History Of Aspirin Use Research Articles

Risk factors for hemorrhage in patients with long-term aspirin therapy undergoing emergency external ventricular drainage/intracranial pressure probe placement

BackgroundStudies have been inconclusive on the risk for hemorrhage in patients with a history of aspirin use who underwent emergency external ventricular drainage (EVD)/intracranial pressure (ICP) probe placement. The aim of this study was to explore hemorrhage-related risk factors in order to reduce the risk for hemorrhage in these patients. MethodsBetween July 2014 and July 2020, patients were retrospectively divided into EVD/ICP-related hemorrhage and non-hemorrhage groups. The collected data included age, gender, major diagnosis, medical history, imaging examinations, conventional coagulation test data, thromboelastography with platelet mapping (TEG-PM), surgical procedures and discharge conditions. ResultsIn total 94 patients, 21 in the hemorrhage group (15 males, 6 females) and 73 in the non-hemorrhage group (52 males, 21 females) were included. The majority of hemorrhages were recorded in EVD patients (19/21; 90.5%). Platelet AA pathway inhibition rate of ≥75% (sensitivity: 79.45% specificity: 52.38%) (P = 0.014) and SBP ≥125 mmHg (P = 0.006) were significantly related to hemorrhage. When the platelet AA pathway inhibition rate was ≥75% and the during-procedure SBP was ≥125 mmHg, the hemorrhage rate was significantly higher (83.3%) than with SBP <125 mmHg (6.7%) (P < 0.001). When the inhibition rate was <75%, there were no significant differences in the hemorrhage rates between the during-procedure SBP ≥125 mmHg group (17.2%) and the SBP <125 mmHg group (13.2%) (P > 0.05). Multivariate logistic regression analysis revealed that a platelet AA pathway inhibition rate ≥75% (OR = 5.183, 95% CI: 1.683–15.960) and during-procedure SBP ≥125 mmHg (OR = 4.609, 95% CI: 1.466–14.484) were independent risk factors for EVD/ICP-related hemorrhage. ConclusionPatients with long-term aspirin therapy, a platelet AA pathway inhibition rate ≥75% and during-procedure SBP ≥125 mmHg had a significantly higher risk of hemorrhage, which could be reduced by adjusting the SBP to <125 mmHg.

Bleeding and thrombotic events in bevacizumab-treated patients with colorectal cancer on novel oral anticoagulants and antiplatelet medications

BackgroundBevacizumab is a humanized monoclonal anti-VEGF antibody often given in combination with fluorouracil-based chemotherapy as therapy for metastatic colorectal cancer (mCRC). The bleeding and thrombotic event rates in the setting of concurrent novel oral anticoagulants with and without aspirin and bevacizumab treatment in patients with mCRC remain unclear. Methods462 patients with mCRC at Barnes-Jewish Hospital were identified between December 1, 2016 and December 1, 2021 and screened for concurrent treatment with bevacizumab and anticoagulant or antiplatelet therapy. Demographic and clinical information was extracted by electronic chart review. Results21 patients were identified who received bevacizumab and either apixaban or rivaroxaban for mCRC treatment. Aspirin was prescribed in some of these patients within three years of starting apixaban or rivaroxaban. Of the 13 patients without aspirin prescription, nine were given apixaban, and four were given rivaroxaban while on bevacizumab. Four out of nine of the patients who received apixaban had epistaxis, and only one case resulted in any treatment discontinuation. Three out of four of the patients who received rivaroxaban experienced bleeding, and one of these three patients discontinued bevacizumab. We also looked at eight patients who had received aspirin. Two out of seven patients who received apixaban/bevacizumab/aspirin experienced bleeding and discontinued a medication. The patient who received rivaroxaban/bevacizumab/aspirin experienced bleeding and discontinued bevacizumab. No patient experienced adverse thrombotic events. ConclusionsPatients with mCRC treated with bevacizumab and apixaban with no history of aspirin use within three years have a relatively low risk of bleeding that warrants treatment discontinuation.

Intracranial hemorrhage after recombinant tissue plasminogen Activator: The competing risks survival analysis

Intravenous recombination of tissue plasminogen activator is a recommended treatment for patients with ischemic stroke. However, its side effects are associated with an increased risk of intracerebral hemorrhage. This study aimed to verify the factors associated with hemorrhagic transformation, classified by the clinical system, with time from onset to treatment. The medical records of patients with ischemic stroke who underwent recombination tissue plasminogen activator therapy at Siriraj Hospital, Thailand from October 2005 to June 2017 were included in this study. A sub-distribution hazard function by Fine-Gray model was applied to the data. Of the 241 records, 12.9 % presented with intracerebral hemorrhage, 4.6 % were symptomatic, and 8.3% were asymptomatic. The factors associated with increased risks of symptomatic intracerebral hemorrhage were older age (6.38–7.62 times higher than that compared with patients of younger age), high initial blood glucose (14.5 times higher), and systolic blood pressure (7.84 times higher). The factors associated with the asymptomatic type, in comparison with the risk of the symptomatic type, were older age (1.67–9.46 times higher than that compared with patients of younger stroke), higher stroke severity (1.39 times higher), and history of aspirin use (1.79 times higher). Modern technology and medical innovations cannot change the factors affecting intracranial hemorrhage. Screening methods for identifying hemorrhagic transformation after recombinant tissue plasminogen activator are important for patients with ischemic stroke.

