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Importance: Guidelines recommend dose reduction or discontinuation of long-term opioid therapy when harm outweighs benefit, but strategies to help patients do so are limited., Objective: To test optionally switching to buprenorphine as a strategy for improving pain and reducing opioids among patients prescribed high-dose, full agonist long-term opioid therapy., Design, Setting, and Participants: In this pragmatic, multisite, 12-month randomized clinical trial with masked outcome assessment, patients treated at Veterans Affairs primary care clinics were recruited from October 2017 to March 2021, with follow-up completed June 2022. Eligible patients had moderate to severe chronic pain despite high-dose opioid therapy (≥70 mg/d for at least 3 months). Patients were randomized to having the option to switch to buprenorphine or not having the option to switch., Interventions: The buprenorphine option was discussed with eligible patients as part of a larger trial of collaborative pain care interventions. Those who switched had structured follow-up to optimize dosing and address adverse effects., Main Outcomes and Measures: The primary outcome was Brief Pain Inventory total score at 12 months. The main secondary outcome was opioid dose in morphine milligram equivalents at 12 months., Results: Of 207 included participants, 185 (89.4%) were male, and the mean (SD) age was 60.9 (10.2) years. A total of 104 were randomized to the buprenorphine option and 103 to the no buprenorphine option. In the buprenorphine option arm, 27 participants (26.0%) switched. Over 12 months, the mean (SD) Brief Pain Inventory score improved from 6.8 (1.5) to 6.1 (1.9; adjusted mean difference [AMD], -0.59; 95% CI, -0.89 to -0.29) in the buprenorphine option arm and from 6.8 (1.6) to 6.3 (1.7; AMD, -0.50; 95% CI, -0.81 to 0.20) in the no option arm (between-group AMD, -0.09; 95% CI, -0.52 to 0.34). Over 12 months, mean (SD) opioid dosage decreased from 157 (75) mg/d to 94 (98) mg/d in the buprenorphine option arm (AMD, -61.0 mg/d; 95% CI, -74.1 to -47.9) and from 165 (88) mg/d to 107 (89) mg/d (AMD, -58.5 mg/d; 95% CI, -71.6 to -45.4) in the no option arm (between-group AMD, -2.5 mg/d; 95% CI, -21.1 to 16.0)., Conclusions and Relevance: In this trial, outcomes did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage, but the proportion of participants who switched to buprenorphine was low., Trial Registration: ClinicalTrials.gov Identifier: NCT03026790.

Background: Interstitial pneumonia with autoimmune features (IPAF) is a subset of interstitial lung disease that manifests with features of autoimmunity while not meeting classification criteria for a defined rheumatic disease. Comorbidity burden is an important prognostic indicator in various rheumatic and interstitial lung diseases, but few studies have commented on comorbidities in this population. This study was conducted to evaluate the association of individual comorbidities, the Charlson Comorbidity Index (CCI), and the Rheumatic Disease Comorbidity Index (RDCI) with lung disease progression and transplant/mortality outcomes in patients with IPAF., Methods: In a retrospective study, we evaluated the prevalence and severity of comorbidities in an institutional cohort of patients with IPAF. Using Cox regression, we correlated the association of individual comorbidities and comorbidity indices with time to lung disease progression (relative forced vital capacity decline of 10% or more) and with time to lung transplant/death. We compared the performance of CCI and RDCI in predicting outcomes., Results: History of cerebrovascular accident (CVA) or cardiovascular disease (CVD), moderate-severe chronic kidney disease, and fracture was associated with a faster onset of lung disease progression, while a history of gastroesophageal reflux was protective. History of CVA/CVD, diabetes mellitus, and lymphoma were associated with a faster onset of lung transplant/death. Both CCI and RDCI were associated with shorter time to lung disease progression and lung transplant/death in unadjusted analyses. However, only CCI was associated with shorter time to lung transplant/death in analyses adjusted for age, sex, pulmonary function, and radiographic pattern of lung lesion., Conclusions: CCI and RDCI may be useful tools in assessing prognosis in patients with IPAF in terms of both lung disease progression and mortality. Prospective studies are needed to further evaluate the performance of CCI and RDCI and the impact of optimizing comorbid conditions that may mitigate poor outcomes among patients with IPAF., Competing Interests: “Dr. Elena K. Joerns reports prior salary support from a grant from Pfizer, Inc and Ruth L. Kirschstein Institutional National Research Service Award (T32) as well as consulting honoraria from Boehringer-Ingelheim, Inc, in amount of less than $10,000. Dr. Michelle A. Ghebranious and Dr. Traci N. Adams report no conflict of interest, financial or otherwise. Dr. Una E. Makris reports funding by VA HSR&D and NIA for research unrelated to this work/ manuscript with no other conflicts of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.”, (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Importance: Patients prescribed long-term opioid therapy for chronic pain often experience unrelieved pain, poor quality of life, and serious adverse events., Objective: To compare the effects of integrated pain team (IPT) vs pharmacist collaborative management (PCM) on pain and opioid dosage., Design, Setting, and Participants: This study was a pragmatic multisite 12-month randomized comparative effectiveness trial with masked outcome assessment. Patients were recruited from October 2017 to March 2021; follow-up was completed June 2022. The study sites were Veterans Affairs primary care clinics. Eligible patients had moderate to severe chronic pain despite long-term opioid therapy (≥20 mg/d for at least 3 months)., Interventions: IPT involved interdisciplinary pain care planning, visits throughout 12 months with medical and mental health clinicians, and emphasis on nondrug therapies and motivational interviewing. PCM was a collaborative care intervention involving visits throughout 12 months with a clinical pharmacist care manager who conducted structured monitoring and medication optimization. Both interventions provided individualized pain care and opioid tapering recommendations to patients., Main Outcomes and Measures: The primary outcome was pain response (≥30% decrease in Brief Pain Inventory total score) at 12 months. The main secondary outcome was 50% or greater reduction in opioid daily dosage at 12 months., Results: A total of 820 patients were randomized to IPT (n = 411) or PCM (n = 409). Participants' mean (SD) age was 62.2 (10.6) years, and 709 (86.5%) were male. A pain response was achieved in 58/350 patients in the IPT group (16.4%) vs 54/362 patients in the PCM group (14.9%) (odds ratio, 1.11 [95% CI, 0.74-1.67]; P = .61). A 50% opioid dose reduction was achieved in 102/403 patients in the IPT group (25.3%) vs 98/399 patients in the PCM group (24.6%) (odds ratio, 1.03 [95% CI, 0.75-1.42]; P = .85). Over 12 months, the mean (SD) Brief Pain Inventory total score improved from 6.7 (1.5) points to 6.1 (1.8) points (P < .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points (P < .001) in PCM (between-group P = .82). Over 12 months, mean (SD) opioid daily dosage decreased from 80.8 (74.2) mg/d to 54.2 (65.0) mg/d in IPT (P < .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d (P < .001) in PCM (between-group P = .22)., Conclusions and Relevance: Outcomes in this randomized clinical trial did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage., Trial Registration: ClinicalTrials.gov Identifier: NCT03026790.

