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Adverse childhood experiences (ACEs) are associated with elevated risk for poor physical and psychological health outcomes. Nearly all of the literature on the association between ACEs and poor health focuses on the individual and family level; the potential role of neighborhood environment is overlooked. Understanding the relationship between ACEs and characteristics of the neighborhood environment is a necessary first step in determining if and how place-based, trauma-informed interventions might mitigate the negative effects of ACEs. The purpose of this exploratory study was to describe the neighborhood environment of adults who have experienced ≥ 4 versus ≤ 3 ACEs.An exploratory secondary analysis of cross-sectional and geospatial data was conducted during 2021. Data sources included 2011/2012 Philadelphia ACE Survey data, a telephone survey of 1,784 randomly sampled Philadelphia adults, linked with geospatial data on 21 neighborhood-level determinants of health. Neighborhood was defined as participant's home census tract at the time of survey. The sample for this secondary analysis included the 1,679 Philadelphia ACE Survey participants for whom home census tract was available. Bivariate logistic regression examined differences between groups (≤ 3 ACEs vs. ≥ 4 ACEs).Individuals with ≥ 4 ACEs lived in neighborhoods with higher neighborhood poverty rates, less socioeconomic resources, worse food access, poorer perceived physical and mental health, more substance overdose deaths, higher crime, and less green space.Findings suggest future work may benefit from considering neighborhood environments when examining and intervening upon the association between ACEs and poor physical and psychological health. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

This study evaluated methods for creating a neighborhood adverse childhood experiences (ACEs) index, a composite measure that captures the association between neighborhood environment characteristics (e.g., crime, healthcare access) and individual-level ACEs exposure, for a particular population. A neighborhood ACEs index can help understand and address neighborhood-level influences on health among individuals affected by ACEs. Methods entailed cross-sectional secondary analysis connecting individual-level ACEs data from the Philadelphia ACE Survey (n = 1677) with 25 spatial datasets capturing neighborhood characteristics. Four methods were tested for index creation (three methods of principal components analysis, Bayesian index regression). Resulting indexes were compared using Akaike Information Criteria for accuracy in explaining ACEs exposure. Exploratory linear regression analyses were conducted to examine associations between ACEs, the neighborhood ACEs index, and a health outcome—in this case body mass index (BMI). Results demonstrated that Bayesian index regression was the best method for index creation. The neighborhood ACEs index was associated with higher BMI, both independently and after controlling for ACEs exposure. The neighborhood ACEs index attenuated the association between BMI and ACEs. Future research can employ a neighborhood ACEs index to inform upstream, place-based interventions and policies to promote health among individuals affected by ACEs.

Objective The purpose of this study was to understand the physical and psychological impact of high stress clinical environments and contributory factors of burnout in multidisciplinary healthcare workforce during the initial outbreak of COVID-19. Method In-person qualitative interviews informed by an adaptation of Karasek's Job Demand-control model were conducted with a convenience sample of healthcare workforce from March to April 2020. Results Themes emerging from interviews coalesced around three main areas: fear of uncertainty, physical and psychological manifestations of stress, and resilience building. Shifting information, a lack of PPE, and fear of infecting others prompted worry for those working with Covid-infected patients. Participants reported that stress manifested more psychologically than physically. Individualized stress mitigation efforts, social media and organizational transparency were reported by healthcare workers to be effective against rising stressors. Conclusion COVID-19 has presented healthcare workforce with unprecedented challenges in their work environment. With attention to understanding stressors and supporting clinicians during healthcare emergencies, more research is necessary in order to effectively promote healthcare workforce well-being., Highlights • Participants reported that organizations struggled with uniform COVID-19 policies. • Infecting others outside hospital setting was among the highest stressors reported. • Availability of personal protective equipment emerged as a controversial stressor. • Stress manifested more psychologically than physically. • Teamwork, transparency, and solidarity across social media alleviated stressors.

Psychological trauma impacts two-thirds of Americans, suggesting that many intensive care unit (ICU) patients have a history of trauma. Our manuscript calls for translating the well-established system of trauma-informed care to the ICU setting – an approach we term “trauma-informed intensive care.” While trauma-informed approaches are being increasingly applied in medical settings such as emergency departments and burn units, the ICU is often overlooked, despite the fact that the ICU environment may be perceived as particularly threatening to those who have experienced trauma. Now is an ideal time to advance efforts for trauma-informed intensive care, given heightened public attention to the ICU experience as a result of the COVID-19 pandemic. Trauma-informed intensive care may promote more positive patient experiences and support patient recovery from critical illness.

The purpose of this editorial is to discuss the opportunities associated with situating nursing science and public health within a shared context as an avenue for nursing to capitalize on its strong foundation for promoting health equity and mitigating the many social and structural determinants of poor health. We highlight one example of how this might be done, by housing departments of nursing in larger colleges of public health. Conducting nursing science within a college of public health presents both opportunities and challenges which are discussed here. Considering the benefits and challenges of collectively situating nursing and public health with a shared context creates numerous natural starting points for productive conversation, collaboration, and discovery that can benefit both public health and nursing's ability to interrogate past harms and transform our approach to move towards a more healthy and equitable future for all.

The purpose of this study was to propose a definition of "wearing off" at the individual patient-level and determine the percentage of patients with migraine who experience "wearing off" of efficacy of galcanezumab at the end of a treatment cycle using this predefined threshold.Anecdotal reports suggest that some patients may experience "wearing off" of efficacy during the last week of their calcitonin gene-related peptide monoclonal antibody treatment cycle. A previous post hoc analysis of galcanezumab demonstrated consistent efficacy at each week throughout all monthly dosing intervals at the population-level, but "wearing off" has not been assessed at the individual patient-level.Post hoc analyses of clinical trial data from four galcanezumab phase III, randomized, placebo-controlled studies in a total of 2680 patients with high-frequency episodic migraine (EVOLVE-1, EVOLVE-2, and CONQUER studies) or chronic migraine (CM; REGAIN and CONQUER studies) were conducted. "Wearing off" was defined as an increase of greater than or equal to 2 weekly migraine headache days in the last week of the treatment cycle compared to the second week for at least 2 months. The analyses were conducted (1) in all patients and (2) in patients with a clinically meaningful response to treatment.The percentage of patients meeting the threshold of "wearing off" was not statistically significantly different among the placebo, galcanezumab 120 mg, and galcanezumab 240 mg treatment groups, both in the total population and in patients with a clinically meaningful response (all ≤9.0%). Although the frequency of "wearing off" in patients with CM and prior preventive failures was numerically greater in the galcanezumab groups (8/89 or 9.0%) compared to placebo (3/95 or 3.2%), these differences were not statistically significant.Consistent with previous analyses at the population-level that showed no evidence of decreased efficacy at the end of a treatment cycle, rates of individual patients meeting the threshold of "wearing off" in this analysis were low and similar among placebo, galcanezumab 120 mg, and galcanezumab 240 mg treatment groups.