Pre-Diagnosis Aspirin Use Has No Effect on Overall Survival in Patients With Colorectal Cancer: A Study of a Multi-Racial Population.

IntroductionAspirin has been associated with a reduction in mortality in patients diagnosed with colorectal cancer (CRC). A possible mechanism for this is related to the programmed cell death 1 (PD-1) immune checkpoint pathway. Aspirin may have a synergistic effect with PD-1 inhibitors via inhibition of prostaglandin E2 (PGE2) production, which can reverse the ability of tumor cells to evade the immune system. This appears to be strongest in cancers that express PI3 kinase (PI3K) signaling activity, which aspirin downregulates. However, the benefit of pre-diagnosis aspirin use on CRC overall survival (OS) and cancer-specific survival is still controversial, and most studies have been performed in racially homogenous populations. Our study examines the effect of pre-diagnosis aspirin therapy on OS in a racially diverse group of patients with CRC.MethodsThis is a retrospective chart review of 782 patients diagnosed with CRC from January 2007 to December 2020. Kaplan-Meier curve was created to study the association of aspirin exposure compared to no exposure on OS. In addition, univariate and multivariate binary logistic regression analyses were done to investigate potential predictors of survival.ResultsOf the 782 patients with CRC, 55.1% were males, 22.2% whites, 58.5% Asians, and 17.7% Pacific-Islanders. Moreover, 38.4% of the patients had a history of aspirin use, 79% of them used it for more than one year. There were more patients with hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), and chronic kidney disease (CKD) among those with a history of aspirin use. There was no difference in one, three, and five-year OS among aspirin users compared to non-users, p-value = 0.63. Age, grade, and stage were potential predictors of worsened OS. However, treatment with chemotherapy and CKD were potential predictors of worsened OS on univariate analysis only. No significant association was noticed with gender, tumor location, or other associated comorbidities.ConclusionThe effect of pre-diagnosis aspirin use on CRC survival is not clear. In this retrospective analysis of a racially diverse population of CRC patients, we found that aspirin use was not associated with improved OS. Therefore, physicians should be careful about using aspirin as adjuvant therapy in CRC patients until high-quality prospective data are available, given the potential associated complications.

Evaluation of ventricular tachyarrhythmias in patients with myocardial infarction after streptokinase therapy

Objectives: The occurrence of arrhythmias after myocardial infarction is associated with an increased risk of mortality. The purpose of this study was to investigate tachyarrhythmias after streptokinase therapy in myocardial infarction patients. Methods: This study was a case-control study. Among 262 patients with myocardial infarction who received streptokinase, 168 patients with ventricular tachyarrhythmia, ventricular fibrillation, or both (case group), and 94 patients without arrhythmia (control group) were selected. Their clinical information were collected by questionnaire. Data were analyzed using SPSS 20 software through chi-square test and Wilcoxon rank-sum. Results: There was no relationship between demographic variables or electrocardiogram changes and the type of arrhythmia in 168 participants in the group 1 (p &gt; 0.05). However, there was a significant relationship between age (p = 0.04), sex (p = 0.049), diabetes (p = 0.039), hypertension (p = 0.037), history of beta-blocker use (p = 0.028), history of aspirin use (p = 0.023), number of the leads involved (p = 0.023) and occurrence of arrhythmia among the participants in the group 2. Conclusions: According to the findings of this study, patients with myocardial infarction who need to receive thrombolysis and who have any of the following conditions should be monitored by the health care staff to prevent development of ventricular tachyarrhythmias: old age, male gender, history of diabetes mellitus, hypertension or more lead involvement in their electrocardiogram.

Popeye sign with ecchymosis

A 94-year-old man with a history of aspirin use for coronary artery disease presented with left arm pain and ecchymosis. He experienced sharp pain in his left upper arm during...