Objective: Racial and ethnic disparities in rheumatoid arthritis (RA) outcomes are well recognized. However, whether disparities in RA treatment selection and outcomes differ by urban versus rural residence, independent of race, have not been studied. Our objective was to evaluate whether biologic disease-modifying antirheumatic drug (bDMARD) initiation after methotrexate administration differs by rural versus urban residence among veterans with RA., Methods: In this retrospective cohort study using national US Veterans Affairs (VA) databases, we identified adult patients with RA based on the presence of diagnostic codes and DMARD administration. We included patients receiving an initial prescription of methotrexate (index date) between 2005 and 2014, with data through 2016 used for follow-up. Urban-rural status was categorized using the Veteran Health Administration's Urban/Rural classification. Our primary outcome of interest was time to biologic initiation within two years of starting methotrexate. Multivariable Cox proportional hazards models were conducted adjusting for demographics, comorbidities, and rheumatoid factor or anti-cyclic citrullinated peptide positivity., Results: Among 17,395 veterans with RA (88% male, 42% with rural residence) fulfilling eligibility criteria, 3,259 (19%) initiated a biologic within the first two years of follow-up. In multivariable models, residence in an urban area was associated with a statistically significant higher biologic administration compared to rural areas (adjusted hazard ratio 1.10 [95% confidence interval 1.02-1.18])., Conclusion: Our study found only modest differences in the initiation of biologic therapies among rural- versus urban-residing veterans with RA in the VA health care system. These findings suggest that disparities are not easily explained by rurality within the VA health care system., (© 2024 American College of Rheumatology.)

The global population is ageing and the rheumatology workforce should be prepared to take care of the inevitable complexities of ageing patients. We can learn from our colleagues and experts in geriatrics about how best to manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older patients in the context of delivering care for rheumatic diseases. One approach to learning and adopting key ageing constructs within rheumatology practice is to incorporate the established Geriatric 5Ms-principles fundamental to caring for older adults. In this Series paper we discuss the 5Ms in the context of rheumatology practice (1) multicomplexity: assessing and managing multimorbidity and challenging biopsychosocial situations, (2) medications: ensuring that medications do not interfere with the other Ms, (3) mind: managing neurocognitive disorders and comorbid mental health conditions, (4) mobility: ensuring older adults can move independently and safely, and (5) what matters most: aligning care with an older adult's specific goals., Competing Interests: Declaration of interests Within the last 3 years, BB received honoraria for consulting or speaking engagements, travel support, or research funding from AbbVie, Alexion, Amgen, AstraZeneca, Biogen, Boehringer–Ingelheim, Gilead/Galapagos, Janssen, Merck Sharpe Dohme, Sanofi Genzyme, Theramex, and UCB. MvO received consultancy fees from Galapagos, Eli Lilly, Novartis, and Pfizer; and a research grant to her department from Pfizer. EM is supported by the National Institutes of Health (NIH), National Institute on Aging (NIA; R01 AG068192 and K24 AG078179). JL is supported by the NIH, NIA (R03 AG067975 and K23 AG082727). UEM is supported in part by a grant from Veteran Affairs Health Services Research and Development (HX003350) and NIH, NIA (P30 AG022845). All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Inflammation is an important risk factor, a potential therapeutic target for cognitive decline and dementia, and an inherent feature of autoimmune and immune-mediated rheumatic diseases. The risk of cognitive impairment and dementia is increased in individuals with immune-mediated rheumatic diseases, particularly in those with cardiovascular risk factors and cardiovascular disease. Immunomodulatory medications have been associated with a reduced risk of dementia, but whether this effect is mediated through their anti-inflammatory immunomodulating properties or other mechanisms, such as cardiovascular risk reduction, is unclear. A better understanding of the role of chronic inflammation as a modifiable risk factor for cognitive performance in rheumatic diseases will help inform opportunities for the management of cognitive impairment in people with rheumatic diseases and other chronic inflammatory diseases. In this Series paper, we discuss the epidemiology, risk factors, and current evidence on the role of immunomodulatory medications in cognitive impairment and dementia in people with rheumatic diseases., Competing Interests: Declaration of interests EM reports consultancy fees from Amgen. SES reports research support from AstraZeneca and GSK; consultancy and advisory board fees from Sanofi and Amgen; speaker fees from Fresenius Kabi; and is supported by a Bristol Myers Squibb Foundation Robert A Winn Diversity in Clinical Trials Career Development Award. JTO reports consultancy fees from TauRx, Novo Nordisk, Biogen, GE Healthcare, Roche, and Eli Lilly; and has received research support from Eli Lilly, Merck, and Alliance Medical. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Competing Interests: RY receives grants from the National Institute on Aging–National Institutes of Health, the Claude D. Pepper Older Americans Independence Center, and the Veterans Affairs Ann Arbor Geriatrics Research, Education and Clinical Center. UEM is supported in part by a grant from Veterans Affairs Health Services Research and Development (HX003350, IIR 20–256) and National Institutes of Health (NIA P30 AG022845). All other authors declare no competing interests.

