Alyssa Michelle Howren

All Publications

• Mental healthcare utilisation among individuals with colorectal cancer: population-based cohort studies. BMJ oncology Cheng, V., Sayre, E. C., Cheng, V., Loree, J. M., Gill, S., Murphy, R. A., Howren, A., De Vera, M. A. 2025; 4 (1): e000690

  Abstract

  Individuals with colorectal cancer (CRC) have an increased risk of mental disorders, yet mental healthcare utilisation has not been adequately examined. We evaluated mental healthcare utilisation and receipt of minimally adequate treatments for anxiety and/or depression among individuals with and without CRC.We used administrative health databases from British Columbia, Canada, comprised of individuals with CRC and individuals without CRC, matched (1:1 ratio) on age, sex and incident mental disorder(s) (ie, occurring after CRC diagnosis/matched date). Primary outcomes were minimally adequate antidepressant pharmacotherapy (≥84 days' supply) and psychological (≥4 services) treatment.Among individuals with CRC, 1462 had incident anxiety (mean age 64.6±12.5 years, 59.2% females), 4640 had incident depression (mean age 66.3±12.3 years, 51.2% females). Approximately one in four individuals with CRC were diagnosed with anxiety (23.4%) and/or depression (23.2%) in the first year after CRC diagnosis. Minimally adequate antidepressant pharmacotherapy (36.2%) and psychological treatment (15.9%) for anxiety were significantly lower in CRC patients than in those without CRC (pharmacotherapy adjusted OR (aOR) 0.74; 95% CI 0.61, 0.88; psychological treatment aOR 0.74; 95% CI 0.58, 0.95). Similar findings were observed for depression (pharmacotherapy aOR 0.81; 95% CI 0.74, 0.90). Among individuals with CRC, mental healthcare utilisation persisted up to 10 years post-mental disorder diagnosis.Individuals with CRC receive less mental health treatment for anxiety and/or depression, compared with those without CRC. Findings raise awareness for the need for ongoing mental healthcare throughout and beyond CRC.

  View details for DOI 10.1136/bmjonc-2024-000690

  View details for PubMedID 40177172

  View details for PubMedCentralID PMC11962786

• Do individuals with inflammatory arthritis receive minimally adequate treatment for incident depression and anxiety: A population-based study ARTHRITIS RESEARCH & THERAPY Howren, A., Sayre, E. C., Avina-Zubieta, J., Puyat, J. H., Da Costa, D., Xie, H., Davidson, E., Gupta, A., De Vera, M. A. 2025; 27 (1): 13

  Abstract

  Describe patterns of pharmacotherapy and psychological treatment and evaluate receipt of minimally adequate treatment for incident depression and anxiety in individuals with inflammatory arthritis (IA).We used population-based linked administrative health databases from British Columbia, Canada to evaluate pharmacotherapy and psychological treatments for incident depression and/or anxiety among individuals with IA and without IA ('IA-free controls'). We defined minimally adequate pharmacotherapy as antidepressant prescriptions filled with ≥ 84 days' supply and adequate psychological treatment as ≥ 4 counselling/psychotherapy services. Multivariable logistic regression models were used to evaluate the odds of individuals with IA receiving minimally adequate pharmacotherapy and/or psychological treatment compared to IA-free controls.6,951 (mean age 54.8 ± 18.3 years; 65.5% female) individuals with IA had incident depression and 3,701 (mean age 52.9 ± 16.8 years; 74.3% female) had incident anxiety. Minimally adequate pharmacotherapy and psychological treatment for depression was respectively observed in 50.5% and 19.6% of those with IA, proportions similar to IA-free controls (pharmacotherapy: aOR 1.10, 95% CI 1.00 to 1.21; psychological: aOR 1.07, 95% CI 0.94 to 1.21). Results were similar regarding anxiety treatment. Individuals with IA had a significantly greater likelihood of dispensing ≥ 1 benzodiazepine (anxiety: IA 45.0%, IA-free controls 39.0%, p-value < 0.001) and ≥ 1 tricyclic antidepressant prescription (anxiety: IA 12.8%, IA-free controls 7.8%, p-value < 0.001). Significantly higher average days' supply of benzodiazepines was observed for IA (anxiety: IA 123.7 days, controls 112.4 days, p-value = 0.003).A substantial proportion of individuals with IA were not receiving adequate mental health treatment for depression and anxiety, a finding similar for IA-free controls. The undertreatment of mental disorders for people with IA has well-known negative implications for the provision of effective rheumatology care. It remains fundamental to expand publicly funded health care to include mental health services in an effort to address unmet counselling needs.

  View details for DOI 10.1186/s13075-024-03466-8

  View details for Web of Science ID 001403053900001

  View details for PubMedID 39838484

  View details for PubMedCentralID PMC11748246

• Beyond the Symptoms: Exploring Cognitive Bias in Lupus Diagnosis Within Primary Care Howren, A., Quan Le Tran, Sediqi, S., Hawa, S., Linos, E., Falasinnu, T., Chaichian, Y., Simard, J. WILEY. 2024: 374-375

  View details for Web of Science ID 001331419100192

• "What Came First?" Population-Based Evaluation of Health Care Encounters for Depression and Anxiety Before and After Inflammatory Arthritis Diagnosis: Disentangling the Relationship Between Mental Health and Arthritis ARTHRITIS CARE & RESEARCH Howren, A., Sayre, E. C., Avina-Zubieta, J., Puyat, J. H., Da Costa, D., Xie, H., Davidson, E., De Vera, M. A. 2024; 76 (5): 743-752

  Abstract

  The study objective was to describe patterns of depression and anxiety health care use before and after diagnosis among patients with inflammatory arthritis (IA), namely, ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis.We used population-based linked administrative health data from British Columbia, Canada, to build a cohort of individuals (≥18 years) with incident IA and individuals without IA ("IA-free controls") matched on age and sex. We computed the proportion of individuals with IA and controls who had one or more depression or one or more anxiety health care encounters and the use of one or more antidepressants or one or more anxiolytics in each yearly interval five years before and after IA diagnosis. We used multivariable logistic regression models to evaluate the association between IA status and aforementioned depression and anxiety health care use outcomes in each yearly interval.A total of 80,238 individuals with IA (62.9% female; mean ± SD age 56.2 ± 16.7 years) and 80,238 IA-free controls (62.9% female; mean ± SD age 56.2 ± 16.6 years) were identified between January 1, 2001, and March 31, 2018. Individuals with IA had significantly increased odds of depression and anxiety health care encounters and dispensation of antidepressants and anxiolytics for each yearly interval before and after diagnosis. Adjusted odds ratios (ORs) were highest in the year immediately before (one or more depression visits: adjusted OR 1.61, 95% confidence interval [CI] 1.55-1.66; one or more anxiolytics: adjusted OR 1.71, 95% CI 1.66-1.77) or after (one or more antidepressants: adjusted OR 1.95, 95% CI 1.89-2.00) IA diagnosis.Findings suggest a role for depression and anxiety in characterizing the IA prodrome period and generate hypotheses regarding overlapping biopsychosocial processes that link IA and mental health comorbidities.

