Risk of acute myocardial infarction with NSAIDs in real world use : bayesian meta-analysis of individual patient data

OBJECTIVE To characterise the determinants, time course, and risks of acute myocardial infarction associated with use of oral non-steroidal anti-inflammatory drugs (NSAIDs). DESIGN Systematic review followed by a one stage bayesian individual patient data meta-analysis. DATA SOURCES Studies from Canadian and European healthcare databases. REVIEW METHODS Eligible studies were sourced from computerised drug prescription or medical databases, conducted in the general or an elderly population, documented acute myocardial infarction as specific outcome, studied selective cyclo-oxygenase-2 inhibitors (including rofecoxib) and traditional NSAIDs, compared risk of acute myocardial infarction in NSAID users with non-users, allowed for time dependent analyses, and minimised effects of confounding and misclassification bias. EXPOSURE AND OUTCOMES Drug exposure was modelled as an indicator variable incorporating the specific NSAID, its recency, duration of use, and dose. The outcome measures were the summary adjusted odds ratios of first acute myocardial infarction after study entry for each category of NSAID use at index date (date of acute myocardial infarction for cases, matched date for controls) versus non-use in the preceding year and the posterior probability of acute myocardial infarction. RESULTS A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations. CONCLUSIONS All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction. Risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDS and was lower than for rofecoxib. Risk was greatest during the first month of NSAID use and with higher doses.Peer reviewe

Improving post-stroke health outcomes: Can facilitated care help?

Objectives The objectives of this study were (1) identifying the patterns of post-stroke care, (2) determining the care-provider and patient characteristics associated with optimal management of post-stroke care and (3) estimating the potential influence of various facilitated care policies on outcomes.Methodology The 3946 subjects included in the study were admitted to one of Quebec's acute-care hospitals with confirmed diagnosis of stroke and subsequently discharged to their home. The records related to fee-for-service billings of this sample were obtained for the 3 months following discharge and used to define the care-provider path for each stroke survivor. These paths were analyzed and the potential impact of various facilitated care interventions was estimated via a Markov model.Results The rate of mortality for this sample was 3.2% during the first 3 months after discharge. For the patients who were re-hospitalized, however, the mortality rates were up to 10.3% depending on the care-provider visited prior to re-hospitalization. Our analyses indicate that by avoiding such critical sub-paths via facilitated care, it is possible to achieve improvements in health outcomes as well as cost.Discussion There is a window of opportunity for improving community-based post-stroke care. Facilitated care policies concerning planned visits upon discharge from hospital or following ER visits can improve the outcomes.Stroke Post-discharge Markov modeling Facilitated care Health policy