It remains unknown whether frailty status confers an increased risk of readmission in patients with rheumatoid arthritis (RA). From the 2018 Nationwide Readmissions Database (NRD), we identified adult patients (age ≥ 18 years) admitted with a diagnosis of RA between January to June 2018. Utilizing validated Hospital Frailty Score, patients' frailty risk score was calculated at the time of index admission and categorized into frail (score ≥ 5) and non-frail (score < 5) groups. Our primary outcomes of interest were (1) 180- day readmission rate (2) inpatient mortality; secondary outcomes included prolonged length of stay, LOS (LOS ≥ 7 days), and costs of hospitalization. Multivariable Cox proportional hazard analysis was performed to evaluate the independent effect of frailty adjusting for confounding variables. 133,187 patients met inclusion criteria, with mean age 67.7 years, of whom 64,131 (48.1%) patients were categorized as frail. The rate of readmission was significantly higher in the frail (56.60%) compared to the non-frail group (30.61%). At index hospitalization, frail patients also had significantly higher inpatient mortality compared to non-frail patients (3.36% vs 0.39%, p < 0.005), longer LOS (26.24% vs 7.82%, p < 0.005). On multivariate analysis frailty was independently associated with a 9% increased risk of readmission (adjusted hazard ratio, 1.09; 95% confidence interval, 1.08 - 1.11). People with RA who are frail have higher rates of readmission than those who are not frail. These findings are crucial in identifying at-risk patients with RA and in discharge planning after hospitalization. Key Points • People with RA who are frail have higher rates of readmission than those who are not frail. • Frail RA patients are also at higher risk of hospitalization-related adverse outcomes, including inpatient mortality and longer hospital stay. • Sepsis is the most common cause for readmission identified in frail patients with RA. • These findings suggest that frailty may be a useful metric in identifying patients with RA at an increased risk of adverse health outcomes., Competing Interests: Declarations. Conflict of interest: No conflicts of interest to disclose., (© 2024. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Background: Despite the increased availability of evidence-based treatments for chronic pain, many patients in rural areas experience poor access to services. Patients receiving care through the VA may also need to navigate multiple systems of care., Objective: To examine the effectiveness of a remotely delivered collaborative care intervention for improving pain interference among veterans with high-impact chronic pain living in rural areas., Design: We will conduct a four-site pragmatic effectiveness trial of remotely delivered collaborative care for high-impact chronic pain. Participants (n = 608) will be randomized to the Tele-Collaborative Outreach to Rural Patients (CORPs) intervention or to minimally enhanced usual care (MEUC). Participants randomized to CORPs will complete a biopsychosocial assessment and five follow-up sessions with a nurse care manager (NCM), who will collaborate with a consulting clinician to provide personalized recommendations and care management. CORP participants will also be invited to a virtual 6-session pain education group class. Participants randomized to MEUC will receive a one-time education session with the NCM to review available pain services. All participants will complete quarterly research assessments for one year. The primary study outcome is pain interference. This trial will oversample veterans of female birth sex and minoritized race or ethnicity to test heterogeneity of treatment effects across these patient characteristics. We will conduct an implementation process evaluation and incremental cost-effectiveness analysis., Discussion: This pragmatic trial will test the real-world effectiveness of a remotely delivered collaborative care intervention for chronic pain. Study findings will inform future implementation efforts to support potential uptake of the intervention., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: The objective of this study was to evaluate the association between frailty status and risk of readmissions, inpatient death, and cost of admission among patients with systemic lupus erythematosus (SLE)., Methods: We conducted a retrospective cohort study using the National Readmissions Database. Using International Statistical Classification of Diseases, Tenth Revision codes, we identified individuals >18 years of age who had a primary or secondary diagnosis of SLE and were hospitalized between January and June 2018. Using the validated claims-based Hospital Frailty Risk Score, we categorized individuals as frail (score ≥ 5) or nonfrail (score < 5) at the time of index hospitalization. Our primary outcome was readmission rates post discharge from index hospitalization. Secondary outcomes were rates of inpatient mortality and the total cost of hospitalizations. Cox proportional hazard models were used to estimate the association between frailty and risk of readmissions, with adjustment for age, sex, insurance type, household income, and Elixhauser Comorbidity Index score., Results: A total of 39,738 patients with SLE met eligibility criteria. Over a median follow-up of eight months, frail patients with SLE (n = 18,385) had higher Elixhauser Comorbidity Index scores and longer length of stay compared to nonfrail patients with SLE (n = 21,353). Frail patients with SLE had higher readmission rates, a higher proportion of prolonged hospitalizations, and higher costs per hospitalization. Frailty was independently associated with a 10% higher risk of readmission after adjustment for covariates., Conclusion: Among hospitalized adults with SLE, presence of frailty was associated with higher readmission and inpatient mortality rates. Our results highlight that frailty status can help risk stratify patients with SLE at increased risk for readmissions and other adverse health outcomes., (© 2024 The Author(s). ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Objective: The aim was to evaluate prevalence and factors associated with anti-tumor necrosis factor (anti-TNF) de-escalation in older adults with rheumatoid arthritis (RA)., Methods: We identified adults ≥ 66 years of age with RA on anti-TNF therapy within 6 months after RA diagnosis with at least 6-7 months duration of use (proxy for stable use), using 20% Medicare data from 2008-2017. Patient demographic and clinical characteristics, including concomitant use of glucocorticoid (GC), were collected. Anti-TNF use was categorized as either de-escalation (identified by dosing interval increase, dose reduction, or cessation of use) or continuation. We used (1) an observational cohort design with Cox regression to assess patient characteristics associated with de-escalation and (2) a case-control design with propensity score-adjusted logistic regression to assess the association of de-escalation with different clinical conditions and concomitant medication use., Results: We identified 5106 Medicare beneficiaries with RA on anti-TNF, 65.5% of whom had de-escalation. De-escalation was more likely with older age (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.02) or greater comorbidity (HR 1.07, 95% CI 1.05-1.09), but was less likely with low-income subsidy status (HR 0.85, 95% CI 0.78-0.92), adjusting for patient sex and race/ethnicity. Lower odds of de-escalation were associated with serious infection (odds ratio [OR] 0.79, 95% CI 0.66-0.94), new heart failure diagnosis (OR 0.70, 95% CI 0.52-0.95), and long-term GC use (OR 0.84, 95% CI 0.74-0.95), whereas higher odds were associated with concomitant methotrexate use (OR 1.16, 95% CI 1.03-1.31)., Conclusions: Anti-TNFs are de-escalated in two-thirds of older adults with RA in usual care. Further study is needed on RA outcomes after anti-TNF de-escalation., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: Cytokines can help predict prognosis in interstitial lung disease (ILD) and to differentiate between ILD subtypes. The objectives of our study were to evaluate association of baseline cytokine levels with time to ILD progression and to compare baseline cytokine levels between ILD subtypes., Methods: We quantified 27 cytokines using a multiplex assay in peripheral blood samples from 77 patients. Cox proportional hazards regression analysis was performed to evaluate cytokine impact on the time to progression in the total cohort and within each ILD type. We evaluated for significant differences in cytokine levels between ILD types using ANOVA, Wilcoxon signed-rank test and Tukey method., Results: Higher IL-13 level was associated with longer time to progression (hazard ratio 0.52 [0.33-0.81], p-value 0.004). FGF-β, GM-CSF, and IL-17 levels differed significantly between fibrotic and inflammatory ILD subgroups., Conclusion: IL-13 may be a useful biomarker predicting ILD stability., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Elena K. Joerns reports financial support was provided by Ruth L. Kirschstein Institutional National Research Service Award (T32). Chad A. Newton reports financial support was provided by 10.13039/100000050National Heart, Lung, and Blood Institute, grant number K23HL148498. Song Zhang reports financial support was provided by 10.13039/100006108National Center for Advancing Translational Sciences of the 10.13039/100000002National Institutes of Health. Elena K. Joerns reports a relationship with 10.13039/100004319Pfizer, Inc that includes: funding grants. Chad A. Newton reports a relationship with Boehringer Ingelheim Pharmaceuticals Inc that includes: consulting or advisory. Jeffrey 10.13039/501100000861Sparks reports a relationship with the 10.13039/100000069National Institute of Arthritis and Musculoskeletal and Skin Diseases that includes: funding grants. Jeffrey Sparks reports a relationship with R. Bruce nd Joan M. Mickey Research Scholar Fund that includes: funding grants. Jeffrey 10.13039/501100000861Sparks reports a relationship with Gordon and Llura 10.13039/100001149Gund Foundation that includes: funding grants. Jeffrey 10.13039/501100000861Sparks reports a relationship with 10.13039/100002491Bristol-Myers Squibb Co that includes: funding grants. Jeffrey Sparks reports a relationship with AbbVie Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Amgen Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Boehringer Ingelheim Pharmaceuticals Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Bristol Myers Squibb Co that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Gilead Sciences Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with INOVA Diagnostics Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Janssen Pharmaceuticals Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Optum that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Pfizer Inc that includes: consulting or advisory. Jeffrey Sparks reports a relationship with ReCor that includes: consulting or advisory. Jeffrey Sparks reports a relationship with Sobi that includes: consulting or advisory. Jeffrey Sparks reports a relationship with UCB that includes: consulting or advisory.If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objective: It remains unknown whether frailty status portends an increased risk of adverse outcomes in patients with rheumatoid arthritis (RA) initiating biologic or targeted-synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs). The objective of our study was to evaluate the association between frailty and serious infections in a younger population of patients (<65 years old) with RA who initiated b/tsDMARDs., Methods: Using MarketScan data, we identified new users of tumor necrosis factor inhibitors (TNFi), non-TNFi biologic DMARDs, or Janus kinase inhibitors (JAKi) between 2008 and 2019 among those with RA. Patients' baseline frailty risk score was calculated using a Claims-Based Frailty Index (≥0.2 defined as frail) 12 months prior to drug initiation. The primary outcome was time to serious infection; secondarily, we examined time-to-any infection and all-cause hospitalizations. We used Cox proportional hazards to estimate adjusted hazard ratios and 95% confidence intervals (95% CIs) and assessed the significance of interaction terms between frailty status and drug class., Results: A total of 57,980 patients, mean (±SD) age 48.1 ± 10.1 were included; 48,139 (83%) started TNFi, 8,111 (14%) non-TNFi biologics, and 1,730 (3%) JAKi. Among these, 3,560 (6%) were categorized as frail. Frailty was associated with a 50% increased risk of serious infections (adjusted hazard ratio [95% CI] 1.5, 1.2-1.9) and 40% higher risk of inpatient admissions (1.4 [1.3-1.6]) compared with nonfrail patients among those who initiated TNFi. Frailty was also associated with a higher risk of any infection relative to nonfrail patients among those on TNFi (1.2 [1.1-1.3]) or non-TNFi (1.2 [1.0-1.4]) or JAKi (1.4 [1.0-2.0])., Conclusion: Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with biologic or targeted-synthetic DMARDs., (© 2023 American College of Rheumatology.)

