Search

Introduction This paper describes the epidemiology and clinical presentation of complex regional pain syndrome (CRPS) in a large, integrated health care delivery system; and CRPS incidence rates (IRs) over a time period spanning human papillomavirus (HPV) vaccine licensure and published case reports of CRPS following HPV vaccination. Methods The authors examined CRPS diagnoses in patients aged 9-30 years between January 2002 and December 2017 using electronic medical records, excluding patients with lower limb diagnoses only. Medical record abstraction and adjudication were conducted to verify diagnoses and describe clinical characteristics. CRPS IRs were calculated for 3 periods: Period 1 (2002-2006: before HPV vaccine licensure), Period 2 (2007-2012: after licensure but before published case reports), and Period 3 (2013-2017: after published case reports). Results A total of 231 individuals received an upper limb or unspecified CRPS diagnosis code during the study period; 113 cases were verified through abstraction and adjudication. Most verified cases (73%) were associated with a clear precipitating event (eg, non-vaccine-related injury, surgical procedure). The authors identified only 1 case in which a practitioner attributed CRPS onset to HPV vaccination. Twenty-five incident cases occurred in Period 1 (IR = 4.35/100,000 person-years (PY), 95% confidence interval (CI) = 2.94-6.44), 42 in Period 2 (IR = 5.94/100,000 PY, 95% CI = 4.39-8.04), and 29 in Period 3 (IR = 4.53/100,000 PY, 95% CI = 3.15-6.52); differences between periods were not statistically significant. Conclusion These data provide a comprehensive assessment of the epidemiology and characteristics of CRPS in children and young adults and provide further reassurance about the safety of HPV vaccination., Competing Interests: Conflicts of InterestDr Naleway reports receiving research funding from Pfizer and Vir Biotechnology for unrelated studies. Dr Mittendorf reports support from institutional funding from GE Healthcare. The other authors have no conflicts of interest.

Context: Workplace stress and burnout are pervasive problems, affecting employee performance and personal health., Objective: To evaluate the effects of the Transcendental Meditation program on psychological distress and burnout among staff at a residential therapeutic school for students with severe behavioral problems., Design: A total of 40 secondary schoolteachers and support staff at the Bennington School in Vermont, a therapeutic school for children with behavioral problems, were randomly assigned to either practice of the Transcendental Meditation program or a wait-list control group. The Transcendental Meditation course was provided by certified instructors., Main Outcome Measures: Outcome measures were assessed at baseline and four months, and included perceived stress, depression, and burnout. A multivariate analysis of covariance was used to determine overall effects., Results: Analysis of the 4-month intervention data indicated a significant improvement in the main outcomes of the study resulting from practice of the Transcendental Meditation program compared with controls (Wilks Λ [3,28] = 0.695; p = 0.019). Results of univariate F tests indicated a significant reduction of all main outcome measures: perceived stress (F[1,32] = 13.42; p = < 0.001); depression (F[1,32] = 6.92; p = 0.013); and overall teacher burnout (F[1,32] = 6.18; p = 0.018). Effect sizes ranged from 0.40 to 0.94., Conclusions: The Transcendental Meditation program was effective in reducing psychological distress in teachers and support staff working in a therapeutic school for students with behavioral problems. These findings have important implications for employees’ job performance as well as their mental and physical health.

Context: Participants in a randomized trial of traditional Chinese medicine (TCM) for temporomandibular joint dysfunction (TMD) had a linear decline in pain over 16 TCM visits., Objective: To investigate whether reductions in pain among participants receiving TCM can be explained by increased use of pain medications, or whether use of pain medications also declined in this group., Design: One hundred sixty-eight participants with TMD were treated with TCM or enhanced self-care according to a stepped-care design. Those for whom self-care failed were sequentially randomized to further self-care or TCM. This report includes 111 participants during their first 16 TCM visits. The initial 8 visits occurred more than once a week; participants and practitioners determined the frequency of subsequent visits., Outcome Measures: Average pain (visual analog scale, range 0-10) and morphine and aspirin dose equivalents., Results: The sample was 87% women and the average age was 44 ± 13 years. Average pain of narcotics users (n = 21) improved by 2.73 units over 16 visits (p < 0.001). Overall narcotics use trended downward until visit 11 (-3.27 doses/week, p = 0.156), and then trended upward until week 16 (+4.29 doses/week, p = 0.264). Among those using narcotics, use of nonsteroidal anti-inflammatory drugs (NSAIDs) declined linearly over visits 1-16 (-1.94 doses/week, p = 0.002).Among the top quartile of NSAID-only users (n = 22), average pain decreased linearly over 16 visits (-1.52 units, p = 0.036). Overall NSAID doses/week declined between visits 1 and 7 (-9.95 doses/week, p < 0.001) and then remained stable through 16 visits. NSAID use also declined among the third quartile (n = 23) and remained low and stable among the lower half (sorted by total intake) of NSAID users., Conclusions: Among the heaviest NSAID users, we observed a short-term reduction in NSAID use that was sustained as TCM visits became less frequent. There was no indication that pain reduction during TCM treatment was influenced by drug use.

Herbal and other dietary supplements are popular among patients. Whether and how to establish and manage an herbal formulary remains a challenge for conventional managed-care organizations. Pharmacists and clinicians depend on evidence-based guidelines to help determine which products (whether pharmaceutical or herbal) to make available to patients. Evidence from randomized controlled trials that supports the use of most herbal supplements is scarce, yet for some supplements, credible evidence supports the possibility of efficacy. Quality control remains of concern for the supplement industry and for patients and clinicians considering the use of supplements.Clinicians may improve care by both disseminating educational materials and making available to patients popular quality-controlled herbal supplements deemed safe and effective. Kaiser Permanente Northwest (KPNW) has adopted a comprehensive and systematic approach to managing and stocking herbal supplements that can serve as a model for other conventional and managed care organizations.KPNW's dedicated Natural Products Advisory Committee (NPAC) has made considerable progress toward developing a constructive response to KPNW patients' herbal supplement use. Making supplements available at pharmacies can improve clinical outcomes, patient convenience, and quality control. NPAC currently limits its reviews to randomized, controlled trials and data from meta-analyses and systematic reviews for single-ingredient supplements. As interest in this area maintains steady growth, NPAC will continue to study how best to meet patients' needs.