Highlights • Many individuals and communities have a history of trauma. • Neighborhood built environments can trigger re-traumatization or foster healing. • Trauma-informed approaches merit attention in urban design and public planning. • Research is needed to explore the idea of trauma-informed neighborhoods. • Trauma-informed neighborhoods may promote individual and community well-being., Trauma is a response to a deeply distressing or disturbing event, such as sexual assault, violent crime, or childhood abuse. Trauma has impacted the majority of Americans, with racial/ethnic minority and socioeconomically disadvantaged populations being disproportionately affected. Extensive evidence demonstrates trauma’s harmful effects on physical and psychosocial functioning and healthcare costs. Over the past decade, there has been greater recognition of the need to respond to trauma across various care delivery and program settings. Such recognition led to development of trauma-informed care, an approach that acknowledges trauma’s widespread impact and delivers care in a manner to promote healing and avoid re-traumatization. To date, trauma-informed approaches have been applied to clinical interventions, social programs, and community organizations. However trauma-informed approaches have not been widely applied to the built environment. Here, we propose the concept of a trauma-informed neighborhood. The idea of a trauma-informed neighborhood has not been elucidated in public health or medicine, yet merits attention because physical aspects of the neighborhood environment, such as lighting, traffic density, noise, and greenspace, may either trigger trauma or promote healing for individuals and communities. Research using geospatial, population health, and community-engaged approaches is needed and could build from the existing literature on how the built environment impacts mental health. Evidence would have direct implications for public policy and urban planning, particularly for neighborhoods where residents bear a disproportionate trauma burden. Until the built environment is routinely included in trauma-informed efforts, a key setting that influences trauma recovery, health, and well-being will remain overlooked.

BackgroundThere has been much variation between epidemiological studies that report the prevalence of ankylosing spondylitis (AS). This study aimed to analyze the diagnostic prevalence rates and treatment patterns of male and female AS patients in the United States adult insured population from 2006 to 2016.MethodsTrends in AS prevalence were calculated for the 11-year period covering January 1, 2006 to December 31, 2016. Adult (18+ years old) AS patients were included in this retrospective analysis of medical and pharmacy claims data from the IBM Marketscan Commercial, Medicaid and Medicare-Supplemental Claims database. Prevalence was determined as having ≥1 AS diagnostic codes (ICD-9:720.0; ICD-10:M45.x). Trends in treatment patterns were also analyzed and stratified by gender.ResultsThe AS prevalence increased from 0.04 to 0.09% from 2006 to 2016. The mean age between 2006 and 2016 ranged from 49.52–50.00 years. In 2006, approximately 40% of AS patients were female, while in 2016 over 47% of AS patients were female. Rates of use of TNF inhibitors and oral glucocorticoids increased, while NSAIDs and non-biologic DMARDs (sulfasalazine & methotrexate) rates decreased. Opioid use rates were stable. In 2016, males were more likely to be prescribed biologics, while females were more likely to be prescribed methotrexate, sulfasalazine, NSAIDs, muscle relaxants, anticonvulsants, opioids, and glucocorticoids.ConclusionsThe prevalence of AS diagnosis codes more than doubled between 2006 and 2016, but the very low prevalence suggests that AS continues to be underdiagnosed and under-addressed in routine clinical practice. Despite the increase in female AS patients, females were less likely to be prescribed biologics compared to male AS patients.

Background. Regular physical activity is associated with improved physical and psychosocial well-being. Increasing access to physical activity in underresourced communities requires collaborative, community-engaged methods. One such method is community workgroups. Purpose. The purpose of this article is to describe implementation, strengths, challenges, and results of the workgroup approach as applied to increasing access to physical activity, using our recent study as an illustrative example. Method. A 1-day conference was held in April 2017 for community leaders. The first half of the conference focused on disseminating results of a multifaceted community assessment. The second half entailed community workgroups. Workgroups focused on applying community assessment results to develop strategies for increasing access to physical activity, with plans for ongoing workgroup involvement for strategy refinement and implementation. A professional artist documented the workgroup process and recommendations via graphic recording. Results. Sixty-three community leaders attended the conference and participated in the workgroups. Workgroup participants reported that greater macrosystem collaboration was critical for sustainability of physical activity programming and that, particularly in underresourced urban communities, re-imagining existing spaces (rather than building new spaces) may be a promising strategy for increasing access to physical activity. Discussion. Considered collectively, the community workgroup approach provided unique insight and rich data around increasing access to physical activity. It also facilitated stakeholder engagement with and ownership of community health goals. With careful implementation that includes attention to strengths, challenges, and planning for long-term follow-up, the community workgroup approach can be used to develop health promotion strategies in underresourced communities.

Introduction The primary goals of treating ankylosing spondylitis (AS) patients are to maximize long-term health-related quality of life through control of symptoms and inflammation, prevention of progressive structural damage, and preservation of function. The objective of this study was to describe treatment patterns (persistence, discontinuations, and switch) in the 2 years following the initiation of tumor necrosis factor inhibitors (TNFi) therapy in AS patients. Methods Adult patients with ≥ 2 AS diagnostic codes (ICD-9: 720.0 and/or ICD-10:M45.x) by a healthcare provider were included in this retrospective analysis of data from the IBM MarketScan Commercial Claims database. Patients who newly initiated a TNFi from 01/01/2009 to 12/31/2013 were indexed on their first TNFi. Patients were required to have a 1-year pre-index period free of TNFi and continuous enrollment 1-year pre-index and 2-year post-index. Patients were excluded if they had ≥ 2 diagnostic codes for any of the following conditions: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, plaque psoriasis, hidradenitis suppurativa, or uveitis. Demographic, clinical, and treatment patterns were analyzed. Treatment patterns included switching to a new TNFi, discontinuation (≥ 90-day gap in therapy without starting a new TNFi), or persistence (no gaps in therapy ≥ 90 days) during the 2-year follow-up period. Logistic regression analyses predicting persistent vs. non-persistent and switching vs. discontinuation were conducted. Results A total of 1372 AS patients (846 males/526 females) met the inclusion criteria for this study. Males had a mean age of 44.3 years, while females had a mean age of 42.3 years. Adalimumab was the first biologic for the majority of patients (44.6% males/43.3% females), followed by etanercept (40.4% males/41.6% females), infliximab (10.4% males/10.8% females), golimumab (4.6% males/3.8% females), and certolizumab pegol (0.0% males/0.4% females). During the follow-up period, 33.1% of patients (n = 454) were persistent on their index TNFi, 40.7% (n = 559) discontinued their index TNFi and did not restart a TNFi, and 26.1% (n = 359) switched to a second TNFi. Patients prescribed cDMARDs were more likely to be persistent, while females and opioid users were less likely to be persistent on their first TNFi. Among those that discontinued their first TNFi, 32.8% (n = 187) of males and 43.6% (n = 177) of females switched to a second TNFi. Conclusions This study suggests that approximately 67% of male AS patients and 77% of female AS patients newly initiating a TNFi do not remain on the index therapy 2 year post initiation. Funding Eli Lilly and Company.

