A Randomized Trial of Yoga for Children Hospitalized With Sickle Cell Vaso-Occlusive Crisis

Yoga as a non-pharmacologic therapy to reduce dinutuximab-induced pain in patients with neuroblastoma

BACKGROUND

Anti-GD2 antibodies are key components of treatment for high-risk neuroblastoma; however, they cause neuropathic pain. Yoga therapy may help reduce pain and distress associated with anti-GD2 therapy.

PROCEDURE

Children 3 years of age or older with neuroblastoma participated in individualized yoga therapy while receiving the anti-GD2 antibody dinutuximab (DIN). Yoga therapy was deemed feasible if patients participated during 60% or more of DIN admissions. Patients and caregivers assessed pain/distress before and after yoga therapy with a distress thermometer (DT) and Wong-Baker FACES pain rating scale and completed questionnaires regarding satisfaction with yoga therapy. Therapy was deemed efficacious if there was a ≥1 point pain score change and reduction in distress after yoga.

RESULTS

Eighteen patients were enrolled; 52 encounters (admissions for DIN) were evaluable. Ten of 18 were female, three of 18 were Hispanic, and 10/18 were White. Median age at enrollment was 5.5 years (range: 3-11). Yoga therapy was feasible in 39/52 (75%) encounters. Significant reductions in caregiver-reported pain and distress and reductions in patient-reported pain and distress after yoga therapy were reported. Twelve of 18 caregivers completed questionnaires: seven agreed/strongly agreed that yoga was valuable, and nine agreed/strongly agreed to continued participation in yoga. Thirty-four of 36 clinicians reported that they would recommend yoga therapy for other patients receiving DIN.

CONCLUSIONS

Yoga therapy was feasible during DIN therapy and may be effective in reducing DIN-associated pain and distress. Future studies are needed to evaluate changes in opioid usage with the addition of yoga therapy during anti-GD2 antibody therapy.

Tailored Yoga Intervention for Postlumbar Spine Surgical Pain Management: A Feasibility Study

Introduction: Severe pain, anxiety, and high opioid use are common following lumbar spine surgery (LSS). Yoga helps to reduce pain and anxiety, but it has not been considered for postsurgical care. The authors developed and tested the feasibility of a tailored yoga program designed for individuals undergoing LSS and explored clinical feasibility of yoga intervention on measures of pain, function, psychological status, and opioid use. Methods: Individuals scheduled for LSS were randomized into yoga versus control groups presurgery. Participants in the yoga group received tailored yoga sessions plus usual care, whereas participants in the control group received usual care only during the hospital stay post-LSS. In-person daily yoga sessions were individually presented and performed in the participant's hospital room. Feasibility was assessed by recruitment and retention rates, rate of yoga session completion, tolerance to yoga intervention, and ability to carry out planned assessment. Exploratory clinical outcomes included pain, psychological measures, Timed-Up-and-Go test, gait distance, and opioid use, during the hospital stay post-LSS. Results: Forty-one participants were enrolled, of which 30 completed. There were no dropouts. Planned assessments were completed within 45 min, suggesting no excessive burden on participants. Baseline variables were similar across both groups. The majority of participants participated in yoga intervention on the day of surgery or one day after surgery with acceptance rate of 100%. Participants showed good tolerance to yoga intervention on 0-4 tolerance scale and by their reports of exploratory clinical outcomes. Conclusion: This study indicates feasibility for a modified yoga program for postoperative care following LSS due to participant tolerance and retention. The results provide preliminary framework for future confirmatory studies that can assess the potential benefits of yoga in reducing pain, catastrophizing behavior, and opioid use and improving function. A modified yoga program focusing on diaphragmatic breathing, relaxation, and core isometric contraction exercises can be an important adjunct intervention for patients undergoing LSS. CTR Number: This trial was registered in UMIN CTR (https://rctportal.niph.go.jp/en/) with registration number: UMIN000032595.

A prospective, controlled multisite trial of yoga in pediatric inflammatory bowel disease

AIM

To investigate whether a structured yoga program improves health-related quality of life (HRQOL) and self-efficacy in pediatric patients receiving care for inflammatory bowel disease (IBD).

METHODS

IBD patients who were 10-17 years old participated in a 12 week, in-person yoga intervention at two clinical sites. Outcomes were measured at time of consent (T0), start of yoga (T1), and completion of yoga (T2) and 3 months after yoga completion (T3) using the IMPACT-III, Pediatric Quality of Life Inventory (PedsQL), and General Self Efficacy (GSE) scales.