Characteristics of and Risk Factors for Monoclonal Gammopathy of Undetermined Significance (MGUS) in the Multiethnic Cohort Study

Background: There is a 2-3-fold excess of both monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) among African Americans (AAs) compared to non-Hispanic whites (NHWs) for unknown reasons. It is unclear if risk of progression from MGUS to MM is similar across racial/ethnic groups. We identified MGUS patients and controls from the Multiethnic Cohort (MEC), a population-based cohort study in Los Angeles and Hawaii, described characteristics of and examined risk factors for MGUS among different racial/ethnic groups. Methods: A total of 637 MEC participants with a diagnosis of MGUS by CMS billing codes and 1,065 race/ethnicity-matched MM-free and presumed MGUS-free controls were identified. Screening for monoclonal proteinemia was performed at the USC Clinical Laboratories using serum protein electrophoresis (SPEP) with reflex to immunofixation (IFX) when SPEP was abnormal. For this study, MGUS was defined as IFX positive with M-protein concentration&amp;lt; 3g/dL. Controls were SPEP- and IFX-negative with no history of MGUS or MM. MGUS cases who progressed to MM during a mean 8.11-year follow-up were identified by linkage with the SEER databases of the Hawaii Tumor Registry and the California Cancer Registry. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for the effect of body mass index kg/m2 (BMI), diabetes or aspirin use prior to diagnosis on the risk of MGUS and progression to MM. Results: A total of 452 participants had laboratory validated MGUS. The racial/ethnic distribution was 109 AAs, 107 NHWs, 95 Latinos, 105 Japanese and 36 Hawaiian's. 58.6% were males. From the pool of laboratory-validated controls, an equal number of controls were frequency matched to cases by race/ethnicity, age and sex. Mean age at blood draw was 65 years for Hawaiians, 69 years for NHWs and Latinos, and 70 years for AAs and Japanese. The distribution of immunoglobulin (Ig) isotypes differed significantly by race/ethnicity(p=0.001) (Figure 1), with AAs having the highest proportion of IgG Kappa (48.1%) and the lowest proportion of IgM (2.8%) compared to other racial/ethnic groups (range IgG Kappa 31.8%-40%, range IgM 11.1%-28.0%). There was no difference in isotype distribution by sex (p=0.28). AAs and NHWs had the highest (mean=0.75 mg/dL ±0.6) and lowest (mean=0.53 mg/dL ±0.6) levels of M-protein, respectively, but there was no significant difference when all racial/ethnic groups were compared. Each unit of BMI (kg/m2) was associated with a 16% increase in risk of MGUS among Hawaiians (95% CI= 1.04,1.30); and a borderline increased risk ranging from 2%-7% among the other racial/ethnic groups. Neither history of aspirin use nor diabetes mellitus were significantly associated with MGUS risk. A total of 109/452 MGUS patients progressed to MM between 1 to 10 years after blood draw. Compared to NHWs, AAs (OR=2.09; 95%CI= 1.08-4.05) and Latinos (OR= 2.55, 95% CI=1.29-5.08) were more likely to progress. Progression was not significantly associated with sex (p=0.34) or BMI (p=0.12). Progressors were slightly younger than non-progressors (-1.6 years, p=0.057). A higher risk of progression was associated with IgA compared to IgG Kappa (OR=2.45; 95% CI=1.34-4.48) and an M-spike &amp;gt;1.5 g/dL compared to &amp;lt;1.5g/dL (OR=5.81, 95% CI=2.92-11.57). IgM was associated with a lower risk of progression (OR=0.03, 95% CI= 0.00-0.23). Conclusion: The distribution of MGUS isotypes and risk of progression to MM differed by race/ethnicity, with AA and Latinos more likely to progress, not explained by age at blood draw. Because we detected prevalent MGUS, lead time bias could explain racial/ethnic differences in risk. More studies with diverse populations and large sample sizes are needed to better understand the disparities in MGUS risk and progression, along with the underlying biological explanations. Disclosures No relevant conflicts of interest to declare.

