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The Effect of Perioperative Ketorolac Administration on Opioid Use After Hip Arthroscopy.
Cunningham, D, Lewis, B
Orthopedics. 2021;(3):e417-e421
Abstract
Patients undergoing hip arthroscopy often have postoperative pain that is managed in part with opioids. The hypothesis of this study was that administration of ketorolac at the conclusion of the case may improve postoperative pain control and reduce opioid use. This investigation was a retrospective, observational study of opioid use, pain, and time spent in the postanesthesia care unit (PACU) among opioid-naïve patients undergoing primary hip arthroscopy (Current Procedural Terminology code 29914 or 29916) for femoroacetabular impingement syndrome before and after the institution of a surgeon-driven policy to administer ketorolac at the end of the case. Baseline characteristics and perioperative ketorolac administration were recorded. Outcomes included opioids used in the PACU through discharge measured in oral morphine equivalents, time spent in the PACU, and pain reported by the patient in the PACU. Comparative statistics, including multivariable main effects linear regression modeling, were performed to determine the effect of ketorolac administration on outcomes. Patients who did not receive ketorolac consumed a median of 22.5 oral morphine equivalents in the PACU through discharge, whereas patients who received ketorolac consumed a median of 17.5 oral morphine equivalents. No significant difference was found in pain reported or time spent in the PACU through discharge, although the results favored ketorolac administration. This study showed a modest but statistically significant reduction in early postoperative opioid use among patients receiving ketorolac at closure. Ketorolac could be part of a multimodal preemptive pain management strategy to help to reduce postoperative opioid use. [Orthopedics. 2021;44(3):e417-e421.].
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Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids.
Walter, KA, Lee, RY, Chen, K, Komanski, C
Arquivos brasileiros de oftalmologia. 2020;(1):55-61
Abstract
PURPOSE To evaluate the rate of cystoid macular edema development among cataract surgery patients on four different therapeutic regimens. METHODS The present study is a retrospective analysis of 5,380 eyes following uncomplicated phacoemulsification at Wake Forest University. The study period went from July 2007 to December 2012. Patients received one of four regimens, as follows: postoperative generic ketorolac 0.4% and prednisolone 1%, postoperative name-brand ketorolac 0.45% and prednisolone 1%, postoperative bromfenac 0.09% and prednisolone 1%, preoperative and postoperative bromfenac 0.09% alone. A statistical analysis was performed to assess the differences in rate of cystoid macular edema development among the four different therapeutic regimens. The diagnosis of cystoid macular edema required worsening of vision and evidence of increased macular thickness on optical coherence tomography. RESULTS The overall rate of cystoid macular edema was 0.82%. Treatment by postoperative generic ketorolac 0.45% and prednisolone 1% demonstrated the highest rate of cystoid macular edema development (2.20% of the cases). Postoperative name-brand ketorolac 0.45% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.90% of the cases). Postoperative administration of bromfenac 0.09% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.44% of the cases). Preoperative and postoperative bromfenac 0.09% alone resulted in the lowest rate of cystoid macular edema development (0.09% of the cases). The rate of cystoid macular edema was significantly lower when bromfenac was used alone vs. either regimen where ketorolac and prednisolone were used (OR 0.043, 95% CI 0.002 to 0.312; p<0.001). CONCLUSIONS Post-cataract surgery cystoid macular edema developed less frequently following topical non-steroidal anti-inflammatory drugs regimen compared to the other therapies evaluated. Bromfenac, without corticosteroids, achieved lower rates of cystoid macular edema vs. various combinations of non-ste-roidal anti-inflammatory drugs with corticosteroids.
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The use of 5-aminosalicylate for patients with Crohn's disease in a prospective European inception cohort with 5 years follow-up - an Epi-IBD study.