Migraine is a common and disabling neurological disease associated with substantial economic burden. Among patients with migraine, it is unknown if cost differences exist when preventive migraine medication (PMM) switches occur.To understand the cost burden and health care resource utilization of patients who discontinue or cycle through 1 (PMM1), 2 (PMM2), or ≥ 3 (PMM3) unique PMM drug classes over a 12-month period versus patients who adhere persistently to their initial PMM class.This retrospective observational study used the Truven Health Analytics MarketScan databases to identify adult patients with migraine initiating their first PMM class (antidepressants, antiepileptics, beta blockers, or neurotoxins) from 2011-2013 (index date = first PMM claim). Patients were required to have ≥ 2 outpatient (1 if inpatient) migraine diagnosis codes (ICD-9-CM 346.xx) from 1 year pre-index to 1 year post-index with ≥ 1 code occurring pre-index. Inclusion criteria also required 12 months of pre- and post-index continuous medical and prescription enrollment. All-cause and migraine-specific total direct costs (outpatient, inpatient, emergency department, and prescriptions), based on the 2014 Consumer Price Index, were estimated for each PMM versus a persistent subgroup during the 12-month post-index period. Propensity score bin bootstrapping, controlling for patient baseline characteristics, was used to adjust separate cost comparisons between each PMM subgroup and the persistent subgroup; bootstrap simulations yielded propensity score-adjusted P values.The study population included 55,402 patients who received a PMM. The study population was mainly female (85%) with a mean age of 39.2 years and mean Charlson Comorbidity Index of 0.31. Antiepileptics were the most common drug class chosen at index across all subgroups; however, lower use of antiepileptics was observed in PMM2 and PMM3 subgroups, which were more likely to be prescribed either antidepressants or beta blockers at index. Mean all-cause total direct costs, including prescription costs, were significantly higher in PMM2 ($13,429) and PMM3 ($18,394) subgroups versus the persistent subgroup ($11,941; each adjusted pairwise comparison, P0.001). Mean migraine-specific total direct costs were significantly lower for the persistent subgroup ($2,420) versus PMM2 and PMM3 subgroups and escalated with increasing numbers of drug class discontinuations or switches, from a mean of $2,997 to $5,004 (both adjusted pairwise comparisons, P0.001). Subgroup differences in all-cause and migraine-specific direct costs were primarily due to variations in outpatient and emergency department services.All-cause total direct costs rose with increasing number of PMM switches over the 12-month post-index period, and were significantly higher than in the persistent subgroup, with the exception of PMM1. Additional analyses indicated that the lack of increase between PMM-persistent and PMM1 costs was due to higher pharmacy costs that were likely related to continuous use of medication in the PMM-persistent subgroup. These data suggest an increased cost burden among patients with migraine who cycle through ≥ 2 PMMs versus those who continue to receive their initial medication class.Eli Lilly and Company was the sole sponsor and funder for this study and was responsible for the study design, data collection, data analysis, interpretation of data, and decision to publish the findings. All authors are employees and minor stockholders of Eli Lilly and Company. Nyhuis was employed by Eli Lilly and Company at the time of this study. The findings of this study were presented in part at the 18th Congress of the International Headache Society; September 7-10, 2017; Vancouver, Canada.

This study assessed associations between school nurse workload and student health and academic outcomes. We hypothesized that lower school nurse workload would be associated with better student outcomes, with associations being greater for members of groups who experience health disparities. Our methods entailed secondary analysis of data for New York City school students in kindergarten through 12th grade during 2015–2016 ( N = 1,080,923), using multilevel multivariate regression as the analytic approach. Results demonstrated lower school nurse workload was associated with better outcomes for student participation in asthma education but not chronic absenteeism, early dismissals, health office visits, immunization compliance, academic achievement, or overweight/obesity. Our findings suggest school nurses may influence proximal outcomes, such as participation in disease-related education, more easily than downstream outcomes, such as absenteeism or obesity. While contrary to our hypotheses, results align with the fact that school nurses deliver community-based, population health–focused care that is inherently complex, multilevel, and directly impacted by social determinants of health. Future research should explore school nurses’ perspectives on what factors influence their workload and how they can best impact student outcomes.

Diagnosis and hospitalization for COVID-19 are disproportionately higher among black persons. The purpose of this study was to explore the lived experience of being diagnosed with COVID-19 among black patients. Semistructured one-on-one interviews with black patients diagnosed with COVID-19 were conducted. Data were analyzed using conventional content analysis and a directed content approach. Fifteen patients participated and 3 themes were identified: Panic amidst a COVID-19 diagnosis, Feeling the repercussion of the diagnosis, and Personal assessment of risks within one’s individual environment. Fear of dying, inadequate health benefits, financial issues, and worries about spreading the virus to loved ones were acknowledged by the patients as critical areas of concerns. Majority of the patients looked to God as the ultimate way of surviving COVID-19. However, none of the patients reported receiving support for spiritual needs from health care providers. This is the first study to investigate the lived experience of being diagnosed with COVID-19 among black patients. Our results highlight several factors that put this group at increased risk for COVID-19 and where additional strategies are needed to address these inadequacies. Integrating public health interventions to reduce socioeconomic barriers and integrating spirituality into clinical care could improve patient care delivery.