Association of Aspirin with Hepatocellular Carcinoma and Liver-Related Mortality

BackgroundMore information is needed about the long-term effects of low-dose aspirin (≤160 mg) on incident hepatocellular carcinoma, liver-related mortality, and gastrointestinal bleeding in persons with chronic hepatitis B or hepatitis C virus infection.MethodsUsing nationwide Swedish registries, we identified all adults who received a diagnosis of chronic hepatitis B or hepatitis C from 2005 through 2015 and who did not have a history of aspirin use (50,275 patients). Patients who were starting to take low-dose aspirin (14,205 patients) were identified by their first filled prescriptions for 90 or more consecutive doses of aspirin. We constructed a propensity score and applied inverse probability of treatment weighting to balance baseline characteristics between groups. Using Cox proportional-hazards regression modeling, we estimated the risk of hepatocellular carcinoma and liver-related mortality, accounting for competing events.ResultsWith a median of 7.9 years of follow-up, the estimated cumulative incidence of hepatocellular carcinoma was 4.0% among aspirin users and 8.3% among nonusers of aspirin (difference, −4.3 percentage points; 95% confidence interval [CI], −5.0 to −3.6; adjusted hazard ratio, 0.69; 95% CI, 0.62 to 0.76). This inverse association appeared to be duration-dependent; as compared with short-term use (3 months to <1 year), the adjusted hazard ratios were 0.90 (95% CI, 0.76 to 1.06) for 1 to less than 3 years of use, 0.66 (95% CI, 0.56 to 0.78) for 3 to less than 5 years of use, and 0.57 (95% CI, 0.42 to 0.70) for 5 or more years of use. Ten-year liver-related mortality was 11.0% among aspirin users and 17.9% among nonusers (difference, −6.9 percentage points [95% CI, −8.1 to −5.7]; adjusted hazard ratio, 0.73 [95% CI, 0.67 to 0.81]). However, the 10-year risk of gastrointestinal bleeding did not differ significantly between users and nonusers of aspirin (7.8% and 6.9%, respectively; difference, 0.9 percentage points; 95% CI, −0.6 to 2.4).ConclusionsIn a nationwide study of patients with chronic viral hepatitis in Sweden, use of low-dose aspirin was associated with a significantly lower risk of hepatocellular carcinoma and lower liver-related mortality than no use of aspirin, without a significantly higher risk of gastrointestinal bleeding. (Funded by the National Institutes of Health and others.)

Abstract 2333: Aspirin may extend biliary tract cancer survival: Results from population-based cohort

Abstract Background: Biliary tract cancers (BTCs) are rare, but lethal cancers with a median survival of &amp;lt;12 months. Because of this poor prognosis, there is a critical need for treatments that extend survival. Cyclooxygenase-2 (COX-2) is an enzyme responsible for producing prostaglandin E (PGE). PGEs increase mucin production and reduce bile flow in the gallbladder, leading to gallstones, a precursor to gallbladder cancer. Overexpression of COX-2 due to chronic inflammation from cholangiocarcinoma has been found to enhance PGE production and promote tumor growth. Previous research suggests that COX-2 inhibitors, such as aspirin, may slow cancer cell growth. We investigated aspirin use following diagnosis and overall survival in a large cohort of patients with BTCs. Methods: All patients diagnosed with incident biliary tract cancer between 1990 to 2017 were selected from the population-based United Kingdom’s Clinical Practice Research Datalink. Site-specific associations between aspirin use after BTC diagnosis and overall survival was analyzed using Cox proportional hazards models with aspirin use modeled as time-dependent, adjusting for age at diagnosis, sex, comorbidities, history of aspirin use, and use of statins, using follow-up time as the time scale. Results: We identified 3,211 biliary tract cancer cases in which 2,694 (84%) deaths occurred after an overall median follow-up time of 5 months. The table presents the number of cases by cancer subtype, deaths, and median survival time. Aspirin use following a diagnosis of BTC was associated with a reduction in mortality for each of the BTC sites: gallbladder, HR 0.41 (95% CI: 0.28, 0.61); cholangiocarcinoma, HR 0.46 (95% CI: 0.36, 0.60); ampulla of Vater, HR 0.24 (95% CI: 0.11, 0.51); and mixed, HR: 0.51 (95% CI: 0.33, 0.78). Conclusions: The use of aspirin after BTC diagnosis was associated with a lower risk of overall mortality. These results warrant additional studies to understand the mechanisms underlying improved survival with aspirin use. Table.Association between post-BTC diagnosis aspirin use versus no use and survival in the UK CPRD datasetCancer siteBTC patients N (%)Mortality N (%)Median survival time in months (interquartile range)HR (95% CI)*Gallbladder668 (23)555 (83)3.9 (2 - 11)0.41 (0.28, 0.61)Cholangiocarcinoma1,560 (53)1321 (85)4.8 (2 - 12)0.46 (0.36, 0.60)Ampulla of Vater224 (8)142 (63)9 (4 - 21)0.24 (0.11, 0.51)Mixed484 (16)401 (83)5 (2 - 13)0.51 (0.33, 0.78)*Adjusted for age at diagnosis, comorbidities, prior aspirin use, and use of statins.Abbreviations: CPRD, Clinical Practice Research Datalink; CI, confidence interval; HR, hazard ratio; N, number; and UK, United Kingdom. Citation Format: Sarah S. Jackson, Bin Zhu, Ruth Pfeiffer, Zhiwei Liu, Shahinaz Gadalla, Jill Koshiol. Aspirin may extend biliary tract cancer survival: Results from population-based cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2333.