Objective: Older adults with rheumatoid arthritis (RA) account for up to one-third of the RA population and are less likely to receive optimal treatment. For the subgroup of older adults with late-onset RA (LORA), who experience more symptomatic and progressive disease, suboptimal treatment could be more consequential than the general population who age with RA. We evaluated use of disease-modifying antirheumatic drugs (DMARDs) in older adults with a new diagnosis of LORA., Methods: In this retrospective observational study, we identified adults 66 years of age or older with a new diagnosis of LORA using Medicare data from 2008 to 2017. Information on baseline patient characteristics and DMARD initiation during the first 12 months after LORA diagnosis were collected. We also assessed concomitant use of glucocorticoids (GCs)., Results: We identified 33,373 older adults with new diagnosis of LORA. Average age at LORA diagnosis was 76.7 (SD 7.6); 75.4% were female, 76.9% were White, and 35.6% had low-income subsidy (LIS). Less than one-third were initiated on a DMARD (28.9%). In multivariable analyses, DMARD initiation was associated with younger age, fewer comorbidities, and absence of LIS status. Concomitant long-term (>3 months) GC use was higher among those on any DMARD (44.3%) compared with those without (15.2%)., Conclusions: DMARD initiation after new diagnosis of LORA is low despite current clinical practice guidelines recommending early aggressive initiation of treatment. Long-term GC use is common among those on any DMARDs, raising concern for suboptimal DMARD use. Further studies are needed to understand drivers of DMARD use in older adults., (© 2023 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

There is a paucity of data regarding the use of non-pharmacologic therapies for pain in sickle cell disease. The purpose of this pilot study was to assess the acceptability and feasibility of video-guided mindfulness meditation, breathing exercises, and yoga, in addition to standard of care, during admission for painful vaso-occlusive crisis. Feasibility was demonstrated by the enrollment rate of > 90% and high level of participant engagement in the intervention. Acceptability was demonstrated by positive feedback obtained in post-intervention surveys and the majority of subjects who expressed interest in participating in future mindfulness and yoga therapy sessions., Competing Interests: Dr. Una E. Makris reports funding by VA Health Services Research and Development (HX003350) and NIA (P30 AG022845) for research unrelated to this work/manuscript with no other conflict of interest., (© 2023 The Authors. eJHaem published by British Society for Haematology and John Wiley & Sons Ltd.)

Chronic musculoskeletal (MSK) pain remains a leading cause of disability and functional impairment among older adults and is associated with substantial societal and personal costs. Chronic pain is particularly challenging to manage in older adults because of multimorbidity, concerns about treatment-related harm, as well as older adults' beliefs about pain and its management. This narrative review presents data on nine high-quality, peer-reviewed clinical trials published primarily over the past two years that focus on MSK pain management in older adults, of which four were comprehensively reviewed. These studies address contributors to knee osteoarthritis (OA) pain (insomnia), provide evidence for digital delivery or artificial intelligence driven behavioral interventions and potentially more efficient/equally effective modes of delivering glucocorticoids for OA; each of the selected studies have potential for scalability and meaningful impact in the care of older adults., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background/objective: Women with interstitial pneumonia with autoimmune features (IPAFs), a subset of interstitial lung disease (ILD), are at risk for pregnancy complications. Family planning discussions improve pregnancy outcomes in women with ILD. The objective of this study was to evaluate the documentation of reproductive counseling in IPAF female patients of childbearing age by pulmonary and rheumatology providers at an academic medical center., Methods: We conducted a medical record review study of pulmonary and rheumatology encounters in reproductive-aged women with IPAF to evaluate documentation of family planning discussions and contraceptive use. We used nonparametric measures of association and logistic regression to evaluate the relationship between patient characteristics and the presence of reproductive counseling documentation by providers., Results: Thirty-one women met IPAF classification and were ≤50 years at initial ILD clinic visit. Twenty-five (81%) of these women had risk factors for adverse pregnancy outcomes. Ten women (32%) had a record of reproductive counseling during any visit with their pulmonary provider. Of the 21 patients who also saw a rheumatology provider, 12 (57%) women had a record of reproductive counseling during any visit with their rheumatology provider. No baseline characteristics were associated with odds of reproductive counseling documentation., Conclusions: Neither pulmonary nor rheumatology providers consistently discussed family planning/contraceptive use with reproductive-aged women with IPAF. There was a trend for rheumatology providers to discuss reproductive issues with IPAF patients more frequently than pulmonary providers. Efforts should focus on educating providers about the need for reproductive counseling in women with IPAF of childbearing age., Competing Interests: U.E.M. reports funding by VA HSR&D and NIA for research unrelated to this work/manuscript with no other conflicts of interest. B.M., T.N.A., and B.B. report no conflict of interest, financial, or otherwise., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Black patients and those with co-occurring mental health disorders are disproportionately affected by chronic pain, but few interventions target these populations. This is a secondary analysis of a randomized trial of a walking-focused proactive counseling intervention for Black Veterans with chronic musculoskeletal pain (ACTION). The primary aim was to examine intervention effectiveness among Veterans with an electronic health record-documented mental health diagnosis [depressive disorder, anxiety disorder, substance use disorder, post-traumatic stress disorder or serious mental illness (n = 205)] and those without a diagnosis (n = 175). About 380 Black Veterans receiving care at the Atlanta VA Health Care System were enrolled from 2016 to 2019 and randomized to the intervention or usual care (UC) (1:1). The intervention featured 6 telephone coaching sessions over 8-14 weeks to encourage walking. Participants with a mental health disorder were more likely to complete all counseling sessions (56% vs 38%) and reported improvements in global perceptions of pain and pain intensity/interference (secondary outcomes) at 3-months vs UC. Among participants without a mental health disorder, the intervention was associated with an improvement in pain-related disability at 6-months (primary outcome). Black chronic pain patients with co-occurring mental health disorders may require more intensive treatment to affect improvement in pain-related disability. PERSPECTIVE: This study examines the effectiveness of a walking intervention for chronic pain among Black Veterans with a mental health disorder. These patients were more engaged with the intervention than those without a mental health disorder. However, they did not experience reductions in pain-related disability, suggesting more intensive treatment is needed., (Published by Elsevier Inc.)

