Improving Pneumococcal Vaccination Rates in Immunosuppressed Pediatric Patients with Rheumatic Disease.

Background: Patients with rheumatic diseases are at a high risk of invasive pneumococcal disease due to immunosuppression. We conducted a quality improvement project, and the first aim was to increase the percentage of patients with systemic lupus erythematosus and mixed connective tissue disease that is up to date on pneumococcal vaccinations from 9.6% to 80% within one year. Subsequently, the second aim was to increase the percentage of patients on immunosuppression with systemic lupus erythematosus, mixed connective tissue disease, juvenile dermatomyositis and systemic vasculitis that is up to date on pneumococcal vaccinations from 62.6% to 80% within one year. Methods: Two process measures were up-to-date vaccination status on (1) 13-valent pneumococcal conjugated vaccine (PCV13) and (2) 23-valent pneumococcal polysaccharide vaccine (PPSV23). Our outcome measure was being fully up to date on both pneumococcal vaccinations. Interventions included an immunization algorithm, reporting of eligible patients, education, reminders, and pre-visit planning. Results: There were shifts in the centerline for all quality measures in both phases of this project. The combined pneumococcal vaccination rate for Phase 1 increased from 9.6% to 91.1%, and this centerline was sustained. Pneumococcal vaccination rates also significantly increased for Phase 2: 68.8% to 93.4% for PCV13, 65.2% to 88.5% for PPSV23, and 62.6% to 86.5% for the combined pneumococcal vaccination rate. Conclusions: Quality improvement methodology significantly increased and sustained pneumococcal vaccination rates in our high-risk, immunosuppressed patients. We continue to prioritize this important initiative to mitigate the risk of invasive pneumococcal disease.

Psychosocial Functioning of Parents of Youth Receiving Intensive Interdisciplinary Pain Treatment.

OBJECTIVE: Parents of youth with chronic pain report psychosocial difficulties, yet treatment often focuses on improving their child's functioning and pain. This study evaluated changes in parents' social and emotional functioning and explored predictors of change, as they completed a parent-focused intervention while their child was enrolled in an intensive interdisciplinary pain treatment (IIPT) program. METHODS: Parents (n = 69) completed questionnaires at baseline and weekly (average duration of 4 weeks) during their child's participation in IIPT. Parents engaged in 3 groups per week providing education, therapeutic art, and psychotherapy (3 hr/week total). RESULTS: At baseline, 38% of parents reported scores in the clinically elevated range for at least 1 psychosocial variable. Linear mixed modeling for the full sample indicated reduced parent anxiety (t = -2.72, p <.01) and depression (t = -3.59, p <.001), but not increased emotional support (t = 1.86, p >. 05) or reduced social isolation (t = -1.20, p >.05). For parents with at least moderately elevated psychosocial concerns, statistically significant improvements were observed for all 4 outcomes (all p's<.01). Psychological flexibility, cognitive reappraisal, and emotional suppression were found to be related to changes in parent outcomes (anxiety, depression, isolation, and support). CONCLUSIONS: Findings support the benefit of parent-focused interventions in addition to child-focused interventions. Many parents of youth participating in IIPT had elevated scores for at least 1 psychosocial concern at baseline. Brief, parent-focused intervention including psychoeducation, therapeutic art, and psychotherapy targeting mindfulness, acceptance, and values had a significant impact on these parents, particularly those with greater struggles at baseline.

Pediatric Neural Changes to Physical and Emotional Pain After Intensive Interdisciplinary Pain Treatment: A Pilot Study.

Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth. This study examined changes in brain activation associated with experiencing physical pain, and the observation of physical and emotional pain in others, by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youth (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain. Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus). These changes support interpretation that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Dietary Effects on Pain Symptoms in Patients with Fibromyalgia Syndrome: Systematic Review and Future Directions.