Adverse childhood experiences (ACEs) are associated with numerous physical and mental health issues in children and adults. The effect of ACEs on development of childhood obesity is less understood. This systematic review was undertaken to synthesize the quantitative research examining the relationship between ACEs and childhood obesity. PubMed, PsycInfo, and Web of Science were searched in July 2020; Rayyan was used to screen studies, and the Newcastle-Ottawa Scale was used to assess risk of bias. The search resulted in 6,966 studies screened at title/abstract and 168 at full-text level. Twenty-four studies met inclusion criteria. Study quality was moderate, with greatest risk of bias due to method of assessment of ACEs or sample attrition. Findings suggest ACEs are associated with childhood obesity. Girls may be more sensitive to obesity-related effects of ACEs than boys, sexual abuse appears to have a greater effect on childhood obesity than other ACEs, and co-occurrence of multiple ACEs may be associated with greater childhood obesity risk. Further, the effect of ACEs on development of childhood obesity may take 2-5 years to manifest. Considered collectively, findings suggest a need for greater attention to ACEs in the prevention and treatment of childhood obesity.

Objective: Pathways underlying the sleep-obesity relationship in youth are poorly understood. In this study, we examined associations of sleep with sedentary time and moderate-to-vigorous physical activity (MVPA) among youth, stratified by weight category (obesity versus no obesity). A sub-aim examined whether controlling for screen time changed the sleep-sedentary time association. Methods: Methods entailed secondary analysis of baseline data collected June-August 2014-2017 during a school-based healthy weight management trial in Minneapolis/St. Paul, Minnesota. Participants (N = 114) were 8-to-12 years old with BMI ≥ 75th percentile, most of whom were members of racial/ethnic minority groups (57%) or from households receiving economic assistance (55%). Mean nightly sleep duration and daily screen time were measured by survey, MVPA and sedentary time by accelerometer, and height and weight by research staff. Multivariate linear regression examined associations of sleep with sedentary time and MVPA. Results: Sleep was inversely associated with hours of sedentary time (β = -1.34 [-2.11, -0.58] p = .001) and percent of time spent sedentary (β = -2.92 [-4.83, -1.01], p = .004), for youth with obesity only. The association was unchanged by screen time. Sleep was not significantly associated with MVPA in total sample or stratified models. Conclusions: Associations among sleep, activity levels, and obesity may differ based upon movement type (sedentary time vs MVPA) and weight category (obesity vs no obesity).

BackgroundNursing Assistants (NA) who feel empowered tend to perform their duties better, have higher morale and job satisfaction, and are less likely to leave their jobs. Organizational empowerment practices in hospitals likely shape the psychological experiences of empowerment among these personnel; however, little is known about this relationship.ObjectiveWe used qualitative inquiry to explore the relationship between organizational empowerment structural components and feelings of psychological empowerment among hospital frontline workers during a public health emergency.MethodsKanter’s Theory of Structural Empowerment and Spreitzer’s Psychological Empowerment in the Workplace Framework were applied to identify the conceptual influences of organizational practices on psychological experiences of empowerment. In-depth interviews were conducted with a convenience sample of NAs, caring for hospitalized COVID-19 patients. Directed content analysis was performed to generate a data matrix consisting of the psychological experiences of meaning, competence, self-determination, and impact embedded under the organizational structural components of information, resources, support, and opportunity.ResultsThirteen NAs (mean age = 42 years, 92% female) completed interviews.Information, or lack thereof, provided to the NAs influenced feelings of fear, preparation, and autonomy.Resources(e.g., protocols, equipment, and person-power) made it easier to cope with overwhelming emotions, affected the NAs’ abilities to do their jobs, and when limited, drove NAs to take on new roles. NAs noted thatsupportwas mostly provided by nurses and made the NAs feel appreciated, desiring to contribute more. While NAs felt they could consult leadership when needed, several felt leadership showed little appreciation for their roles and contributions. Similar to support, theopportunityto take care of COVID-19 patients yielded a diverse array of emotions, exposed advances and gaps in NA preparation, and challenged NAs to autonomously develop new care practices and processes.ConclusionManagement and empowerment of healthcare workers are critical to hospital performance and success. We found many ways in which the NAs’ psychological experiences of empowerment were shaped by the healthcare system’s empowerment-related structural conditions during a public health emergency. To further develop an empowered and committed critical workforce, hospitals must acknowledge the organizational practice influence on the psychological experiences of empowerment among NAs.

Highlights • Three themes emerged from the data: Risk assessment and planning, innovative evolution of roles and responsibilities, and pandemic response and capacity. • In a rapidly changing landscape of practice protocols and discipline-specific responsibilities, it is key to secure capacity-building resources early on. • Hierarchies seemed to compress during the pandemic, with a leveling of the traditional roles played by different professions. • Clear, concise and consistent information must be accessible to all staff., Background Little is known about clinical staff's perspectives on preparedness for a pandemic. The purpose of this study was to obtain various clinical staff perspectives about preparedness to meet the demands for care during the early phase of the SARS-CoV-2 (COVID-19) pandemic. Methods We conducted a qualitative study using semi-structured in-person interviews from March 2020 to April 2020 at a large tertiary academic urban hospital center. Interview guides were informed by the Resilience Framework for Public Health Emergency Preparedness and analyzed using a directed content analysis approach. Results Fifty-five clinical staff participated in the study. Three themes emerged from the data: 1) Risk assessment and planning: “The powder keg”, 2) Innovative evolution of roles and responsibilities, and 3) Pandemic response and capacity. In the early phases of the pandemic, participants reported varying levels of risks for dying. However, most participants adapted to practice changes and became innovative in their roles over time. Hierarchies were less relevant during care delivery, whereas team collaboration became crucial in managing workforce capacity. Discussion As the pandemic progressed, staff preparedness evolved through a trial-and-error approach. Conclusion The pandemic is evolving as is clinical staff preparedness to meet the demands of a pandemic. In order to get a grasp on the crisis, clinical staff relied on each other and resorted to new workarounds.

Background: Youth experience a decrease in physical activity (PA) and an increase in sedentary time during adolescence. Better understanding of factors associated with activity levels during preadolescence may inform interventions to minimize decline. This study compared the association of self-efficacy for PA, parent support for PA, and peer support for PA with moderate-to-vigorous PA (MVPA) and sedentary time among 8- to 12-year-old children with body mass index ≥75th percentile. Methods: This study analyzed baseline data from a school-based healthy weight management intervention trial, conducted in metropolitan Minnesota. Self-efficacy for PA, parent support for PA, and peer support for PA were measured by child survey using reliable tools. MVPA and sedentary time were measured using accelerometer. Results: Participants included 114 children; mean age was 9.4 (0.9) years, 51% were females, 55% received public assistance, and 57% were racial/ethnic minorities. Self-efficacy for PA was positively associated with moderate to vigorous PA for girls (β = 1.83, P β = −7.00, P = .03). Parent support for PA was positively associated with sedentary time for girls (β = 9.89, P = .04) and the total sample (β = 7.83, P = .04). Conclusions: Interventions for preadolescents with elevated body mass index may improve activity levels by increasing self-efficacy for PA.

