Avoidance Of Nonsteroidal Anti-inflammatory Drugs Research Articles

NSAID use in orthopedic surgery:A review of current evidence and clinical practice guidelines.

Nonsteroidal anti-inflammatory drugs (NSAIDs)are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control. However, there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease. This review summarizes the mechanism of action of NSAIDs as well as provides an overview of commonly used NSAIDs and the differences between them. It provides a concise summary on the osseous effects of NSAIDs with regard to bone healing and heterotopic ossification. Most of all, it serves as a guide or reference for orthopedic providers when counseling patients on the risks and benefits of NSAID use, as it addresses the common stipulations encountered: "It irritates my stomach," "I have a history of bariatric surgery," "I'm already on a blood thinner," "I've had a heart attack," and "I've got kidney problems" and synthesizes both current research and society recommendations regarding safe use and avoidance of NSAIDs.

Assessing care quality: impact on renal outcomes in non-diabetic chronic kidney disease patients

Abstract Background Chronic kidney disease (CKD) is a major global noncommunicable disease, with significant burden on healthcare systems. Quality indicators (QIs) are useful tools for evaluating healthcare quality, but existing QIs for renal care mainly focus on dialysis population. This study aims to explore the association between quality of renal care and outcomes in non-diabetic CKD patients. Methods This study utilized Taiwan's National Health Insurance claims data and death registries to enroll non-diabetic adults with advanced CKD (stage 3B-5) from 2016 to 2019, following them through 2020. QIs evaluated included prescription of renin-angiotensin system (RAS) inhibitors, testing for proteinuria, and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs). An overall quality score was calculated by summing scores of each QI. The primary outcome was long-term dialysis, and secondary outcomes included death, acute kidney injury (AKI), hyperkalemia, and acidosis. Univariate and multivariate Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of the effects of QIs on outcomes. Results Among 27,842 patients, 59.8% received RAS inhibitors, 56.5% underwent proteinuria testing, and NSAIDs were avoided in 97.9% of cases. Only 33.5% received the highest QI score of 3. Multivariate Cox proportional hazard models showed that higher overall quality scores were associated with a lower risk of long-term dialysis (HR 0.87, 95% CI 0.83-0.92), death (HR 0.90, 95% CI 0.86-0.94), and acidosis (HR 0.87, 95% CI 0.79-0.96). Additionally, higher overall quality scores were borderline associated with a lower risk of AKI and hyperkalemia. Conclusions QIs for renal care were associated with better outcomes in non-diabetic patients with advanced-stage CKD, particularly in long-term dialysis, death, and acidosis. More patients need to be prescribed RAS inhibitors and tested for proteinuria to achieve better quality of renal care. Key messages • Our study shows quality of renal care can impact outcomes for non-diabetic CKD patients, with higher quality indicator scores associated with lower risk of long-term dialysis, death, and acidosis. • Prescription of RAS inhibitors had the most significant protective effect, but more patients need to be prescribed RAS inhibitors and tested for proteinuria to achieve better renal care quality.

Peptic Ulcer Disease and Its Implications

Peptic ulcer disease (PUD) is one of the commonest diseases seen throughout the world. Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is stomach pain. There are various risk factors for the development of peptic ulcer disease, but the most important ones are Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs). Patients generally present with dyspepsia or peptic ulcer bleeding. Acid suppressant therapy, H. pylori eradication, and avoidance of nonsteroidal anti-inflammatory drugs are the cornerstones of treatment of peptic ulcer disease. Peptic ulcer bleeding could be life-threatening. It is managed by appropriate supportive care, intravenous proton pump inhibitor therapy, and endoscopic homeostasis. Trans arterial embolization (TAE), Herbal treated and surgery are rarely required if endoscopic therapy fails.

Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery - an International Experts' Survey.

