomatic MTPJs. US detected very few MRI erosions, but several observed erosions corresponded to grade ≥ 2 MRI erosions.Clinical swelling and PD are highly specific for active inflammation in the MTPJs. US supplemented CE by allowing observation of subclinical inflammation and structural damage. Key Points • Ultrasonography detected many subclinical synovial inflammations in metatarsophalangeal joints (MTPJs), many confirmed by MRI • Ultrasonography may best be used clinically to supplement clinical examination by assessing non-swollen joints • Ultrasonography provided quick method of visualizing bone erosions that were grade ≥ 2 on MRI.

© 2019 The Author(s). Background: To determine the known-group validity, a type of construct validity, and the test-retest reliability of a newly developed tool, the Personalized Exercise Questionnaire (PEQ), that assesses the barriers, facilitators, and preferences to exercise in individuals with low bone mass and osteoporosis. Methods: A comparative design was used to assess known-group validity and a test-retest design to examine the reproducibility. Ninety-five participants with low bone mass and osteoporosis were recruited from an outpatient clinic in Hamilton, Ontario. The questionnaire was administered to 95 participants at baseline and a subset of 42 participants completed the survey again one week later. The known-group validity of the PEQ was determined using four hypotheses that compared two known groups based on employment level, age, socioeconomic status, and physical activity level. The reproducibility of individual responses was analyzed using the Kappa Coefficient (κ). Results: There was known-group validity for three of the four hypotheses. Test-retest reliability scores ranged from no agreement to almost perfect agreement; seven items had almost perfect agreement (κ: 0.81-1.00), 12 substantial agreement (κ: 0.68-0.74), six moderate agreement (κ: 0.56-0.60), two fair agreement (κ: 0.36-0.40), one slight agreement (κ = 0.23) and one no agreement (κ = - 0.03). Conclusion: Preliminary support for the usefulness of the PEQ is indicated since the majority of the items had at least substantial agreement and known-group validity was moderately supported for some items. Trial registration: This study was retrospectively registered with ClinicalTrials.gov, NCT03125590, on April 24, 2017.

To the Editor: Changes in appearance, significant morbidity, and the absence of disease-modifying therapies may lead to psychosocial issues in patients with systemic sclerosis (SSc)1,2,3,4. Limited education may contribute to poor medication adherence5. Education of patients could potentially mediate some of these outcomes2,6 because patient education in rheumatic disease improves self-efficacy and self-management7,8. An Educational Needs Assessment Tool (ENAT) was developed to assess the perceived educational needs of people with rheumatic disease9, and has been validated in patients with SSc10. We used the ENAT to survey a sample of Canadians with SSc to understand their educational need(s) to inform educational initiatives and future research. This project was not deemed to require ethics approval by the Hamilton Integrated Research Ethics Board, and thus written consent was not required. The ENAT questionnaire was posted on the Scleroderma Society of Ontario and Scleroderma Society of Canada social media accounts in August 2017. Patients from 2 clinics were also provided with the online survey link. … Address correspondence to Dr. T. Semalulu, Department of Medicine, Internal Medicine Training Program, McMaster University Medical Centre, Room 1K11, 1200 Main St. West, Hamilton, Ontario L8N 3Z5, Canada. E-mail: teresa.semalulu{at}medportal.ca

Decreased muscle mass and increased fat mass are commonly seen in the thighs of individuals with knee osteoarthritis (OA). Despite the role of calf muscles in activities of daily living and knee mechanics, little work has investigated calf changes in knee OA. Unlike the thigh, muscle and fat in the lower leg can be imaged using a peripheral magnetic resonance imaging (MRI) scanner. We aimed to assess agreement between subcutaneous fat, intermuscular fat (IMF), intramuscular fat (intraMF), and lean muscle volumes acquired using a peripheral 1.0T as compared to a reference whole-body 3.0T MRI scanner. A calf MRI scan from each scanner was acquired from twenty women >55 years with knee OA. The different tissues were segmented on each of ten axial slices for every participant using SliceOmatic 5.0 (Tomovision, Magog, QC). Tissue volumes were determined for each outcome. Agreement between tissue volumes from the two scanners was assessed using intraclass correlation (ICC(2,1)) coefficients, standard error, and Bland-Altman plots. Agreement between tissue volumes was strong to very strong, with ICCs ranging from 0.842 to 0.991 for all outcomes. However, wide confidence intervals for IMF and intraMF suggest there is less confidence in agreement with segmentation of images from the 1.0T scanner generally underestimating fat volume relative to the 3.0T scanner. The 3.0T's superior between-tissue contrast likely resulted in more accurate segmentation of IMF and intraMF compared to the 1.0T scanner. Comparisons of tissue volume between studies using different scanners/sequences should be interpreted cautiously.