  View details for DOI 10.1002/acr.25294

  View details for Web of Science ID 001176366700001

  View details for PubMedID 38191988

• Evaluation of the Receipt of Adequate Pharmacological and Psychological Treatment for Incident Depression and Anxiety in Individuals Living with Inflammatory Arthritis Howren, A., Sayre, E., Avina-Zubieta, A., Puyat, J., Da Costa, D., Xie, H., Gupta, A., De Vera, M. WILEY. 2023: 3686-3688

  View details for Web of Science ID 001190014303358

• Impact of Loneliness and Social Isolation on Mental Health Outcomes Among Individuals With Rheumatic Diseases During the COVID-19 Pandemic ACR OPEN RHEUMATOLOGY Howren, A., Avina-Zubieta, J., Puyat, J. H., Da Costa, D., Xie, H., Davidson, E., Rebic, N., Gastonguay, L., Dau, H., De Vera, M. A. 2023; 5 (5): 243-250

  Abstract

  The study objective was to assess mental and social health outcomes for individuals with rheumatic disease during the COVID-19 pandemic and evaluate the relationship of loneliness and social isolation with depression and anxiety.We administered an international cross-sectional online survey to individuals with rheumatic disease(s) (≥18 years) between April 2020 and September 2020, with a follow-up survey from December 2020 to February 2021. We used questionnaires to evaluate loneliness (3-item UCLA Loneliness Scale [UCLA-3]), social isolation (Lubben Social Network Scale [LSNS-6]), depression (Patient Health Questionnaire [PHQ-9]), and anxiety (Generalized Anxiety Disorder 7-item [GAD-7] Scale). We used multivariable linear regression models to evaluate the cross-sectional associations of loneliness and social isolation with depression and anxiety at baseline.Seven hundred eighteen individuals (91.4% women, mean age: 45.4 ± 14.2 years) participated in the baseline survey, and 344 completed the follow-up survey. Overall, 51.1% of participants experienced loneliness (UCLA-3 score ≥6) and 30.3% experienced social isolation (LSNS-6 score <12) at baseline. Depression (PHQ-9 score ≥10) and anxiety (GAD-7 score ≥10) were experienced by 42.8% and 34.0% of participants at baseline, respectively. Multivariable models showed that experiencing both loneliness and social isolation, in comparison to experiencing neither, was significantly associated with an average 7.27 higher depression score (ß = 7.27; 95% confidence interval [CI]: 6.08-8.47) and 5.14 higher anxiety score (ß = 5.14; 95% CI: 4.00-6.28).Aside from showing substantial experience of loneliness and social isolation during the COVID-19 pandemic, our survey showed significant associations with depression and anxiety. Patient supports to address social health have potential implications for also supporting mental health.

  View details for DOI 10.1002/acr2.11539

  View details for Web of Science ID 000956199700001

  View details for PubMedID 36964954

  View details for PubMedCentralID PMC10184014

• Onset of depression and anxiety among patients with gout after diagnosis: a population-based incident cohort study BMC RHEUMATOLOGY Howren, A., Sayre, E. C., Choi, H. K., Avina-Zubieta, J., Shojania, K., Park, J. Y., De Vera, M. A. 2022; 6 (1): 56

  Abstract

  Gout may be associated with an increased incidence of mental health disorders, however, published findings have been limited and inconsistent. Therefore, our objective was to conduct a population-based cohort study to evaluate the incidence of depression and anxiety after gout diagnosis.We used linked population-based administrative health data in British Columbia, Canada that includes information on demographics, outpatient visits, and inpatient visits from the period of January 1, 1990 to March 31, 2018. We assessed depression and anxiety using validated International Classification of Diseases, 9th and 10th Revision coding algorithms. We applied multivariable Cox proportional hazard models to evaluate incident depression and anxiety among patients with gout in comparison to non-gout controls, adjusting for age, sex, neighbourhood income quintile, residence, comorbidities, and health care utilization.We included 157,426 incident cases of gout (60.2% male; mean age 57.1 years) and 157,426 non-gout controls (60.2% male; mean age 56.9 years). The incidence rate of depression among individuals with gout and non-gout controls was 12.9 (95% confidence interval [CI] 12.7-13.2) and 11.1 (95% CI 10.9-11.4) per 1000 person-years, respectively. The incidence rate of anxiety for those with gout was 5.4 (95% CI 5.3-5.5) per 1000 person-years and for non-gout controls was 4.6 (95% CI 4.4-4.7) per 1000 person-years. Individuals with gout had an increased onset of depression (adjusted hazard ratio [aHR], 1.08; 95% CI 1.05-1.11) and anxiety (aHR, 1.10; 95% CI 1.05-1.14) compared to non-gout controls.Our population-based study shows an increased incidence of depression and anxiety following gout diagnosis in comparison to non-gout controls. Findings suggest the importance of considering psychiatric impacts in addition to the physical impacts of gout.

  View details for DOI 10.1186/s41927-022-00288-6

  View details for Web of Science ID 000862711300001

  View details for PubMedID 36184626

  View details for PubMedCentralID PMC9528093

• Risk of Anxiety and Depression after Diagnosis of Young-Onset Colorectal Cancer: A Population-Based Cohort Study CURRENT ONCOLOGY Howren, A., Sayre, E. C., Cheng, V., Oveisi, N., McTaggart-Cowan, H., Peacock, S., De Vera, M. A. 2022; 29 (5): 3072-3081

  Abstract

  Given the increasing incidence of young-onset colorectal cancer (yCRC; <50 years), we aimed to evaluate the risk of depression and anxiety in individuals with yCRC in comparison to average-age-onset CRC (aCRC; ≥50 years) and to cancer-free controls, with stratification by sex. Our cohort study identified individuals (≥18 years) with CRC and cancer-free controls (10:1) matched on age and sex using population-based linked administrative health databases in British Columbia, Canada. We assessed depression and anxiety using validated algorithms. We evaluated the risk of depression and anxiety using multivariable Cox proportional hazard models. The cohort included 54,634 individuals with CRC (46.5% female, mean age 67.9 years) and 546,340 controls (46.5% female, mean age 67.9 years). Those with yCRC as compared to aCRC had an increased risk for depression (adjusted hazard ratio [aHR] 1.41; 95% confidence interval [CI] 1.25 to 1.60), and when stratified by sex, the risk was only significant among males (aHR 1.76; 95% CI 1.48 to 2.10). When comparing individuals with yCRC to cancer-free controls, the overall risk of depression (aHR 1.00; 95% CI 0.92 to 1.10) and anxiety (aHR 1.10; 95% CI 0.95 to 1.27) was non-significant; however, males had a significantly higher risk for mental health disorders, specifically depression (aHR 1.17; 95% CI 1.03 to 1.33). Altogether, our findings that individuals with yCRC experience higher risk of depression compared to those with aCRC as well as cancer-free controls, particularly among males, suggest effects of age and sex on mental health outcomes.