This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate perioperative interventions to prevent gastroesophageal reflux disease (GERD) and marginal ulcers (MU) after MBS. Very important long-term complications after MBS include GERD, Barrett's esophagus, and MU. Prevention might be fundamental to reduce the incidence, severe complications, and the increasing number of revisional bariatric surgeries. An international scientific team designed an online confidential questionnaire with 45 multiple-choice questions. The survey was sent to 110 invited experts and 96 of them (from 41 different countries) participated from 21 July 2022 to 4 September 2022. Most experts (≥ 90%) prescribe postoperative acid suppression agents after MBS. Life-long proton pump inhibitors prophylaxis in smokers with avoidance of non-steroidal anti-inflammatory drugs are recommended by most of the experts (66%, 73%) after any type of gastric bypass. Two-thirds of experts (69%) perform Helicobacter pylori eradication prior to MBS. Two-thirds of experts (68%) routinely perform EGD and biopsy before MBS. Follow-up esophagogastroduodenoscopy (EGD) and timing threshold for revisional and conversional MBS were variable among experts. This expert survey underlines important perioperative interventions that reached a two-thirds consensus among MBS international experts. Variability in follow-up EGD, approach to complication management, and thresholds for revisional and conversional MBS emphasize the need for further researches and consensus guidelines.

S3646 Double Pylorus: A Case of Chronic Peptic Ulcer Disease Leading to Formation of a Gastroduodenal Fistula

Introduction: Double pylorus is a rare condition, either congenital or acquired, that results in a gastroduodenal fistula, forming an additional connection between the antrum of the stomach and the duodenal bulb. Case Description/Methods: A 75-year-old female with past medical history of cervical cancer (in remission), hypertension, tobacco use, chronic constipation, and peptic ulcer disease (PUD) presented to the emergency department (ED) with diffuse abdominal pain and blood in her stool. Patient reported intermittent black stools with occasional rectal bleeding. She was using non-steroidal anti-inflammatory drugs (NSAIDs) for headaches. In the ED, patient was hypertensive to 170/75, but other vital signs were stable. Her labs showed a hemoglobin of 12.6 g/dL (normal 12-16 g/dL) without evidence of coagulopathy. Imaging of the abdomen and pelvis did not show any acute findings. Esophagogastroduodenoscopy (EGD) showed two openings to the duodenal bulb, a functional pylorus inferiorly and an accessory channel superiorly (Figure). The two lumens of the duodenum appeared normal without evidence of acute ulceration. Colonoscopy showed a non-bleeding arteriovenous malformation in the proximal ascending colon and internal hemorrhoids, which were likely the cause of her bleeding. Discussion: Acquired double pylorus (ADP) is usually an incidental finding with a prevalence of approximately 0.001-0.4%, affecting males and females in a 2:1 ratio, respectively. Most cases of ADP are secondary to PUD, often an ulcer in the antrum of the stomach or duodenum penetrating directly into the duodenal bulb. Patients can be asymptomatic with ADP, but some may experience vomiting, epigastric pain, or dyspepsia. Melena may also be present with active ulceration. Initial diagnostic approach to ADP should include EGD, assessing NSAID or corticosteroid use, and H. pylori testing. Treatment involves proton-pump inhibitor administration or other mucosal protective agents, avoidance of NSAIDs and steroids, and eradication of H. pylori. Endoscopic division of the tissue bridge with a sphincterome should be considered if severe symptoms of gastric outlet obstruction persist. In severe cases where perforation, refractory bleeding and/or obstruction occurs, a surgical consultation should be pursued. The accessory pathway will typically remain patent for life, but rarely, the channel will close completely or merge to form a single connection to the duodenal bulb.Figure 1.: Double pylorus on EGD. The accessory channel is observed superiorly, revealing a gastroduodenal fistula.

Evaluating the Safety of Non-Steroidal Anti-inflammatory Drugs use in Asthmatic Patients: A Systematic, Critical Review of Literature