RESULTS

Seventy-eight patients were enrolled. Fifty-six patients completed nine or more classes. 73.2% had Crohn's disease and 26.8% ulcerative colitis or IBD-unclassified. A significant increase in IMPACT-III was seen from T1 to T3 (mean change of 5.22, SD = 14.33, p = 0.010), in the PedsQL (mean change = 2.3, SD = 10.24, p = 0.050), and GSE (mean change = 1, SD = 3.60, p = 0.046). 85.2% of patients reported yoga helped them to control stress. Long-term data was available for 47 subjects with 31.9% (n = 15) continuing to practice yoga one to 3 years after study completion.

CONCLUSION

This structured 12-week yoga program showed significant improvements in HRQOL and general self-efficacy, particularly 3 months after classes were concluded suggesting that yoga's benefits may persist. Yoga is a safe and effective adjunct to standard medical care to improve QOL and self-efficacy in youth with IBD.

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.

Chronic pain management in sickle cell disease: A systematic scoping review of controlled trials

Existing treatment for chronic pain in sickle cell disease (SCD) is opioid-dependent, which is ineffective and carries risks. We conducted a scoping literature review to assess the size and scope of available literature about controlled trials of therapies for SCD chronic pain and identify research gaps. The search strategy in PubMed and EMBASE utilized keywords for chronic pain and sickle cell and identified seven original articles that met inclusion criteria. Six of the studies recruited from clinics while one recruited from community sources. Cannabis and behavioral modification were associated with improvements in pain scores. However, existing evidence does not represent best practices for assessing chronic pain, and this along with small sample sizes prevents translation to clinical care. The limited evidence concerning treatment for SCD chronic pain highlights the need for larger trials of opioid alternatives and the utilization of chronic pain measures that capture nociplastic pain in SCD.

Yoga Module Development and Validation for Sickle Cell Disease

Introduction

Sickle cell disease (SCD) is a genetic blood disorder that affects the shape and function of red blood cells (RBCs), which can lead to several health problems affecting the quality of life. SCD can be treated with certain expensive treatments such as RBC transfusion, hydroxyurea, stem cell transplantation, gene therapy, or bone marrow transplant. However, some of the most common symptoms such as pain, anxiety, and stress can also be alleviated with alternative therapies like yoga. In light of this, there is a need for the development of a specific yoga module (YM) for SCD that can complement the current therapies.

Objective

To develop and validate a YM for SCD.

Methodology

Concise literature reports on yoga practices used for varied symptoms/comorbidities associated with SCD were compiled and presented to focus groups. Based on the presented report and personal experience, the focus group created a preliminary version of the module. The preliminary module was further refined based on content validity ratio (CVR) following module validation by 33 yoga experts.

Results

One hour ten minutes module developed by the focus group had in total 27 practices including, loosening exercises, asanas, pranayama, relaxation techniques, and meditation. After validation by the experts, 21 practices with a CVR ≥ 0.33 were retained. The predominant reason for excluding 12 practices was intensity, which may have some adverse effect on sickle cell comorbidities.

Conclusion

The module developed is the first validated module for SCD.

Adolescents and Young Adults With Sickle Cell Disease: Nociplastic Pain and Pain Catastrophizing as Predictors of Pain Interference and Opioid Consumption

OBJECTIVES

Some patients with sickle cell disease (SCD) have features of nociplastic pain. While research suggests that many patients with nociplastic pain consume more opioids due to opioid nonresponsiveness, little is known about the impact of nociplastic pain and pain catastrophizing on opioid consumption and pain interference among adolescents and young adults (AYA) with SCD. The purpose of this study was to (1) characterize nociplastic pain and pain catastrophizing among AYA with SCD, and (2) determine whether these characterizations are associated with subsequent opioid consumption and pain interference 1 month after characterization.

METHODS

Participants completed surveys characterizing nociplastic pain and catastrophizing at a routine clinic visit (baseline). Thereafter, participants received weekly text messages that included pain interference and opioid consumption surveys. Multipredictor 2-part models were used to evaluate the predictive relationships between baseline characterizations and subsequent pain interference, and opioid consumption.

