1 Rat Bite Fever Resembling Rheumatoid Arthritis in a 46 Year Old Female



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Results: Counting the maximum number of erosions seen on 1 slice for each of the 4 articular surfaces (total erosion score) was not inferior to counting the number of erosions seen on every slice in either transverse or coronal views. A total erosion score of ≥3 had the highest sensitivity and specificity for AS. Within the derivation cohort, the presence of ankylosis or a total erosion score of ≥3 had a sensitivity and specificity of 100%. Features with the highest +LR included ankylosis, number of erosions, iliac sclerosis >0.5cm, and sacral sclerosis >0.3cm. Inter-reader reliability for these variables were 1.0 for ankylosis, 0.99 for number of iliac erosions, 0.99 for number of sacral erosions, 0.58 for iliac sclerosis, and 0.39 for sacral sclerosis. Within the validation cohort, the presence of >1cm of ankylosis or a total erosion score of ≥3 resulted in a sensitivity of 91% and specificity of 91%. The addition of >0.5cm of iliac sclerosis or >0.3cm of sacral sclerosis marginally increased the sensitivity to 94% but decreased specificity to 85%.
Conclusion: It is proposed that the presence of ankylosis >1cm or ≥3 total erosions has an optimal sensitivity and specificity for AS.  
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Acute Anterior Uveitis in Ankylosing Spondylitis: Association with Inflammatory Bowel Disease and Psoriasis Independent of HLA B27
Ahmed Omar (Toronto Western Research Institute, University of Toronto, Ontario, Canada., Toronto, ON); Tristan Boyd (Rheumatology Division, St. Joseph's Health Care, London); Ismail Sari (Toronto Western Hospital, Toronto, Toronto); Arane Thavaneswaran (NA, Toronto); Renise Ayearst (University Health Network, Toronto); Robert Inman (University Health Network, Toronto); Nigil Haroon (University Health Network, Toronto)
Objectives: Acute anterior uveitis (AAU) is the most common extra-articular manifestation in patients with ankylosing spondylitis (AS), developing in 20-30% of these patients during the course of their disease. Our aim was to study the characteristics and risk factors associated with AAU in our cohort of AS patients.  
Methods: From our longitudinal observational cohort, 716 patients with AS (meeting modified New York Criteria) and at least 2 years follow up were included and who were followed from January 2006 to November 2013. Patients with (AAU+) and without (AAU-) uveitis were compared. T-test, Chi-squared tests and logistic regression were used where appropriate.  
Results: Of the 716 patients, 225 (31.4%) had a reported diagnosis of AAU at their baseline clinic visit. Patients with AAU+ were older compared to the AAU- group (mean age of 42.6 vs 37.9 years; p< 0.001). AAU started after onset of back pain in the majority of patients with only 10.5% of patients reporting onset of AAU before onset of AS related back pain. Patients with AAU had higher HLA-B27 (B27) prevalence (91.8% vs 82.1%, p<0.05). In the multivariate analysis (MVA),  AAU was independently associated with age,  B27, psoriasis, IBD and elevated CRP.  B27 (OR=2.66 [95% CI=1.44-4.9]), psoriasis (OR=2.36 [95% CI=1.41-3.97]) and IBD (OR=2.25 [95% CI=1.27-4]) are the strongest independent predictors of AAU.  Within the AS/IBD group (n=86), 43% of these patients had a history of AAU, of which 81% were B27 positive. In patients with AAU , there was a trend towards more peripheral arthritis/enthesitis. The BASMI score was higher in patients with AAU (3.3 vs 2.7, P<0.05), however there was no association found on MVA. No significant difference was found between the two groups in terms of BASDAI score, hypertension, diabetes, previous history of myocardial infarctions and smoking. There was no difference found between NSAID use at baseline (66.1% vs. 66.5%, p=0.90). Patients with AAU were more frequently treated with DMARDs (26% vs. 16.5%, p<0.01). Sulfasalazine was used more frequently in the AAU+ group (14.2% vs. 7.9%, p<0.01). Use of biologics was similar at baseline (22.2% vs. 18.4%, p=0.23). 