Abstract PD1-04: Association of aspirin and clinical outcomes in patients with invasive breast cancer

Abstract Long-term low-dose aspirin use has been observed to reduce the risk of colorectal, breast and other cancers. The most prominent effect has been in colorectal cancer, in which large-scale meta-analyses have shown that there is an approximately 20% relative risk reduction in participants who took aspirin for four or more years. The role of long-term NSAID use in breast cancer risk is less clear although preliminary observational case-control studies suggest an association between aspirin use and reduced incidence of hormone receptor-positive breast cancers though no clear evidence exists to support a clear mortality benefit among patients with a history of prior NSAID use as opposed to those who do not. To investigate whether a history of aspirin use is associated with improved clinical outcome in breast cancer, we examined the pattern of aspirin use, cancer pathology and overall survival of over 1000 patients diagnosed with and treated for invasive breast cancer at our institution, for whom long-term follow up was available. A history of aspirin use for at least a period of 30 days prior to breast cancer diagnosis was reported in nearly 14% of individuals. Aspirin use was associated with being older than the age of 50 at diagnosis (79.8% vs 66.5%; Fisher's Exact Test (P &amp;lt; 3.2x10-3) and being of African American race (49.1% vs 28.7%; P &amp;lt; 3.4x10-2), when compared to those who have not used aspirin. Aspirin use correlated with prognostic factors that are known to be associated with poor outcomes. They include axilla node positive disease (44.5% vs 27.0%, p&amp;lt; 0.032), evidence of lymphovascular invasion (24.7% vs 15.4%, p&amp;lt; 0.049), Her2-neu positive disease (&amp;lt;0.0083). In contrast to prior retrospective case-control studies, no significant association between aspirin use and hormone receptor positive disease was noted for either ER (p=0.19) or PR(+) receptor status (p=0.12). Finally, we examined if aspirin use prior to breast cancer diagnosis has any impact on disease outcome. Over a median follow up of 60.0 months, univariate analysis using cox proportional hazard modeling demonstrated that the use of low-dose aspirin prior to the diagnosis of breast cancer was associated with an increased all-cause mortality when compared to patients without aspirin use prior to cancer diagnosis (HR=3.084, 95% CI=1.961 to 4.848). On multivariate analysis, we found that recent history of aspirin use was significantly associated with a worse overall survival (HR 2.65; 95%CI 1.37 -5.12, P &amp;lt; 3.77 x 10-3), when controlled for other prognostic factors including receptor status, tumor size, tumor grade, number of positive regional lymph nodes, positive margins, as well as race and age at diagnosis. This is the first study to report on the association of aspirin use with breast cancer outcomes in a large patient cohort treated at a single institution. Although aspirin in breast and cancers has been associated with reduced cancer incidence, a history of aspirin use prior to breast cancer diagnosis does not appear to be protective or associated with improve clinical outcomes or survival among breast cancer patients. Ongoing efforts are examining the mechanism underlying this association. Citation Format: Li YR, Steel L, Carrigan E, Tchou J. Association of aspirin and clinical outcomes in patients with invasive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD1-04.

Long-Term Outcomes of NSAID-Induced Small Intestinal Injury Assessed by Capsule Endoscopy in Korea: A Nationwide Multicenter Retrospective Study.

Background/AimsWe evaluated the long-term outcome and clinical course of patients of nonsteroidal anti-inflammatory drug (NSAID)-induced small intestinal injury by performing capsule endoscopy (CE).MethodsA multicenter retrospective study was conducted using data collected from the CE nationwide database registry, which has been established since 2002.ResultsA total of 140 patients (87 males; mean age, 60.6±14.8 years) from the CE nationwide database registry (n=2,885) were diagnosed with NSAID-induced small intestinal injury and enrolled in our study. Forty-nine patients (35.0%) presented with a history of aspirin use and an additional 49 (35.0%) were taking NSAIDs without aspirin. The most prominent findings after performing CE were multiple ulcerations (n=82, 58.6%) and erosions or aphthae (n=32, 22.9%). During the follow-up period (mean, 15.9±19.0 months; range, 0 to 106 months), NSAID-induced small intestinal injury only recurred in six patients (4.3%). Older age and hypertension were positive predictive factors for recurrence.ConclusionsThese results suggest that the recurrence of NSAID-induced small bowel injury was not frequent in the presence of conservative treatment. Therefore, the initial diagnosis using CE and the medication history are important.

Correlation between long-term aspirin use and F-fluorodeoxyglucose uptake in colorectal cancer measured by PET/CT.