Purpose: To describe perceptions of physical activity, opinions, on intergenerational approaches to physical activity and a vision for increasing physical activity in an underresourced urban community. Approach: Focus groups embedded in a large Community-Based Participatory Research Project. Setting: West and Southwest Philadelphia. Participants: 15 parents, 16 youth, and 14 athletic coaches; youth were 13 to 18 years old and attended West Philadelphia schools; parents’ children attended West Philadelphia schools; and coaches worked in West Philadelphia schools. Methods: Six focus groups (2 youth, 2 parent, and 2 coach) were conducted guided by the Socio-Ecological Model; transcriptions were analyzed using a rigorous process of directed content analysis. Results: Factors on all levels of the Socio-Ecological Model influence the perception of and engagement in physical activity for youth and their families. Future strategies to increase engagement in physical activity need to be collaborative and multifaceted. Conclusion: When physical activity is reframed as a broad goal that is normative and gender-neutral, a potential exists to engage youth and their families over their lifetimes; with attention to cross-sector collaboration and resource sharing, engaging and sustainable intergenerational physical activity interventions can be developed to promote health in underresourced urban communities.

Childhood obesity increases the risk for poor health during childhood, as well as for adult obesity and its associated comorbidities. Children from racial/ethnic minority groups or who live in poverty experience elevated rates of obesity. One potential method for reducing childhood obesity disparities is to involve community health workers (frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served). The purpose of this systematic review and meta-analysis was to explore the role and effectiveness of community health workers in childhood obesity interventions. Eleven studies met inclusion criteria, of which nine were eligible for inclusion in the meta-analysis. Results demonstrated that community health workers played various roles in childhood obesity interventions in the home, clinic, school, and community setting. Interventions focused primarily on children from underserved populations. Meta-analytic findings demonstrated a small but significant impact on BMIz and BMI percentile (BMIz [7 studies]: -0.08, 95% CI: -0.15, -0.01, p = 0.03, I2 = 39.4%; BMI percentile [2 studies]: -0.25, 95% CI: -0.38, -0.11, p

Purpose The purpose of this study was to evaluate Dance for Health, an intergenerational program to increase access to physical activity in an underserved, high risk urban community. Design and Methods Dance for Health was developed using community-based participatory research methods and evaluated using an observational study design. The program entailed two hour line dancing sessions delivered by trained dance instructors in the neighborhood recreation center. The weekly sessions were delivered for one month in the spring and one month in the fall from 2012–2016. Nurse practitioner students mentored local high school students to assess outcomes: achievement of target heart rate, Borg Rating of Perceived Exertion, number of pedometer steps during dance session, Physical Activity Enjoyment Scale, and adiposity. Analytic methods included descriptive statistics and mixed effects models. Results From 2012–2016, 521 participants ranging from 2–79 years attended Dance for Health. Approximately 50% of children and 80% of adults achieved target heart rate. Achievement of target heart rate was not related to perceived exertion, though it was related to pedometer steps in adults. All participants rated the program highly for enjoyment. There was no change in adiposity. Conclusions Dance for Health demonstrated high levels of community engagement and enjoyment. It led to adequate levels of exertion, particularly for adults. Our evaluation can inform program refinement and future intergenerational physical activity programs. Practice Implications Dance is an enjoyable, culturally appropriate, low cost method for increasing access to physical activity for children and families.

Objective To characterize baseline gene expression and pharmacodynamically induced changes in whole blood gene expression in 1,760 systemic lupus erythematosus (SLE) patients from 2 phase III, 52-week, randomized, placebo-controlled, double-blind studies in which patients were treated with the BAFF-blocking IgG4 monoclonal antibody tabalumab. Methods Patient samples were obtained from SLE patients from the ILLUMINATE-1 and ILLUMINATE-2 studies, and control samples were obtained from healthy donors. Blood was collected in Tempus tubes at baseline, week 16, and week 52. RNA was analyzed using Affymetrix Human Transcriptome Array 2.0 and NanoString. Results At baseline, expression of the interferon (IFN) response gene was elevated in patients compared with controls, with 75% of patients being positive for this IFN response gene signature. There was, however, substantial heterogeneity of IFN response gene expression and complex relationships among gene networks. The IFN response gene signature was a predictor of time to disease flare, independent of anti–double-stranded DNA (anti-dsDNA) antibody and C3 and C4 levels, and overall disease activity. Pharmacodynamically induced changes in gene expression following tabalumab treatment were extensive, occurring predominantly in B cell–related and immunoglobulin genes, and were consistent with other pharmacodynamic changes including anti-dsDNA antibody, C3, and immunoglobulin levels. Conclusion SLE patients demonstrated increased expression of an IFN response gene signature (75% of patients had an elevated IFN response gene signature) at baseline in ILLUMINATE-1 and ILLUMINATE-2. Substantial heterogeneity of gene expression was detected among individual patients and in gene networks. The IFN response gene signature was an independent risk factor for future disease flares. Pharmacodynamic changes in gene expression were consistent with the mechanism of BAFF blockade by tabalumab.

A recent evaluation of a school nurse–led obesity intervention demonstrated a 5% implementation rate. The purpose of this study was to explore school nurses’ perceived barriers to and facilitators of the intervention in order to understand reasons for the low implementation rate. Methods included semi-structured individual interviews with school nurses. Data were analyzed using content analysis and heat mapping. Nineteen nurses participated and eight themes were identified. Parental and administrative gatekeeping, heavy nurse workload, obesogenic environments, and concerns about obesity stigma were barriers to implementation. Teamwork with parents and school staff was a key facilitator of implementation. Nurses also noted the importance of cultural considerations and highlighted the need to tailor the intervention to the unique needs of their school environment and student population. These findings suggest that for school nurses to play a key role in school-based obesity interventions, barriers must be identified and addressed prior to program implementation.