Objective To review the literature on chronic disease self-management programs that blend face-to-face and online/computer-based education design and delivery. Methods A critical interpretive synthesis was conducted. Studies that described blended chronic disease self-management programs were reviewed. Two reviewers performed independent database searches, eligibility screening, and data extraction. Findings were synthesized using a conceptual mapping process. Results Twelve articles were included in the final review. Studies focused on patients with diagnoses of diabetes, asthma, and chronic obstructive pulmonary disorder. Factors influencing the design and delivery of programs focused on patient characteristics (such as disease prognosis, time since diagnosis, social determinants of health, health literacy, and proficiency with online/computer-based technologies). Conclusions Blended learning self-management programs should consider the suitability of programs in light of health conditions and patient characteristics. Individual patient needs can be identified through clinician-driven assessments, including collaborative goal setting and the selection of pertinent educational tools. Practice Implications When considering the design and delivery of chronic disease self-management education programs, healthcare providers should consider three factors: 1) patient characteristics, 2) learning perspectives, and 3) design technology options that best meet patient abilities, clinician expertise, and administrative capacity.

© 2017 Hanley & Belfus Study Design: Descriptive/Longitudinal cohort. Introduction: Distal radius fracture (DRF) is a common fall related fragility fracture that is known to be an early and independent predictor of secondary osteoporotic (OP) fractures. Changes in falls risk status, bone status and general health has not been evaluated prospectively in a population that has sustained a DRF. Purpose of the Study: The purpose of our study was to describe the status of fracture-specific pain/disability, fall risk factors such as physical activity (PA) and fear of falling (FOF), bone mineral density (BMD) and general health status (HS) in people with a DRF and how these variables change over four years with respect to sex, age, incidence of secondary falls and secondary OP fractures. Methods: Patients (n = 94) self-reported their fracture-specific pain and disability (Patient-Rated Wrist Evaluation), PA (Rapid Assessment of Physical Activity), FOF (Modified Fall Efficacy Scale), HS (12-item Short Form Health Survey) and completed dual-energy X-ray absorptiometry scan based BMD assessment (lumbar spine and total hip) at baseline (1-2 weeks post-fracture), six months and four years after DRF. Descriptive statistics and general linear models were used to describe changes in recovery patterns over four years. Results: There was significant (p

Objectives Almost all patients with SSc have gastrointestinal manifestations. Small intestinal bacterial overgrowth (SIBO) occurs in 30-60% of patients and leads to malnutrition and impaired quality of life. Recent systematic reviews have reported efficacy of treatments for SIBO, but these are not specific to patients with SSc. We conducted a systematic review of the evidence for all possible SIBO treatments in the SSc population. Methods The following databases were searched: MEDLINE, EMBASE and the Cochrane Library, from database inception to 1 January 2017. All evidence for all possible SIBO treatments including antibiotics, prokinetics, probiotics and alternative treatments was included. Treatment outcomes included symptomatic relief or demonstrated SIBO eradication. Results Of 5295 articles, five non-randomized studies were reviewed with a total of 78 SSc patients with SIBO. One trial assessed octreotide while the remaining four trials investigated the effectiveness of ciprofloxacin, rifaximin, norfloxacin and metronidazole, and the combination of amoxicillin, ciprofloxacin and metronidazole. Studies were generally of low quality and most were un-controlled. Conclusion Data indicate that, for some SSc patients, antibiotics can eradicate SIBO. There is a paucity of data reporting the effectiveness of either prokinetics or probiotics in SSc.

