Recent evidence has linked abnormal body weight, underweight or obesity, with poor disease outcomes in adults with inflammatory arthritis. Yet, little is known about potential similar associations in children with JIA. Therefore, we investigated the association between BMI categories and time to start treatments and attain disease outcomes in children with JIA. Data were captured prospectively through the Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) JIA Registry. This national research registry follows newly diagnosed patients with JIA and collects data at each clinic visit. Based on age, sex, height, and weight at enrollment, BMI was categorized for each patient as underweight (<5 th percentile), healthy (5th to <85th percentile), overweight (85th to <95th percentile), or obese (≥95th percentile) according to the WHO growth charts. For each BMI category, Kaplan-Meier curves examined time to clinical Juvenile Arthritis Disease Activity Score 10 (cJADAS10) ≤1, pain score (parent- and patient-reported) <1, quality of life (patient-reported) >9, parent global assessment <1, physician global assessment <1, and active joint count <1. For these disease outcomes, shorter times are considered optimal. Time to start treatments included conventional DMARD, biologic DMARD, joint injections, and systemic corticosteroids. Log-rank tests compared outcomes across BMI categories; healthy served as the reference category. We included 759 patients enrolled in the Registry between February 2017 and May 2023 (61% female; mean±SD age 9.5±4.7 years). The obese group took significantly longer to attain cJADAS10 ≤1 (χ2(1)=5.53, p=0.019, median difference in time to reach outcomes compared to reference category [MD]=36 weeks), parent pain score <1 (χ2(1)=5.90, p=0.015, MD=46 weeks), and parent global assessment <1 (χ2(1)=5.49, p=0.019, MD=11 weeks). Time to first DMARD was significantly shorter in obese patients (χ2(1) =4.34, p=0.037, MD=15 weeks), and time to first biologic was significantly shorter in underweight patients (χ2(1)=4.65, p=0.031, MD=185 weeks) (Figure 1). No other examined treatments or outcomes were significantly different between BMI categories. Figure 1: Kaplan Meier Curves Children with JIA in the obese group took longer to attain disease control based on both clinical and parent-reported outcomes compared to those with healthy BMI, despite earlier treatment escalation to DMARDs. Additionally, those who were underweight also required earlier treatment escalation to biologics. Further analyses will explore weight percentile groups, covariates including ethnicity and JIA subtype, and changes in body composition overtime. Altogether, these findings may help inform clinicians on anticipated treatment responses and disease outcomes when educating and counseling families about body composition.

OBJECTIVE:Using Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) juvenile idiopathic arthritis (JIA) registry data, we describe (1) clinical characteristics of patients with JIA transitioning to adult care, (2) prevalence of disease-related damage and complications, and (3) changes in disease activity during the final year prior to transfer.METHODS:Registry participants who turned 17 years between February 2017 and November 2021 were included. Clinical characteristics and patient-reported outcomes (PROs) at the last recorded pediatric rheumatology visit, and changes observed in the year prior to that visit were analyzed. Physicians completed an additional questionnaire characterizing cumulative disease-related damage and adverse events by age 17 years.RESULTS:At their last visit, 88 of 131 participants (67%) had inactive and 42 (32%) had active disease. Overall, 96 (73%) were on medications and 41 (31%) were on biologic disease-modifying antirheumatic drugs. Among 80 participants for whom the additional questionnaire was completed, 26% had clinically detected joint damage, 31% had joint damage on imaging, 14% had uveitis, and 7.5% had experienced at least 1 serious adverse event. During the final year, 44.2% of patients were in remission, 28.4% attained inactive disease, and 27.4% became or remained active. Mean scores of PROs were stable overall during that last year, but a minority reported marked worsening.CONCLUSION:A substantial proportion of youth with JIA transitioning to adult care in Canada had a high disease burden, which was reflected by their degree of disease activity, joint damage, or ongoing medication use. These results will inform pediatric and adult providers of anticipated needs during transition of care.

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

Objective. To develop best practice statements for the provision of virtual care in adult and pediatric rheumatology for the Canadian Rheumatology Association's (CRA) Telehealth Working Group (TWG). Methods. Four members of the TWG representing adult, pediatric, university-based, and community rheumatology practices defined the scope of the project. A rapid literature review of existing systematic reviews, policy documents, and published literature and abstracts on the topic was conducted between April and May 2021. The review informed a candidate set of 7 statements and a supporting document. The statements were submitted to a 3-round (R) modified Delphi process with 22 panelists recruited through the CRA and patient advocacy organizations. Panelists rated the importance and feasibility of the statements on a Likert scale of 1-9. Statements with final median ratings between 7-9 with no disagreement were retained in the final set. Results. Twenty-one (95%) panelists participated in R1, 15 (71%) in R2, and 18 (82%) in R3. All but 1 statement met inclusion criteria during R1. Revisions were made to 5/7 statements following R2 and an additional statement was added. All statements met inclusion criteria following R3. The statements addressed the following themes in the provision of virtual care: adherence to existing standards and regulations, appropriateness, consent, physical examination, patient-reported outcomes, use in addition to in-person visits, and complex comanagement of disease. Conclusion. The best practice statements represent a starting point for advancing virtual care in rheumatology. Future educational efforts to help implement these best practices and research to address identified knowledge gaps are planned.