The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty., (© 2022 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Objective: To identify perceived health literacy (HL) and patient activation (PA) needs during the transition from pediatric to adult rheumatology among patients with childhood-onset systemic lupus erythematosus (cSLE)., Methods: Semistructured interviews of patients and health care professionals were conducted from November 2019 through May 2020, until thematic saturation was achieved. Interviews were audio-recorded, transcribed, coded, and analyzed using thematic analysis., Results: Thirteen post-transition adult female participants with cSLE were recruited from a public safety-net hospital system or from private practice. Thirteen health care team members were recruited from two pediatric and four adult rheumatology clinical sites serving patients in the same metropolitan area. Patients and health care team members acknowledged numerous HL components as important to transition, including language fluency, education, SLE-specific knowledge, self-efficacy, and accurate knowledge of personal medical history. Our interviews found PA to be an important component of the transition process, driven by internalization of the implications of cSLE diagnosis, self-education, autonomy, introspection, and trustworthy doctor-patient relationships. Patients valued access to their online electronic medical record, recommended multimodal SLE-specific education materials, and desired increased access to social workers. Health care team members stressed the importance of early preparation for transition and use of mobile medical applications and endorsed interventions such as lupus camp and increased partnership with psychologists and social workers., Conclusion: HL and PA are perceived by patients and health care team members as substantially influencing transition success. Further research is needed to evaluate whether interventions to improve HL and PA positively influence cSLE transition outcomes., (© 2022 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Quality measures (QMs) are tools that help measure or quantify health care processes, outcomes, patient perceptions, and organizational structures and systems associated with the ability to provide high-quality health care. QMs are often developed from clinical practice guidelines (CPGs), as they summarize the best available evidence to create standards for optimizing patient care. The authors provide a framework for learners to understand the relevance, development, and testing of QMs in rheumatology, touching on their relationship to CPGs and appropriate use criteria. They describe measure implementation across different health care settings and reflect on challenges and opportunities associated with this process., Competing Interests: Disclosure Dr. Makris was a VA HSR&D Career Development Awardee at the Dallas VA (CDA 14-425). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs., (Published by Elsevier Inc.)

Background: The psychosocial burden of having a chronic disease can be substantial for adolescents with childhood-onset systemic lupus erythematosus (cSLE). Current literature is scarce on interventions that can improve psychosocial outcomes for this population. Therapeutic recreation camps have been proposed as a beneficial experience for chronically ill pediatric populations. However, their effective components have not been well characterized in patients with cSLE. In this study, we sought to understand the various components of the camp experience for adolescents with cSLE from both the patient and parent perspective., Methods: We recruited patients with cSLE who had participated in one or more annual, weekend-long recreational lupus camp(s) near Dallas, Texas. Semi-structured in-depth telephone interviews were conducted from March-June 2020 with both the patients and parents. Questions focused on overall patient experience, psychosocial impact of camp participation, coping skills gained, and opportunities to prepare for the transition from pediatric to adult care. Interviews were coded and analyzed using inductive thematic analysis., Results: We interviewed 9 current and former campers (ages 16-24), including a current camp counselor, and 3 of their parents separately. Reported benefits included a positive impact on social support through peer bonding, opportunities to develop coping mechanisms through structured activities and peer/medical staff interactions, opportunities for education about the cSLE disease experience, improved adherence through peer modeling, overall increase in self-efficacy, and better parental insight into the patient experience. Participants also provided suggestions for expansion and improvement in program development to optimize educational opportunities for both campers and parents. In addition, they advocated for longitudinal social support and community building., Conclusions: In this qualitative study, in which cSLE patients and their parents reflected on their experiences with therapeutic recreation camps, we found several perceived benefits impacting the patient and parent experience. Participants expressed a desire for more educational opportunities that could contribute to their successful transition from pediatric to adult care. Further studies are needed to demonstrate the effects of therapeutic recreation camps on the psychosocial health of this population., (© 2022. The Author(s).)

Purpose of Review: This narrative review will focus on the role of the rheumatologist in evaluating patients with interstitial lung disease (ILD) without a defined rheumatic disease and will outline the current classification criteria for interstitial pneumonia with autoimmune features (IPAF) and describe what is known regarding IPAF pathobiology, natural history, prognosis, and treatment. Lastly, knowledge gaps and opportunities for future research will be discussed., Recent Findings: IPAF is a recently defined classification of ILD patients who have features suggesting an autoimmune-mediated process, but do not fulfill current rheumatic disease criteria. The goal of the IPAF criteria is to provide a uniform case definition for the study of autoimmune ILD patients who do not currently fit within standard ILD diagnostic categories, ultimately improving diagnosis and therapy. Many of these patients are referred for rheumatologic evaluation to aid the diagnostic process. The care of the IPAF patient is complex and is multidisciplinary with pulmonology, rheumatology, pathology, radiology, physical therapy, primary care, pulmonary transplant providers all serving vital roles. The rheumatologist has several roles which include classification, disease monitoring, and management., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Study Design: Retrospective., Objective: To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity., Summary of Background Data: Surgery for correction of adult spinal deformity is often beneficial; however, in over 20% of older adults (≥ 65 yrs of age), outcomes from surgery are less desirable., Materials and Methods: We conducted semistructured, in-depth interviews with six patients and five spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes., Results: Patients themes: 1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; 2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; 3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and 4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: 1) surgeons varied substantially in their interpretations of shared decision-making; 2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; 3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and 4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration., Conclusion: Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision-making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness., Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antiphospholipid syndrome (APS) is an autoimmune prothrombotic condition with significant morbidity. The objective of this study was to identify additional clinical and epidemiological risks of arterial thrombosis, venous thrombosis, and pregnancy morbidities in a large cohort of persistent antiphospholipid antibodies (aPLs)-positive carriers., Methods: This was a cross-sectional cohort study of 453 consecutive patients with a documented positive aPL who attended Peking University People's Hospital. Among 453 patients screened, 297 patients had persistent positive aPL. We compared asymptomatic aPL carriers with thrombotic and obstetric APS patients. And the univariate analysis and multivariable logistic regression were used to evaluate the association between different risk factors and APS clinical manifestations. The levels of circulating markers of neutrophil extracellular traps (NETs) (cell-free DNA and citrullinated histone H3 [Cit-H3]) were assessed and compared among aPL-positive carriers with or without autoimmune disease and APS patients., Results: Additional risk factors associated with arterial thrombosis among aPL-positive carriers included: smoking (odds ratio [OR] = 6.137, 95% confidence interval [CI] = 2.408-15.637, P  = 0.0001), hypertension (OR = 2.368, 95% CI = 1.249-4.491, P  = 0.008), and the presence of underlying autoimmune disease (OR = 4.401, 95% CI = 2.387-8.113, P < 0.001). Additional risks associated with venous thrombosis among aPL carriers included: smoking (OR = 4.594, 95% CI = 1.681-12.553, P  = 0.029) and the presence of underlying autoimmune disease (OR = 6.330, 95% CI = 3.355-11.940, P < 0.001). The presence of underlying autoimmune disease (OR = 3.301, 95% CI = 1.407-7.744, P  = 0.006) is the additional risk, which demonstrated a significant association with APS pregnancy morbidity. Higher circulating levels of cell-free DNA and Cit-H3 were observed among APS patients and aPL patients with autoimmune diseases compared with those aPL carriers without underlying autoimmune diseases. Furthermore, control neutrophils that are conditioned with APS patients'sera have more pronounced NET release compared with those treated with aPL carriers'sera without underlying autoimmune diseases., Conclusions: We identified several potential additional risk factors for APS clinical manifestations among a large cohort of Chinese aPL carriers. Our data may help physicians to risk stratify aPL-positive Asian patients., (Copyright © 2022 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