RESULTS

Forty-eight AYA aged 14 to 35 completed baseline measures. Twenty-five percent of participants had scores suggestive of nociplastic pain. Greater nociplastic pain features significantly increased the odds of consuming opioids (odds ratio=1.2) and having greater interference from pain (odds ratio=1.46). Regression analyses found that greater baseline nociplastic pain characteristics were significantly associated with opioid consumption (β=0.13) and pain interference (β=0.061); whereas higher pain catastrophizing scores predicted less opioid consumption (β=-0.03) and less pain interference (β=-0.0007).

DISCUSSION

In this sample of AYA with SCD, features of nociplastic pain predicted higher subsequent opioid consumption and pain interference. Being aware of nociplastic pain features in patients with SCD may better guide individualized pain management.

Non-pharmacological pain interventions for sickle cell crisis in pediatrics: A scoping review

PROBLEM

Sickle cell crises (SCC) are recurrent, severe pain episodes experienced by people living with sickle cell disease (SCD). Non-pharmacological interventions have been recommended for SCC pain management however, little is known about the impact of these interventions on SCC pain. This scoping review aims to systematically identify evidence on the use and effectiveness of non-pharmacological interventions for pain management during SCC in the pediatric population.

ELIGIBILITY CRITERIA

Studies were eligible if they are published in English and focusing on the use of any non-pharmacological interventions on pain during SCC in pediatric patients. Nine databases were searched including Medline, CINAHL and PsychInfo. Also, the reference lists of relevant studies were searched.

SAMPLE

The database searching yielded 1517 studies. After the title and abstract screening, 1348 studies were excluded, and 169 full texts were retrieved and screened. One study was identified through handsearching. Finally, 27 articles were included in this scoping review.

RESULTS

Across all studies, 27 different non-pharmacological interventions were identified. There were inconsistent results regarding the effectiveness of virtual reality, guided imagery, and cognitive-behavioral interventions in experimental studies. The most common interventions used at home were prayer, massage, and distraction. The main interventions used in hospitals were prayer and fluid intake, but this was explored by a few studies.

CONCLUSION

Pediatric SCD patients use numerous non-pharmacological interventions to manage pain during SCC. However, the impact of many interventions on SCC pain has not been empirically investigated.

IMPLICATIONS

Further research is necessary to establish the effectiveness of non-pharmacological interventions on SCC pain.

Dr Amir Mohammadamini The effect of exercise on suicidal behaviors: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although exercise may positively impact those with mental or other medical illnesses, there is a lack of understanding on how it influences suicidal ideation or risk.

METHODS

We conducted a PRISMA 2020-compliant systematic review searching MEDLINE, EMBASE, Cochrane, and PsycINFO from inception to June 21, 2022. Randomized controlled trials (RCTs) investigating exercise and suicidal ideation in subject with mental or physical conditions were included. Random-effects meta-analysis was conducted. The primary outcome was suicidal ideation. We assessed bias of studies with risk of bias tool 2.

RESULTS

We identified 17 RCTs encompassing 1021 participants. Depression was the most included condition (71 %, k = 12). Mean follow up was 10.0 weeks (SD = 5.2). Post-intervention suicidal ideation (SMD = -1.09, CI -3.08-0.90, p = 0.20, k = 5) was not significantly different between exercise and control groups. Suicide attempts were significantly reduced in participants randomized to exercise interventions as compared to inactive controls (OR = 0.23, CI 0.09-0.67, p = 0.04, k = 2). Fourteen studies (82 %) were at high risk of bias.

LIMITATIONS

This meta-analysis is limited by few, and underpowered and heterogenous studies.

CONCLUSION

Overall, our meta-analysis did not find a significant decrease in suicidal ideation or mortality between exercise and control groups. However, exercise did significantly decrease suicide attempts. Results should be considered preliminary, and more and larger studies assessing suicidality in RCTs testing exercise are needed.

Complementary and alternative medicine for children with sickle cell disease: A systematic review

BACKGROUND

Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population.

METHODS

The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science.

RESULTS

Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores.

CONCLUSIONS

CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Quality of Life, Participation, and Individualized Support in a Community-Based Yoga Class: A Case Series

PURPOSE

To assess quality of life and participation in children with disabilities following a community-based yoga class, to examine the feasibility of implementing a community-based program with individualized support, and to make recommendations for the development of future programs.

SUMMARY OF KEY POINTS

Four children participated in a 10-week yoga class, with doctor of physical therapy students providing individualized physical and behavioral support. Children improved in components of the Children's Assessment of Participation and Enjoyment (CAPE) following the program; however, changes in quality of life on the Pediatric Quality of Life Inventory (PedsQL) were inconsistent. Parents provided feedback regarding the family's experience and reported that the children improved behavior, communication, and relationships following the yoga class.