Objective To describe the frequency and severity of parent‐reported medication side effects (SEs) in children with juvenile idiopathic arthritis (JIA) relative to physician‐reported actionable adverse events (AEs), and to assess their impact on health‐related quality of life (HRQoL). Methods Newly diagnosed JIA patients recruited between 2017 and 2019 to the Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) Registry were included. Parents reported presence and severity (0 = no problem, 10 = very severe) of medication SEs at every clinic visit. Physicians were asked to report any actionable AE. HRQoL was assessed using the Quality of My Life (QoML) questionnaire (0 = the worst, 10 = the best) and parent's global assessment (0 = very well, 10 = very poor). Analyses included proportion of visits with SEs or actionable AEs, cumulative incidence by Kaplan‐Meier methods, and HRQoL impact measured with longitudinal mixed‐effects models. Results SEs were reported at 371 of 884 (42%) visits (95% confidence interval [95% CI] 39, 45%) in 249 patients, with a median of 2 SEs per visit (interquartile range [IQR] 1–3), and median severity of 3 (IQR 1.5–5). Most SEs were gastrointestinal (32.5% of visits) or behavioral/psychiatric (22.4%). SE frequency was lowest with nonsteroidal antiinflammatory drugs alone (34.7%) and highest with prednisone and methotrexate combinations (66%). SE cumulative incidence was 67% (95% CI 59, 75) within 1 year of diagnosis, and 36% (95% CI 28, 44) for actionable AEs. Parent global and QoML scores were worse with SEs present; the impact persisted after adjusting for pain and number of active joints. Conclusion Parents report that two‐thirds of children with JIA experience SEs impacting their HRQoL within 1 year of diagnosis. SE mitigation strategies are needed in managing JIA.

OBJECTIVE:To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players.DESIGN:Secondary analyses of 2 prospective cohort studies.SETTING:Canadian youth ice hockey teams.PARTICIPANTS:Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season).ASSESSMENT OF RISK FACTORS:Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition.MAIN OUTCOME MEASURES:Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression.RESULTS:When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion.CONCLUSIONS:Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies.

Objective The aim of this study was to develop and validate a brief disability screen for children with JIA, the Kids Disability Screen (KDS). Methods A total of 216 children enrolled in the Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) Registry in 2017-2018 formed a development cohort, and 220 children enrolled in 2019-2020 formed a validation cohort. At every clinic visit, parents answered two questions derived from the Childhood Health Assessment Questionnaire (CHAQ): 'Is it hard for your child to run and play BECAUSE OF ARTHRITIS?' ('Hard' 0-10), and 'Does your child usually need help from you or another person BECAUSE OF ARTHRITIS?' ('Help', 0-10). We used 36-fold cross-validation and tested nine different mathematical methods to combine the answers and optimize psychometric properties. The results were confirmed in the validation cohort. Results Expressed as the mean of the two answers, KDS best balanced ease of use and psychometric properties, while a LASSO regression model combining the two answers with other patient characteristics [estimated CHAQ [eCHAQ]) had the highest responsiveness. In the validation cohort, 22.7%, 25.9% and 28.6% of patients had a score of 0 at enrolment for the KDS, eCHAQ and CHAQ, respectively. Responsiveness was 0.67, 0.74 and 0.62, respectively. Sensitivity to detect a CHAQ > 0 was 0.90 and specificity 0.56, KDS detecting some disability in 44% of children with a CHAQ = 0. Conclusion This simple KDS has psychometric properties comparable with those of a full CHAQ and may be used at every clinic visit to identify those children who need a full disability assessment.

Introduction The application of topical diclofenac has been suggested as a possible treatment for Achilles tendinopathy. Our aim was to answer the question, is topical diclofenac more effective than placebo for the treatment of Achilles tendinopathy?. Methods 67 participants with persistent midportion or insertional Achilles tendinopathy were randomly assigned to receive a 4 week course of 10% topical diclofenac (n = 32) or placebo (n = 35). The a priori primary outcome measure was change in severity of Achilles tendinopathy (VISA-A score) at 4 and 12 weeks. Secondary outcome measures included numeric pain rating, and patient-reported change in symptoms using a 7 point scale, from substantially worse to substantially better. Pressure pain threshold (N) and transverse tendon stiffness (N/m) were measured over the site of maximum Achilles tendon pathology at baseline and 4 weeks. Results There were no statistically or clinically significant differences between the diclofenac and placebo groups in any of the primary or secondary outcome measures at any timepoint. Average VISA-A score improved in both groups (p<0.0001), but the improvements were marginal: at 4 weeks, the improvements in VISA-A were 9 (SD 11) in the diclofenac group and 8 (SD 12) in the placebo group, and at 12 weeks the improvements were 9 (SD 16) and 11 (SD13) respectively–these average changes are smaller than the minimum clinically important difference of the VISA-A. Conclusion The regular application of topical diclofenac for Achilles tendinopathy over a 4 week period was not associated with superior clinical outcomes to that achieved with placebo.