A recent report described a novel mechanism of action for an anti-proprotein convertase subtilisin-kexin type 9 (PCSK9) monoclonal antibody (LY3015014, or LY), wherein the antibody has improved potency and duration of action due to the PCSK9 epitope for LY binding. Unlike other antibodies, proteolysis of PCSK9 can occur when LY is bound to PCSK9. We hypothesized that this allowance of PCSK9 cleavage potentially improves LY efficiency through two pathways, namely lack of accumulation of intact PCSK9 and reduced clearance of LY. A quantitative modeling approach is necessary to further understand this novel mechanism of action. We developed a mechanism-based model to characterize the relationship between antibody pharmacokinetics, PCSK9 and LDL cholesterol levels in animals, and used the model to better understand the underlying drivers for the improved efficiency of LY. Simulations suggested that the allowance of cleavage of PCSK9 resulting in a lack of accumulation of intact PCSK9 is the major driver of the improved potency and durability of LY. The modeling reveals that this novel ‘proteolysis-permitting’ mechanism of LY is a means by which an efficient antibody can be developed with a total antibody dosing rate that is lower than the target production rate. We expect this engineering approach may be applicable to other targets and that the mathematical models presented herein will be useful in evaluating similar approaches.

Purpose To examine the association between parents and children meeting physical activity (PA) guidelines, by gender, among 8–12 year old children with BMI ≥75th percentile Design and methods This was a secondary analysis of baseline data from a school-based healthy weight management intervention in Minnesota for 8–12 year old children. Survey data about PA participation were collected from 2014 through 2018. Analyses entailed descriptive statistics and multivariate logistic regression controlling for child age, race/ethnicity, BMIz, child's perception of parent support for activity, and number of sports played. Results Children's (n = 132) mean age was 9.32 ± 0.89 years, 49% were female, 63% were members of racial/ethnic minority groups, and 33% met PA Guidelines (≥60 minutes daily). Parents' (n = 132) mean age was 39.11 ± 7.05 years, mean BMI of 30.90 ± 8.44, 94% were female, 42% were members of racial/ethnic minority groups, and 57% met PA Guidelines for Americans (≥150 minutes moderate or >75 minutes vigorous PA weekly). There was no association between parents and children meeting PA guidelines for the total sample (OR = 1.43, 95% CI = 0.63–3.24, p = 0.39) or girls (OR = 0.65, 95% CI = 0.18–2.33, p = 0.51). Boys whose parents met PA guidelines had 3.84 times greater odds of meeting PA guidelines (95% CI = 1.28–13.4, p = 0.04). Conclusions PA interventions for boys may benefit from focus on parents' PA. Further research should investigate correlates of girls' PA. Practice implications Pediatric nurses working with children to increase PA should encourage parents' PA. For parents of boys, this may increase the child's PA. Considered broadly, nurses should be aware of gender influences on children's engagement in PA.

Krista M Schroeder,1 Steve Gelwicks,1 April N Naegeli,1 Pamela C Heaton2 1Global Patient Outcomes – Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA; 2James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USACorrespondence: Krista M SchroederEli Lilly and Company, Indianapolis, IN 46285, USATel +1 317 276 3039Email schroeder_krista_marie@lilly.comBackground: Establishing disease-related cost and/or healthcare resource utilization (HCRU) is an important aspect of health outcomes research, particularly when considering the cost offset of novel treatments. However, few studies have compared methodologies used to assess disease-related cost/HCRU.Methods: Data from the United States IBM® MarketScan® Research Databases were used to compare four different methods of calculating disease-related cost and HCRU in patients with rheumatoid arthritis (RA). The analysis was repeated, in part, for patients with ulcerative colitis (UC) to explore the generalizability of findings to a second autoimmune disease. Four methods of disease-related cost/HCRU attribution were selected following a literature search for potential methods: Method 1, claim-wide cost/HCRU attribution based on claim-listed diagnosis codes and a predetermined disease-related medication list (pharmacy claims only); Method 2, line-item cost/HCRU attribution based on procedures/medications more likely to occur in disease cases than in matched controls at two likelihood ratio cutoffs (1.5× and 3.5×); Method 3, disease-related cost/HCRU calculated as the difference in total average cost/HCRU between cases and matched controls; Method 4, line-item cost/HCRU attribution based on clinician manual determination of procedures/medications related to the disease.Results and conclusion: Overall, 24,373 patients with RA and 9665 with UC were included. Average total cost during 2015 was $US28,750 per patient with RA and $US20,480 per patient with UC. Disease-related cost and HCRU for RA calculated using Method 4 were most closely approximated by Methods 1 and 2 (3.5×), with Method 2 (3.5×) the closest approximation. However, in certain research scenarios, the simplest method compared in this analysis, Method 1, may provide an adequate approximation of disease-related cost and HCRU. Although Method 4 was not executed in the UC analysis because of its labor-intensive nature, similar patterns of disease-related cost and HCRU were observed for Methods 1–3 in patients with UC and RA.Keywords: health outcomes research, methods, disease-related cost, administrative claims databases, autoimmune diseases

Objective: Despite guidelines that identify potential patients eligible for preventive migraine medications, their underutilization leaves patients at risk of acute medication overuse, disease progression, and higher healthcare resource utilization and disability. This exploratory, retrospective, observational study aimed to identify which factors predict preventive migraine medication initiation. Demographics and initiation of acute medication use were hypothesized to be predictive of initiation of preventive migraine medication. Methods: The Truven Health Analytics MarketScan1 U.S. Commercial and Medicare Supplemental claims database (2011-2013) was used to identify adults newly diagnosed with migraine. Patients were divided into 2 subgroups: initiated a preventive migraine medication (antidepressants, anti-epileptics, beta-blockers, or neurotoxins) within 1 year of migraine diagnosis and did not initiate a preventive migraine medication. Logistic regression models were constructed to identify factors associated with preventive migraine medication initiation. Results: Study population included 147,923 patients: 43,660 preventive migraine medication initiators and 104,263 non-preventive migraine medication patients. Best-fit model for predicting preventive migraine medication initiation included: female gender (odds ratio = 1.181 [95% CI = 1.144,1.218]; measured at date of first migraine diagnosis); headache diagnosis prior to migraine diagnosis (odds ratio = 1.538 [95% CI = 1.498,1.579]; measured 1-year before first migraine diagnosis); and sleep disorder (odds ratio = 1.206 [95% CI = 1.161,1.252]), headache/migraine-specific Emergency Department (ED) visit (odds ratio = 1.224 [95% CI = 1.168,1.283]), neurologist visit (odds ratio = 1.502 [95% CI = 1.459,1.547]), and acute medication refills with Conclusions: In addition to consistent acute medication refills, specific comorbidity diagnoses, headache/migraine-specific ED utilization, and neurologist care are predictive of preventive migraine medication initiation in the 1-year post-incident migraine diagnosis.