Background: Evidence suggest avoidance of Non-steroidal anti-inflammatory drugs (NSAID) in aspirinintolerantasthmatics due to the risk of triggering exacerbation attack; however, evidence around avoidingNSAIDs in all other asthmatic patients are unclear. This study aimed to evaluate the evidence surroundingthe safety of using NSAIDs, including selective COX-2 inhibitors, among asthmatic patients.Methods: A systematic review used Medline (OVID), Scopus and Embasefrom January-2008 toJanuary-2019. Inclusion criteria includedEnglish, and human studies that evaluated the use of NSAID inasthmatics. Data was screened/extracted using a pre-designed data extraction form using Covidence®,thenwere critically appraised.Conclusion: Of the 49 identified studies,eight were eligible. Prevalence of NSAID-induced asthmaexacerbation was 9%(95%CI:6.0–12.0%)-9.9% (95%CI:9.4-10.5%). Asthmatics who were aspirin/NSAIDintolerant had 37% higher risk of hospitalisation compared to tolerant patients (RR:1.37; 95%CI:1.12–1.67).Use of COX-2 inhibitors showed non-significant associations with worsening respiratory symptoms/exacerbation. Only low-quality evidence was found for the safety of topical NSAID. NSAIDs-inducedrespiratory reactions/symptoms is relatively uncommon with the majority of asthmatic patients couldtolerate NSAIDs therapy. Asthmatic patients who suffer from aspirin-induced asthma or NSAIDsexacerbatedrespiratory disease (NSAIDs intolerant) should be avoided NSAIDs prescribing but could besafely prescribed selective COX-2 inhibitors as an alternative.

A Patient Safety Educational Tool for Patients With Chronic Kidney Disease: Development and Usability Study.

BackgroundChronic kidney disease (CKD) is a health condition that threatens patient safety; however, few interventions provide patient-centered education about kidney-specific safety hazards.ObjectiveWe sought to develop and test the usability of a mobile tablet–based educational tool designed to promote patient awareness of relevant safety topics in CKD.MethodsWe used plain language principles to develop content for the educational tool, targeting four patient-actionable safety objectives that are relevant for individuals with CKD. These four objectives included avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs); hypoglycemia awareness (among individuals with diabetes); temporary cessation of certain medications during acute volume depletion to prevent acute kidney injury (ie, “sick day protocol”); and contrast dye risk awareness. Our teaching strategies optimized human-computer interaction and content retention using audio, animation, and clinical vignettes to reinforce themes. For example, using a vignette of a patient with CKD with pain and pictures of common NSAIDs, participants were asked “Which of the following pain medicines are safe for Mr. Smith to take for his belly pain?” Assessment methods consisted of preknowledge and postknowledge surveys, with provision of correct responses and explanations. Usability testing of the tablet-based tool was performed among 12 patients with any stage of CKD, and program tasks were rated upon completion as no error, noncritical error (self-corrected), or critical error (needing assistance).ResultsThe 12 participants in this usability study were predominantly 65 years of age or older (n=7, 58%) and female (n=7, 58%); all participants owned a mobile device and used it daily. Among the 725 total tasks that the participants completed, there were 31 noncritical errors (4.3%) and 15 critical errors (2.1%); 1 participant accounted for 30 of the total errors. Of the 12 participants, 10 (83%) easily completed 90% or more of their tasks. Most participants rated the use of the tablet as very easy (n=7, 58%), the activity length as “just right” (rather than too long or too short) (n=10, 83%), and the use of clinical vignettes as helpful (n=10, 83%); all participants stated that they would recommend this activity to others. The median rating of the activity was 8 on a scale of 1 to 10 (where 10 is best). We incorporated all participant recommendations into the final version of the educational tool.ConclusionsA tablet-based patient safety educational tool is acceptable and usable by individuals with CKD. Future studies leveraging iterations of this educational tool will explore its impact on health outcomes in this high-risk population.