  View details for DOI 10.3390/curroncol29050249

  View details for Web of Science ID 000803565500001

  View details for PubMedID 35621639

  View details for PubMedCentralID PMC9140150

• Factors Associated With Depression and Anxiety in People Living With Rheumatic Disease: Findings from an International Survey Administered During the COVID-19 Pandemic Howren, A., Avina-Zubieta, A., Da Costa, D., Puyat, J., Xie, H., De Vera, M. J RHEUMATOL PUBL CO. 2021: 1124-1125

  View details for Web of Science ID 000680554800074

• Virtual Oncology Appointments during the Initial Wave of the COVID-19 Pandemic: An International Survey of Patient Perspectives CURRENT ONCOLOGY Loree, J. M., Dau, H., Rebic, N., Howren, A., Gastonguay, L., McTaggart-Cowan, H., Gill, S., Raghav, K., De Vera, M. A. 2021; 28 (1): 671-677

  Abstract

  There has been rapid implementation of virtual oncology appointments in response to the COVID-19 pandemic, particularly in its first wave. Our objective was to assess patterns and perspectives towards virtual oncology appointments during the pandemic among patients with cancer undergoing active treatment. We conducted an international Internet-based cross-sectional survey. Participants were eligible if they (1) were ≥18 years of age; (2) had been diagnosed with cancer (3) were currently undergoing cancer treatment, and (4) spoke English or French. Between 23 April 2020 and 9 June 2020, 381 individuals accessed the survey, with 212 actively undergoing treatment for cancer, including 27% with colorectal, 21% with breast, 7% with prostate and 7% with lung cancer. A total of 52% of respondents were from Canada and 35% were from the United States. Many participants (129, 62%) indicated having had a virtual oncology appointment during the COVID-19 pandemic and most were satisfied with their experience (83%). We found older participants (≥50 years; adjusted OR 0.22, 95% CI 0.06 to 0.85 compared to <50 years) and those with shortest duration of treatment (≤3 months; adjusted OR 0.06; 95% CI 0 to 0.69 compared to >12 months) were less likely to be satisfied with virtual oncology appointments. Virtual health platforms used differed across countries with higher telephone use in Canada (87%) and other countries (86%) as compared to the United States (54%; p-value < 0.05), where there was higher use of video conferencing. Altogether, our findings demonstrate favorable patient perspectives towards virtual oncology appointments experienced during the first wave of the COVID-19 pandemic.

  View details for DOI 10.3390/curroncol28010065

  View details for Web of Science ID 000623279100065

  View details for PubMedID 33499380

  View details for PubMedCentralID PMC7924350

• Trends in the Incidence of Young-Onset Colorectal Cancer With a Focus on Years Approaching Screening Age: A Population-Based Longitudinal Study JNCI-JOURNAL OF THE NATIONAL CANCER INSTITUTE Howren, A., Sayre, E. C., Loree, J. M., Gill, S., Brown, C. J., Raval, M. J., Farooq, A., De Vera, M. A. 2021; 113 (7): 863-868

  Abstract

  With recent evidence for the increasing risk of young-onset colorectal cancer (yCRC), we had the objective to evaluate the incidence of yCRC in 1-year age increments, particularly focusing around the screening age of 50 years.We conducted a longitudinal study using linked administrative health databases in British Columbia, Canada, including a provincial cancer registry, inpatient and outpatient visits, and vital statistics from January 1, 1986, to December 31, 2016. We calculated incidence rates per 100 000 at every age from 20 to 60 years and estimated annual percent change in incidence (APCi) of yCRC using joinpoint regression analysis.We identified 3614 individuals with yCRC (49.9% women). The incidence of CRC steadily increased from 20 to 60 years, with a marked increase from 49 to 50 years (incidence rate ratio = 1.19, 95% confidence interval [CI] = 1.04 to 1.34). Furthermore, there was a trend of increased incidence of yCRC among women (APCi = 0.79%, 95% CI = 0.22% to 1.36%) and men (APCi = 2.17%, 95% CI = 1.59% to 2.76%). Analyses stratified by age yielded APCis of 2.49% (95% CI = 1.36% to 3.63%) and 0.12% (95% CI = -0.54% to 0.79%) for women aged 30-39 years and 40-49 years, respectively, and 2.97% (95% CI = 1.65% to 4.31%) and 1.86% (95% CI = 1.19% to 2.53%) for men.Our findings indicate a steady increase over 1-year age increments in the risk of yCRC during the years approaching and beyond screening age. These findings highlight the need to raise awareness as well as continue discussions regarding considerations of lowering the screening age.

  View details for DOI 10.1093/jnci/djaa220

  View details for Web of Science ID 000734339300011

  View details for PubMedID 33492399

  View details for PubMedCentralID PMC8246802

• Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis JOURNAL OF RHEUMATOLOGY Howren, A., Bowie, D., Choi, H. K., Rai, S. K., De Vera, M. A. 2021; 48 (1): 129-137

  Abstract

  To conduct a systematic review of depression and anxiety among patients with gout that specifically evaluates the prevalence, incidence, determinants, and effects of these mental health comorbidities.We conducted a literature search in Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO using indexed terms and key words to identify studies reporting on depression/anxiety in patients with gout. This review included full-text articles published in English that reported on patients with gout, evaluated depression/anxiety using a routinely reported measure, and provided estimates or sufficient data on the prevalence, incidence, determinants, or effects of depression/anxiety. Metaanalyses were conducted using random effects models.Twenty of 901 articles identified through the search strategy met our inclusion criteria. All 20 studies evaluated depression, while only 10 assessed anxiety (50%). Metaanalyses suggest a positive association between mental health disorders and gout, as resultant pooled OR were 1.29 (95% CI 1.07-1.56) for depression and 1.29 (95% CI 0.96-1.73) for anxiety. Findings from four studies reporting on the incidence of depression in patients with gout resulted in a pooled HR of 1.17 (95% CI 1.01-1.36). Significant determinants of depression included number of tophi, frequency of flares, and oligo/polyarticular gout.Our systematic review suggests that depression and anxiety are significantly associated with gout, highlighting the need for future research to focus on the onset of mental disorders after gout diagnosis. We also identify potential targets for intervention.