Determine the reliability of a magnetic resonance (MR) image segmentation protocol for quantifying intramuscular adipose tissue (IntraMAT), subcutaneous adipose tissue, total muscle and intermuscular adipose tissue (InterMAT) of the lower leg.Ten axial lower leg MRI slices were obtained from 21 postmenopausal women using a 1 Tesla peripheral MRI system. Images were analyzed using sliceOmatic™ software. The average cross-sectional areas of the tissues were computed for the ten slices. Intra-rater and inter-rater reliability were determined and expressed as the standard error of measurement (SEM) (absolute reliability) and intraclass coefficient (ICC) (relative reliability).Intra-rater and inter-rater reliability for IntraMAT were 0.991 (95% confidence interval [CI] 0.978-0.996, p0.05) and 0.983 (95% CI 0.958-9.993, p0.05), respectively. For the other soft tissue compartments, the ICCs were all0.90 (p0.05). The absolute intra-rater and inter-rater reliability (expressed as SEM) for segmenting IntraMAT were 22.19 mm(2) (95% CI 16.97-32.04) and 78.89 mm(2) (95% CI 60.36-113.92), respectively.This is a reliable segmentation protocol for quantifying IntraMAT and other soft-tissue compartments of the lower leg. A standard operating procedure manual is provided to assist users, and SEM values can be used to estimate sample size and determine confidence in repeated measurements in future research.

Conflicting evidence suggests that bone lead or blood lead may reduce areal bone mineral density (BMD). Little is known about how lead at either compartment affects bone structure. This study examined postmenopausal women (N=38, mean age 76 ± 8, body mass index (BMI): 26.74 ± 4.26 kg/m(2)) within the Hamilton cohort of the Canadian Multicentre Osteoporosis Study (CaMos), measuring bone lead at 66% of the non-dominant leg and at the calcaneus using (109)Cadmium X-ray fluorescence. Volumetric BMD and structural parameters were obtained from peripheral quantitative computed tomography images (200 μm in-plane resolution, 2.3 ± 0.5mm slice thickness) of the same 66% site and of the distal 4% site of the tibia length. Blood lead was measured using atomic absorption spectrometry and blood-to-bone lead partition coefficients (PBB, log ratio) were computed. Multivariable linear regression examined each of bone lead at the 66% tibia, calcaneus, blood lead and PBB as related to each of volumetric BMD and structural parameters, adjusting for age and BMI, diabetes or antiresorptive therapy. Regression coefficients were reported along with 95% confidence intervals. Higher amounts of bone lead at the tibia were associated with thinner distal tibia cortices (-0.972 (-1.882, -0.061) per 100 μg Pb/g of bone mineral) and integral volumetric BMD (-3.05 (-6.05, -0.05) per μg Pb/g of bone mineral). A higher PBB was associated with larger trabecular separation (0.115 (0.053, 0.178)), lower trabecular volumetric BMD (-26.83 (-50.37, -3.29)) and trabecular number (-0.08 (-0.14, -0.02)), per 100 μg Pb/g of bone mineral after adjusting for age and BMI, and remained significant while accounting for diabetes or use of antiresorptives. Total lead exposure activities related to bone lead at the calcaneus (8.29 (0.11, 16.48)) and remained significant after age and antiresorptives-adjustment. Lead accumulated in bone can have a mild insult on bone structure; but greater partitioning of lead in blood versus bone revealed more dramatic effects on both microstructure and volumetric BMD.

The objective was to determine the extent to which the external peak knee adduction moment (KAM) and cumulative knee adductor load explained variation in medial cartilage morphology of the tibia and femur in knee osteoarthritis (OA). Sixty-two adults with clinical knee OA participated (61.5 ± 6.2 years). To determine KAM, inverse dynamics was applied to motion and force data of walking. Cumulative knee adductor load reflected KAM impulse and loading frequency. Loading frequency was captured from an accelerometer. Magnetic resonance imaging scans were acquired with a coronal fat-saturated sequence using a 1.0 T peripheral scanner. Scans were segmented for medial cartilage volume, surface area of the bone-cartilage interface, and thickness. Forward linear regressions assessed the relationship of loading variables with cartilage morphology unadjusted, then adjusted for covariates. In the medial tibia, age and peak KAM explained 20.5% of variance in mean cartilage thickness (p