Management of Respiratory Symptoms Induced by Non-Steroidal Anti-Inflammatory Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (NERD) is defined by the combination of chronic rhinosinusitis, nasal polyps, bronchial asthma, and hypersensitivity reactions involving upper and/or lower airways after the exposure to acetylsalicylic acid (ASA) and other NSAIDs. However, airway inflammation occurs even in the absence of exposure to these drugs, leading to disease progression with aggressive polyp formation and non-optimal controlled asthma and rhinosinusitis. In this review, we discuss current and potential management strategies of NERD. This management should be multidisciplinary and comprise medical and surgical treatment of the underlying diseases. In order to prevent reactions due to NSAIDs, avoidance of COX-1 inhibitors with provision of safe therapeutic alternatives should be indicated. However, avoidance of NSAIDs does not ensure disappearance of the airway inflammation and this progresses and persists for life. ASA desensitization followed by daily ASA therapy remains the gold standard of NERD treatment. It is indicated in patients with uncontrolled bronchial and nasal symptoms as well as in patients who require NSAID treatment for specific diseases, such as rheumatic or cardiovascular conditions. ASA desensitization improves upper and lower respiratory symptoms, reduces the need for new nasal surgeries and increases quality of life. Different ASA desensitization protocols have been reported, although the addition of intranasal ketorolac and lysine aspirin prior to an oral ASA schedule has made ASA desensitization safer and more efficient. New therapeutic strategies are being investigated and may provide an alternative treatment for those patients in which ASA desensitization are contraindicated or continuous ASA therapy is discontinued because of adverse effects. Among them, biologic agents are an important treatment option, useful for controlling symptoms of the upper and lower airways. More investigation studies into the mechanisms involved in NERD are needed in order to identify additional therapeutic targets.

A novel treatment adjunct for aspirin exacerbated respiratory disease: the low-salicylate diet: a multicenter randomized control crossover trial.

Aspirin-exacerbated respiratory disease (AERD) is a clinical triad consisting of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Although respiratory reactions following ingestion of ASA and other nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a hallmark of the condition, respiratory inflammation persists despite patients' avoidance of NSAIDs. Treatment of this condition remains challenging and includes both medical and surgical options. A prospective crossover single-blind multicenter study involving 4 tertiary rhinology care centers (n = 30) was conducted in which patients were randomized to start with either 6 weeks of a regular diet or 6 weeks of a low-salicylate diet and then crossed-over for a total study duration of 12 weeks. Patients were evaluated at baseline, 6 weeks (at crossover) and 12 weeks using subjective measures (22-item Sino-Nasal Outcome Test-22 [SNOT-22], Nasal Sinus Symptom Scale [NSSS], and 7-item Asthma Control Questionnaire [ACQ-7]) and objective outcome instruments (Perioperative Sinus Evaluation [POSE] and Lund-Kennedy Endoscopic Score [LKES]). Data was analyzed for 30 patients. Wilcoxon rank sum tests determined that patients had improvement in their median difference in scores, which were all statistically significant, when they followed the low-salicylate diet compared to their regular diet: SNOT-22: 15 (95% confidence interval [CI], 10 to 23.25), p < 0.001; NSSS: 3 (95% CI, 1.75 to 4), p < 0.001; ACQ-7: 4.5 (95% CI, 1.5 to 8.5), p < 0.001; POSE 6 (95% CI, 2.5 to 10), p < 0.001; and LKES: 2.5 (95% CI, 1.5 to 4), p < 0.001). The low-salicylate diet may offer a novel treatment adjunct to the current management of AERD. Clinically and statistically significant improvements on both subjective and objective outcome measures were noted for the upper and lower respiratory tracts.

Effect of Systemically Used Anti-Tumor Necrosis Factor-α Medication on the Corneal Epithelium and Stroma of Patients with Ankylosing Spondylitis

ABSTRACTPurpose: To evaluate the effect of systemically used anti-tumor necrosis factor alpha (TNF-α) medication on the thickness of corneal epithelium and stroma in patients with ankylosing spondylitis (AS).Methods: A total of 125 eyes of 69 participants were included in this retrospective study of three groups: healthy participants (Group 1), AS patients receiving anti–TNF-α medication (Group 2), and AS patients receiving a nonsteroidal anti-inflammatory medication (Group 3).Results: According to anterior segment optical coherence tomography, the mean thickness of the corneal epithelium was significantly thicker in Group 2 than in Group 3 (51.6 ± 3.2 µm versus 50.4 ± 3 µm, p = 0.01), as was that of the stroma (475 ± 33 µm versus 443 ± 29 µm, p = 0.002).Conclusions: Anti–TNF-α medication and/or avoidance of nonsteroidal anti-inflammatory drugs could improve the thickness of both the corneal epithelium and stroma in AS patients.