  View details for DOI 10.3899/jrheum.190974

  View details for Web of Science ID 000604916900021

  View details for PubMedID 32115430

• Epidemiology of depression and anxiety in patients with psoriatic arthritis: A systematic review and meta-analysis SEMINARS IN ARTHRITIS AND RHEUMATISM Zusman, E. Z., Howren, A. M., Park, J. Y. E., Dutz, J., De Vera, M. A. 2020; 50 (6): 1481-1488

  Abstract

  To conduct a systematic review and meta-analysis of the prevalence, incidence, and medication treatment of depression and anxiety among patients with psoriatic arthritis (PsA).We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO for full-length studies that: utilized an observational design; included patients with PsA with/without a comparator group; evaluated depression and/or anxiety as an outcome, comorbidity, or predictor of a health outcome; and reported relevant estimates. We pooled estimates using random effects models.Of 683 titles identified in our search, 18 studies met inclusion criteria. The pooled prevalence proportion for depression based on 11 studies was 17% (95% confidence interval [CI], 13% to 21%). In addition, a meta-analysis of four studies comparing the prevalence of depression in patients with PsA to those without PsA yielded a pooled odds ratio (OR) of 1.68 (95% CI, 1.37 to 2.08). The incidence of depression in PsA patients compared to the general population yielded a pooled incidence rate of 21.27 (95% CI, 16.28 to 26.27) per 1,000 person-years and a pooled incidence rate ratio of 1.44 (95% CI, 1.20 to 1.73). The pooled prevalence proportion of anxiety based on seven studies was 19% (95% CI, 11% to 29%) and a meta-analysis of two studies comparing the prevalence of anxiety in patients with PsA to those without PsA yielded a pooled OR of 1.49 (95% CI, 1.39 to 1.59). Only a small proportion of patients, between 2.4% and 13.5%, were reported to be taking antidepressant or antianxiety medications.We identified substantial prevalence of depression and anxiety as well as elevated incidence of depression among patients with PsA. These findings should raise awareness of the importance of mental health care in this population.

  View details for DOI 10.1016/j.semarthrit.2020.02.001

  View details for Web of Science ID 000600697500005

  View details for PubMedID 32178850

• Perinatal exposure to conventional synthetic disease-modifying anti-rheumatic drugs in women with rheumatic disease and neonatal outcomes: a population-based study CLINICAL AND EXPERIMENTAL RHEUMATOLOGY Howren, A., Rebic, N., Sayre, E. C., Tsao, N. W., Amiri, N., Baldwin, C., De Vera, M. A. 2020; 38 (6): 1080-1087

  Abstract

  Epidemiologic studies evaluating associations between specific arthritis medications and perinatal outcomes are limited. We evaluated the association between conventional synthetic DMARD (csDMARD) use among women with rheumatic disease (RD) and neonatal outcomes.We linked population-based data in British Columbia, Canada from 01/01/2002 to 12/31/2012 on all inpatient/outpatient visits and medications with a perinatal registry. For small-for-gestational-age (SGA) births, we assessed csDMARD exposure 90 days preconception or during pregnancy until date of delivery. For congenital anomalies, we determined csDMARD exposure 90 days preconception or during the first trimester. We used multivariable logistic regression models fitted with generalised estimating equations and calculated post-hoc power.There were 185 pregnancies in 175 women (31.3±5.4 years) and 6,064 pregnancies in 4,387 women (31.1±5.4 years) in the csDMARD exposed and unexposed groups, respectively. Hydroxychloroquine, azathioprine, sulfasalazine, and methotrexate exposure before or during pregnancy were not associated with SGA births. The most sufficiently powered analyses were those for hydroxychloroquine, where exposure during pregnancy resulted in an adjusted odds ratio (aOR) of 1.12 (95% confidence interval [CI], 0.65-1.94) for SGA births. Although post-hoc power calculations indicate less power to detect associations between csDMARDs and congenital anomalies, results indicate methotrexate exposure during the first trimester is associated with elevated odds for congenital anomalies (aOR 6.58, 95% CI 1.15-37.75).Findings are consistent with current guidelines regarding specific csDMARD use during the perinatal period for women with RD. It is important to report well-designed epidemiologic studies to facilitate future RD/csDMARD-specific meta-analyses.

  View details for Web of Science ID 000600601200006

  View details for PubMedID 32141437

• Virtual rheumatology appointments during the COVID-19 pandemic: an international survey of perspectives of patients with rheumatic diseases CLINICAL RHEUMATOLOGY Howren, A., Avina-Zubieta, J., Rebic, N., Dau, H., Gastonguay, L., Shojania, K., Davidson, E., De Vera, M. A. 2020; 39 (11): 3191-3193

  View details for DOI 10.1007/s10067-020-05338-3

  View details for Web of Science ID 000559939900007

  View details for PubMedID 32803570

  View details for PubMedCentralID PMC7429087

• Defining Depression and Anxiety in Individuals With Rheumatic Diseases Using Administrative Health Databases: A Systematic Review ARTHRITIS CARE & RESEARCH Howren, A., Avina-Zubieta, J., Puyat, J. H., Esdaile, J. M., Da Costa, D., De Vera, M. A. 2020; 72 (2): 243-255

  Abstract

  To conduct a systematic review to describe how administrative health databases have been used to study depression and anxiety in patients with rheumatic diseases and to synthesize the case definitions that have been applied.Search strategies to identify articles evaluating depression and anxiety among individuals with rheumatic diseases were employed in Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and PsycINFO. Studies included were those using administrative health data and reporting case definitions for depression and anxiety using International Classification of Diseases (ICD) codes. We extracted information on study design and objectives, administrative health database, specific data sources (e.g., inpatient, pharmacy records), ICD codes, operational definitions, and validity of case definitions.Of the 36 studies included in this review, all studies assessed depression, and 13 studies (36.1%) evaluated anxiety. A number of specific ICD-9/10 codes were consistently applied to identify depression and anxiety, but the overall combination of ICD codes and operational definitions varied across studies. Twenty-four studies reported operational definitions, and 19 of these studies (79.2%) combined claims from more than 1 type of administrative data source (e.g., inpatient, outpatient). Validated case definitions were used by 6 studies (16.7%), with sensitivity estimates for depression and anxiety case definitions ranging from 33% to 74% and 42% to 76%, respectively.We identified numerous case definitions used to evaluate depression and anxiety among individuals with rheumatic diseases within administrative health databases. Recommendations include using case definitions with demonstrated validity as well as operationalizing case definitions within multiple data sources.