Conclusion: In our cohort of AS patients, an increased frequency of HLA-B27 was seen in AAU+ AS. AAU+ AS is associated with psoriasis and IBD. The psoriasis and IBD association is independent of HLA-B27, suggesting an interaction of other genetic as well as environmental factors. At baseline DMARD use was associated with AAU, likely reflecting the association with peripheral joint disease.  
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Prevalence of Sacroiliitis in Inflammatory Bowel Disease Using a Standardized CT Screening Tool
Jonathan Chan (UBC, Vancouver); Ismail Sari (Toronto Western Hospital, Toronto, Toronto); David Salonen (Toronto Western Hospital, University of Toronto, Toronto); Mark Silverberg (Mount Sinai Hospital, Toronto); Nigil Haroon (University Health Network, Toronto); Robert Inman (University Health Network, Toronto)
Objectives: Previous studies assessing the prevalence of sacroiliitis in patients with inflammatory bowel disease (IBD) using CT scans have relied on a radiologist’s gestalt. These estimates have ranged between 30-45%; however, only a small proportion of these patients were symptomatic and only patients who had symptoms suggestive of spondylitis had an increased frequency of HLA-B27. To date, the prevalence of sacroiliitis in IBD patients using a validated CT screening tool is not known. Our aim is to determine the prevalence of sacroiliitis in patients with IBD using a validated standardized CT screening tool and to compare this prevalence to that in a non-IBD control population.  
Methods: 306 IBD were recruited from one gastroenterology clinic and 108 control patients were recruited from a urology clinic. The chart of each control patient was reviewed to ensure there was no history suggestive of spondyloarthritis. We utilized a CT scan screening tool that had been previously developed and validated to have a sensitivity of 91% and a specificity of 91% for the identification of sacroiliitis. Two readers blinded to each patient’s clinical information scored the CT scans as positive if there was >1cm of ankylosis or ≥3 total erosion score. The presence of lumbar spine syndesmophytes and radiologists comments of the SI joints were noted.
Results: There was no significant difference in prevalence of sacroiliitis between patients with Crohn's disease (CD) and Ulcerative colitis (UC) (Chi2 test= 0.725). The prevalence of sacroiliitis amongst control, CD, and UC patients were 5.6%, 15.0%, and 16.9% respectively. Amongst the 49 CT scan positive patients, the radiologist commented on 39 images and described 59% as having normal SI joints. 9/49 patients had lumbar syndesmophytes. 21/49 patients were able to be contacted and 14% had a previous diagnosis of spondyloarthritis. Amongst the 267 CT scan negative patients, radiologists commented on 184 images and noted 5 definite and 4 possible cases of sacroiliitis.  
Conclusion: We report that the prevalence of sacroiliitis in IBD patients is 16% with no difference between CD and UC patients. There was a major discordance between the use of a validated CT screening tool and radiologist’s gestalt for the identification of sacroiliitis. Despite the awareness of the strong relationship between IBD and spondyloarthritis, a significant proportion of patients are missed. Finally, there may be a small proportion of asymptomatic patients who have changes in their sacroiliac joints suggestive of sacroiliitis, though this is of uncertain clinical significance.  
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Twitter and Rheumatology: Significant and Incremental Growth in Usage
Ahmed Omar (Toronto Western Research Institute, University of Toronto, Ontario, Canada., Toronto, ON); Ismail Sari (Toronto Western Hospital, Toronto, Toronto); Jonathan Chan (UBC, Vancouver); Nigil Haroon (University Health Network, Toronto); Robert Inman (University Health Network, Toronto)
Objectives: The continued growth of social media has allowed people to rapidly communicate, share, and develop ideas and information.  Twitter is an online social networking service which allows users to submit and to read short 140 character messages called "tweets". Since its creation in 2006, its user base has continued to grow with an estimated current active user base of half a billion people. Sixty million tweets are estimated to be generated each day. Twitter can be a valuable portal to educate patients, share research ideas and findings and increase awareness of important health related issues. With regards to Rheumatology, there is lack of knowledge in terms of its online twitter presence and its development over the years. The aim of this study is to highlight the use of Twitter in relation to Rheumatology. To the best of our knowledge, no previous research has examined this area before.