Fibromyalgia syndrome (FMS) is recognized for its difficulty to diagnose and its subjective symptomatology. There is neither a known cure nor a recommended therapeutic diet to aid in the multidisciplinary treatment. We conducted a systematic review to investigate if diets can improve pain symptoms of fibromyalgia. Through the PubMed search in March 2022, 126 abstracts were identified. We included both intervention and observational studies of diets and pain symptoms among patients with FMS. After screening titles, abstracts, and full-texts, 12 studies, including 11 intervention and one observational study, were selected. These studies included 546 participants and investigated plant-based diets (n = 3), anti-inflammatory diets (n = 1), gluten-free diets (n = 2), and elimination/restrictive diets (n = 6). These studies assessed pain symptoms through visual analogue scale for pain, fibromyalgia impact questionnaire/revised fibromyalgia impact questionnaire, tender point count, pain pressure threshold, and/or total myalgic score. Nine studies, including all three plant-based diet studies, reported statistically significant beneficial effects of their respective diets on pain symptom measurements. Given the small sample size and short intervention duration of the included studies, limited evidence currently exists to recommend any specific diet to patients with FMS. Further research is warranted to clarify specific diets to recommend and explore their potential mechanisms.

Parent Responses to Child Pain During Intensive Interdisciplinary Pain Treatment and 1-Year Follow-Up.

Targeting parents' responses to their child's pain during intensive interdisciplinary pain treatment (IIPT) could influence child functioning. This longitudinal, observational study investigated changes in these responses and concurrent relationships between parent responses and changes in levels of child functioning and pain. Parents of youths 10 to 19 years of age (mean = 15 years, SD = 1.98 years) participated in twice weekly, parent-only groups while their teens were enrolled in IIPT (mean length of treatment = 3.93 weeks, SD = 1.16 weeks). Parent responses to child symptoms, as well as child pain and functional disability, were assessed weekly during treatment (n = 114) and at 3 follow-up visits: 1 month (n = 96), 6 months (n = 68), and 12 months (n = 45). Longitudinal multilevel modeling analyses indicated statistically significant decreases during treatment in parents' protective, monitoring, and minimizing responses and further improvement in all responses during follow-up. These changes were associated with concurrent changes in child disability. However, changes in parent behaviors occurred independently from changes in child pain levels. Baseline child characteristics affected neither baseline parent responses to pain nor changes over time. Results indicate that, in the context of IIPT, parental responses are amenable to change and that these changes may impact child pain-related functioning, providing further support for the role of parent-specific programming within IIPT. PERSPECTIVE: During intensive IIPT, parents made statistically significant changes in responses to their child's pain, which was associated with improvements in child disability, but not child pain. Changes were sustained through 1-year follow-up. Targeting parental responses to child pain is feasible and may relate to improved child functioning.

Amplified pain syndromes in children: treatment and new insights into disease pathogenesis.

PURPOSE OF REVIEW: Although many diagnostic terms are used for pediatric chronic pain, evidence suggests a common thread of signal amplification, leading to the unifying term 'amplified pain syndromes'. Ongoing research provides new insights into biopsychosocial contributors and treatments for pediatric amplified pain syndromes. RECENT FINDINGS: Basic science indicates a complex interplay of genetic, epigenetic, neurochemical, endocrine, and inflammatory contributors, along with environmental and psychological factors. Although medications and interventions remain common approaches to children with chronic pain, their evidence is limited. Preliminary evidence exists for mindfulness-based therapies, yoga, and other complementary/alternative medicine approaches. The strongest evidence is for exercise-based and cognitive-behavioral treatments, in particular, when combined in a multidisciplinary format. Intensive approaches (pain rehabilitation) have the potential to effectively and efficiently treat those most disabled by amplified pain syndromes, and lead to sustained improvement in pain, functioning, and medical utilization. SUMMARY: Although understanding of the mechanisms underlying pediatric amplified pain syndromes evolves, standard of care is multidisciplinary emphasizing exercise therapy, cognitive-behavioral treatment, and self-regulation. Treatment should target full return to physical function, which leads to subsequent improvement or resolution of pain. Multidisciplinary care can be coordinated by a rheumatologist or other physician with appropriate referrals, or through a multidisciplinary team.