  View details for DOI 10.1002/acr.24048

  View details for Web of Science ID 000506372700001

  View details for PubMedID 31421021

• Medication adherence teaching activity for first year pharmacy students in a Canadian university: Description and evaluation CURRENTS IN PHARMACY TEACHING AND LEARNING Seet, T., De Vera, M. A., Howren, A., Chan, D., Albon, S. 2020; 12 (1): 65-73

  Abstract

  Medication non-adherence is a significant health problem in Canada and pharmacists are ideally positioned to help patients adhere to their regimens. There is an urgent need for pharmacy schools to ensure graduates receive training in this area. In this paper, we describe a medication taking simulation activity for first year pharmacy students using a multi-method approach to evaluation.Students were provided with placebo capsules and instructed to take one capsule twice per day for two weeks, complete the Beliefs About Medications Questionnaire (BMQ) before the activity, and provide a pill count and reflection on their experiences afterwards. Quantitative analysis involved calculation of percent adherence from pill counts and establishing beliefs about medications from BMQ scores. Perceptions of the teaching activity were determined using qualitative inductive content analysis of a sub-set of student reflections.All 224 students participated and complete pill count and BMQ data was obtained from 190 students (85%). Applying a cut-off of 80% to categorize adherence status, 51.8% of students were adherent. BMQ analyses indicated collective student uncertainty in three BMQ sub-scales (specific-necessity, specific-concern, and general-overuse) and a significant difference between adherent and non-adherent students in the specific-necessity sub-scale. Qualitative analyses of a set of student reflections resulted in two major themes: (1) developing empathy and (2) learning about adherence.This activity provided opportunities for students to experience the challenges involved in medication-taking from the patient's perspective and to realize the pharmacist's role to facilitate medication adherence.

  View details for DOI 10.1016/j.cptl.2019.10.013

  View details for Web of Science ID 000502976800011

  View details for PubMedID 31843167

• The incidence of depression and anxiety in patients with ankylosing spondylitis: a systematic review and meta-analysis BMC RHEUMATOLOGY Park, J. Y. E., Howren, A. M., Zusman, E. Z., Esdaile, J. M., De Vera, M. A. 2020; 4 (1): 12

  Abstract

  As awareness for the importance of mental health continues to expand in rheumatology, it is important to understand the epidemiology of psychiatric complications in ankylosing spondylitis (AS) with the ultimate goal of future prevention and improved quality of care. This study aims to review evidence on the incidence and determinants of depression and/or anxiety among patients with AS.We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL Complete, and PsycINFO for full-length observational studies that involved a sample or population of patients with AS and assessed depression and/or anxiety. Primary outcomes extracted were: 1) risk estimates for depression and/or anxiety (e.g., relative risk [RR]); and 2) determinants or factors identified as independent predictors of depression and/or anxiety using multivariable regression approaches and corresponding estimates (e.g., odds ratios [OR]). Where relevant, we pooled estimates using random effects models.Out of 783 titles from our search strategy, we reviewed 39 manuscripts. Four studies assessed the incidence of depression and meta-analyzing reported estimates from three of these studies yielded a pooled RR of 1.51 (95% CI 1.28 to 1.79). Differences in risk of depression among men and women with AS were inconclusive, suggesting need for further study. The incidence of anxiety was comparatively less studied with only one included study reporting a hazard ratio of 1.85 (95% CI 1.37 to 2.49). Education level was a key determinant, with lower levels associated with higher odds of depression (OR 6.65; 9% CI 1.36 to 32.51) and anxiety (OR 9.31; 9% CI 1.39 to 62.19) among AS patients.Our systematic review and meta-analysis shows an increased risk of depression and anxiety among patients with AS. These findings suggest the importance of monitoring and care for psychiatric conditions in AS.

  View details for DOI 10.1186/s41927-019-0111-6

  View details for Web of Science ID 000648516200012

  View details for PubMedID 32159073

  View details for PubMedCentralID PMC7050143

• Impact of arthritis on the perceived need and use of mental healthcare among Canadians with mental disorders: nationally representative cross-sectional study BMJ OPEN Howren, A., Avina-Zubieta, J., Da Costa, D., Puyat, J. H., Xie, H., De Vera, M. A. 2020; 10 (12): e041371

  Abstract

  To evaluate the association between having arthritis and the perceived need for mental healthcare and use of mental health support among individuals with mental disorders.A cross-sectional analysis using data from Canadian Community Health Survey-Mental Health (2012).The survey was administered across Canada's 10 provinces using multistage cluster sampling.The study sample consisted of individuals reporting depression, anxiety or bipolar disorder.The explanatory variable was self-reported doctor-diagnosed arthritis, and outcomes were perceived need for mental healthcare and use of mental health support. We computed overall and gender-stratified multivariable binomial logistic regression models adjusted for age, gender, race/ethnicity, income and geographical region.Among 1774 individuals with a mental disorder in the study sample, 436 (20.4%) reported having arthritis. Arthritis was associated with increased odds of having a perceived need for mental healthcare (adjusted OR (aOR) 1.71, 95% CI 1.06 to 2.77). In the gender-stratified models, this association was increased among men (aOR 2.69, 95% CI 1.32 to 5.49) but not women (aOR 1.48, 95% CI 0.78 to 2.82). Evaluation of the association between arthritis and use of mental health support resulted in an aOR of 1.50 (95% CI 0.89 to 2.51). Individuals with arthritis tended to use medications and professional services as opposed to non-professional support.Comorbid arthritis among individuals with a mental disorder was associated with an increased perceived need for mental healthcare, especially in men, underscoring the importance of understanding the role of masculinity in health seeking. Assessing the mental health of patients with arthritis continues to be essential for clinical care.

  View details for DOI 10.1136/bmjopen-2020-041371

  View details for Web of Science ID 000600203600043

  View details for PubMedID 33303458

  View details for PubMedCentralID PMC7733182

• Insights on mental health when living with rheumatoid arthritis: a descriptive qualitative study of threads on the Reddit website BMC RHEUMATOLOGY Park, J. Y. E., Howren, A. M., Davidson, E., De Vera, M. A. 2020; 4 (1): 62

  Abstract

  Reddit is a highly visited social news and discussion website where individuals anonymously ask questions, post opinions and share experiences, which provide a valuable pool of publicly available data. Our objective was to systematically search and analyze threads on the social news website, Reddit, to understand experiences of individuals with rheumatoid arthritis (RA) regarding their mental health.We conducted a patient-oriented descriptive qualitative study. We identified threads from two subreddits, "r/Thritis" and "r/Rheumatoid", using keywords such as "mood", "mental health", "stressed", "depressed", "anxious" over a 1-year period between June 2018 and June 2019. For included threads, we extracted the title, original post, and corresponding comments and responses. We applied thematic analysis using an inductive approach.Of 81 threads identified, we included 27. We identified four themes: 1) Navigating the management of RA explores how the physical impacts of the disease, lack of health resources/support and the complexity of medications affect mental health; 2) Experiencing impact on relationships and social isolation includes experiencing misconceptions of RA, feeling misunderstood and feeling guilt; 3) Experiencing loss, touches on the helplessness brought by challenges with performing self-defining activities such as self-care, work, and childbearing/parenting; and finally, 4) Experiencing emotional struggles captures how tension between fighting through and despair has led some to suicide ideation and thoughts of death.Online forums and communities such as Reddit have created opportunities for individuals with RA to share experiences on mental health matters, which they may not necessarily be able to share with others.