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.

Objectives. The aim was to describe the design, methods and initial findings of a new Canadian inception cohort of children with JIA, The Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) JIA Registry. Methods. The CAPRI JIA Registry was started in 2017 to collect information prospectively on children enrolled within 3 months of JIA diagnosis across Canada. The registry has a non-traditional modular design, with no artificially set times for registry visits to occur, streamlined multi-method data collection that requires 2-4 min per visit, and reports cumulative incidence of treatments, outcomes and adverse events calculated by Kaplan-Meier survival methods. Results. A total of 166 patients, enrolled a median of 6weeks after JIA diagnosis at 10 centres, were included. The median age at diagnosis was 9years [interquartile range (IQR) 3, 13], 61% were female and 51% had oligoarticular JIA. The median three-variable clinical Juvenile Arthritis Disease Activity Score was 6.5 (IQR 4, 10) at enrolment, and the median time to first attainment of clinically inactive disease (CID) was 24 weeks (by 1 year, 81%). Within 1 year of diagnosis, 70% of patients had started a DMARD and 35% a biologic agent. The rates of adverse events and serious adverse events were 60 and 5.8 per 100 patient-years, respectively. Conclusion. This streamlined and flexible registry minimizes the burden of data collection and interference with clinic operations. Initial findings suggest that treatments for newly diagnosed patients with JIA in Canada have intensified, and now 81% of patients attain CID within 1 year of diagnosis.

Background Treatments for juvenile idiopathic arthritis (JIA) are changing rapidly. Healthcare providers and families require up-to-date knowledge of current treatment practices and expected outcomes to inform their decisions. Objectives To assess changes in treatment practices and outcomes for children in a new Canadian inception cohort diagnosed with JIA in 2017-2018, compared to children in the Research in Arthritis in Canadian Children emphasizing Outcomes cohort (ReACCh-Out) diagnosed in 2005-2010 1. Methods A new investigator-driven Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) JIA Registry was started in February 2017 to prospectively collect information on children enrolled within 3 months of JIA diagnosis. Information about disease activity, treatments, outcomes and adverse events is collected at all clinic visits. Registry data were extracted in October 2018 and clinical characteristics at presentation, use of anti-rheumatic medications, attainment of inactive disease, cJADAS10 scores and adverse events were described. Selected findings were compared to those observed in the ReACCh-Out cohort. The proportion of patients (cumulative incidence) receiving various treatments and their outcomes were estimated with Kaplan Meier survival methods. Results A total of 166 patients enrolled a median of 6 weeks after diagnosis at 10 centres were included. Median age at diagnosis was 9 years (IQR 3, 13), 61% were female and 51% had oligoarthritis. At enrolment, subjects had a median of 2 active joints (IQR 1, 3), a Physician Global Assessment of 3 (1.5, 4) and a Parent Global Assessment of 1 (0, 3). The median cJADAS10 score was 6.5 (4, 10). Table 1 compares baseline characteristics and the cumulative incidence of medication use and inactive disease at one year after diagnosis with those observed in the ReACCh-Out cohort, diagnosed on average 10 years earlier. Figure 1 shows the Kaplan Meier curves for attainment of inactive disease. Conclusion In Canada, treatments for newly diagnosed patients with JIA have intensified in the last 10 years, and 35% will now start their first biologic within 1 year of diagnosis. Short-term outcomes have improved, 81% of current patients now attaining inactive disease within one year of diagnosis. Funding: The Arthritis Society, Canada. References [1] Guzman J, Oen K, Tucker LB, et al. The outcomes of juvenile idiopathic arthritis in children managed with contemporary treatments: results from the ReACCh-Out cohort. Ann Rheum Dis.2015;74:1854-60 Acknowledgement Funding: The Arthritis Society, Canada. Disclosure of Interests Jaime Guzman: None declared, Michelle Batthish Speakers bureau: Novartis, Abbvie, Roberta Berard: None declared, Roxana Bolaria: None declared, David Cabral: None declared, Gaëlle Chédeville: None declared, Ciaran Duffy: None declared, Kerstin Gerhold: None declared, Tommy Gerschman: None declared, Adam Huber: None declared, Jean-Philippe Proulx-Gauthier: None declared, Alan Rosenberg: None declared, Dax Rumsey: None declared, Heinrike Schmeling Grant/research support from: F. Hoffmann-La Roche Ltd, Natalie Shiff: None declared, Gordon Soon: None declared, Lori Tucker: None declared