Background/objective: We have limited knowledge regarding characteristics of patients with interstitial pneumonia with autoimmune features (IPAF) that are associated with response to immunosuppression. In this study, we used published IPAF criteria to characterize features associated with response to treatment., Methods: We conducted a single-center medical records review study of 63 IPAF patients to evaluate for serological, clinical, and morphological characteristics that are associated with response to immunosuppression. Response was defined as % relative functional vital capacity decline of less than 10% and absence of death or lung transplant within the first year of continuous immunosuppressive therapy. Nonparametric measures of association and multivariate logistic regression were used to evaluate the relationship between baseline characteristics and immunosuppressive response., Results: There was a trend of greater progression among men, ever smokers, those negative for antisynthetase antibodies, and those with usual interstitial pneumonia radiographic pattern, but no statistically significant relationship was found between baseline serological, clinical, or morphological features and response to immunosuppression. Patients on combination therapy with mycophenolate mofetil and prednisone had less disease progression (p = 0.018) than those on regimens that did not include both of these medications., Conclusions: In our cohort, baseline clinical assessment did not identify which patients with IPAF will respond to immunosuppressive therapy. Combination therapy with mycophenolate mofetil and prednisone was associated with lack of disease progression in our IPAF patients, including in IPAF-usual interstitial pneumonia. Further studies are needed to evaluate which IPAF patients would benefit from immunosuppressive therapy, antifibrotic therapy, or a combination of both., Competing Interests: E.K.J. reports salary support from a grant from Pfizer, Inc and Ruth L. Kirschstein Institutional National Research Service Award (T32). C.A.N. reports career development award from the National Heart, Lung, and Blood Institute (K23HL148498) and have received consulting fees from Boehringer-Ingelheim in the amount less than $10,000. U.E.M. reports funding by VA HSR&D and NIA for research unrelated to this work/manuscript with no other conflicts of interest. The other authors declare no conflict of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The transfer from pediatric to adult care for young adults is a vulnerable period. Our objectives were to quantify the time between the final pediatric and the first adult visit and to evaluate unscheduled utilization in care and progression to end-stage renal disease (ESRD) or death., Methods: We conducted a retrospective analysis of pediatric patients transferring to a large adult rheumatology clinic. Outcomes included time to first completed adult visit, unscheduled health care utilization (hospitalizations and emergency department [ED] visits), and progression to ESRD or death. Multivariable regression models assessed variables predictive of outcomes of interest., Results: A total of 141 pediatric patients who transferred care were identified: 77% female, 65% Hispanic, and 60% with connective tissue diseases (CTDs). The mean time between final pediatric and first completed adult rheumatology visit was 221 days (range 0-1,207 days). In regression modeling, we found that continued insurance coverage, younger age at referral, and referral from a pediatric rheumatologist were predictive of shorter time to completed adult visit (P < 0.005). Factors associated with hospitalizations and ED visits included CTD diagnosis and Black race (odds ratio [OR] 8.54 [95% confidence interval (95% CI) 1.84-39.58] and 3.04 [95% CI 1.02-9.12] for hospitalizations and OR 3.6 [95% CI 1.59-8.14] and 6.0 [95% CI 1.60-22.69] for ED visits, respectively). ESRD or death occurred among 15% of patients with a CTD., Conclusion: In pediatric patients transferring to an adult rheumatology clinic, continued insurance coverage and referral from a pediatric rheumatologist decreased delays in attending an adult visit; CTD and Black race were associated with high rates of unscheduled health care utilization., (© 2020, American College of Rheumatology.)

Background: The transition from pediatric to adult care is a vulnerable period for individuals with chronic diseases. We sought to identify risk factors associated with poor outcomes in patients with childhood-onset systemic lupus erythematosus (cSLE) who have transitioned to adult care., Methods: A retrospective analysis of cSLE patients was performed. Outcomes of interest were development of end-stage renal disease (ESRD) or death and time to first hospitalization following final pediatric rheumatology visit. Multivariable logistic and Cox regression models were used., Results: Of 190 patients with cSLE, 21 (11%) developed ESRD and 9 (5%) died following the final pediatric rheumatology visit. In logistic regression, public insurance, history of Child Protective Services involvement, and an unscheduled hospitalization during the final year in pediatric care were predictive of ESRD or death (odds ratio (95% confidence intervals (CI)) 6.7 (1.5-30.7), 6.6 (2.3-19.1), and 3.2 (1.3-8.3), respectively). Among 114 patients with healthcare utilization data, 53% had a hospitalization in adult care. In Cox regression analysis, a pediatric outpatient opioid prescription was associated with shorter time to adult hospitalization and White or Asian race was associated with longer time to adult hospitalization (hazard ratio (CI) 3.5 (1.7-7.0) and 0.1 (0.03-0.4), respectively)., Conclusions: Risks factors associated with poor outcomes in adult care amongst patients with cSLE include public insurance, history of Child Protective Services involvement, unscheduled care utilization in pediatric care, pediatric outpatient opioid prescription, Black race and Hispanic ethnicity. Efforts to improve long-term outcomes among patients with cSLE should focus on these populations., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Given the rising media attention regarding various adverse conditions attributed to breast implants, the authors examined the association between breast implantation and the risk of being diagnosed with connective tissue diseases, allergic reactions, and nonspecific constitutional complaints in a cohort study with longitudinal follow-up., Methods: Women enrolled in a regional military health care system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match women who underwent breast implantation with women who did not undergo breast implantation. The propensity score included age, social history, health care use, comorbidities, and medication use. Outcomes assessed included International Classification of Diseases, Ninth Revision, diagnoses codes for (1) nonspecific constitutional symptoms, (2) nonspecific cardiac conditions, (3) rheumatoid arthritis and systemic lupus erythematosus, (4) other connective tissue diseases, and (5) allergic reactions., Results: Of 22,063 women included in the study (513 breast implants and 21,550 controls), we propensity score-matched 452 breast implant recipients with 452 nonrecipients. Odds ratios and 95 percent confidence intervals in breast implant recipients compared to nonrecipients were similar, including nonspecific constitutional symptoms (OR, 0.77; 95 percent CI, 0.53 to 1.13), nonspecific cardiac conditions (OR, 0.97; 95 percent CI, 0.69 to 1.37), rheumatoid arthritis and systemic lupus erythematosus (OR, 0.66; 95 percent CI, 0.33 to 1.31), other connective tissue diseases (OR, 1.02; 95 percent CI, 0.78 to 1.32), and allergic reactions (OR, 1.18; 95 percent CI, 0.84 to 1.66)., Conclusions: Women with breast implants did not have an increased likelihood of being diagnosed with nonspecific constitutional symptoms, connective tissue disorders, and/or allergic reaction conditions., Clinical Question/level of Evidence: Therapeutic, III., Competing Interests: Disclosure:The authors have no commercial associations and no potential conflict of interest to report. No funding was provided for the conduct of this study or the preparation of this article., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Objective: The transition from pediatric to adult care for youth with childhood-onset systemic lupus erythematosus (SLE) is a vulnerable period. Adverse outcomes during this transition include gaps in care, unscheduled health care utilization, loss of insurance, and high disease activity. The objective of this study was to examine the clinical care teams' perspective on the psychosocial factors associated with transition outcomes, which are poorly understood in this population., Methods: We conducted in-depth interviews with clinical care team members who interact with childhood-onset SLE patients during transfer from pediatric to adult rheumatology. A semistructured interview guide was used to prompt participants' perspectives about the psychosocial factors associated with the transition process for patients with childhood-onset SLE. Audio recordings were transcribed and analyzed using the constant comparative method. We stopped conducting interviews once thematic saturation was achieved., Results: Thirteen in-depth interviews were conducted. Participants included pediatric rheumatologists (n = 4), adult rheumatologists from both academic and private practice settings (n = 4), nurses (n = 2), a nurse practitioner, a social worker, and a psychologist. We identified several themes deemed by clinical care teams as important during the transition, including the impact of the family, patient resilience and coping mechanisms, the role of mental health and emotional support, and the need for education, peer support, and social connectedness., Conclusion: We identified several psychosocial themes that clinical team members believe impact the transition of patients with childhood-onset SLE into adult care. The role of parental modeling, youth resilience, mental health and emotional care, improved childhood-onset SLE education, and structured peer support and social connectedness are highlighted, which may be amenable to interventions., (© 2020, American College of Rheumatology.)