PurposeThe aim of this study was to evaluate the relationship between long-term aspirin use with pretreatment 18 Fluorodeoxyglucose (FDG) uptake of primary lesions of Colorectal cancer (CRC) and evaluate their clinical significance.Materials and MethodsWe enrolled 84 patients with CRC who underwent 18F-FDG PET/CT scanning before surgery between 1st July 2008 and 1st March 2013 and followed up until 1st March 2014. Maximum standardized uptake value (SUVmax) of the primary tumor was measured by 18F-FDG PET/CT. The history of aspirin taken and other clinicopathogical factors were also obtained and their relationships were examined by Mann-Whitney or χ2 tests. Progression-free survival (PFS) was determined by standard Kaplan-Meier survival analysis. Cox proportional hazards regression was performed to determine whether history of aspirin taken, pretreatment SUVmax, age, gender, TNM stage, tumor sizes and differentiation influenced outcomes.ResultsCRC Patients with long-term history of aspirin use had lower SUVmax of primary lesions than control group (9.74±2.62 vs. 13.91±6.18) and showed a trend towards improved PFS after curative surgery. However, pretreatment of SUVmax showed no prognostic value in patients with CRC.ConclusionsLong-term aspirin use is associated with lower pretreatment SUVmax of CRC and is a promising prognostic factor for predicting PFS in patients with CRC.

Biopsy of the Superficial Cortex

Abstract BACKGROUND: Brain biopsies of superficial cortex are performed for diagnosis of neurological diseases, but preoperative predictors of successful diagnosis and risks are lacking. OBJECTIVE: We evaluated effectiveness and outcomes of superficial cortical biopsies and determined preoperative predictors of diagnosis, outcomes, morbidities, and mortality. METHODS: A single-institution retrospective analysis of 170 patients who underwent open brain biopsies of superficial cortex was performed. Clinical predictors of effectiveness and outcomes were determined using univariate/multivariate analyses and a system for risk-benefit stratification was created and tested. RESULTS: Brain biopsies led to successful diagnosis in 122 of 170 (71.8%) and affected management in 97 of 170 (57.1%) cases. Factors increasing the odds of diagnostic pathology included age older than 45 years (odds ratio [OR]: 2.67, 95% confidence interval [CI]: 1.34-5.27, P &amp;lt; .01), previous cancer diagnosis (OR: 3.64, 95% CI: 1.69-7.85, P &amp;lt; .001), focal (OR: 3.90, 95% CI: 1.91-8.00, P &amp;lt; .001) and enhancing (OR: 5.03, 95% CI: 2.41-10.52, P &amp;lt; .001) lesions on magnetic resonance imaging, biopsy of specific lesions on magnetic resonance imaging (OR: 9.34, 95% CI: 4.29-20.33, P &amp;lt; .001), and use of intraoperative navigation (OR: 6.59, 95% CI: 3.04-14.28, P &amp;lt; .001). Brain biopsies led to symptomatic intracranial hemorrhage, seizures, other significant morbidities, and perioperative mortality in 12.4%, 16.2%, 37.1%, and 8% of cases, respectively. Risk of postoperative intracranial hemorrhage was increased by a history of aspirin use (OR: 2.51, 95% CI: 1.23-5.28, P &amp;lt; .05) and age older than 60 years (OR: 2.66, 95% CI: 1.36-5.18, P &amp;lt; .01). CONCLUSION: Effectiveness and risk of morbidity/mortality can be estimated preoperatively for patients undergoing open brain biopsies of the superficial cortex. Older age and specific imaging characteristics increase the odds of diagnostic biopsy. Conversely, older age and aspirin use increases the risk of postoperative complications.

Mortality in patients with premature lower extremity atherosclerosis

Lower extremity peripheral artery disease occurs mostly in the elderly and is associated with high mortality. Limited data are available regarding long-term mortality in patients with premature lower extremity atherosclerosis (PLEA). Our objective was to determine the all-cause mortality and its predictors in younger PLEA patients. We studied patients with severe PLEA who were <55 years of age at diagnosis and treated at a single academic vascular center between 1998 and 2010. Data were collected prospectively at the initial evaluation for vascular care. National Death Index and hospital records were used to determine all-cause mortality. Demographic and clinical characteristics were summarized using count (%), mean (standard deviation), or median (interquartile range), and associations with aspirin use were tested using χ2 test, t-test, or Wilcoxon test. Survival times were estimated using Kaplan-Meier estimates, and associations with covariates were tested using simple and multivariable Cox proportional hazards models. A total of 564 patients were analyzed (46% female; 20% nonwhite; mean age 49.4 [6.4] years). Ninety-five percent of patients had ≥2 cardiovascular risk factors, 31% had coronary artery disease (CAD), and 10% had a history of cancer. During median follow-up of 5.6 years (interquartile range, 2.3-8.3 years), 108 deaths (19%) were recorded. Two-year estimated mortality (standard error) was 6% (0.01), and 5-year estimated mortality was 16% (0.02). In univariate regression analysis, patient age (P=.04), prior amputation (P<.01), history of cancer (P=.03), and established CAD (P=.04) were associated with increased risk of mortality. Aspirin use and lipid-lowering therapy at the time of first evaluation were associated with improved survival (P<.01 and P=.02, respectively). A multivariable Cox proportional hazards model identified age (hazard ratio [HR] for 5-year increase, 1.17; 95% CI, 1.01-1.36; P=.04), prior amputation (HR, 1.99; 95% CI, 1.18-3.34; P=.01), history of cancer (HR, 2.35; 95% CI, 1.36-4.07; P<.01), and CAD (HR, 1.76; 95% CI, 1.16-2.67; P<.01) as independent predictors of mortality in patients with PLEA. Importantly, history of aspirin use had a significant protective effect (HR, 0.45; 95% CI, 0.30-0.69; P<.01). The impact of lipid-lowering therapy was no longer significant in multivariable modeling. Patients with PLEA demonstrate high all-cause mortality. No traditional cardiovascular risk factors predicted mortality. Aspirin therapy at the time of first evaluation was a significant and independent predictor of improved survival in patients with PLEA.