Burisch, J, Bergemalm, D, Halfvarson, J, Domislovic, V, Krznaric, Z, Goldis, A, Dahlerup, JF, Oksanen, P, Collin, P, de Castro, L, et al
United European gastroenterology journal. 2020;(8):949-960
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Abstract
BACKGROUND The lack of scientific evidence regarding the effectiveness of 5-aminosalicylate in patients with Crohn's disease is in sharp contrast to its widespread use in clinical practice. AIMS The aim of the study was to investigate the use of 5-aminosalicylate in patients with Crohn's disease as well as the disease course of a subgroup of patients who were treated with 5-aminosalicylate as maintenance monotherapy during the first year of disease. METHODS In a European community-based inception cohort, 488 patients with Crohn's disease were followed from the time of their diagnosis. Information on clinical data, demographics, disease activity, medical therapy and rates of surgery, cancers and deaths was collected prospectively. Patient management was left to the discretion of the treating gastroenterologists. RESULTS Overall, 292 (60%) patients with Crohn's disease received 5-aminosalicylate period during follow-up for a median duration of 28 months (interquartile range 6-60). Of these, 78 (16%) patients received 5-aminosalicylate monotherapy during the first year following diagnosis. Patients who received monotherapy with 5-aminosalicylate experienced a mild disease course with only nine (12%) who required hospitalization, surgery, or developed stricturing or penetrating disease, and most never needed more intensive therapy. The remaining 214 patients were treated with 5-aminosalicylate as the first maintenance drug although most eventually needed to step up to other treatments including immunomodulators (75 (35%)), biological therapy (49 (23%)) or surgery (38 (18%)). CONCLUSION In this European community-based inception cohort of unselected Crohn's disease patients, 5-aminosalicylate was commonly used. A substantial group of these patients experienced a quiescent disease course without need of additional treatment during follow-up. Therefore, despite the controversy regarding the efficacy of 5-aminosalicylate in Crohn's disease, its use seems to result in a satisfying disease course for both patients and physicians.
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Nonsteroidal Anti-Inflammatory Drugs and Risk of First Hospitalization for Heart Failure in Patients with No History of Heart Failure: A Population-Based Case-Crossover Study.
Huang, SP, Wen, YC, Huang, ST, Lin, CW, Wang, TD, Hsiao, FY
Drug safety. 2019;(1):67-75
Abstract
INTRODUCTION Traditional nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) are known to cause salt and fluid retention and should thus be used cautiously in patients with documented heart failure. Recent studies have found that some NSAIDs, including cyclooxygenase (COX)-2 inhibitors, are associated with an increased risk of incident heart failure regardless of the related medical history of the patient. OBJECTIVE This study aimed to investigate the potential link between NSAIDs (both COX-2 inhibitors and traditional nonselective NSAIDs) and heart failure in patients without a history of heart failure. METHODS We conducted a case-crossover study using the National Health Insurance Research Database (NHIRD) in Taiwan. A total of 5615 subjects with a first hospitalization for heart failure between 2005 and 2013 were identified from the NHIRD. Exposure to individual NSAIDs between the case period (1-30 days before the index date) and control period (121-150 days before the index date) were retrieved. Multivariable conditional logistic regression models were used to estimate the adjusted odds ratios (aORs) of the incident heart failure associated with NSAID use after adjustments for potential confounders. Multiple sensitivity analyses, including the case-time-control analysis, were performed to test the robustness of the study results. RESULTS Overall, NSAID use was associated with a 1.58-fold risk [aOR 1.58; 95% confidence interval (CI) 1.40-1.79] of heart failure leading to hospitalization in the main analysis, and similar results were obtained in the case-time-control analysis [aOR 1.40 (95% CI 1.18-1.67)]. The increased risks of heart failure were comparable between traditional NSAIDs [aOR 1.53 (95% CI 1.35-1.74)] and COX-2 inhibitors [aOR 1.74 (95% CI 1.25-2.44)]. Among all NSAIDs, ketorolac was associated with the highest risk of heart failure [aOR 1.98 (95% CI 1.37-2.86)]. CONCLUSION Both traditional NSAIDs and COX-2 inhibitors were associated with an increased risk of heart failure leading to hospitalization in patients without a related history of heart failure.