  View details for DOI 10.1186/s41927-020-00163-2

  View details for Web of Science ID 000648516200059

  View details for PubMedID 33292866

  View details for PubMedCentralID PMC7690206

• eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study CLINICAL RHEUMATOLOGY Howren, A., Tsao, N. W., Choi, H. K., Shojania, K., Kydd, A., Friesen, R., Avina-Zubieta, J., De Vera, M. A. 2020; 39 (4): 1241-1249

  Abstract

  To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian.We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 μmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists' electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 μmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients' perspectives.Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 μmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility.Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Key Points• We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics• Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas.

  View details for DOI 10.1007/s10067-019-04809-6

  View details for Web of Science ID 000495974900001

  View details for PubMedID 31720913

  View details for PubMedCentralID 3619972

• THE IMPACT OF ARTHRITIS ON UTILIZATION OF MENTAL HEALTH TREATMENT FOR COMORBID MENTAL DISORDERS: FINDINGS FROM A NATIONALLY REPRESENTATIVE MENTAL HEALTH SURVEY Howren, A., Avina, A., De Vera, M. BMJ PUBLISHING GROUP. 2019: 1376

  View details for DOI 10.1136/annrheumdis-2019-eular.3711

  View details for Web of Science ID 000472207104164

• Mobile Phone Apps Targeting Medication Adherence: Quality Assessment and Content Analysis of User Reviews JMIR MHEALTH AND UHEALTH Park, J., Li, J., Howren, A., Tsao, N., De Vera, M. 2019; 7 (1): e11919

  Abstract

  With the accessibility and widespread use of mobile phones, mobile phone apps targeting medication adherence may be useful tools to help patients take medications as prescribed.Our objectives were to (1) characterize and assess mobile phone medication adherence apps guided by a conceptual framework on the focus of adherence interventions and (2) conduct a content analysis of Web-based reviews to explore users' perspectives and experiences with mobile phone medication adherence apps.We searched for mobile phone medication adherence apps using keyword searches in Apple and Android operating systems. We characterized all apps in terms of number of downloads, ratings, languages, cost, and disease target. We categorized apps according to 4 key features of (1) alerting to take medication, (2) tracking medication taking, (3) reminding to refill or indicating amount of medication left, and (4) storing medication information. We then selected representative apps from each operating system for detailed quality assessment and user testing. We also downloaded Web-based reviews for these selected apps and conducted a qualitative content analysis using an inductive approach involving steps of initial open coding, construction of categories, and abstraction into themes.We identified 704 apps (443 from Apple and 261 from Android). The majority of apps across both operating systems had 1 or 2 features-specifically, 37.2% (165/443) and 38.1% (169/443) of Apple apps, respectively, and 41.4% (108/261) and 31.4% (108/261) of Android apps, respectively. Quality assessment and user testing of 20 selected apps revealed apps varied in quality and commonly focused on behavioral strategies to enhance medication adherence through alerts, reminders, and logs. A total of 1323 eligible Web-based reviews from these 20 selected apps were analyzed, and the following themes emerged: (1) features and functions appreciated by users, which included the ability to set up customized medication regimen details and reminders, monitor other health information (eg, vitals, supplements, and manage multiple people or pets), support health care visits (eg, having a list of medications and necessary health information in 1 app); (2) negative user experiences that captured technical difficulties (glitches, confusing app navigation, and poor interoperability), dosage schedule, and reminder setup inflexibility; and (3) desired functions and features related to optimization of information input, improvement of reminders, and upgrading app performance (better synchronization or backup of data and interoperability).A large number of mobile phone medication adherence apps are currently available. The majority of apps have features representing a behavioral approach to intervention. Findings of the content analysis offer mostly positive feedback as well as insights into current limitations and improvements that could be addressed in current and future medication adherence apps.

  View details for DOI 10.2196/11919

  View details for Web of Science ID 000457517600001

  View details for PubMedID 30702435

  View details for PubMedCentralID PMC6374723

• Management of Inflammatory Arthritis in pregnancy: a National Cross-Sectional Survey of Canadian rheumatologists BMC RHEUMATOLOGY De Vera, M. A., Baldwin, C., Tsao, N. W., Howren, A., Hazlewood, G. S., Rebic, N., Ensworth, S. 2019; 3 (1): 18

  Abstract

  With improved therapies and management, more women with inflammatory arthritides (IA) are considering pregnancy. Our objective was to survey rheumatologists across Canada about their IA management in pregnancy to identify practice patterns and knowledge gaps.We administered an online survey with questions regarding medications for IA treatment including conventional synthetic disease modifying antirheumatic drugs (csDMARDs) and biologics/small molecules in planned and unplanned pregnancies. Email invitations were sent to members of the Canadian Rheumatology Association. We calculated responses frequencies and a priori set a cut-off of ≥75% to define consensus.Ninety rheumatologists participated in the survey (20% participation rate); 57% have been practicing for > 10 years, 32% for ≤10 years, and 11% in training. There was consensus on discontinuation of 4 csDMARDs - cyclophosphamide (100%), leflunomide (98%), methotrexate (96%), and mycophenolate mofetil (89%) - in planned pregnancies but varied responses on when to discontinue them or what to do in unplanned pregnancies. Respondents agreed that 3 csDMARDs - azathioprine (84%), hydroxychloroquine (95%), and sulfasalazine (77%) - were safe to continue in planned and unplanned pregnancies. There was consensus with use of 4 biologics - adalimumab (81%), certolizumab (80%), etanercept (83%), and infliximab (76%) - in planned pregnancies but uncertainty on when they should be discontinued and their use in unplanned pregnancies.This national survey shows consensus among rheumatologists on the use of some csDMARDs and biologics/small molecules in IA patients planning pregnancy but varied knowledge on when to discontinue and what to do in unplanned pregnancies.