Implementation of a CKD checklist for primary care providers.

CKD is associated with significant morbidity, mortality, and financial burden. Practice guidelines outlining CKD management exist, but there is limited application of these guidelines. Interventions to improve CKD guideline adherence have been limited. This study evaluated a new CKD checklist (a tool outlining management guidelines for CKD) to determine whether implementation in an academic primary care clinic improved adherence to guidelines. During a 1-year period (August 2012-August 2013), a prospective study was conducted among 13 primary care providers (PCPs), four of whom were assigned to use a CKD checklist incorporated into the electronic medical record during visits with patients with CKD stages 1-4. All providers received education regarding CKD guidelines. The intervention and control groups consisted of 105 and 263 patients, respectively. Adherence to CKD management guidelines was measured. A random-effects logistic regression analysis was performed to account for intra-group correlation by PCP assignment and adjusted for age and CKD stage. CKD care improved among patients whose PCPs were assigned to the checklist intervention compared with controls. Patients in the CKD checklist group were more likely than controls to have appropriate annual laboratory testing for albuminuria (odds ratio [OR], 7.9; 95% confidence interval [95% CI], 3.6 to 17.2), phosphate (OR, 3.5; 95% CI, 1.5 to 8.3), and parathyroid hormone (OR, 8.1; 95% CI, 4.8 to 13.7) (P<0.001 in all cases). Patients in the CKD checklist group had higher rates of achieving a hemoglobin A1c target<7% (OR, 2.7; 95% CI, 1.4 to 5.1), use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (OR, 2.1; 95% CI, 1.0 to 4.2), documentation of avoidance of nonsteroidal anti-inflammatory drugs (OR, 41.7; 95% CI, 17.8 to 100.0), and vaccination for annual influenza (OR, 2.1; 95% CI, 1.1 to 4.0) and pneumococcus (OR, 4.7; 95% CI, 2.6 to 8.6) (P<0.001 in all cases). Implementation of a CKD checklist significantly improved adherence to CKD management guidelines and delivery of CKD care.

Avoidance of nonsteroidal anti-inflammatory drugs after negative provocation tests in urticaria/angioedema reactions: Real-world experience.

Drug provocation tests (DPTs) are the gold standard in diagnosing nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity; however, only few data about follow-up of patients with negative DPTs are actually available. The aim of this study was to assess patients' behavior in taking NSAIDs again and to evaluate NSAID tolerability after negative allergological workup. This is a follow-up study involving patients evaluated for history of cutaneous reactions (urticaria and or angioedema) after NSAID intake and with negative DPTs with the suspected NSAID. Patients were asked during a phone interview about the intake of NSAIDs, tolerance, or reasons of avoidance. The negative predictive value (NPV) of NSAIDs DPTs was calculated. One hundred eleven of 142 patients were successfully contacted; 46/111 (41.44%) took the same NSAID previously tested with two adverse reactions reported (4.34%). Fifty-three of 111 (47.74%) patients did not take the same NSAID, but 34 of them took at least another strong cyclooxygenase (COX) 1 inhibitor, with 1 adverse reaction (2.94%) and 19 of them took only weak COX-1 inhibitors. Twelve of 111 patients (10.8%) did not take any NSAID. Reasons for drug avoidance were mainly fear of reactions (70.8%) and no need (29.2%). NPV, overall, was 96.97% (95% confidence interval, 91-99%). Although NSAID hypersensitivity diagnosis was ruled out by oral provocation test, the majority of patients with a history of urticaria/angioedema avoided the intake of the tested NSAIDs for fear of new reactions, particularly when strong COX-1 inhibitor NSAIDs were involved. The high NPV value of DPT resulting from this study should reassure NSAID intake.