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Indomethacin Dosing and Constriction of the Ductus Arteriosus During Open Fetal Surgery for Myelomeningocele Repair.
Howley, LW, Chatterjee, D, Patel, SS, Cuneo, BF, Crombleholme, TM, Behrendt, N, Zaretsky, MV, Marwan, AI, Zuk, J, Galan, HL, et al
Fetal diagnosis and therapy. 2019;(5):339-344
Abstract
INTRODUCTION The use of perioperative tocolytic agents in fetal surgery is imperative to prevent preterm labor. Indomethacin, a well-known tocolytic agent, can cause ductus arteriosus (DA) constriction. We sought to determine whether a relationship exists between preoperative indomethacin dosing and fetal DA constriction. MATERIALS AND METHODS This is an IRB-approved, single-center retrospective observational case series of 42 pregnant mothers who underwent open fetal myelomeningocele repair. Preoperatively, mothers received either 1 (QD) or 2 (BID) indomethacin doses. Maternal anesthetic drug exposures and fetal cardiac dysfunction measures were collected from surgical and anesthesia records and intraoperative fetal echocardiography. Pulsatility Index was used to calculate DA constriction severity. Comparative testing between groups was performed using t- and chi-square testing. RESULTS DA constriction was observed in all fetuses receiving BID indomethacin and in 71.4% of those receiving QD dosing (p = 0.0002). Severe DA constriction was observed only in the BID group (35.7%). QD indomethacin group received more intraoperative magnesium sulfate (p < 0.0001). Minimal fetal cardiac dysfunction (9.5%) and bradycardia (9.5%) were observed in all groups independent of indomethacin dosing. CONCLUSIONS DA constriction was the most frequent and severe in the BID indomethacin group. QD indomethacin and greater magnesium sulfate dosing was associated with reduced DA constriction.
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The Use of 5-Aminosalicylic Acid in Children and Adolescents With Inflammatory Bowel Disease.
Sokollik, C, Fournier, N, Rizzuti, D, Braegger, CP, Nydegger, A, Schibli, S, Spalinger, J, ,
Journal of clinical gastroenterology. 2018;(10):e87-e91
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BACKGROUND In ulcerative colitis (UC) 5-aminosalicylic acid (5-ASA) is recommended as primary therapy for mild to moderate disease. Topical 5-ASA has been proven especially effective. In Crohn's disease (CD) the evidence for a beneficial role of 5-ASA is weak. We investigated the use of topical and systemic 5-ASA therapy in children and adolescents with inflammatory bowel disease. MATERIALS AND METHODS Data of patients younger than 18 years, registered between April 2008 and December 2015 in the Swiss Inflammatory Bowel Disease Cohort, were analyzed. RESULTS Three hundred twenty pediatric inflammatory bowel disease patients were included; 189 with CD and 131 with UC. Over one third of UC patients [51 (39%)] received topical 5-ASA therapy and 43 (33%) received combination therapy during their disease course. UC patients with left-sided colitis or proctitis were more likely to receive topical or combination therapy as compared with patients with pancolitis (P<0.001 and <0.001, respectively). An increase in the use of topical 5-ASA therapy in UC patients was noted over time from 5% to 38%. Forty-seven percent of CD patients were treated with oral 5-ASA during their disease course. The usage was stable over time at approximately 15% to 20%. CONCLUSIONS In recent years a very positive trend showing an increase in topical 5-ASA therapy in children and adolescents with UC has been observed. However topical therapy is still used with relative low frequency, especially in patients with a more extensive disease. Conversely, despite weak evidence supporting 5-ASA use in CD patients it has been frequently prescribed. Physicians should continue to encourage their UC patients to use topical therapy.