  View details for DOI 10.1186/s41927-019-0065-8

  View details for Web of Science ID 000648488500018

  View details for PubMedID 31143850

  View details for PubMedCentralID PMC6530147

• Botulinum Toxin Type A Versus Placebo for Idiopathic Clubfoot A Two-Center, Double-Blind, Randomized Controlled Trial JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Alvarez, C. M., Wright, J. G., Chhina, H., Howren, A., Law, P. 2018; 100 (18): 1589-1596

  Abstract

  Congenital idiopathic clubfoot is a condition that affects, on average, approximately 1 in 1,000 infants. One broadly adopted method of management, described by Ponseti, is the performance of a percutaneous complete tenotomy when hindfoot stall occurs. The use of onabotulinum toxin A (BTX-A) along with the manipulation and cast protocol described by Ponseti has been previously reported. Our goal was to compare the clinical outcomes between BTX-A and placebo injections into the gastrocnemius-soleus muscle at the time of hindfoot stall in infants with idiopathic clubfoot treated with the Ponseti method of manipulation and cast changes.This was a double-blind, placebo-controlled, parallel-group study with balanced randomization.At 6 weeks after the study injection (T1), 66% of the 32 feet in the BTX-A arm and 63% of the 30 in the placebo arm responded to the treatment (i.e., obtained ≥15° of dorsiflexion). Seven of the 11 patients in the BTX-A arm and all of the 11 in the placebo arm who had not responded at T1 responded to a rescue BTX-A injection at 12 weeks after the first injection (T2). The combined response rate at T2, which included the first-time responders as well as the patients who did not respond at T1 but did at T2, was 88% in the BTX-A arm and 100% in the placebo arm, culminating in a 94% response rate at T2. At T3 (2 years of age), 89% of the feet continued to respond and there was an 8% surgical rate.There was no difference in outcomes between the BTX-A and placebo groups when the injection was performed at the time of hindfoot stall. Overall, 92% of the clubfeet in this study responded to a manipulation and cast protocol alone, with or without BTX-A injection, by 12 weeks after hindfoot stall, or we can say that 92% of the clubfeet did not require percutaneous Achilles tendon lengthening by 2 years of age. The need for tenotomy is limited to those who have not responded to treatment at this point, and the need for surgery is limited to those for whom all attempts at treatment with sequential casts, BTX-A, and percutaneous Achilles tendon lengthening have failed.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.17.01652

  View details for Web of Science ID 000444981400013

  View details for PubMedID 30234623

• Exposure to Disease Modifying Antirheumatic Drugs during Pregnancy in Women with Inflammatory Arthritis and the Risk of Serious Maternal Infection: A Population-Based Cohort Study De Vera, M. A., Tsao, N. W., Sayre, E. C., Howren, A. WILEY. 2018

  View details for Web of Science ID 000447268903345

• Prevalence, Incidence, Determinants, and Impacts of Depression and Anxiety in Gout: A Systematic Review Howren, A., Zusman, E. Z., Rai, S. K., Shojania, K., De Vera, M. A. WILEY. 2018

  View details for Web of Science ID 000447268902230

• Epidemiology of Depression and Anxiety in Patients with Psoriatic Arthritis: A Systematic Review and Meta-Analysis Zusman, E. Z., Howren, A., Dutz, J., De Vera, M. A. WILEY. 2018

  View details for Web of Science ID 000447268902750

• The Prevalence, Incidence, and Determinants of Depression and Anxiety in Less Common Systemic Autoimmune Rheumatic Diseases: A Systematic Review and Meta-Analysis Howren, A., Zusman, E. Z., Avina-Zubieta, J., De Vera, M. A. WILEY. 2018

  View details for Web of Science ID 000447268903365

• Exploring How Individuals with Gout Experience an eHealth Supported Collaborative Care Model: An Explanatory Sequential Mixed Methods Study Howren, A., Tsao, N., Shojania, K., Choi, H., Avina-Zubieta, A., Kydd, A., Friesen, R., De Vera, M. J RHEUMATOL PUBL CO. 2018: 1042

  View details for Web of Science ID 000438512300224

• How patients with gout become engaged in disease management: a constructivist grounded theory study ARTHRITIS RESEARCH & THERAPY Howren, A., Cox, S. M., Shojania, K., Rai, S. K., Choi, H. K., De Vera, M. A. 2018; 20: 110

  Abstract

  Prior qualitative research on gout has focused primarily on barriers to disease management. Our objective was to use patients' perspectives to construct an explanatory framework to understand how patients become engaged in the management of their gout.We recruited a sample of individuals with gout who were participating in a proof-of-concept study of an eHealth-supported collaborative care model for gout involving rheumatology, pharmacy, and dietetics. Semistructured interviews were used. We analyzed transcripts using principles of constructivist grounded theory involving initial coding, focused coding and categorizing, and theoretical coding.Twelve participants with gout (ten males, two females; mean age, 66.5 ± 13.3 years) were interviewed. The analysis resulted in the construction of three themes as well as a framework describing the dynamically linked themes on (1) processing the diagnosis and management of gout, (2) supporting management of gout, and (3) interfering with management of gout. In this framework, patients with gout transition between each theme in the process of becoming engaged in the management of their gout and may represent potential opportunities for healthcare intervention.Findings derived from this study show that becoming engaged in gout management is a dynamic process whereby patients with gout experience factors that interfere with gout management, process their disease and its management, and develop the practical and perceptual skills necessary to manage their gout. By understanding this process, healthcare providers can identify points to adapt care delivery and thereby improve health outcomes.

  View details for DOI 10.1186/s13075-018-1608-x

  View details for Web of Science ID 000434326200004

  View details for PubMedID 29859127

  View details for PubMedCentralID PMC5984761

• Utility of Electronic Medical Records in Community Rheumatology Practice for Assessing Quality of Care Indicators for Gout: A Feasibility Study JCR-JOURNAL OF CLINICAL RHEUMATOLOGY Estrada, A., Tsao, N. W., Howren, A., Esdaile, J. M., Shojania, K., De Vera, M. A. 2018; 24 (2): 75-79

  Abstract

  With comprehensive capture of information on patient encounters, electronic medical records (EMRs) may have utility for assessing adherence to quality indicators (QIs) in gout. Our objectives were to translate 10 previously established gout QIs into relevant EMR data and evaluate and describe the feasibility of using EMRs to assess gout QIs.Using EMRs from 3 community rheumatology practices in Vancouver, British Columbia, Canada, we identified gout patients seen between January 1, 2012, and December 31, 2013. We translated each gout QI into potential EMR variables that would allow identification of patients the QI pertains to and whether the QI could be assessed. We extracted deidentified EMR data on gout diagnosis, medications, laboratory tests, radiological tests, and clinical notes and calculated the percent availability of data for each QI.We included 125 patients with gout, with mean age of 64 ± 17 years and with males comprising 78%. Overall, there were sufficient EMR data to allow translation of 7 QIs and assessment of 6 QIs including therapy-related gout QIs (69%-83% data availability) and one counseling-related QI (8% data availability). The highest percent data availability was observed in the single QI translated into EMR data and assessed based on diagnostic codes and prescription medications and not laboratory tests.Electronic medical records are promising tools for assessing QIs for gout. It was feasible to translate seven gout QIs into relevant EMR variables and there was sufficient EMR data to feasibly assess six of these QIs -Our findings lend evidence to support the utility of EMRs for ut QI assessment, with implications for helping improve management of this disease.