Competing Interests: Competing interests: None declared.

Background: Chronic low back pain (cLBP) results in significant physical, psycho-social and socioeconomic burden. Identifying efficient and reliable patient reported outcome measures is critical for research and clinical purposes. The NIH's Patient Reported Outcomes Measurement Information System (PROMIS) instruments have not been compared to validated "legacy" instruments in older adults with cLBP. This study evaluates construct (convergent and discriminant) validity and time to complete (TTC) PROMIS as compared to legacy instruments., Methods: We enrolled older Veterans (age 60+) with cLBP with/without leg pain scheduled for lumbar epidural steroid injections. Subjects completed PROMIS computer adaptive test item banks and corresponding legacy instruments in the following domains: pain intensity, interference, and behavior; functional status; depression and anxiety; fatigue; sleep and social functioning. Convergent and discriminant validity between PROMIS and legacy instruments was evaluated using Spearman rank order correlations; Mann-Whitney U tests compared TTC., Results: Of the 71 Veterans recruited, the median (IQR) age was 67 (63-71) years old, 94% were men, 76% were White, 17% Black, and 96% were Non-Hispanic. Spearman correlations between PROMIS and legacy instruments showed moderate to very strong convergent validity in all domains (r = 0.4-1.0), except for social functioning and pain behavior (PROMIS Pain Behavior with Fear Avoidance Belief Questionnaire). The total median TTC for all PROMIS items was significantly shorter than legacy items, 8 min 50 s vs 29 min 14 s respectively, p < 0.001., Conclusions: Given time efficiency of using PROMIS, along with strong construct validity, PROMIS instruments are a practical choice for measuring multidimensional PROs in older Veterans with cLBP for both research and clinical purposes.

Persistent pain in older adults is a widely prevalent and disabling condition that is the manifestation of multiple contributing physical, mental, social, and age-related factors. To effectively treat pain, the clinician must assess and address contributing factors using a comprehensive approach that includes pharmacologic and nonpharmacologic therapies within the context of a strong therapeutic relationship among the patient, caregivers, and a multidisciplinary team. This article reviews the current understanding of persistent pain in older adults and suggests a general approach to its assessment and management, followed by specific considerations for musculoskeletal pain conditions commonly seen in older adults., Competing Interests: Disclosure Dr. Makris is supported by a VA HSR&D Career Development Award at the Dallas VA (IK2HX001916)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Rheumatoid arthritis (RA) is associated with increased atherosclerotic cardiovascular disease (ASCVD). General population cohorts have shown African American individuals to have greater and Hispanic Americans to have lower cardiovascular disease prevalence when compared with non-Hispanic white individuals; however, the reasons for these findings are not clear. This systematic review seeks to describe the incidence and prevalence of ASCVD stratified by race/ethnicity within the US RA population., Methods: MEDLINE, Embase, and Cochrane databases were searched for studies that reported incidence or prevalence of ASCVD (including, but not limited to, fatal and nonfatal stroke, myocardial infarction, and cardiovascular death) in those with RA. Abstracts and full texts were screened separately for inclusion by two reviewers, with a third reviewer to resolve discrepancies., Results: We screened 2625 abstracts and fully reviewed 138 manuscripts. Twenty-one were included that cited at a minimum the percentage of non-Hispanic whites in their population. No publication meeting entry criteria initially stratified ASCVD by race/ethnicity. The average prevalent ASCVD in RA is 46.9% (95% CI: 46.8-47) (range of prevalent ASCVD: 30%-47%). The average incident ASCVD is 8.2% (95% CI: 8.14-8.25) (range of incident ASCVD 1%-46%)., Conclusion: In this systematic review, we found a paucity of data on racially/ethnically diverse RA patients and ASCVD outcomes. Future studies should report the prevalence of ASCVD in various races/ethnicities with RA in the United States. These data would help inform clinicians on how best to manage cardiovascular disease risk in RA., (© 2020 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

The purpose of the ongoing trial is to improve care of older Veterans with chronic low back pain (CLBP, i.e., low back pain for ≥6 months on ≥ half the days). Current CLBP care is limited by being either overly spine-focused or non-specifically prescribed and both approaches frequently lead to suboptimal reduction in pain and improvement in function. Through prior studies we have laid the foundation for a patient-centered approach to care for older Veterans with CLBP in which the spine is a source of vulnerability but not the sole treatment target. The approach considers CLBP a geriatric syndrome, a final common pathway for the expression of multiple contributors rather than a disease of the spine. We describe here the rationale and design of a randomized controlled trial to test the efficacy of an older Veteran-centered approach to CLBP care in "Aging Back Clinics (ABCs)" compared with Usual Care (UC). Three hundred thirty Veterans age 65-89 with CLBP will be randomized to ABCs or UC and followed for 12 months after randomization. We will assess the impact of ABCs on our primary outcome of pain-associated disability with the Oswestry Disability Index at 6 and 12 months, and secondary outcomes of pain intensity, health-related quality of life, balance confidence, mobility and healthcare utilization. If shown efficacious, the approach tested in ABCs has the potential to transform the care of older adults with CLBP by improving the quality of life for millions, reducing morbidity and saving substantial healthcare costs., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier Inc.)

Objective: To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain., Methods: We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting., Results: Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format., Conclusions: Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options., (2019 American Academy of Pain Medicine. This work is written by US Government employees and is in the public domain in the US.)