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Characteristics of the use of cold combination products among older ambulatory patients at the National Hospital Organization Tochigi Medical Center in Japan: a retrospective single-center observational study.
Komagamine, J
BMC research notes. 2017;(1):728
Abstract
OBJECTIVE This study aimed to determine the frequency and characteristics of prescriptions of cold combination products among older ambulatory patients. A retrospective observational study was conducted using electronic medical records. All patients aged 65 years or older who continued visiting internal medicine physicians for at least 1 year were included. The primary outcome was the prescription of cold combination products by any physicians in National Hospital Organization Tochigi Medical Center during a 1-year follow-up. RESULTS Seven hundred fifty-six patients were included. The mean age was 75.4 years, 392 (51.9%) were men, the mean Charlson Comorbidity Index was 1.8, and the mean number of medications was 4.9. The proportion of patients who were prescribed cold combination products during the 1-year follow-up was 6.1% (95% confidence interval 4.4-7.8%). The prescription of cold combination products was not significantly associated with age (p = 0.11) or Charlson Comorbidity Index (p = 0.93) but was associated with an increasing number of medications (p < 0.001). A substantial proportion of older ambulatory patients were exposed to cold combination products during a 1-year follow-up.
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Regular Aspirin Use Associates With Lower Risk of Colorectal Cancers With Low Numbers of Tumor-Infiltrating Lymphocytes.
Cao, Y, Nishihara, R, Qian, ZR, Song, M, Mima, K, Inamura, K, Nowak, JA, Drew, DA, Lochhead, P, Nosho, K, et al
Gastroenterology. 2016;(5):879-892.e4
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BACKGROUND & AIMS Aspirin use reduces colorectal cancer risk. Aspirin, a nonsteroidal anti-inflammatory drug, inhibits prostaglandin-endoperoxide synthase 2 (PTGS2 or cyclooxygenase-2); PTGS2 promotes inflammation and suppresses T-cell-mediated adaptive immunity. We investigated whether the inverse association of aspirin use with colorectal carcinoma risk was stronger for tumors with lower degrees of lymphocytic infiltrates than for tumors with higher degrees of lymphocytic infiltrates. METHODS We collected aspirin use data biennially from participants in the Nurses' Health Study and Health Professionals Follow-up Study. Participants were asked whether they took aspirin in most weeks, the number of tablets taken per week, and years of aspirin use. We collected available tumor specimens (n = 1458) from pathology laboratories in the United States. A pathologist confirmed the diagnosis of colorectal adenocarcinoma (excluding anal squamous cell carcinoma), and evaluated histopathology features, including patterns and degrees of lymphocytic infiltrates within and around tumor areas. Person-years of follow-up evaluation were accrued from the date of return of questionnaires until dates of colorectal cancer diagnosis, death, or the end of follow-up evaluation (June 2010). Duplication-method Cox proportional hazards regression was used to assess the association of aspirin with the incidence of colorectal carcinoma subgroups according to the degree of tumor-infiltrating lymphocytes (TILs), intratumoral periglandular reaction, peritumoral reaction, or Crohn's-like reaction. RESULTS We documented 1458 rectal and colon cancers. The inverse association between regular aspirin use and colorectal cancer risk significantly differed by concentrations of TILs (Pheterogeneity = .007). Compared with nonregular use, regular aspirin use was associated with a lower risk of tumors that had low levels of TILs (relative risk, 0.72; 95% confidence interval, 0.63-0.81), and strength of the association depended on aspirin dose and duration (both Ptrend < .001). In contrast, aspirin use was not associated with a risk of tumors having intermediate or high levels of TILs. This differential association was consistent regardless of the status of tumor microsatellite instability, mutations in BRAF, or expression of PTGS2. Regular aspirin use was associated with a lower risk of tumors that contained low levels of CD3+ T cells, CD8+ T cells, or CD45RO (PTPRC)+ T cells (measured by immunohistochemistry and computer-assisted image analysis). CONCLUSIONS Based on data from the prospective cohort studies, regular use of aspirin is associated with a lower risk of colorectal carcinomas with low concentrations of TILs. These findings indicate that the immune response in the tumor microenvironment could be involved in the chemopreventive effects of aspirin.