Non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely regarded as one risk factor, which influences chronic kidney disease (CKD) progression. However, previous literature reviews have not quantified the risk in moderate to severe CKD patients. To estimate the strength of association between chronic NSAID use and CKD progression. We conducted a systematic review and meta-analysis of observational general practice or population studies featuring patients aged 45 years and over. The electronic databases searched were MEDLINE, EMBASE, Cochrane, AMED, BNI and CINAHL until September 2011 without date or language restrictions. Searches included the reference lists of relevant identified studies, WEB of KNOWLEDGE, openSIGLE, specific journals, the British Library and expert networks. For relevant studies, random effects meta-analysis was used to estimate the association between NSAID use and accelerated CKD progression (estimated glomerular filtration rate decline ≥ 15 ml/min/1.73 m2). From a possible 768 articles, after screening and selection, seven studies were identified (5 cohort, 1 case-control and 1 cross-sectional) and three were included in the meta-analysis. Regular-dose NSAID use did not significantly affect the risk of accelerated CKD progression; pooled odds ratio (OR) = 0.96 (95%CI: 0.86-1.07), but high-dose NSAID use significantly increased the risk of accelerated CKD progression; pooled OR = 1.26 (95%CI: 1.06-1.50). The avoidance of NSAIDs in the medium term is unnecessary in patients with moderate to severe CKD, if not otherwise contraindicated. As the definition of high-dose of NSAID use remains unclear, the lowest effective dose of NSAIDs should be prescribed where indicated.

Treatment of inherited platelet disorders

For patients affected by severe inherited platelet dysfunctions, e.g. Glanzmann thrombasthenia (GT) or Bernard-Soulier syndrome (BSS), platelet transfusion is frequently needed for controlling spontaneous bleeding, and is always needed when trauma occurs or surgery is performed. For the mild-to-moderate bleeding entities, e.g. storage pool disease, thrombaxane A2 receptor defect, platelet transfusion is usually unnecessary. Transfusion of platelets should be used selectively and sparingly because of the substantial risk of alloimmunization against HLA antigens and/or platelet glycoproteins (GP) αIIb, β(3), or αIIbβ(3) in GT, and GPI-IX-V in BSS, which may lead to refractoriness to therapy. To reduce the risk, HLA-matched single donors of platelets should be used. If such donors are unavailable, leucocyte-depleted blood components should be used. Therapy other than platelet transfusion includes: (i) Prevention (vaccination against hepatitis B, avoidance of non-steroidal anti-inflammatory drugs, preservation of dental hygiene, correction of iron deficiency and prenatal diagnosis). (ii) Topical measures (compression with gauze soaked with tranexamic acid, fibrin sealants, splints for dental extractions and packing for nose bleeds). (iii) Antifibrinolytic agents that are useful for minor surgery and as adjuncts for other treatment modalities. (iv) Desmopressin that increases plasma levels of von Willebrand factor and factor VIII giving rise to increased platelet adhesiveness and aggregation associated with shortened bleeding time. (v) Recombinant factor VIIa (rFVIIa). GT patients have been treated for bleeding episodes by rFVIIa with partial success. The mechanism by which rFVIIa arrests bleeding is probably related to increased thrombin generation by a tissue factor-independent process, enhanced platelet adhesion and restoration of platelet aggregation. (vi) Female hormones. Excessive bleeding during menarche in patients with GT or BSS can be controlled by high doses of oestrogen followed by high doses of oral oestrogen-progestin. Menorrhagia later in life can be managed by continuous oral contraceptives. Depo-medroxyprogesterone acetate administered every 3 months is an alternative when combined oral contraceptives are contraindicated.

Factors predicting older adults’ use of exercise and acetaminophen for osteoarthritis pain

To identify predictors of older adults' use of exercise and/or acetaminophen, and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat their osteoarthritis pain. Data were analyzed from 457 adults aged 60 and older with moderate or greater osteoarthritis pain intensity who responded to the Brief Pain Inventory between 2006 and 2007. The following predictors were entered into a logistic regression to predict use of exercise and/or acetaminophen and nonuse of NSAIDs: age, gender, ethnicity, race, education, arthritis treatment by a practitioner, pain treatment by a practitioner, pain intensity, functional interference from the pain, and percent of pain relief from current treatments. A total of 213 (46.6%) reported using exercise and/or acetaminophen and did not report using NSAIDs. Older adults reporting arthritis treatment by a practitioner were 2.2 (confidence interval 1.08-4.59) more likely to use recommended arthritis pain treatment, p < .03. Only 3-4% of the variance for use of recommended pain management treatment was explained by the predictors. Results underscore the importance of guidance by practitioners who are knowledgeable about safe osteoarthritis pain management for older adults.