The blind spot of an EGD: capsule endoscopy pinpointed the source of obscure GI bleeding on the dark side of the pylorus

The patient is a 58-year-old man with a 5-year history of hemodialysis for diabetic nephropathy, an 8-year history of aspirin use for angina pectoris, and a 4-year history of chronic anemia. He was referred to our institution for evaluation of obscure GI bleeding and melena. EGD and colonoscopy findings had been negative. Test results for Helicobacter pylori infection were negative. Laboratory test results revealed a progressing anemia with a recent hemoglobin decrease from 10.1 g/dL to 7.2 g/dL. Capsule endoscopy revealed an elliptical and well-demarcated ulcer with regenerating epithelium adjacent to the back side of the pylorus, also known as the “dark side” of the pylorus (A, arrows). Treatment with a proton pump inhibitor was given with resolution of melena and improvement in anemia. One year later, follow-up capsule endoscopy revealed the previously shown ulcer to have healed (B, arrows).

Splenic Injury as a Complication of Colonoscopy – a Case Series

Purpose: To recognize splenic injury as under-recognized and under-reported complication of colonoscopy. To also recognize 5 associated factors that may play a role in splenic injury during colonoscopy. Methods: We examined the medical records from nine patients who underwent colonoscopy and developed a complication of splenic rupture. Results: The patients' ages ranged from 44 to 77, 7 were women and 2 were men. The time to completion of the procedure (s) ranged from 8 minutes to 36 minutes. All patients experienced pain at the completion of the procedure and one patient fainted in recovery but all were discharged home except one despite complaining of pain that became more severe requiring transfer to the emergency department. Abdominal X-rays did not show free air and did not indicate a colon perforation. On the other hand, a CT abdomen was virtually diagnostic showing the pooling of blood in the abdominal cavity and splenic damage in all cases. Five of nine patients had a history of taking aspirin regularly. All patients except for one were long term cigarette smokers. Sedation was provided by an anesthesiologist in five patients with propofol being the predominant sedative. All patients were seen by surgeons: Seven patients required splenectomies while two patients were treated conservatively with blood transfusions. Conclusion: In conclusion, though screening colonoscopy is a generally safe and well tolerated procedure, good bowel prep is important and endoscopists must be vigilant to avoid complications. Passage of the colonoscope around the splenic and hepatic flexure needs to be performed carefully with minimal force in order to prevent shearing forces that may tear the splenocolic ligaments and splenic blood vessels and result in splenic rupture. Conscious sedation where the patient remains awake might be safer than propofol because the patient can respond to abdominal pain and warn the endoscopist prior to injury. In these cases, excessive force used to pass the colonoscope seemed responsible for the ruptured spleen. A history of cigarette smoking, a history of aspirin use, inadequate colon clean-out, and the use of stronger sedatives such as propofol may increase the risk of splenic injury. Furthermore, we found contrast enhanced CT of the abdomen to be the test of choice in patients complaining of abdominal pain post colonoscopy and should be performed immediately when the abdominal x-ray is negative.

The naked fat sign

View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image A general practitioner referred an asymptomatic 71-year-old woman for investigation of a persistently low ferritin of 43 μg/L (normal 45-250 μg/L). She had a history of aspirin use for atrial fibrillation and no family history of bowel cancer. The patient was enrolled in a trial in which a virtual colonoscopy (V3D, Viatronix, Stony Brook, NY) and an optical colonoscopy were performed on the same day. On virtual colonoscopy, a polyp was discovered near the ileocecal valve (A). The polyp was well circumscribed and of uniform very low–density on the CT image (B). Optical colonoscopy confirmed the presence of the polyp (C). The overlying mucosa appeared normal. Biopsy was performed and fat was seen to extrude through the denuded mucosa (D). No further action was taken and the marginally low ferritin was presumed to be secondary to inadequate dietary iron intake. View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image