Methods: The Symplur® healthcare analytics website was used to retrospectively examine traffic related to chosen Rheumatology associated hashtags. Symplur® was used to generate statistics for the number of impressions, unique tweets (excluding retweets) and number of participants. Some of the hashtags chosen include: #Rheum, #Lupus, #Fibro, #Arthritis, #Osteoporosis, #Spondylitis (AS), #RheumatoidArthritis, and #Vasculitis. #Diabetes, #IBD (Inflammatory Bowel Disease), and #Psoriasis were also chosen as comparators.  Statistics were obtained from a 5 year period (2010 to 2014).
Results: The total number of  Rheumatology related tweets related to the major hashtags grew from only 319 tweets in 2010 to 497,595 tweets in 2014. The #Lupus hashtag showed the most activity, followed by #Fibro (fibromyalgia), #Arthritis and #Rheum. Between the years 2013 and 2014, there was an average growth in number of total tweets by 37%. When comparing #Diabetes with Rheumatology related hashtags in 2014, there were a total of 1,037,211 tweets related to #Diabetes vs 538,186 tweets related to #Rheum hashtags. In terms of number of contributors, in 2014, there were a total of 135,237 participants using Rheumatology related hashtags.  When looking at influence, the top 10 contributors tweeting in the #lupus, #RheumatoidArthritis and #Spondylitis hashtags contributed 12.6 %, 11% and 61.4% of total number of tweets respectively
Conclusion: Twitter usage in relation to Rheumatology has shown a dramatic growth over the last 5 years and continues to show sustained growth.  These novel findings suggest this social media portal has the potential to be a valuable tool in informing and shaping Rheumatology related healthcare.
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Internal Medicine Resident Knowledge and Perceptions about Rheumatology – Results from the MSQuébec Workshop
Mayank Jha (McGill University, Montreal); Denis Choquette (Institut de rhumatologie de montréal, Montréal); Nancy Fortin (Association des medecins rhumatologues du Quebec, Montreal); Marie Hudson (McGill University, Jewish General Hospital, Lady Davis Institute for medical research,, Montreal)
Objectives: MSQuébec is an annual workshop offered by the Association des Médecins Rhumatologues du Québec to PGY1 and PGY2 internal medicine residents for over 10 years. The aim is to introduce rheumatology to residents early in their training by teaching musculoskeletal exam and introduction to rheumatology in a highly motivating setting. The program consists of 8 level-one (4 physical exam [shoulder, knee, hand, spine], musculoskeletal ultrasound, videocapillaroscopy, lab testing and approach to arthritis) and 6 level-two (osteoporosis, spondyloarthropathies, connective tissue diseases, vasculitis, advanced therapeutics, joint injection techniques) workshops for first and second time participants, respectively. Since its inception, the workshop has run at full capacity and the majority of fellows recruited in the Quebec rheumatology training programs are graduates of the workshop. While these provide some measures of effectiveness, the objective of the current study was to measure the impact of the workshop on resident knowledge and perceptions.
Methods: A survey was developed by the faculty to test resident knowledge of and perceptions to rheumatology. The survey was administered a first time (pre-test) at the time of registration for the workshop and a second time (post-test) in the 2 weeks following the completion of the workshop. Fourteen knowledge questions were scored as right or wrong and 9 perception questions were scored using a 5-point Likert scale (ranging from 1 [poor] to 5 [excellent]). Pre- and post-test Results were compared using paired t-tests and Wilcoxon signed-rank test.