WHAT THIS CASE ADDS TO EVIDENCEBASED PRACTICE

A community-based yoga class for children with disabilities using individualized support is feasible and can improve participation and enjoyment in recreational activities.

Neurocognitive Changes in Sickle Cell Disease: A Comprehensive Review

Background:

Sickle cell disease (SCD) is a type of hemoglobinopathy characterized by abnormal hemoglobin molecules, which includes numerous acute and chronic complications. Ischemic stroke, silent cerebral infarction, headache, and neurocognitive impairment are the most common neurological complications associated with SCD.

Summary:

Acute anemia because of SCD can cause cognitive impairments because of cerebral hypoxia. Cognitive abnormalities in SCD manifest in various aspects such as working memory, verbal learning, executive functions, and attention. These neurocognitive impairments have been associated with poor functional results, such as transitioning from juvenile to adult care, adherence to medications, and unemployment.

Key message:

In this review, we focus on neurocognitive aspects of SCD patients based on different imaging techniques, psychological batteries, associated neuromarkers, and interventions for managing of cognitive deficiencies..

Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review

Purpose of Review

Sickle cell disease (SCD) is an inherited hemoglobinopathy with potential life-threatening complications that affect millions of people worldwide. Severe and disabling acute pain, referred to as a vaso-occlusive crisis (VOC), is a fundamental symptom of the disease and the primary driver for acute care visits and hospitalizations. Despite the publication of guidelines for VOC management over the past decade, management of VOCs remains unsatisfactory for patients and providers.

Recent Findings

Acute SCD pain includes pain secondary to VOCs and other forms of acute pain. Distinguishing VOC from non-VOC pain may be challenging for both patients and clinicians. Further, although opioids have been the gold-standard for VOC pain management for decades, the current highest standard of care for all acute pain is a multimodal approach that is less dependent on opioids, and, instead incorporates analgesics and adjuvants from different mechanistic pathways. In this narrative review, we focus on a multimodal pharmacologic approach for acute SCD pain management and explore the evidence for existing non-opioid pharmacological adjuncts. Moreover, we present an explanatory model of pain, which is not only novel in its application to SCD pain but also captures the multidimensional nature of the SCD pain experience and supports the need for such a multimodal approach. This model also highlights opportunities for new investigative and therapeutic targets - both pharmacological and non-pharmacological.

Summary

Multimodal pain regimens that are less dependent on opioids are urgently needed to improve acute pain outcomes for individuals with SCD. The proposed explanatory model for SCD pain offers novel opportunities to improve acute pain management for SCD patients.

Complementary and Alternative Medicine Mind-Body Approaches Used Among Racially and Ethnically Diverse Adolescents

PURPOSE

The aim of this paper is to examine complementary and alternative medicine (CAM) use among racially and ethnically diverse adolescents. Greater understanding of CAM use among this group is warranted to better inform health care providers in delivering a culturally relevant health promotion approach.

DESIGN AND METHODS

A secondary data analysis was conducted using the 2012 Child Complementary and Alternative Medicine Supplement of the National Health Interview Survey (CAM-NHIS) data, which was collected from a national sample of adolescents aged 12-17 years. A logistic regression test was employed to investigate the predictors associated with CAM use among racially and ethnically diverse adolescents.

RESULTS

While Black and Hispanic adolescents were the least likely to use CAM compared to their White counterparts, families with higher incomes, higher education attainment, and adolescents who experienced pain were more likely to use CAM.

CONCLUSIONS

Findings suggest the need for future research to gain a greater understanding of CAM use among racially and ethnically diverse adolescents, and insights into how health disparities impact CAM use. Greater understanding of how CAM use intersects with health beliefs and outcomes is also warranted.

PRACTICE IMPLICATIONS

Based on the CAM-NHIS survey, few racially and ethnically diverse adolescents have reported use of CAM. Development of culturally appropriate instruments and methods to assess CAM use among racially and ethnically diverse adolescents may yield specific data for this population. Informed health care providers can advocate for improved access to CAM for minority adolescents and alter disparate use.