Nonsteroidal Anti-Inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States

Because avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended for most individuals with chronic kidney disease (CKD), we sought to characterize patterns of NSAID use among persons with CKD in the United States. A total of 12,065 adult (aged 20 years or older) participants in the cross-sectional National Health and Nutrition Examination Survey (1999-2004) responded to a questionnaire regarding their use of over-the-counter and prescription NSAIDs. NSAIDs (excluding aspirin and acetaminophen) were defined by self-report. CKD was categorized as no CKD, mild CKD (stages 1 and 2; urinary albumin-creatinine ratio of ≥ 30 mg/g) and moderate to severe CKD (stages 3 and 4; estimated glomerular filtration rate of 15-59 mL/min/1.73 m(2)). Adjusted prevalence was calculated using multivariable logistic regression with appropriate population-based weighting. Current use (nearly every day for 30 days or longer) of any NSAID was reported by 2.5%, 2.5%, and 5.0% of the US population with no, mild, and moderate to severe CKD, respectively; nearly all of the NSAIDs used were available over-the-counter. Among those with moderate to severe CKD who were currently using NSAIDs, 10.2% had a current NSAID prescription and 66.1% had used NSAIDs for 1 year or longer. Among those with CKD, disease awareness was not associated with reduced current NSAID use: (3.8% vs 3.9%, aware vs unaware; P=.979). Physicians and other health care clinicians should be aware of use of NSAIDs among those with CKD in the United States and evaluate NSAID use in their CKD patients.

Identification of Novel Genetic Markers and Improved Treatment Options for Diabetic Kidney Disease

Diabetic nephropathy, a kidney disease that develops secondary to diabetes mellitus, accounts for most of the reduced life expectancy in individuals with diabetes and is the most common cause of chronic renal failure in developed countries [1]. In its early stages of development, diabetic kidney disease has no symptoms, and is characterized by a reduced glomerular filtration rate and atypical excretion of protein into the urine (i.e., microalbuminuria: 150–300 mg/day). In approximately 20–40% of individuals with diabetes, microalbuminuria progresses to overt nephropathy (urinary protein excretion >300 mg/day) and eventually culminates in end-stage renal disease (ESRD), where renal replacement therapy is necessary to control uremia and other metabolic consequences of kidney failure. ESRD is associated with substantial mortality and economic costs. In the USA alone, mortality rates are approximately 23% per year and nearly 400,000 people receive renal replacement therapy as a result of ESRD, incurring direct medical costs in excess of US$16 billion annually [2]. Unsurprisingly, diabetic kidney disease presents a major public health concern in countries with burgeoning rates of diabetes. At present, there is no cure for diabetic nephropathy; instead, current treatment strategies focus on prevention or delay of disease develop ment and progression. In the early stages of diabetic kidney disease, lifestyle modification (i.e., maintenance of healthy weight, physical activity, dietary restriction of protein, salt and alcohol, avoidance of nonsteroidal anti-inflammatory drugs and smoking cessation), coupled with intensive pharmacological control of glycemia and blood pressure, are prescribed for most patients. However, following

Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation

Michael R. Charlton, William J. Wall, Akinlolu O. Ojo, Pere Gines, Stephen Textor, Fuad S. Shihab, Paul Marotta, Marcelo Cantarovich, James D. Eason, Russell H. Wiesner, Michael A. Ramsay, Juan C. Garcia-Valdecasas, James M. Neuberger, Sandy Feng, Connie L. Davis, Thomas A. Gonwa, and the International Liver Transplantation Society Expert Panel Mayo Clinic, Rochester MN; Department of General Surgery, London Health Science Center, London, Ontario, Canada; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; Liver Unit, Hospital Clinic, University of Barcelona School of Medicine, Barcelona, Spain; Department of Nephrology, University of Utah School of Medicine, Salt Lake City, UT; Medical School, University of Western Ontario, London, Ontario, Canada; Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada; Transplant Institute, University of Tennessee, Memphis, TN; Baylor University Medical Center, Dallas, TX; Hospital Clinic I Provincial, Barcelona, Spain; Queen Elizabeth Hospital, Birmingham, England; Department of Transplant Surgery, University of California San Francisco Medical Center, San Francisco, CA; Department of Medicine, University of Washington Medical Center, Seattle, WA; and Mayo Clinic, Jacksonville, FL

A survey of hypertensive practices at two community health centres in Cape Town.