  View details for DOI 10.1097/RHU.0000000000000621

  View details for Web of Science ID 000426550600004

  View details for PubMedID 29232325

• Exploring strategies to support medication adherence in patients with inflammatory arthritis: a patient-oriented qualitative study using an interactive focus group activity PATIENT PREFERENCE AND ADHERENCE Rai, S. K., Howren, A., Wilcox, E. S., Townsend, A. F., Marra, C. A., Avina-Zubieta, J., De Vera, M. A. 2018; 12: 2015-2025

  Abstract

  Medication non-adherence is a substantial problem among patients with inflammatory arthritis (IA). Our aim was to explore IA patients' perspectives on strategies to support medication adherence.We collaborated with a leading arthritis patient group and conducted a qualitative study on individuals with IA who were taking at least one medication for their IA. An experienced facilitator led participants through a focus group exercise where participants were asked to design, and then discuss, strategies and/or tools supporting medication use. We applied thematic analysis using an iterative, constant comparative approach.We studied six focus groups with 27 participants diagnosed with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and comparatively under-represented conditions in this research area such as Sjögren's syndrome. Five themes emerged throughout the analysis. Two themes - 1) adapting to life with IA and 2) the complexities and dynamic nature of taking medications - describe learning to live with a chronic condition and the challenges encountered when using long-term medications. Three themes - 3) developing lifestyle strategies for medication use (eg, having physical reminders and prompts), 4) becoming informed about medications (eg, information at time of diagnosis, means of receiving information) and 5) receiving support (eg, from health care team members, from family) - offer perspectives on facilitators to medication use. From the relationship between the latter themes, a framework was developed that encompasses means of receiving information and support as actionable targets for patient-oriented adherence interventions for IA.This patient-oriented study highlights the importance of developing timely adherence interventions for IA. Our findings also led to a framework describing means of receiving information, such as through digital media and support, including from health care team members and family, as actionable targets for patient-oriented adherence interventions for IA.

  View details for DOI 10.2147/PPA.S174672

  View details for Web of Science ID 000446718300001

  View details for PubMedID 30323571

  View details for PubMedCentralID PMC6179243

• Management of Inflammatory Arthritis in Pregnancy: A National Survey of Canadian Rheumatologists De Vera, M., Baldwin, C., Tsao, N., Howren, A., Ensworth, S. J RHEUMATOL PUBL CO. 2017: 935

  View details for Web of Science ID 000404641800241

• eHealth Supported Collaborative Care for Gout Involving Rheumatology, Pharmacy, and Dietetics: Mid-Term Outcomes Howren, A., Tsao, N., Shojania, K., Kydd, A., Friesen, R., De Vera, M. J RHEUMATOL PUBL CO. 2017: 935

  View details for Web of Science ID 000404641800242

• Exploring how Individuals with Gout Experience an eHealth Supported Collaborative Care Model: Preliminary Results from a Qualitative Study Howren, A., De Vera, M. J RHEUMATOL PUBL CO. 2017: 935-936

  View details for Web of Science ID 000404641800243

• Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox® : a double-blind randomized control trial JOURNAL OF CHILDRENS ORTHOPAEDICS Howren, A. M., Jamieson, D. H., Alvarez, C. M. 2015; 9 (1): 85-91

  Abstract

  The manipulations, casts, and Botox(®) method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox(®)-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle-tendon unit following Botox(®).Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox(®) or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox(®) and contralateral controls using repeated measures ANOVA.The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox(®).Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

  View details for DOI 10.1007/s11832-015-0633-4

  View details for Web of Science ID 000215433000010

  View details for PubMedID 25609054

  View details for PubMedCentralID PMC4340848

• The contralateral foot in children with unilateral clubfoot, is the unaffected side normal? GAIT & POSTURE Cooper, A., Chhina, H., Howren, A., Alvarez, C. 2014; 40 (3): 375-380

  Abstract

  The unilateral unaffected clubfoot has previously been used as a control in longitudinal studies of clubfoot outcomes. However, we have observed that the unaffected clubfoot does not necessarily exhibit the same pedobarographic measurements as seen in normal control subjects. The purpose of this study was to evaluate whether the unaffected foot is indeed normal or if there are differences in the pedobarographic measurements of the unaffected foot compared to healthy normal controls.The Tekscan HR Mat™ was used to dynamically test the walking pattern of 103 subjects with unilateral clubfeet and compare the results to our previously published series of normal controls. Patients were divided into three groups: Group 1 (< 2 years), Group 2 (2-5 years) and Group 3 (>5 years). An unpaired t-test (p < 0.05) was used to compare percentage of stance at initiation of force, the percentage of stance at maximum force, the percentage of stance at termination of force, the maximum percentage force and the average force/time integral between a group of normal age matched controls and the unaffected foot in patients with unilateral clubfoot. Significant differences were identified between the unaffected side and normal controls for the pressure distribution, order of initial contact and foot contact time. These differences evolved and changed with age. The pedobarographic measurements of patients with clubfoot are not normal for the unaffected foot. As such the unaffected foot should not be referred to as normal, nor should it be used as a control.

  View details for DOI 10.1016/j.gaitpost.2014.05.004

  View details for Web of Science ID 000340017800008

  View details for PubMedID 25001577

• Onabotulinumtoxin A® injections: A safety review of children with clubfoot under 2 years of age at BC Children's Hospital EUROPEAN JOURNAL OF PAEDIATRIC NEUROLOGY Chhina, H., Howren, A., Simmonds, A., Alvarez, C. M. 2014; 18 (2): 171-175

  Abstract

  Pediatric indications for Onabotulinumtoxin A extend beyond treatment of skeletal muscle conditions. Each of the indications for Onabotulinumtoxin A use have adverse events reported in the past. The aim of this study was to review dverse events in children less than 2 years of age who were treated with Onabotulinumtoxin A injections as part of equinus foot deformity, in the setting of clubfoot at British Columbia's Children Hospital.A retrospective review of all clubfoot patients at British Columbia's Children Hospital, less than 2 years of age, who received a Onabotulinumtoxin A injection for equinus correction, between September 2000 and December 2012 was conducted. Data collected included demographics, clinical diagnosis, treatment history, ankle range of motion and any adverse event noted by the clubfoot team or reported by the families.A total of 239 eligible subjects (361 feet) had received 523 Onabotulinumtoxin A injections before the age of 2 years. There was only one adverse event reported out of the 523 Onabotulinumtoxin A injections (adverse events rate of 0.19%) given at British Columbia's Children Hospital. However, this adverse event was not found related to the Onabotulinumtoxin A injection.Onabotulinumtoxin A appears to be safe with respect to the adverse events, for use in children under 2 years of age with the diagnosis of clubfoot when dosed at 10 units per kilogram. However, the dose of Onabotulinumtoxin A and underlying diagnosis should always be kept in mind.

  View details for DOI 10.1016/j.ejpn.2013.11.002

  View details for Web of Science ID 000333731200009

  View details for PubMedID 24268889