Pain in sickle cell disease: current and potential translational therapies

Pain is a major comorbidity of sickle cell disease (SCD). Patients with SCD may suffer from both acute and chronic pain. Acute pain is caused by recurrent and unpredictable episodes of vaso-occlusive crises (VOC), whereas the exact etiology of chronic pain is still unknown. Opioids are the mainstay for pain treatment, but the opioid epidemic has significantly altered access to prescription opioids and has brought concerns over their long-term use into the forefront, which have negatively impacted the treatment of sickle pain. Opioids remain potent analgesics but growing opioid-phobia has led to the realization of an unmet need to develop nonopioid therapies that can provide relief for severe sickle pain. This realization has contributed to the approval of 3 different drugs by the Food and Drug Administration (FDA) for the treatment of SCD, particularly to reduce VOC and/or have an impact on the pathobiology of SCD. In this review, we outline the challenges and need for validation of side-effects of opioids and provide an update on the development of mechanism-based translational therapies, specifically targeting pain in SCD.

Sickle Cell Disease Care Planning for School Nurses

Schoolchildren with sickle cell disease (SCD) experience physiologic and psychologic stress that can affect school functioning, mental well-being, and physical health. Student needs are unique and individualized; however, school nurses can support students and families with SCD through comprehensive and thorough care planning efforts. In addition to components specific to individual prescriptions and other nonpharmacological therapies, school nurses should consider school access and inclusion, pain management, racism, and disease self-management when care planning. As a healthcare provider who may have several continuous years of near-daily contact with students, the school nurse is an imperative provider, educator, and advocate for students learning to manage their SCD and avoid the related complications and challenges.

American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain

BACKGROUND

The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care.

OBJECTIVE

These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD.

METHODS

ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery.

CONCLUSIONS

Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.

Adverse Events of Mind-Body Interventions in Children: A Systematic Review

Mind-body interventions (MBIs) are one of the top ten complementary approaches utilized in pediatrics, but there is limited knowledge on associated adverse events (AE). The objective of this review was to systematically review AEs reported in association with MBIs in children. In this systematic review the electronic databases MEDLINE, Embase, CINAHL, CDSR, and CCRCT were searched from inception to August 2018. We included primary studies on participants ≤ 21 years of age that used an MBI. Experimental studies were assessed for whether AEs were reported on or not, and all other study designs were included only if they reported an AE. A total of 441 were included as primary pediatric MBI studies. Of these, 377 (85.5%) did not explicitly report the presence/absence of AEs or a safety assessment. There were 64 included studies: 43 experimental studies reported that no AE occurred, and 21 studies reported AEs. There were 37 AEs found, of which the most serious were grade 3. Most of the studies reporting AEs did not report on severity (81.0%) or duration of AEs (52.4%). MBIs are popularly used in children; however associated harms are often not reported and lack important information for meaningful assessment.

A pilot study of the acceptability, feasibility and safety of yoga for chronic pain in sickle cell disease

OBJECTIVES

To determine the acceptability, feasibility and safety of yoga for chronic pain in sickle cell disease.

DESIGN AND SETTING

In Part A of this two-part study, adolescents with SCD and chronic pain (Group 1) and their parent (Group 2) completed a survey designed to capture pain characteristics, attitudes and practices related to yoga, and potential acceptability of a yoga program. In Part B, the study assessed the feasibility and safety of an instructor-led group yoga program. The study was registered on clinicaltrials.gov (NCT03694548).

INTERVENTION

Eight instructor-led group yoga sessions.

MAIN OUTCOME MEASURES

Feasibility and safety outcomes were chosen a priori, as follows: 1) Proportion of adolescent patients with SCD and chronic pain approached that consent to participate in Part A, 2) Proportion of adolescent participants enrolled in Part A that consent to participate in Part B, 3) Proportion of participants enrolled in Part B that attend at least 6 of 8 yoga sessions, 4) Proportion of participants enrolled in Part B with an ED visit or a hospitalization for pain within 24 h of completion of each yoga session, 5) Proportion of participants in Part B who complete all study assessments before, and at the end of the yoga program, 6) Adherence to submission of pain diary.

RESULTS

The median age of 15 patient participants in Part A was 16 (IQR 14-17), and 14 parents was 43.5 (IQR 42-51). Most participants were female. Most participant responses indicated a positive opinion of yoga. Nine adolescents (60 %) from Part A participated in Part B of the study. The median age of 9 participants in Part B was 17 (IQR 15-18), and 5 of the 9 participants were female (53.3 %). Only one participant was able to attend 3 of the 8 yoga sessions offered, and did not experience any ED visits or hospitalizations following the yoga sessions. None of the other feasibility endpoints were met in this study.

