<p><strong>OBJECTIVE: </strong>To estimate the differential effect of tumor necrosis factor inhibitor (TNFi) therapies and presence/absence of conventional synthetic disease-modifying antirheumatic drug (DMARD) on the incidence of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic nonbacterial osteomyelitis (CNO).</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study from 2008 to 2020. TNFi and DMARD exposures were dichotomized as ever/never. The primary outcome was incident psoriasis. Incidence rates (IRs) of psoriasis were stratified by underlying diagnosis, TNFi agent, and DMARD use. Poisson regression was used to assess the IR ratios (IRR) between exposure groups.</p>

<p><strong>RESULTS: </strong>5088 children met inclusion criteria - 3794 (75%) had IBD, 1189 (23%) had JIA, and 105 (2%) had CNO. 613 (30%) and 1410 (70%) had TNFi exposure with or without a DMARD, respectively. IRR of developing psoriasis in patients exposed to adalimumab was 2.70 times higher (95% CI: 1.52-4.75; p&lt;0.001) than those who did not receive any TNFi treatment, when controlling for DMARD, sex, and family history of psoriasis. IRR was lower, but not significantly different, for patients exposed to infliximab (IRR=2.34; 95% CI: 1.56-3.51; p&lt;0.001) and etanercept (IRR=2.22; 95% CI: 1.17-4.21; p=0.006) compared to TNFi unexposed patients. IRR of TNFi exposure was lower by 0.25 (p&lt;0.001) in DMARD exposed patients compared to non- DMARD exposed patients.</p>

<p><strong>CONCLUSION: </strong>IRR of TNFi-induced psoriasis was not significantly different amongst adalimumab, infliximab, and etanercept. However, for patients with exposure to any of the TNFi evaluated, the IRR was significantly lower in those also exposed to a DMARD.</p>

<p>The success of rare disease research relies heavily on robust partnerships with clinicians to help identify new patients and collect samples. Many studies for paediatric rheumatic diseases requiring pretreatment samples have suffered from slow enrolment rates due to the low incidence of disease and relative urgency to treat. Therefore, timely identification of all potentially eligible patients is crucial. The objective of this project was to apply quality improvement methods to increase the frequency and timeliness of identification of eligible patients with new paediatric rheumatic diagnoses to approach for research studies. A retrospective chart review was undertaken in our paediatric rheumatology clinic to measure the number of eligible patients identified for potential research recruitment between missed recruitment opportunities. Improvement methodology was used to integrate standardised communication between clinicians and the research team into clinic workflow, to leverage social feedback as positive reinforcement for good communication and to measure change in response to the interventions. The number of eligible patients identified between missed recruitment opportunities increased from every 0-1 patient to every 14 patients during the project period, corresponding to an increase in the overall identification rate from 32% to 91% of all eligible patients. Quality improvement methods can be used to successfully integrate research recruitment into routine clinical care and accelerate advances necessary to improve health outcomes.</p>

<p><strong>OBJECTIVE: </strong>We aimed to estimate the incidence rate (IR) of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic noninfectious osteomyelitis (CNO) with tumor necrosis factor-alpha inhibitor (TNFi) exposure as compared to those without TNFi exposure and to the general pediatric population.</p>

<p><strong>METHODS: </strong>This was a single-center retrospective cohort study of children with IBD, JIA, or CNO from 2008 to 2018. TNFi exposure was defined as a prescription for adalimumab, etanercept, infliximab, certolizumab, or golimumab, and the primary outcome was incident psoriasis. IRs and standardized incidence ratios (SIRs) were calculated. Cox proportional hazards models were used to assess the association of psoriasis with TNFi exposure and other risk factors.</p>

<p><strong>RESULTS: </strong>Of the 4111 children who met inclusion criteria, 1614 (39%) had TNFi exposure and 2497 (61%) did not with 4705 and 6604 person-years of follow-up, respectively. There were 58 (IR 12.3 per 1000 person-years) and 25 (IR 3.8 per 1000 person-years) cases of psoriasis in children with and without TNFi exposure, respectively. The SIR was 18 (95% confidence interval [CI] 15, 22) overall, 30 (95% CI 23, 39) for children with TNFi exposure, and 9.3 (95% CI 6.3, 14) for children without TNFi exposure. The hazard ratio (HR) of psoriasis comparing TNFi exposure to no TNFi exposure was 3.84 (95% CI 2.28, 6.47, p&lt;0.001).</p>

<p><strong>CONCLUSION: </strong>Children with IBD, JIA, and CNO had an increased rate of psoriasis compared to the general pediatric population, with the highest rate in those with TNFi exposure.</p>