Introduction: Musculoskeletal conditions, including osteoarthritis (OA), result in tremendous disability and cost. Statins are among the most commonly prescribed medications and their use for primary prevention in many otherwise healthy individuals, including those who are physically active, is increasing. There is conflicting evidence regarding the relationship of statin use and musculoskeletal conditions. Given the rising disability associated with musculoskeletal conditions, understanding predisposing factors, including medication-related exposures, deserves further attention., Objectives: We examined the association between statin use and the risk of being diagnosed with non-traumatic arthropathies, use-related injury, and undergoing rehabilitation in a cohort with longitudinal follow-up., Methods: Patients enrolled in a regional military healthcare system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match statin-users and nonusers using 115 baseline characteristics. Outcomes included ICD-9 diagnoses codes for Agency for Healthcare Research and Quality disease categories of: non-traumatic arthropathies, use-related injury and undergoing rehabilitation. Primary analysis examined the outcomes in statin-users and nonusers after propensity score matching using conditional logistic regression analysis., Results: Initially, 60,455 patients were identified. We propensity score-matched 6728 statin users with 6728 nonusers (52 years of age, ~ 47% women). In the propensity score-matched cohort, non-traumatic arthropathies occurred in 59.8% of statin users and 56.0% of nonusers [odds ratio (OR) 1.17, 95% confidence interval (95% CI) 1.09-1.25] and use related injury occurred in 31.9% of statin users and 29.8% of nonusers (OR 1.11, 95% CI 1.03-1.19). There was no difference between statin users and nonusers undergoing rehabilitation (22.6% among statin users, 21.9% among nonusers, OR 1.04, 95% CI 0.96-1.13)., Conclusion: Statin use was associated with a significant increased risk of non-traumatic arthropathies and use-related injury. Our results provide additional data that can inform patient and clinician conversations about the benefits and risks of statin use.

Objective: To evaluate the relationship between back pain severe enough to restrict activity (restricting back pain) and subsequent disability in essential (e) and instrumental (i) activities of daily living (ADL) among community-living older adults., Method: In this prospective cohort study, we evaluated 754 adults, aged ≥70 years who were initially nondisabled in eADL. Restricting back pain and disability were assessed during monthly interviews for up to 159 months. Associations between restricting back pain and subsequent eADL and iADL disability were evaluated using recurrent events Cox models, adjusted for fixed-in-time and time-varying covariates., Results: Strong associations were found between restricting back pain and eADL and iADL disability, with hazard ratios (95% confidence intervals) of 3.47 [3.01, 3.90] and 2.33 [2.08, 2.61], respectively., Discussion: Restricting back pain was independently associated with subsequent disability in eADL and iADL. Interventions focused on decreasing restricting back pain in older adults may have the potential to reduce the subsequent burden of disability.

The evaluation of thrombotic and pregnancy risks associated with antiphospholipid antibodies (aPL)in individual patients without antiphospholipid syndrome (APS) clinical manifestation is challenging. Our aim is to identify additional risk factors or potential candidate "second hits" for APS clinical events in a large cohort of ethnically diverse aPL-positive patients. We included 219 consecutive aPL-positive patients who attended clinic at our institution. All patients had at least 1 persistent high titer (≥99 percentiles) aPL. Independent risk factors for thrombosis and pregnancy morbidities among patients with positive aPL were evaluated. When assessing risk factors associated with pregnancy morbidities, only female controls of reproductive age (age ≤45) were used. Pearson χ 2 analysis and multivariable logistic regression were used to evaluate correlation between different risk factors and clinical manifestations. Of the 219 aPL-positive patients, 120 (54.8%) patients had criteria APS clinical manifestations and 99 patients did not. A total of 46.1% were Caucasian, 26.4% of African descent, 16.9% Hispanic, 1.8% Asian, and 8.7% were unspecified. Among traditional risk factors and signs of endothelial injury, only hypertension demonstrated an independent association with arterial thrombosis (odds ratio [OR] = 3.826, 95% confidence interval [CI]: 1.597-9.167, P = .0026), and lupus anticoagulant (LA) demonstrated an independent association with venous thrombosis (OR = 3.308, 95% CI: 1.544-7.085, P = .0021). None of the evaluated risk factors demonstrated a significant association with pregnancy morbidity. Hypertension is a potential predictor of arterial thrombosis and the presence of LA is a potential predictor of venous thrombosis in aPL-positive patients.

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.

Objective: To determine perceived barriers and facilitators to effective mentoring for early career rheumatology investigators and to develop a framework for an inter-institutional mentoring program., Methods: Focus groups or interviews with rheumatology fellows, junior faculty, and mentors were conducted, audiorecorded, and transcribed. Content analysis was performed using NVivo software. Themes were grouped into categories (e.g., mentor-mentee relationship, barriers, and facilitators of a productive relationship). Rheumatology fellows and early career investigators were also surveyed nationwide to identify specific needs to be addressed through an inter-institutional mentoring program., Results: Twenty-five individuals participated in focus groups or interviews. Attributes of the ideal mentee-mentor relationship included communication, accessibility, regular meetings, shared interests, aligned goals, and mutual respect. The mentee should be proactive, efficient, engaged, committed, focused, accountable, and respectful of the mentor's time. The mentor should support/promote the mentee, shape the mentee's goals and career plan, address day-to-day questions, provide critical feedback, be available, and have team leadership skills. Barriers included difficulty with career path navigation, gaining independence, internal competition, authorship, time demands, funding, and work-life balance. Facilitators of a successful relationship included having a diverse network of mentors filling different roles, mentor-mentee relationship management, and confidence. Among 187 survey respondents, the primary uses of an inter-institutional mentoring program were career development planning and oversight, goal-setting, and networking., Conclusions: In this mixed-methods study, tangible factors for optimizing the mentor-mentee relationship were identified and will inform the development of an adult rheumatology inter-institutional mentoring program., (© 2017, American College of Rheumatology.)

Background: Musculoskeletal pain is associated with increased fall risk among older men. However, the association of back pain, the most prevalent type of pain in this population, and fall risk is unknown., Methods: We conducted a prospective investigation among 5,568 community-dwelling U.S. men at least 65 years of age from the Osteoporotic Fractures in Men Study (MrOS). Baseline questionnaires inquired about back pain and its location (such as low back), severity, and frequency in the past year. During 1 year of follow-up, falls were summed from self-reports obtained every 4 months. Outcomes were recurrent falls (≥2 falls) and any fall (≥1 fall). Associations of back pain and fall risk were estimated with risk ratios (RRs) and 95% confidence intervals (CIs) from multivariable log-binomial regression models adjusted for age, dizziness, arthritis, knee pain, urinary symptoms, self-rated health, central nervous system medication use, and instrumental activities of daily living., Results: Most (67%) reported any back pain in the past year. During follow-up, 11% had recurrent falls and 25% fell at least once. Compared with no back pain, any back pain was associated with elevated recurrent fall risk (multivariable RR = 1.3, 95% CI: 1.1, 1.5). Multivariable RRs for 1, 2, and 3+ back pain locations were, respectively, 1.2 (95% CI: 1.0, 1.5), 1.4 (1.1, 1.8), and 1.7 (95% CI: 1.3, 2.2). RRs were also elevated for back pain severity and frequency. Back pain was also associated with risk of any fall., Conclusions: Among older men, back pain is independently associated with increased fall risk., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults., Design: This was a qualitative study using semi-structured interviews and focus groups., Setting and Patients: This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain., Methods: We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories., Results: Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies)., Conclusions: These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine 2016. This work is written by US Government employees and is in the public domain in the US.)