CONCLUSIONS

Patients with SCD and chronic pain overall have a positive opinion of yoga, but there are challenges with recruitment and retention of participants in a clinical trial of yoga, and barriers to feasibility of an in-person group yoga intervention.

Opioid Prescription Filling Trends Among Children with Sickle Cell Disease After the Release of State-Issued Guidelines on Pain Management

OBJECTIVE

To assess the impact of Ohio's 2012, 2013, and 2016 opioid prescribing guidelines on opioid and nonsteroidal anti-inflammatory drug (NSAID) prescription filling and health care utilization for pain among children with sickle cell disease (SCD).

DESIGN

Quasi-experimental retrospective cohort study.

SETTING

Ohio Medicaid claims data from August 2011 to August 2016.

SUBJECTS

Medicaid beneficiaries under age 19 years with SCD.

METHODS

Interrupted time series analyses comparing population-level rates of opioids and NSAID prescriptions filled, standardized amounts of opioids dispensed, and acute health care utilization for pain before and after release of each guideline.

RESULTS

In our cohort of 1,505 children with SCD, there was a temporary but significant decrease in the opioid filling rate (-2.96 prescriptions per 100 children, P = 0.01) and in the amount of opioids dispensed (-31.39 milligram morphine equivalents per filled prescription, P < 0.001) after the 2013 guideline but a temporary but significant increase in the opioid filling rate (7.44 prescriptions per 100 children, P < 0.001) and in the amount of opioids dispensed (72.73 mg morphine equivalents per filled prescription, P < 0.001) after the 2016 guideline. The NSAID filling rate did not significantly change after any of the guidelines. Acute health care utilization rates for pain after the 2016 guideline were similar to those before the 2013 guideline (rate ratio = 1.04, P = 0.63).

CONCLUSIONS

Our results suggest that Ohio's 2013 and 2016 guidelines were associated with significant but nonsustained changes in opioid prescription filling among children with SCD. Additional studies are needed to confirm that opioid guidelines have a sustained impact on excessive opioid prescribing, filling, and misuse.

Physical exercise in sickle cell anemia: a systematic review

INTRODUCTION AND OBJECTIVE

Sickle cell anemia (SCA) is a genetic condition that alters the conformation of deoxygenated red blood cells, which results in their stiffening and the occurrence of vaso-occlusive crises, endothelium damage, organ dysfunction and systemic complications. Additionally, SCA limits the participation of individuals in physical and social activities. As we consider that physical exercise promotes the recovery of functional capacity and cardiorespiratory conditioning, we aim to verify the patterns of prescription, the effects and safety of exercise for individuals with SCA.

METHODOLOGY

We systematically reviewed the published literature focusing on clinical trials that correlated physical exercise with SCA patients and cross-sectional studies that applied the stress test. The data research was based on the PRISMA recommendations and the following databases were used: Medline by PubMed, Cochrane, PEDro, Scielo.

RESULTS

Six studies which were based on the evaluation of 212 patients aged between 13 and 40 years, were selected from 122 identified studies. Those studies associated the individual effort tolerance improvement, its inflammatory profile adjustment and the absence of alteration in the autonomic nervous system activity to physical exercise or stress test.

CONCLUSION

Low-to-moderate intensity physical exercise increased the SCA individual tolerance without causing vaso-occlusive crises, nor changes in the hemorheological and inflammatory profiles.

Do chronic pain and comorbidities affect brain function in sickle cell patients? A systematic review of neuroimaging and treatment approaches

Sickle cell disease (SCD) is a medical condition in which chronic pain is common and negatively impacts psychosocial function and quality of life. Although the brain mechanisms underlying chronic pain are well studied in other painful conditions, the brain mechanisms underlying chronic pain and the associated psychosocial comorbidities are not well established in SCD. A growing literature demonstrates the effect of treatment of chronic pain, including pharmacological and nonpharmacological treatments, on brain function. The present systematic review aimed to (1) determine the effects of chronic pain and psychosocial comorbidities on brain function of patients with SCD; (2) summarize pharmacological and nonpharmacological approaches to treat these symptoms; and (3) identify areas for further investigation of potential beneficial effects of treatments on brain function. Titles were screened using predefined criteria, including SCD, and abstracts and full texts were reviewed by 2 independent reviewers. A total of 1167 SCD articles were identified, and 86 full articles were included covering 3 sections: chronic pain (4 studies), psychosocial comorbidities (11 studies), and pharmacological and nonpharmacological treatments (71 studies). Neuroimaging evidence demonstrates aberrant neural processing related to chronic pain and psychosocial comorbidities in SCD beyond ischemic stroke and cerebral hemorrhage. Although neuroimaging studies show an important role for psychological factors, pain management is nearly exclusively based on opioids. Behavior therapy seems useful to improve psychological symptoms as well as chronic pain and quality of life. Further investigation is required with larger cohorts, matched controls, and examination of treatment-related neural mechanisms.