Results: The responses from 50 residents (38 level-one and 12 level-two) participating in the 2015 workshop were analyzed. The post-test score was significantly better than the pre-test score (11.4±1.7 (81%) vs 9.2±2.3 (66%); mean difference 2.2, 95% CI, 1.4 to 3.1, p < 0.001). Pre-test scores of level-two compared to level-one residents were significantly better as well (10.6±1.2 vs 8.8±2.1, mean difference 1.9, 95% CI, 0.8 to 2.9, p < 0.001). There was significant improvement in how residents perceived their skills (eg. post vs pre-test ratings for hand exam 3.4 vs 2.2, p < 0.001, lab testing 3.2 vs 1.9, p < 0.001, differential diagnosis 3.2 vs 2.3, p < 0.001).
Conclusion: The MSQuébec annual rheumatology workshop is associated with significant improvement in internal medicine residents’ knowledge and perceptions in key rheumatology topics, with potential long-term benefits indicated by higher pre-test scores for second time participants. This workshop can be used to inform efforts underway in other provinces to develop rheumatology training for internal medicine residents.
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The Validity and Reliability of Online Obituaries as a Source of Mortality Data
Medha Soowamber (University of Toronto, Toronto); John Granton (Univeristiy Health Network Pulmonary Hypertension Programme, Toronto General Hospital and University of Toronto, Toronto); Fatemeh Bavaghar-Zaeimi (Toronto Scleroderma Program, Toronto Western Hospital and Mount Sinai Hospital, Toronto); Sindhu Johnson (Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Toronto)
Objectives: Loss to follow-up is a major threat to the conduct of chronic disease cohort research. Tracking the survival status of patients who are lost to follow-up is limited by restricted access to death certificate data and patients moving. One strategy to gather mortality data is to use online obituaries. Although commonly used clinically, it is uncertain if this is appropriate for research. The primary objective of this study was to evaluate the validity and reliability of online obituaries as a source of mortality data in 2 chronic diseases, systemic sclerosis (SSc) and idiopathic pulmonary arterial hypertension (IPAH). 
Methods: Patients whose survival status was known were randomly selected from the Toronto Scleroderma Program and the University Health Network Pulmonary Hypertension Program. Five commonly used online obituaries were evaluated. Two investigators, blinded to survival status, independently entered the first and last name of each patient in each website. If the patient was identified as deceased, other matching variables (date of birth, postal code, disease) were used to verify the patient. Pearson’s correlation coefficient (r) was used to evaluate the correlation between the website finding and actual survival status. Intra-rater and inter-rater reliability was evaluated using the intra-class correlation coefficient (ICC). 
Results: We studied 365 patients (273 females, 92 males) including 219 SSc (171 females, 48 males) and 146 IPAH (102 females, 44 males) patients. There was a significant positive correlation between website 1 and the actual survival status (r = 0.36 (95%CI 0.27, 0.45, p<0.001)) and was similar across diseases, SSc (r=0.34 (95%CI 0.21, 0.45, p<0.001) and IPAH (r=0.41 (95% CI 0.26, 0.53, p<0.001). The ICC for the intra-rater reliability of websites 1 and 3 were 0.95 (95%CI 0.93, 0.96) and 0.96 (95%CI 0.95, 0.97) respectively, which were higher compared website 2, 4, 5 (0.77 (95%CI 0.72, 0.80), 0.75 (95%CI 0.71, 0.80) and 0.21 (95%CI 0.11, 0.31) respectively). The ICC for inter-rater reliability was strong (0.82 (95%CI 0.78, 0.85).
Conclusion: Use of selected online obituaries is a valid and reliable method to gather mortality data.  They could be used in clinical research to track patients who are lost to follow up.
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What is the Location of Enthesitis in Ankylosing Spondylitis and Psoriatic Arthritis Patients and How Do They Respond to Anti-TNF Treatment?