Research for bleeding tendency in patients presenting with significant epistaxis

To evaluate the association of inherited coagulopathies and acquired conditions (e.g. hypertension, aspirin use) with emergency department admission due to epistaxis. Patients admitted to the emergency department with epistaxis were included. A questionnaire for personal and family history of any bleeding disorder was used. Physical examination including ear, nose and throat examination was performed. Platelet counts, International Normalized Ratio, activated partial thromboplastin time, factors VIII, IX and XI, von Willebrand factor and ristocetin cofactor activity levels were determined. Nineteen patients were included in the study. Personal history of mucocutaneous bleeding was present in four cases and family history in two cases. Only one case (5%) had a decreased von Willebrand factor level (45%), and also had a personal and family history of bleeding tendency. Ten patients (53%) had a history of aspirin use. Thirteen (68%) patients had hypertensive values on admission. Aspirin use and hypertension were the leading causes of emergency service admission in adults due to epistaxis in this study, although the number of the patients was relatively low. Regarding the low prevalence of inherited coagulopathies, detailed coagulation tests should be reserved for adult patients with positive personal and/or family history of bleeding.

Use of Antiplatelet Drugs in the Stroke Unit of a Hong Kong Hospital

Antiplatelet drugs are widely used for secondary prevention of thrombotic cerebrovascular disease. The antiplatelet prescribing patterns has been evaluated in several studies but data about Hong Kong patients are lacking. This study is to investigate the prescribing patterns of antiplatelet agents in a Hong Kong hospital. All patients over 18 years, who attended the stroke unit between 1 October 2002 and 31 December 2002 and were on antiplatelet therapy were included in the study. Data were collected through retrospective chart review and recorded on a standardized data collection form. Continuous and categorical data were expressed as mean and counts respectively. Factors that determine frequency and pattern of antiplatelet therapy were assessed in multiple logistic regression models. Three hundred and nineteen patients were included in the study. Aspirin and clopidogrel accounted for 82.1 and 16.3 of all prescriptions respectively and remaining patients were on aspirin/dipyridamole. Patients with no history of aspirin use were less likely to be treated with clopidogrel compared with those experienced aspirin intolerance (OR=0.004, 95 CI 0.000-0.051). Patients with history of gastrointestinal (GI) diseases were more likely to receive clopidogrel than those had no history of GI disorders (OR=154.86, 95 CI 33.76-710.38). Atrial fibrillation (AF) was positively associated with clopidogrel prescription (OR=11.83, 95 CI 1.21-115.85). In addition, patients with concomitant gastroprotective drugs received clopidogrel significantly less often than those without gastroprotective agents (OR=0.06, 95 CI 0.01-0.29). Use of antiplatelet agents in patients receiving antiplatelet therapy of the stroke unit has complied with existing evidences. Several factors that determine choice between aspirin and clopidogrel were identified which included history of aspirin use and GI disorders, AF and co-prescribed gastroprotective drugs.

A prospective study of aspirin use and the risk of pancreatic cancer in women.

In vitro experiments and limited animal studies suggest that aspirin and nonsteroidal anti-inflammatory drugs may inhibit pancreatic carcinogenesis. Because few studies have examined the association between aspirin use and pancreatic cancer in humans and the results have been inconsistent, we examined the relationship between aspirin use and the development of pancreatic cancer in the Nurses' Health Study. Among 88 378 women without cancer at baseline, we documented 161 cases of pancreatic cancer during 18 years of follow-up. Aspirin use was first assessed at baseline in 1980 and updated biennially thereafter. All statistical tests were two-sided. Participants were classified according to history of aspirin use. In a multivariable analysis, the risk of pancreatic cancer was not associated with current regular aspirin use (defined as two or more standard tablets per week; relative risk [RR] = 1.20, 95% confidence interval [CI] = 0.87 to 1.65), compared with use of fewer than two tablets per week. Increasing duration of regular aspirin use, compared with non-use, was associated with a statistically significant increase in risk: Women who reported more than 20 years of regular aspirin use had an increased risk of pancreatic cancer (RR = 1.58, 95% CI = 1.03 to 2.43; P(trend) =.01). Among women who reported aspirin use on at least two of three consecutive biennial questionnaires compared with consistent non-users of aspirin, the risk increased with dose (one to three tablets per week: RR = 1.11, 95% CI = 0.70 to 1.76; four to six tablets per week: RR = 1.29, 95% CI = 0.70 to 2.40; seven to 13 tablets per week: RR = 1.41, 95% CI = 0.76 to 2.61; and > or = 14 tablets per week: RR = 1.86, 95% CI = 1.03 to 3.35) (P(trend) =.02). Extended periods of regular aspirin use appear to be associated with a statistically significantly increased risk of pancreatic cancer among women.