Integrative approaches to treating pain in sickle cell disease: Pre-clinical and clinical evidence

Sickle cell disease (SCD) is a genetic disorder characterized by hemolysis, end-organ damage, inflammation, and pain. Recurrent and unpredictable episodes of acute pain due to vaso-occlusive crises are a unique feature of SCD. Many patients also develop lifelong chronic pain. Opioids are the primary method of pain treatment in SCD; however, continued use is associated with several adverse effects. Integrative approaches to treating pain in SCD are increasingly being explored to prevent the side effects associated with opioids. In this review, we highlight the mechanisms of pain in SCD and describe mechanism-based integrative approaches for treating pain.

Yoga as a Complementary and Alternative Therapy in Children with Hematologic and Oncologic Disease

A diagnosis of a hematologic or oncologic disease in a child can be stressful for the patient and the family. Yoga as an intervention has been reported to decrease stress in adults diagnosed with chronic disorders but few studies have been reported with children and their families. A convenience sample of patients diagnosed with cancer or a blood disorder (ages 7-17 years) and their caregivers was selected to participate in a single bedside yoga class. Participants were surveyed pre and post yoga with the Spielberger State Trait Anxiety Scale. Children were also surveyed pre and post yoga with the Wong-Baker Faces Pain Scale. Children had a significant decrease in pain post yoga but no change in anxiety. Adolescents and parents had a significant decrease in anxiety post yoga intervention.

Incorporating integrative medicine and patient preferences into a pilot interdisciplinary sickle cell wellness clinic

OBJECTIVE

Sickle Cell Disease (SCD) is an inherited blood disorder that includes acute pain episodes and chronic pain that can dramatically impact quality of life and goal-achievement. Our staff had limited success in connecting families with the Pain, Palliative Care and Integrative Medicine Clinic (PPCIM) to receive specialized skills for pain management. We created a partnership between Hematology and PPCIM to provide SCD patients/families with needed resources.

DESIGN/SETTING

In 2016, key stakeholders collaborated to create a Sickle Cell Wellness Clinic (SCWC) clinic to provide families access to integrative medicine and wellness strategies. Design/structure, based on family focus group data and staff expertise, included a half-day, 7-discipline clinic housed in the PPCIM space. Patients with SCD, ages 8-20, learned strategies in an effort to improve health care utilization and increase overall quality of life.

MAIN OUTCOME MEASURES/RESULTS

Feedback from two successful pilot clinics in 2017 was incorporated into the formal roll-out of SCWC in 2018. SCWCs continued monthly for one year, serving a total of 20 families post-pilot. SCD patients increased follow-up appointment engagement in the PPCIM clinic following SCWC and reported high levels of satisfaction with their healthcare experience.

CONCLUSIONS

It is feasible to run a multidisciplinary clinic focused on pain management, coping skills, and healthy living with SCD. Providers benefited from the opportunity to collaborate with other disciplines. Patient and family feedback was positive, highlighted benefits of being introduced to new modalities, and reported advantages of meeting other patients/families in a new setting.

Inpatient prenatal yoga sessions for women with high-risk pregnancies: A feasibility study

BACKGROUND

Antenatal hospitalization for pregnancy complications can result in significant stress for pregnant women and their families. Prenatal yoga has been investigated in the outpatient setting as a method to alleviate stress. This study was designed to investigate the feasibility of incorporating prenatal yoga into the inpatient environment for women hospitalized with pregnancy complications.

STUDY DESIGN

High-risk women were recruited from the inpatient antepartum service at Tufts Medical Center (Boston, MA; March 2016 to February 2017) to evaluate the feasibility of an inpatient prenatal yoga program. The thirty-minute session was led by a certified instructor in a room adjacent to Labor and Delivery. Participants and antepartum nurses completed study questionnaires addressing logistics such as class duration and frequency. Perceived benefits of yoga were also explored.