Control of hypertension remains an elusive goal, but doctors' non-compliance with guidelines, patient attitudes and adherence to treatment, and poor delivery of care at clinics are important contributing factors. To determine the overall quality of hypertensive care, and compliance with current hypertension guidelines at community health centres (CHCs) in the Western Cape. Consecutive patients attending hypertension clinics at two CHCs were selected to participate. A questionnaire was designed to determine patient demographics, doctors' compliance with hypertension guidelines, factors leading to treatment non-adherence, and delivery of care. Accuracy of blood pressure (BP) recording was evaluated by comparing the clinic BP with that measured using an approved manometer. One hundred and sixty-one patients were evaluated, 100 from CHC 1 and 61 from CHC 2. There was no difference in both control systolic and diastolic BP measured by the hypertension nurse (147.9 v. 144.8 mmHg, p = 0.45, and 89.3 v. 85.6 mmHg, p = 0.14) respectively. All clinic BP readings were recorded to the nearest 10 mmHg mercury. The difference in both systolic and diastolic BP > 10 mmHg between the clinic and control BP was significantly greater at CHC 2 than CHC 1 (28% v. 56%, p = 0.005, and 43% v. 64%, p = 0.007) respectively. Overall, 39.8% of patients had a systolic and diastolic BP < 140 and < 90 mmHg. The mean number of antihypertensive drugs was 2.4 per patient. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and tricyclic antidepressants was high at both centres, and few patients underwent basic investigations, lifestyle interventions, risk stratification or global cardiovascular risk reduction. 39.8% of patients achieved a BP < 140/90 mmHg. There is significant scope for improvement in prescription of medication, application of uniform lifestyle changes, and avoidance of NSAIDs and tricyclic antidepressants. Major deficiencies were identified in BP measurement, assessment of target organ damage, risk stratification and the reduction of overall cardiovascular risk.

Nonpharmacologic Measures and Drug Compliance in Patients with Heart Failure: Data from the EuroHeart Failure Survey

Advice on lifestyle, diet, vaccination, and therapy are part of the standard management of heart failure (HF). However, there is little information on whether patients with HF recall receiving such recommendations and, if so, whether they report following them. We obtained information on the recall of and adherence to nonpharmacologic advice from patients enrolled in the EuroHeart Failure Survey. This article focuses on 2,331 patients who had a clinical diagnosis of HF during the index admission and attended an interview 12 weeks after discharge. Their mean age was 67 +/- 12 years and 38% were women. Patients recalled receiving 4.1 +/- 2.7 items of advice with higher rates in Central Europe and the Mediterranean region. Recall of dietary advice (cholesterol or fat intake, 63%; dietary salt, 60%) was higher than for some other interventions (influenza vaccination, 36%; avoidance of nonsteroidal anti-inflammatory drugs, 17%). Among those who recalled the advice, a substantial proportion indicated that they did not follow advice completely (cholesterol and fat intake, 61%; dietary salt, 63%; influenza vaccination, 75%; avoidance of nonsteroidal anti-inflammatory drugs, 80%), although few patients indicated they ignored the advice completely. Patients who recalled >4 items versus < or =4 items of advice were younger and more often received angiotensin-converting enzyme inhibitors (71% vs 62%), beta-blockers (51% vs 38%), and spironolactone (25% vs 21%). In conclusion, after hospitalization for HF, many patients do not recall nonpharmacologic advice. In addition, a substantial proportion of those who recall the advice follow it incompletely. Younger age and prescription of appropriate pharmacologic treatment are associated with higher rates of recall and implementation.