BACKGROUND: History of childhood maltreatment and psychopathology are common in adults with obesity. OBJECTIVES: To report childhood maltreatment and to evaluate associations between severity and type of childhood maltreatment and lifetime history of psychopathology among adults with severe obesity awaiting bariatric surgery. SETTING: Four clinical centers of the Longitudinal Assessment of Bariatric Surgery (LABS) Research Consortium. METHODS: The Childhood Trauma Questionnaire, which assesses presence/severity (i.e., none, mild, moderate, severe) of physical abuse, mental abuse, physical neglect, mental neglect and sexual abuse, was completed by 302 female and 66 male bariatric surgery patients. Pre-surgery lifetime history of psychopathology and suicidal ideation/behavior (SI/B) were assessed with the Structured Clinical Interview for DSMIV and the Suicidal Behavioral Questionnaire-Revised, respectively. Pre-surgery lifetime history of antidepressant use was self-reported. RESULTS: Two-thirds (66.6%) of females and 47.0% of males reported at least one form of childhood trauma; 42.4% and 24.2%, respectively, at greater than or equal to moderate severity. Among women, presence/greater severity of childhood mental or physical abuse or neglect were associated with a higher risk of history of psychopathology (i.e., major depressive disorder, post-traumatic stress disorder, other anxiety disorder, alcohol use disorder, binge eating disorder), SI/B and antidepressant use (p for all ≤.02). These assosications were independent of age, race, education, body mass index and childhood sexual abuse. Childhood sexual abuse was independently associated with a history of SI/B and antidepressant use only (p for both ≤.05). Statistical power was limited to evaluate these associations among men. CONCLUSION: Among women with obesity, presence/severity of childhood trauma was positively associated with relatively common psychiatric disorders.

Adverse Childhood Experiences (ACEs) have been associated with detrimental long-term health outcomes, including obesity risk. Existing research has yet to examine whether early life ACEs are associated with diet in early childhood within socioeconomic subgroups. Data were drawn from the Early Childhood Longitudinal Study-Birth Cohort (2001-2002). Mother-child dyads (n = 7000) were recruited when children were 9-months old, and followed longitudinally at 2 years, and 4 years. Mothers reported children's exposure to five ACEs at 9-months and 2 years and children's daily intake of fruits, vegetables, sweet snacks, and sugar-sweetened beverages (SSBs) at 4 years. Weighted multiple linear regression models tested the effect of cumulative and individual ACEs on child diet in full, low-, and high-SES samples. Cumulative ACE score was inversely associated with frequency of fruit intake in full (b = -0.08, p = 0.005) and low-SES samples (b = -0.10, p 0.001). Domestic violence was associated with less frequent fruit intake in full (b = -0.21, p = 0.01) and low-SES samples (b = -0.29 p = 0.008). In the full sample, incarceration was associated with less frequent fruit intake (b = -0.24, p = 0.02), and domestic violence was associated with higher sweet snack (b = 0.22, p = 0.01) and SSB intake (b = 0.27, p = 0.009). Results provide preliminary evidence on the association between cumulative and specific ACEs and child diet, and how this relationship varies by SES context. Future research is needed to understand the complex multi-level mechanisms operating along this pathway in order to inform interventions supporting behavior change and to build evidence for policies that may reduce diet-related disparities in ACE exposure.

Background: Propensity score (PS) methods are increasingly being employed by researchers to reduce bias arising from confounder imbalance when using observational data to examine intervention effects. Objective: The purpose of this study was to examine PS theory and methodology and compare application of three PS methods (matching, stratification, weighting) to determine which best improves confounder balance. Methods: Baseline characteristics of a sample of 20,518 school-aged children with severe obesity (of whom 1,054 received an obesity intervention) were assessed prior to PS application. Three PS methods were then applied to the data to determine which showed the greatest improvement in confounder balance between the intervention and control group. The effect of each PS method on the outcome variable—body mass index percentile change at one year—was also examined. SAS 9.4 and Comprehensive Meta-analysis statistical software were used for analyses. Results: Prior to PS adjustment, the intervention and control groups differed significantly on seven of 11 potential confounders. PS matching removed all differences. PS stratification and weighting both removed one difference but created two new differences. Sensitivity analyses did not change these results. Body mass index percentile at 1 year decreased in both groups. The size of the decrease was smaller in the intervention group, and the estimate of the decrease varied by PS method. Discussion: Selection of a PS method should be guided by insight from statistical theory and simulation experiments, in addition to observed improvement in confounder balance. For this data set, PS matching worked best to correct confounder imbalance. Because each method varied in correcting confounder imbalance, we recommend that multiple PS methods be compared for ability to improve confounder balance before implementation in evaluating treatment effects in observational data.

BACKGROUND Schools are a key setting for childhood obesity interventions, yet nurses are not often included in delivering these interventions. The objective of this systematic review and meta-analysis was to examine school-based interventions involving nurses in a role beyond anthropometric measurement for effect on change in body measures. METHODS We performed a systematic review and meta-analysis of these papers. RESULTS The literature search produced 2412 articles. Eleven met inclusion criteria for the systematic review (4 randomized controlled trail [RCT], 7 quasi-experimental) and 8 for the meta-analysis. None have been included in prior meta-analyses. Four studies restricted eligibility to overweight and/or obese children; 7 included all children regardless of body weight. Random effects meta-analytic models represent data from 6050 (body mass index [BMI]), 5863 (BMIz), and 416 (BMI percentile) children, respectively. Pooled analyses demonstrated statistically significant decreases in BMI (6 studies: −0.48 [95% CI −0.84, −0.12]; I2=91.2%, Q=68.1), BMIz (5 studies: −0.10 [95% CI: −0.15, −0.05]; I2=0, Q=2.3), and BMI percentile (3 studies: −0.41 [95% CI: −0.60, −0.21]; I2=0, Q=2.0). CONCLUSIONS These findings are similar to those of other meta-analyses of school-based interventions and suggest that school nurses can play a key role in implementing sustainable, effective school-based obesity interventions.