RESULTS

Thirty-nine women were found eligible for this study and were consented for participation. Of these, fifteen (38%) participated in at least one yoga session. Responses to the to the post-class questionnaire by study participants indicated that the thirty minutes allocated for the yoga class was appropriate. Of the eight participants who responded to the discharge questionnaire, all indicated that the class was helpful with regards to stress reduction. Completed questionnaires by the antepartum nursing staff (n = 14) unanimously indicated that the yoga session was helpful for the patients and was not disruptive to medical care.

CONCLUSION(S)

Prenatal yoga is a technique that has been currently limited to the outpatient setting. This study provides a foundation for continued investigation of inpatient prenatal yoga for women hospitalized with pregnancy complications.

Yoga as an Intervention for the Reduction of Symptoms of Anxiety and Depression in Children and Adolescents: A Systematic Review

Purpose: The purpose of this review is to evaluate the implementation and effectiveness of yoga for the reduction of symptoms of anxiety and depression in youth. To our knowledge, there are no systematic reviews to date looking at the reduction of symptoms of both anxiety and depression. Methods: Numerous scientific databases were searched up to November 2018 for experimental studies assessing changes in symptoms of anxiety and/or depression in youths following yoga interventions. Quality and level of evidence were assessed, and information was synthesized across studies. Results: Twenty-seven studies involving youth with varying health statuses were reviewed. Intervention characteristics varied greatly across studies revealing multiple factors that may impact intervention efficacy, however 70% of the studies overall showed improvements. For studies assessing anxiety and depression, 58% showed reductions in both symptoms, while 25% showed reductions in anxiety only. Additionally, 70% of studies assessing anxiety alone showed improvements and 40% of studies only assessing depression showed improvements. Conclusion: The studies reviewed, while of weak to moderate methodological quality, showed that yoga, defined by the practice of postures, generally leads to some reductions in anxiety and depression in youth regardless of health status and intervention characteristics.

Systematic Review: Pain and Emotional Functioning in Pediatric Sickle Cell Disease

The objective of this systematic review was to assess the relationship between pain (frequency/intensity/duration, impairment, coping) and emotional functioning in pediatric Sickle Cell Disease, and evaluate the state of the literature. Studies were included if they met each of the following criteria: (a) primarily pediatric sample of youth or young adults up to age 21 years with SCD, (b) examined emotional functioning including anxiety and/or depressive and/or internalizing symptoms, and/or affect, (c) examined pain intensity/frequency/duration and/or pain-related impairment and/or pain coping as it relates to emotional functioning, as defined above. Using the established guidelines for systematic reviews, we searched PsycINFO, PubMED, and CINAHL databases for studies published through June 2018. Screening resulted in 33 studies meeting inclusion criteria. Study data were extracted and evaluated for scientific merit, resulting in four studies being removed. 29 studies were included in the final synthesis. Studies provide strongest evidence of a relationship between increased pain frequency and higher depressive and anxiety symptoms. There are moderate-to-strong associations between pain-related impairment and depressive symptoms, and small-to-strong associations between pain-related impairment and anxiety. When examining pain-coping strategies, maladaptive cognitive strategies show the strongest association with emotional functioning. There is a need for more adequately powered, prospective studies based on theoretical frameworks in order to advance our understanding of the relationship between pain and emotional functioning in pediatric SCD.

New and emerging treatments for vaso-occlusive pain in sickle cell disease

Introduction: Acute pain from episodic vaso-occlusion (VOC) spans the lifespan of almost everyone with sickle cell disease (SCD), while additional chronic pain develops in susceptible individuals in early adolescences. Frequent acute pain with chronic pain causes significant physical and psychological morbidity, and frequent health-care utilization. Available pharmacologic therapies reduce acute pain frequency but few evidence-based therapies are available for chronic pain. Areas covered: An extensive PubMed literature search was performed with appropriate search criteria. The pathophysiology of acute pain from VOC in SCD is very complex with many events subsequent to sickle polymer formation. Sensitization of pain pathways and alterations of brain networks contributes to the experience of chronic pain. Numerous therapies targeting putative VOC mechanisms are in clinical trials, and show considerable promise. Alternative analgesic treatments for acute and chronic pain have been examined in small patient cohorts, but formal clinical trials are lacking. Expert opinion: Childhood is likely a critical window for prevention of acute and later chronic pain. New multimodal analgesic therapies are needed, particularly for chronic pain, and should be examined in clinical trials. Given the multifactorial nature of both pain and VOC, simultaneously targeting multiple mechanisms may be the optimal approach for effective preventive therapies.