Prevalence and Factors Associated with De-escalation of Anti-TNFs in Older Adults with Rheumatoid Arthritis: A Medicare Claims-Based Observational Study.

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.

High Interleukin-13 level is associated with disease stability in interstitial Lung disease.

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-ß, 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.

Mindfulness and yoga therapy for acute pain in sickle cell disease.

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.

Frailty and Risk of Serious Infections in Patients With Rheumatoid Arthritis Treated With Biologic or Targeted-Synthetic Disease-Modifying Antirheumatic Drugs.

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.

Initiation of Disease-Modifying Antirheumatic Drugs in Older Medicare Beneficiaries With New Diagnosis of Late-Onset Rheumatoid Arthritis.

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.

Clin-STAR corner: 2021 update in musculoskeletal pain in older adults with a focus on osteoarthritis-related pain.

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.

Low Rates of Reproductive Counseling Documentation in Women With Interstitial Pneumonia With Autoimmune Features.

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.

An Analysis of the Role of Mental Health in a Randomized Trial of a Walking Intervention for Black Veterans With Chronic Pain.

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.

Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More.

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.

Taxonomy of Quality of Care Indicators: Tracing the Path from Clinical Practice Guidelines to Quality Measurement and Beyond.

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.

Interstitial Pneumonia with Autoimmune Features: What the Rheumatologist Needs to Know.

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.

Therapeutic recreation camps for youth with childhood-onset systemic lupus erythematosus: perceived psychosocial benefits.

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.

Health Literacy and Patient Activation in the Pediatric to Adult Transition in Systemic Lupus Erythematosus: Patient and Health Care Team Perspectives.

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.

Additional risk factors associated with thrombosis and pregnancy morbidity in a unique cohort of antiphospholipid antibody-positive patients.

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.

Patient and Spine Surgeon Perceptions on Shared Decision-Making in the Treatment of Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity.

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.

Variables Associated With Response to Therapy in Patients With Interstitial Pneumonia With Autoimmune Features.

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.

Decisional Regret Among Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity: A Single Institutional Study.

STUDY DESIGN: Retrospective. OBJECTIVE: To investigate the prevalence of decisional regret among older adults undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Among older adults (≥65 years old), ASD is a leading cause of disability, with a population prevalence of 60% to 70%. While surgery is beneficial and results in functional improvement, in over 20% of older adults outcomes from surgery are less desirable. METHODS: Older adults with ASD who underwent spinal surgery at a quaternary medical center from January 1, 2016 to March 1, 2019, were enrolled in this study. Patients were categorized into medium/high or low-decisional regret cohorts based on their responses to the Ottawa decision regret questionnaire. Decisional regret assessments were completed 24 months after surgery. The primary outcome measure was prevalence of decisional regret after surgery. Factors associated with high decisional regret were analyzed by multivariate logistic regression. RESULTS: A total of 155 patients (mean age, 69.5 yrs) met the study inclusion criteria. Overall, 80% agreed that having surgery was the right decision for them, and 77% would make the same choice in future. A total of 21% regretted the choice that they made, and 21% responded that surgery caused them harm. Comparing patient cohorts reporting medium/high- versus low-decisional regret, there were no differences in baseline demographics, comorbidities, invasiveness of surgery, length of stay, discharge disposition, or extent of functional improvement 12-months after surgery. After adjusting for sex, American Society of Anesthesiologists score, invasiveness of surgery, and presence of a postoperative complication, older adults with preoperative depression had a 4.0 fold increased odds of high-decisional regret (P  = 0.04). Change in health related quality of life measures were similar between all groups at 12-months after surgery. CONCLUSION: While the majority of older adults were appropriately counseled and satisfied with their decision, one-in-five older adults regret their decision to undergo surgery. Preoperative depression was associated with medium/high decisional regret on multivariate analysis.Level of Evidence: 4.

"You Just Have to Keep Going, You Can't Give Up": Coping mechanisms among young adults with lupus transferring to adult care.

INTRODUCTION: Coping mechanisms and emotional regulation are important contributors to psychosocial health during stressful life events. We sought to describe the coping and emotional responses of persons with childhood-onset systemic lupus erythematosus during the transfer from pediatric to adult healthcare. METHODS: Semi-structured in-depth one-on-one interviews were conducted with 13 young women aged 18-24 of minority background who had transferred to adult care in a public hospital system. Thematic analysis was used to identify themes motifs from the data. RESULTS: Participants described the use of (1) problem-focused coping such as the use of clear communication and self-education, (2) adaptive emotion-focused coping such as cognitive reframing and acceptance, (3) social coping including support-seeking, (4) meaning-making coping including positive religious framing and viewing events as learning opportunities for growth, and (5) disengaged coping including denial and social isolation. A range of emotional responses associated with the transfer were described including fear, anger, loss, and feelings of empowerment and excitement. CONCLUSION: Effective coping and emotional regulation are modifiable factors that may impact transfer-related outcomes and psychosocial health. Addressing coping mechanisms is relevant to the optimized transfer to adult care.