John Kelsall (Mary Pack Arthritis Centre, Vancouver); Denis Choquette (Institut de rhumatologie de montréal, Montréal); Proton Rahman (Memorial University, St. John’s); Regan Arendse (University of Saskatchewan, Saskatoon); Michelle Teo (n/a, Penticton); Isabelle Fortin (CH Rimouski, Rimouski); Antonio Avina-Zubieta (Arthritis Research Centre of Canada, Richmond); Emmanouil Rampakakis (JSS Medical Research, Montreal); Eliofotisti Psaradellis (JSS Medical Research, St-Laurent); Karina Maslova (Janssen Inc, Toronto); Brendan Osborne (Janssen Inc, Toronto); Cathy Tkaczyk (Janssen Inc, Toronto); Francois Nantel (Janssen Inc, Toronto); Allen Lehman (Janssen Inc, Toronto)
Objectives: To identify the location of enthesitis in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) patients and to determine their response to anti-TNF treatment.
Methods: BioTRAC is an ongoing, prospective registry of patients initiating treatment for rheumatoid arthritis, AS, or PsA with infliximab (IFX) or golimumab (GLM). Eligible people for this analysis included AS and PsA patients treated with IFX who were enrolled since 2005 or with GLM enrolled since 2010 who had available information on enthesitis. The paired sampled t-test was used to compare the enthesitis count at baseline and 12 months. 
Results: A total of 260 AS patients and 261 PsA patients were enrolled with a mean (SD) age at baseline of 46.1 (13.0) vs. 50.0 (12.0) years, respectively, and disease duration of 6.4 (9.8) vs. 5.2 (6.8) years. Among patients with AS, 28.1%, 21.7%, 22.4% had enthesitis at baseline, 6 months and 12 months, respectively. For PsA these numbers were 32.2%, 19.7%, and 22.6%, respectively. The presence of enthesitis by anatomical site included higher proportions observed for the greater trochanter (GT) in AS patients (14.2%) and the lateral epicondyle humerus (LEH) in PsA patients (16.1%).  Among AS patients, enthesitis was also present at the suprapsinatus insertion (SI;11.5%), lateral epicondyle humerus (LEH; 10.8%), proximal achilles (PA;10.8%), medial epicondyle humerus (MEH;8.1%), insertion plantar fascia (IPF;7.7%), quadriceps insertion patella (QIP;6.9%), and inferior pole patella or tibial tubercle (PATT;6.9%). Among PsA patients, enthesitis also was present at the PATT (13.8%), PA (13.0%), MEH (12.6%), IPF (11.9%), GT (10.7%), SI (10.7%), and QIP (9.6%). Presence of enthesitis in all anatomical sites was significantly associated with higher HAQ among AS and PsA patients.  The mean (SD) enthesitis count at baseline and 12 months was 4.4 (3.4) vs. 2.6 (2.3) (P=0.061) among AS patients and 5.0 (3.8) vs. 3.8 (3.0) (P=0.006) in PsA patients, respectively.   
Conclusion: A considerable proportion of PsA and AS patients had enthesitis at anti-TNF initiation in this Canadian real-world cohort. Overall, presence of enthesitis was associated with significantly higher functional disability. Treatment with IFX or GLM for 12 months was associated with significant reduction in the mean enthesitis count. 
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Effectiveness and Safety of Golimumab in the Treatment of Rheumatoid Arthritis over a 24 Month Period
William Bensen (McMaster University, St. Joseph`s Healthcare Hamilton, Hamilton); John Kelsall (Mary Pack Arthritis Centre, Vancouver); Denis Choquette (Institut de rhumatologie de montréal, Montréal); Maqbool Sheriff (Nanaimo Regional Hospital, Nanaimo); Andrew Chow (Credit Valley Rheumatology, Mississauga); Dalton Sholter (University of Alberta, Edmonton); Isabelle Fortin (CH Rimouski, Rimouski); Milton Baker (University of Victoria, Victoria); Emmanouil Rampakakis (JSS Medical Research, Montreal); Eliofotisti Psaradellis (JSS Medical Research, St-Laurent); Francois Nantel (Janssen Inc, Toronto); Karina Maslova (Janssen Inc, Toronto); Cathy Tkaczyk (Janssen Inc, Toronto); Allen Lehman (Janssen Inc, Toronto); Brendan Osborne (Janssen Inc, Toronto)
Objectives: Although the efficacy and tolerability of golimumab (GLM) in patients with rheumatoid arthritis (RA) has been demonstrated in several controlled clinical trials, it is essential to assess the real-life effectiveness of therapeutic interventions and demonstrate true population-based benefits. The aim of this analysis was to describe the real-life effectiveness of golimumab in RA patients in a Canadian routine clinical practice setting.