Abus et violence vécus par les jeunes trans et non binaires au Québec

Les jeunes s’identifiant comme étant des personnes trans ou non binaires (TNB) sont exposé·e·s au risque de vivre différentes formes de discrimination, d’abus et de violence de la part des membres de leur famille ou de leur entourage. Cet article a pour but de : 1) faire un portrait des jeunes TNB ayant vécu un ou des types d’abus ; 2) cerner le contexte particulier de cette violence et de ses répercussions sur le bien-être des jeunes TNB. Les données ont été recueillies dans le cadre de « l’Enquête canadienne sur la santé des jeunes trans et non binaires » (ECSJT) menée au pays en 2019. L’échantillon est composé de 220 jeunes TNB âgé·e·s de 14 à 25 ans résidant dans la province de Québec. Des analyses de Test T et Chi carré ont été menées. Elles montrent que près de la moitié de l’échantillon a subi des violences sexuelles (44,1 %) et près de 20 % de l’échantillon a été blessé physiquement par un membre de la famille, phénomène plus fréquemment rencontré chez les 14 à 17 ans (34,2 %) que chez les 18 à 25 ans (14,6 %). En contrôlant pour l’âge, il y avait une association significative entre les liens familiaux et les chances d’être victime (p <.001) ou d’avoir été témoin (p =.03) de violences impliquant un·e membre de la famille. Les résultats de l’enquête en ligne sont cohérents avec les différentes études soulignant les abus et la violence vécus par les jeunes des minorités sexuelles.Objective : Trans or non-binary (TNB) youth are at a higher risk of experiencing various forms of discrimination, abuse and violence at the hands of family members or those around them. As such, the objectives of this article are to : 1) paint a portrait of young TNBs who have experienced one or more types of abuse ; and 2) identify the particular context of this violence, as well as its impact on the well-being of these TNB youth. Method : Data was collected as part of the Canadian Trans and Non-binary Youth Health Survey (CTYHS), which was conducted across Canada in 2019. The sample is composed of 220 TNB youth aged 14 to 25 who reside in the province of Quebec. T-tests and chi-square tests were performed. Results : Nearly half (44.1 %) of the sample experienced sexual violence, while nearly 20 % of the sample had been physically injured by a family member, a phenomenon that occurred more frequently among 14-to-17 year-olds (34.2 %) than among 18-to-25 year-olds (14.6 %). Controlling for age, there was a significant association between family connectivity and the risk of having either been a victim of (p <.001), or a witness to (p =.03), violence involving a family member. Conclusion : The results of the online survey are consistent with the various existing studies highlighting the abuse and violence experienced by sexual minority youth.Los jóvenes que se identifican como trans o no binarios (TNB) corren el riesgo de sufrir diversas formas de discriminación, abuso y violencia por parte de familiares y otras personas. Este artículo pretende 1) ofrecer un retrato de los jóvenes NBT que han experimentado uno o más tipos de abuso ; 2) identificar el contexto particular de esta violencia y su impacto en el bienestar de los jóvenes TNB. Los datos se recopilaron como parte de la « Encuesta canadiense sobre la salud de los jóvenes trans y no binarios » realizada en todo el país en 2019. La muestra consistió en 220 jóvenes TNB de 14 a 25 años residentes en la provincia de Quebec. Se realizaron análisis de prueba T y Chi-cuadrado. Los resultados indican que casi la mitad de la muestra ha experimentado violencia sexual (44,1 %) y casi el 20 % de la muestra ha sufrido lesiones físicas por un miembro de la familia, un fenómeno más frecuente entre los jóvenes de 14 a 17 años (34,2 %) que entre los jóvenes de 18 a 25 años (14,6 %). Controlando la edad, se observó una asociación significativa entre los vínculos familiares y las probabilidades de ser víctima (p < 0,001) o testigo (p = 0,03) de violencia por parte de un miembro de la familia. Los resultados de la encuesta en línea concuerdan con diversos estudios que destacan el abuso y la violencia que sufren los jóvenes de minorías sexuales

Three-month efficacy and safety of once-daily diltiazem in chronic stable angina pectoris

The 3-month efficacy and safety of a once-daily controlled formulation of diltiazem (180 to 360 mg/day) were assessed in a study of 54 patients with angina pectoris. This multicenter study was a nonrandomized, placebo run-in, open-label, 3-month trial followed by a 1-week, double-blind, randomized period during which most patients (89%) received placebo. There were only minimal changes in the time to termination (mean change ± SEM −5.8 ± 9.6 seconds), time to onset of angina (10.5 ± 12.2 seconds), and the time to 1 mm ST-segment depression (2.9 ± 12.5 seconds) from the end of the titrarion phase to the end of the open-label study. There were, however, statistically significant differences between the end of the 3-month treatment phase and the end of the 1-week randomized placebo phase for those 3 efficacy parameters (−37.3 ± 11.2, −58.6 ± 13.6, and −45.6 ± 16.4 seconds, respectively). Diltiazem significantly decreased the frequency of anginal attacks and nitroglycerin use at the end of the 3-month treatment phase compared with results at the end of the randomized double-blind placebo phase. No new or unusual adverse events were reported during treatment. The present results suggest that there is no loss of efficacy of once-a-day diltiazem when administered for a long period to patients with chronic stable angina pectoris