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A Primary-Care Interventional Model on the Diverticular Disease: Searching for the Optimal Therapeutic Schedule.
Campanini, A, De Conto, U, Cavasin, F, Bastiani, F, Camarotto, A, Gardini, L, Geremia, A, Marastoni, C, Missorini, C, Quarantelli, E, et al
Journal of clinical gastroenterology. 2016;:S93-6
Abstract
INTRODUCTION In routine colonoscopy, diverticulosis is the most commonly found feature, but only a minority of these cases show symptoms of diverticular disease.From June 2014 to December 2014, we enrolled prospectively 178 patients affected by symptomatic uncomplicated diverticular disease (Male/Female=0.47, mean age 71.7±11.5 y, range 41 to 95 y) from 15 General Pratictioners patient files. All patients were symptomatic; in all cases, diagnosis was been confirmed by a colonoscopy performed at least 1 year before. Patients with acute diverticulitis were excluded.On the basis of the predominant symptoms (abdominal complaints or constipation), patients were addressed to 4 different therapeutic approaches using mesalamine, rifaximine, probiotics (in a consortium of different species of Lactobacillus and Bifidobacterium), and fibers (Plantago Ovata Husk). All treatments lasted 3 months. RESULTS Sixty-three patients were enrolled in group A (rifaximine), 43 in group A1 (rifaximine+fibers+probiotics), 23 in group B (mesalamine), and 31 in group B1 (mesalamine+fibers).Analysis of variance suggested a statistically significant difference (P<0.003) among groups at the end of the observation period, with Groups A1 and B1 showing a higher number of bowel movement per week. Global linear measurement confirmed the role of treatment as a significant factor (F=2.858; P=0.039) associated with body mass index (F=6.972; P<0.009). CONCLUSIONS In accordance with the baseline clinical presentation, the supplementation of fiber and/or probiotics is associated with a statistically significant improvement in the clinical pattern of symptoms in patients with diverticular disease in a primary-care/family physician setting.
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Aspirin and COX-2 inhibitor use in patients with stage III colon cancer.
Ng, K, Meyerhardt, JA, Chan, AT, Sato, K, Chan, JA, Niedzwiecki, D, Saltz, LB, Mayer, RJ, Benson, AB, Schaefer, PL, et al
Journal of the National Cancer Institute. 2015;(1):345
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We conducted a prospective, observational study of aspirin and COX-2 inhibitor use and survival in stage III colon cancer patients enrolled in an adjuvant chemotherapy trial. Among 799 eligible patients, aspirin use was associated with improved recurrence-free survival (RFS) (multivariable hazard ratio [HR] = 0.51, 95% confidence interval [CI] = 0.28 to 0.95), disease-free survival (DFS) (HR = 0.68, 95% CI = 0.42 to 1.11), and overall survival (OS) (HR = 0.63, 95% CI = 0.35 to 1.12). Adjusted HRs for DFS and OS censored at five years (in an attempt to minimize misclassification from noncancer death) were 0.61 (95% CI = 0.36 to 1.04) and 0.48 (95% CI = 0.23 to 0.99). Among 843 eligible patients, those who used COX-2 inhibitors had multivariable HRs for RFS, DFS, and OS of 0.53 (95% CI = 0.27 to 1.04), 0.60 (95% CI = 0.33 to 1.08), and 0.50 (95% CI = 0.23 to 1.07), and HRs of 0.47 (95% CI = 0.24 to 0.91) and 0.26 (95% CI = 0.08 to 0.81) for DFS and OS censored at five years. Aspirin and COX-2 inhibitor use may be associated with improved outcomes in stage III colon cancer patients.