Part II of this 3-part series demonstrated 1-yr precision, standard error of the estimate, and 1-yr least significant change for volumetric bone outcomes determined using peripheral (p) quantitative computed tomography (QCT) and peripheral magnetic resonance imaging (pMRI) modalities in vivo. However, no clinically relevant outcomes have been linked to these measures of change. This study examined 97 women with mean age of 75 ± 9 yr and body mass index of 26.84 ± 4.77 kg/m 2 , demonstrating a lack of association between fragility fractures and standard deviation, least significant change and standard error of the estimate-based unit differences in volumetric bone outcomes derived from both pMRI and pQCT. Only cortical volumetric bone mineral density and cortical thickness derived from high-resolution pQCT images were associated with an increased odds for fractures. The same measures obtained by pQCT erred toward significance. Despite the smaller 1-yr and short-term precision error for measures at the tibia vs the radius, the associations with fractures observed at the radius were larger than at the tibia for high-resolution pQCT. Unit differences in cortical thickness and cortical volumetric bone mineral density able to yield a 50% increase in odds for fractures were quantified here and suggested as a reference for future power computations.

Objectives. To determine (1) whether intramuscular adipose tissue (IntraMAT) differs between women with and without type 2 diabetes and (2) the association between IntraMAT and mobility and strength.Methods. 59 women ≥ 65 years with and without type 2 diabetes were included. A 1-Tesla MRI was used to acquire images of the leg. Timed-up-and-go (TUG) and grip strength were measured. Regression was used to determine associations between the following: (1) type 2 diabetes and IntraMAT (covariates: age, ethnicity, BMI, waist : hip ratio, and energy expenditure), (2) IntraMAT and TUG (covariates: diabetes, age, BMI, and energy expenditure), and (3) IntraMAT and grip strength (covariates: diabetes, age, height, and lean mass).Results. Women with diabetes had more IntraMAT. After adjustment, IntraMAT was similar between groups (diabetes mean [SD] = 13.2 [1.4]%, controls 11.8 [1.3]%,P=0.515). IntraMAT was related to TUG and grip strength, but the relationships became nonsignificant after adjustment for covariates (difference/percent IntraMAT [95% CI]: TUG = 0.041 seconds [−0.079–0.161],P=0.498, grip strength = −0.144 kg [−0.335–0.066],P=0.175).Conclusions. IntraMAT alone may not be a clinically important predictor of functional mobility and strength; however, whether losses in functional mobility and strength are promoted by IntraMAT accumulation should be explored.

Background Despite the widely known benefits of exercise and physical activity, adherence rates to these activities are poor. Understanding exercise facilitators, barriers, and preferences may provide an opportunity to personalize exercise prescription and improve adherence. The purpose of this study was to develop the Personalized Exercise Questionnaire (PEQ) to identify these facilitators, barriers, and preferences to exercise in people with osteoporosis. Methods This study comprises two phases, instrument design and judgmental evidence. A panel of 42 experts was used to validate the instrument through quantitative (content validity) and qualitative (cognitive interviewing) methods. Content Validity Index (CVI) is the most commonly used method to calculate content validity quantitatively. There are two kinds of CVI: Item-CVI (I-CVI) and Scale-level CVI (S-CVI). Results Preliminary versions of this tool showed high content validity of individual items (I-CVI range: 0.50 to 1.00) and moderate to high overall content validity of the PEQ (S-CVI/UA = 0.63; S-CVI/Ave = 0.91). Through qualitative methods, items were improved until saturation was achieved. The tool consists of 6 domains and 38 questions. The 6 domains are: 1) support network; 2) access; 3) goals; 4) preferences; 5) feedback and tracking; and 6) barriers. There are 35 categorical questions and 3 open-ended items. Conclusions Using an iterative approach, the development and evaluation of the PEQ demonstrated high item-content validity for assessing the facilitators, barriers, and preferences to exercise in people with osteoporosis. Upon further validation it is expected that this measure might be used to develop more client-centered exercise programs, and potentially improve adherence. Electronic supplementary material The online version of this article (10.1186/s12891-017-1914-5) contains supplementary material, which is available to authorized users.