Methods: BioTRAC is an ongoing, prospective registry of patients initiating treatment for RA, ankylosing spondylitis, or PsA with infliximab or GLM. Eligible participants for this analysis included RA patients treated with GLM enrolled since 2010.  Descriptive statistics were produced for clinical outcome measures and patient reported outcomes at baseline and 6, 12, and 24 months of treatment. Within-group changes were assessed for statistical significance with the paired-samples Student’s t-test. Safety was assessed with the incidence of adverse events/100 patient-years.
Results: A total of 318 RA patients were included in this analysis.  The majority were female (72.4%), the mean (SD) age was 57.3 (13.5) years and disease duration since diagnosis was 8.0 (8.6) years. At baseline, the proportion of patients taking concomitant DMARDS, NSAIDS and corticosteroids were, 65.1%, 26.7%, and 18.9%, respectively.  92.8% of patients were biologic naïve. Six-month, 12-month, and 24-month follow-up was available for 236 (74.2%), 171 (53.8%), and 79 (24.8%) patients, respectively. After 6 months of treatment, statistically significant (P<0.001) and clinically meaningful improvements were observed for all disease parameters and were sustained over 24 months of treatment (P<0.001).  The proportion of patients who achieved DAS28 remission at 6, 12, and 24 months was 33.0%, 38.8%, and 42.6%, respectively; SDAI remission was 16.7%, 30.6%, and 33.9%; and CDAI remission was 14.6%, 21.2%, and 25.0%, respectively. A total of 419 AEs (150.3 events/100 patient-years) were reported by 150 (47.2%) patients and 50 (17.9 events/100 patient-years) serious AEs (SAEs) by 39 (12.3%) patients.  The incidence of infections and malignancies were 9 (3.2 events/100 patient-years and 4 (1.4 events/100 patient-years SAEs, respectively. Three deaths were reported during the course of the study (lung adenocarcinoma metastatic, cardiac disorder, and cerebrovascular accident), of which the latter was judged by the treating physician as possibly related to golimumab.
Conclusion: The Results of this Canadian longitudinal observational study have shown that GLM is well tolerated and effective in reducing symptom severity and improving disease outcomes in RA patients over a 2 year period. 
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Minimal Disease Activity among Psoriatic Arthritis Patients in Canada: Which Unmet Criteria are more Prevalent among Responders?
Antonio Avina-Zubieta (Arthritis Research Centre of Canada, Richmond); Andrew Chow (Credit Valley Rheumatology, Mississauga); Philip Baer (Private Practice, Scarborough); John Kelsall (Mary Pack Arthritis Centre, Vancouver); Proton Rahman (Memorial University, St. John’s); Jaqueline Stewart (Penticton); Boulos Haraoui (Institut de Rhumatologie de Montréal, Montreal); Michel Zummer (Université de Montréal, Département de médecine, Montreal); Emmanouil Rampakakis (JSS Medical Research, Montreal); Eliofotisti Psaradellis (JSS Medical Research, St-Laurent); Francois Nantel (Janssen Inc, Toronto); Karina Maslova (Janssen Inc, Toronto); Cathy Tkaczyk (Janssen Inc, Toronto); Brendan Osborne (Janssen Inc, Toronto); Allen Lehman (Janssen Inc, Toronto)
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