Background Research examining RNs’ experiences during the COVID-19 pandemic is lacking, thus inhibiting efforts to optimize nursing care delivery and patient outcomes during the current pandemic and future public health emergencies. Objective To explore the experience of being a registered nurse caring for patients with COVID-19 at an urban academic medical center during the early stages of the pandemic Design Qualitative descriptive study, guided by Donabedian's Quality Framework for Evaluation of Healthcare Delivery which focuses on structures, processes, and outcomes of care delivery Setting Urban academic medical center in the northeast United States Participants Registered nurses cared for or caring for patients with COVID-19, age ≥18 years old, and English-speaking Methods Participants were recruited for individual in-person semi-structured interviews. Interviews occurred during March and April 2020 and were recorded and transcribed. Transcripts were analyzed by two researchers using emergent qualitative content analysis to identify themes. Results Twenty-one registered nurses participated in the study. Three themes emerged from the data, included one relevant to structures and two relevant to processes of care during the pandemic. Registered nurses perceived the clinical context as highly dynamic, but quickly adapted to pandemic-related care delivery. They felt a “sense of duty” to care for patients with COVID-19, despite being fearful of acquiring or spreading infection. Compared to clinical colleagues, registered nurses reported increased patient exposure and performed tasks previously assigned to other clinical team members. Conclusion Roles and nursing practice processes evolved to meet the demand for care despite challenges. Registered nurses require adequate protection for their frontline role which may consist of increased patient exposure compared to clinical colleagues, emotional support, and clear clinical guidance. A deeper understanding of how a public health emergency, such as the COVID-19 pandemic, affects nursing practice can guide future efforts to optimize healthcare structures, nursing care processes, and patient outcomes. Our study can inform strategies for providing registered nurses with adequate communication, protection, and resources during the COVID-19 pandemic and future similar public health emergencies.

Background: Community engagement is a promising method for teaching about social determinants of health (SDOH) through experiential learning. The purpose of this article is to report the implementation and evaluation of a baccalaureate nursing degree course focused on addressing social determinants of health through community engagement. Method: The class was structured as a flipped classroom, during which students spent the majority of the time engaged with a community site. Students were required to attend two in-class seminars. Course evaluations were used to provide feedback to refine course delivery and assess course impact. Results: Thirty-six students enrolled in the course over two semesters. Knowledge and self-reported competencies in addressing SDOH in under-resourced populations increased. Course evaluations demonstrated an increase in students' knowledge and clinical skills related to SDOH. Conclusion: A course focused on addressing SDOH through community engagement provided a promising approach for preparing nursing students to provide care to underresourced populations. [ J Nurs Educ. 2019;58(7):423–426.]

Background: Type 2 diabetes (T2D) is becoming more prevalent in adolescents. Multi-disciplinary care with periodic follow-up is required to ensure optimal management with lifestyle modification and medications. The purpose of this study was to estimate physician visitation rates and antidiabetic medication use (including off-label use) among adolescents with T2D and examine the impact of insurance type (Commercial vs. Medicaid). Methods: We used data from the Truven MarketScan Commercial and Medicaid administrative claims databases to identify a cohort of adolescents aged 10-17 years with T2D (≥2 T2D diagnoses or ≥1 T2D diagnosis and ≥1 antidiabetic medication) with continuous medical and prescription enrollment in 2015. Patients with gestational diabetes, diabetes complicating pregnancy, and secondary diabetes were excluded. Visits to specified providers (pediatric endocrinologist, pediatrician, and family practitioner) and use of medications overall and by class were assessed. Results: Substantially more commercially insured than Medicaid patients had ≥1 visit to any specified provider (88% vs. 45%) and to pediatric endocrinologists (33% vs. 14%). The use of any antidiabetic medication was similar in both insurance types (92% vs. 90%); however, off-label use was higher in commercially insured patients (9% vs. 6%), specifically those visiting only family practitioners (12%). The most commonly used off-label drug class was sulfonylureas. Conclusions: A higher proportion of commercially insured adolescents received multi-disciplinary care. While use of any antidiabetic medication was similar, off-label use was greater among commercially insured. Concerted efforts are needed to enhance patient access, generate evidence regarding non-approved medications, and educate providers about optimal care of youth with T2D, particularly on the use of sulfonylureas, which are not recommended by current guidelines. Disclosure S. Curtis: Employee; Self; Eli Lilly and Company. Employee; Spouse/Partner; Eli Lilly and Company. J.A. Johnston: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. P.W. Anderson: Other Relationship; Self; Eli Lilly and Company. K.M. Schroeder: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. J. Wu: None. P. Zeitler: Consultant; Self; Daiichi Sankyo Company, Limited, Merck & Co., Inc., Eli Lilly and Company, Takeda Development Center Americas, Inc., Boehringer Ingelheim GmbH.

Background Systemic lupus erythematosus (SLE) therapies include non-steroidal anti-inflammatory drugs, antimalarials, systemic immunosuppressants, and biologics with corticosteroids as necessary. The majority of these current therapies are only partially effective in disease control. Despite treatment, patients may experience flares of disease activity, which can lead to progressive end-organ damage. Severe flares may require intensive immunosuppression, including with high-dose corticosteroids, with risk including end-organ damage. Objectives To understand the unmet need in SLE by quantifying use of high-dose (≥40 mg/day) corticosteroids and determining factors associated with its use. Methods This study utilised the Truven Marketscan commercial claims database. Patients were indexed on first use of antimalarial, oral immunosuppressant or biologic during 2012–2013 (first use determined based on no claims for the 3 drug classes during the 1 year pre-index). Included patients had 2 recorded SLE diagnoses, were 18–50 years of age and had continuous medical and prescription enrollment from baseline through the 2 year follow-up. Patients with other pre-specified autoimmune disorders or cancers during the study period (baseline through follow-up) were excluded. During follow-up, fill of at least 1 high-dose corticosteroid prescription was assessed and associative logistic regression modelling performed. Results 1401 patients (93% female; mean age 38.4 years) met the study criteria; 79% were indexed on an antimalarial, 15% on an oral immunosuppressive, 1% on a biologic and 5% on a combination of at least 2 of the aforementioned classes. 16% patients received a diagnosis code for nephritis or chronic kidney disease (CKD), 3% for myocarditis or pericarditis, and 13% for thrombocytopenia or leukopenia. During baseline, 56% of patients had at least 1 visit to a rheumatologist and 13% filled at least 1 high-dose corticosteroid prescription. During follow-up, 22% of patients had at least 1 high-dose corticosteroid prescription. Factors significantly associated (p Conclusions A number of baseline factors were associated with high-dose corticosteroid treatment during the follow-up period; one notable factor is the high percentage of patients using high-dose corticosteroids (≥40 mg/day). This indicates that important subsets of patients experience inadequate disease control with current therapies. This study reveals high-dose corticosteroid use is prevalent in SLE management broadly, underscoring the unmet need in this population. Disclosure of Interest K. Schroeder Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, J. Paik Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, R. Hoffman Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, S. Gelwicks: None declared