© 2018, International Osteoporosis Foundation and National Osteoporosis Foundation. Summary: In a prospective cohort of 113 patients followed 4 years after distal radius fracture (DRF), 24% of patients experienced a subsequent fall and 19% experienced a subsequent fracture. People with poor balance, greater fracture-specific pain/disability, low bone density, and prior falls had nearly a three times higher risk of subsequent falls. Purpose: To determine the extent to which modifiable risk factors alone or in combination with bone mineral density (BMD) and non-modifiable risk factors predict subsequent falls and osteoporotic (OP) fractures after distal radius fracture (DRF). Methods: We assessed a cohort of patients (n = 191; mean age = 62 ± 8 years; female = 88%) shortly after DRF (baseline) and again at 4 years to identify subsequent falls or OP fractures. Baseline predictors included age, sex, prior falls, and modifiable risk factors such as balance, muscle strength, physical activity, fear of falling, BMD, fracture-specific pain/disability, and general health status. Univariate, multivariate, and stepwise logistic regression analyses were conducted to compute odds ratio (OR) with 95% CI to determine the extent of association between the risk factors and outcomes. Results: Among the 113 patients, who completed 4-year follow-up, 24% reported ≥ 1 subsequent fall and 19% reported ≥ 1 subsequent fracture. Significant predictors of subsequent falls included poor balance (OR = 3.3), low total hip BMD (OR = 3.3), high patient-rated wrist evaluation (PRWE) score (OR = 3.0), and prior falls (OR = 3.4). When adjusted for BMD, age, and sex; only prior falls (OR = 4.1) remained a significant independent predictor of future falls. None of the modifiable or non-modifiable risk factors were significantly associated with subsequent fractures. Conclusion: Prior falls (≥ 2) is an independent predictor of subsequent falls in patients with DRF. In clinical practice, screening of patients for prior falls, balance, fracture-specific pain/disability, and BMD may identify those who might be at risk of subsequent falls after their first DRF.

Severe constant and intermittent knee pain are associated with “unacceptable” symptoms in older adults with osteoarthritis (OA) [ 22 ]. We hypothesized that constant and intermittent pain would be independently related to physical function, with intermittent knee pain being a better predictor of future declines in physical function in early symptomatic knee OA. This study included men (n = 189) and women (n = 133) with radiographic, unilateral knee OA, observed using data from the Osteoarthritis Initiative (OAI). Pain types were measured using the Intermittent and Constant Osteoarthritis Pain (ICOAP) scale. Physical function was measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC-PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS-FSR) and physical performance tests. High baseline intermittent (B = 0.277; p = 0.001) and constant (B = 0.252; p = 0.001) knee pain were related to poor WOMAC-PF. Increased constant (B = 0.484; p = 0.001) and intermittent (B = 0.104; p = 0.040) pain were related to 2-year decreased WOMAC-PF. High baseline intermittent knee pain predicted poor KOOS-FSR at year 2 (B = −0.357; p = 0.016). Increased constant pain was related to decreased chair stand test performance over 2 years in women (B = 0.077; p = 0.001). High baseline intermittent pain was related to poor performance on repeated chair stands (B = 0.035; p = 0.021), while baseline constant pain was related to poor 400-m walk performance in women (B = 0.636; p = 0.047). Intermittent and constant knee pain were independent factors in self-perceived physical function and were important predictors of future limitations in physical function. Identifying intermittent and constant pain in early symptomatic OA may allow patients to adopt strategies to prevent worsening pain and future declines in physical function.

© 2014 The International Society for Clinical Densitometry. Canadian guidelines recommend either the FRAX or the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) fracture risk assessment tools to report 10-yr fracture risk as low (20%). It is unknown whether one reporting system is more effective in helping family physicians (FPs) identify individuals who require treatment. Individuals ≥50yr old with a distal radius fracture and no previous osteoporosis diagnosis or treatment were recruited. Participants underwent a dual-energy x-ray absorptiometry scan and answered questions about fracture risk factors. Participants' FPs were randomized to receive either a FRAX report or the standard CAROC-derived bone mineral density report currently used by the institution. Only the FRAX report included statements regarding treatment recommendations. Within 3 mo, all participants were asked about follow-up care by their FP, and treatment recommendations were compared with anosteoporosis specialist. Sixty participants were enrolled (31 to FRAX and 29 to CAROC). Kappa statistics of agreement in treatment recommendation were 0.64 for FRAX and 0.32 for bone mineral density. The FRAX report was preferred by FPs and resulted in better postfracture follow-up and treatment that agreed more closely with a specialist. Either the clear statement of fracture risk or the specific statement of treatment recommendations on the FRAX report may have supported FPs to make better treatment decisions.