Shoulder injury a rare potential side effect of vaccination

1. Shoulder injury a rare potential side effect of vaccination

Abstract: https://www.acpjournals.org/doi/10.7326/M21-3023   

URL goes live when the embargo lifts

A retrospective cohort study found that shoulder injury occurred in fewer than 1 in 10,000 patients who received an intramuscular vaccinations administered in the deltoid muscle between April 2016 and December 2017 (pre-COVID-19 pandemic). The authors say that given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks. While shoulder conditions may be preventable if caused by inappropriate vaccine administration, their study did not determine the cause of vaccine-associated shoulder injuries. The findings are published in Annals of Internal Medicine.

The National Vaccine Injury Compensation Program (VICP) provides financial compensation to those who had serious adverse effects listed in its vaccine injury table. In 2017, shoulder injury related to vaccine administration (SIRVA) was added to the vaccine injury table based on convincing evidence of a causal relationship between the injection of a vaccine and deltoid bursitis. Besides bursitis, other shoulder conditions have been linked to vaccination. The proposed mechanism is that the shoulder conditions are caused by immune responses when vaccines are injected into the shoulder joint, instead of the deltoid muscle. However, epidemiologic data on shoulder conditions after vaccination are limited.

Researchers from Kaiser Permanente Southern California Department of Research & Evaluation studied health records for more than 3.7 million administered vaccinations during the study period to estimate the risk for shoulder conditions after vaccination and assess possible risk factors. A natural-language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes and the characteristics of vaccinated persons with and without shoulder conditions were compared. Among more than 3.7 million administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 per 10,000 adult vaccinations. The incidence was even less for pediatric recipients, with only 4 cases of shoulder conditions in more than 750,000 vaccinations.

The researchers also looked at risk factors for developing shoulder conditions and found that among adults, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, having fewer comorbidities, and receiving pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Chengyi Zheng, PhD, MS, please contact Dani K. Dodge Medlin at Dani.K.Dodge-Medlin@kp.org.

-------------------------------------------------

2. Ophthalmological procedures do not increase risk of heart attack

Abstract: https://www.acpjournals.org/doi/10.7326/M20-6618    

Editorial: https://www.acpjournals.org/doi/10.7326/M22-0709

URLs go live when the embargo lifts

A new case-crossover study has found that outpatient ophthalmological procedures do not increase the risk of acute myocardial infarction (AMI). These findings lend support to American Academy of Ophthalmology guidelines, which recommend that specialists refrain from unnecessary preoperative medical tests for average risk patients scheduled for most types of eye surgery. The study is published in Annals of Internal Medicine.

Invasive surgical procedures and accompanying stress are a transient factor in triggering the onset of AMI for vulnerable patients. Previous cohort studies have suggested associations between ophthalmologic procedures and AMI. However, these studies were not specifically designed to study the effects of transient exposures.

Researchers from the Norwegian University of Science and Technology, Trondheim and Karolinska Institutet, Stockholm conducted a case-crossover study of 353,031 patients in Norway and Sweden who had experienced a first-time AMI incident. Of those patients, 806 had experienced an AMI incident within 36 days of undergoing an ophthalmological procedure. The authors identified a eight-day period immediately after the procedure during which the incidence of AMI would be higher than other times, indicating that ophthalmological procedures are a risk for AMI events. However, the authors found that the likelihood of risk for AMI did not differ between surgical subtypes, anesthesia type, invasiveness of procedures, surgery duration, patient age, or underlying comorbidity.

An accompanying editorial from BobbieJean Sweitzer, MD, FACP notes that despite the growing body of evidence indicating that ophthalmological procedures have low risk of complications in older patients, medical testing and consultations are increasingly common. Sweitzer says that the delay these tests cause may increase the risk of adverse impacts, including more falls, for older patients. According to the authors, although a low relative risk in relation to more invasive ophthalmologic procedures was observed, physicians should still perform a careful evaluation before procedures that are either expected to require long general anesthesia and/or are highly invasive procedures. .

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Abhijit Sen, PhD, please email abhijit.sen@ntnu.no or abhse@tkmidt.no.

-------------------------------------------------

3. Summary of VA/DoD guidelines for management of substance use disorders focuses on key recommendations including the use of telehealth

Telehealth supplemental to, not a replacement for, in-person substance use disorder treatment

Review: https://www.acpjournals.org/doi/10.7326/M21-3931   

Guideline: https://www.acpjournals.org/doi/10.7326/M21-4011    

Editorial: https://www.acpjournals.org/doi/10.7326/M22-0150 

URLs go live when the embargo lifts

In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). These updated guidelines include consideration of telehealth for SUDs, which became an important component of treatment during the COVID-19 pandemic. A summary of key recommendations and a related review of published evidence are published in Annals of Internal Medicine.

As of 2019, 20.4 million Americans met criteria for SUD with rates reportedly increasing during the COVID-19 pandemic. Effective treatment of these patients can help to prevent premature deaths from SUD-related disease, accidents, and suicide. The authors summarize the recommendations that have the most clinical impact, including management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.

In response to safety restrictions during the pandemic, clinicians turned to telehealth services to provide care to patients with SUD. To reflect these changes, the U.S. VA and DoD updated Clinical Practice Guideline for the Management of SUDs provide guidance and evidence related to the implementation of telehealth in SUD treatment. The 2021 guidelines recommend using technology-based interventions in addition to usual care for alcohol use disorder, and structured, telephone-based care as an adjunct to usual care for SUD.

Researchers from the Center for Clinical Excellence, ECRI, and the University of Pennsylvania reviewed randomized controlled trials (RCTs) of adults with a diagnosis of SUD to synthesize recent findings on the efficacy of telehealth for SUDs. Telehealth services included videoconference therapy, web-based cognitive behavioral therapy (CBT), supportive text messaging, other web-based interventions, and enhanced telephone monitoring (ETM) in the treatment of various SUDs. The authors report that the overall strength of evidence was very low, indicating considerable uncertainty about the use of telehealth as an alternative to in-person care for SUD treatment. However, the authors note that the synthesized studies reported fewer participants prematurely dropping out of videoconference therapy or web-based CBT, which the authors say may suggest better adherence with telehealth interventions than in-person care. According to the authors, their findings suggest areas for future research into telehealth's role as an additional way to provide support and access to care among a population that may experience substantial barriers to care.

An editorial by Sarah Wakeman, MD highlights recommendations for the treatment and screening of substance and alcohol use disorders made by the VA and DoD that are applicable to both veterans and the public. The author says that, amidst the growing overdose crisis and rising alcohol-related mortality among younger individuals, the need for standardized approaches to diagnose and manage the full spectrum of unhealthy substance use and SUD in general medical settings is urgent. Wakeman notes that the guidelines do not mention harm reduction, which she argues is an overdue inclusion for SUD treatment in light of the increasing number of overdose deaths in the 2020-2021 year.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the author of the synopsis, James Sall, PhD, please email James.Sall@va.gov. To speak with someone from ECRI, please contact Laurie Menyo at lmenyo@ecri.org.  

-------------------------------------------------

Also new in this issue:

A Patient Price Guide for Prescription Medication

Robin Feldman, JD; Natalie Feldman, MD; and Enrique Seoane-Vazquez, PhD

Ideas and Opinions

Abstract: https://www.acpjournals.org/doi/10.7326/M21-4755   

-------------------------------------------------