Hacene Nedjar

Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction

Background: Patients prescribed antiplatelet treatment to prevent recurrent acute myocardial infarction are often also given a selective serotonin reuptake inhibitor (SSRI) to treat coexisting depression. Use of either treatment may increase the risk of bleeding. We assessed the risk of bleeding among patients taking both medications following acute myocardial infarction. Methods: We conducted a retrospective cohort study using hospital discharge abstracts, physician billing information, medication reimbursement claims and demographic data from provincial health services administrative databases. We included patients 50 years of age or older who were discharged from hospital with antiplatelet therapy following acute myocardial infarction between January 1998 and March 2007. Patients were followed until admission to hospital due to a bleeding episode, admission to hospital due to recurrent acute myocardial infarction, death or the end of the study period. Results: The 27 058 patients in the cohort received the following medications at discharge: acetylsalicylic acid (ASA) (n = 14 426); clopidogrel (n = 2467), ASA and clopidogrel (n = 9475); ASA and an SSRI (n = 406); ASA, clopidogrel and an SSRI (n = 239); or clopidogrel and an SSRI (n = 45). Compared with ASA use alone, the combined use of an SSRI with antiplatelet therapy was associated with an increased risk of bleeding (ASA and SSRI: hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.08–1.87; ASA, clopidogrel and SSRI: HR 2.35, 95% CI 1.61–3.42). Compared with dual antiplatelet therapy alone (ASA and clopidogrel), combined use of an SSRI and dual antiplatelet therapy was associated with an increased risk of bleeding (HR 1.57, 95% CI 1.07–2.32). Interpretation: Patients taking an SSRI together with ASA or dual antiplatelet therapy following acute myocardial infarction were at increased risk of bleeding.

Postdischarge thromboprophylaxis and mortality risk after hip-or knee-replacement surgery

Background: Patients undergoing hip or knee replacement are at high risk of developing a postoperative venous thromboembolism even after discharge from hospital. We sought to identify hospital and patient characteristics associated with receiving thromboprophylaxis after discharge and to compare the risk of short-term mortality among those who did or did not receive thromboprophylaxis. Methods: We conducted a retrospective cohort study using system-wide hospital discharge summary records, physician billing information, medication reimbursement claims and demographic records. We included patients aged 65 years and older who received a hip or knee replace ment and who were discharged home after surgery. Results: In total we included 10 744 patients. Of these, 7058 patients who received a hip replacement and 3686 who received a knee replacement. The mean age was 75.4 (standard deviation [SD] 6.8) years and 38% of patients were men. In total, 2059 (19%) patients received thomboprophylaxis at discharge. Patients discharged from university teaching hospitals were less likely than those discharged from community hospitals to received thromboprophylaxis after discharge (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–1.00). Patients were less likely to receive thromboprophylaxis after discharge if they had a longer hospital stay (15–30 days v. 1–7 days, OR 0.69, 95% CI 0.59–0.81). Patients were more likely to receive thromboprophylaxis if they had hip (v. knee) replacement, osteoarthritis, heart failure, atrial fibrillation or hypertension, higher (v. lower) income or if they were treated at medium-volume hospitals (69–116 hip and knee replacements per year). In total, 223 patients (2%) died in the 3-month period after discharge. The risk of short-term mortality was lower among those who received thromboprophylaxis after discharge (hazard ratio [HR] 0.34, 95% CI 0.20–0.57). Interpretation: Fewer than 1 in 5 elderly patients discharged home after a hip-or knee-replacement surgery received postdischarge thromboprophylaxis. Those prescribed these medications had a lower risk of short-term mortality. The benefits of and barriers to thromboprophylaxis therapy after discharge in this population requires further study.

Hospitalization for gastrointestinal adverse events attributable to the use of low-dose aspirin among patients 50 years or older also using non-steroidal anti-inflammatory drugs: a retrospective cohort study

Background  Use of aspirin with non‐steroidal anti‐inflammatory drugs increases the risk of gastrointestinal ulcers; however, it is not clear if this risk varies with the non‐steroidal anti‐inflammatory drug used.

Long-term prognosis of south Asians following acute coronary syndromes.

BACKGROUND South Asians (SAs) have a higher prevalence of coronary artery disease than Caucasians. The long-term prognosis following acute coronary syndromes (ACS) in SA compared with non-SA patients is unclear. OBJECTIVES To compare the long-term adverse cardiovascular outcomes between SA and non-SA patients who have ACS. METHODS A case-control study of 65 consecutive SA patients admitted with ACS to the McGill University Health Centre (Montreal, Quebec) between 1995 and 2000 was conducted. Control subjects included 65 non-SA patients admitted to the same hospital with ACS matched by age, sex and year of hospitalization. RESULTS The mean +/- SD age was 59.7+/-9.9 years and 12% of patients were women. There were more cases of diabetes mellitus among the SA patients than non-SA patients (43% versus 23%, respectively). Only 19% of SA patients were active smokers, compared with 34% of non-SA patients. At one year, 35% of SA patients had undergone coronary artery bypass graft surgery, compared with 22% of non-SA patients. One-year mortality was increased among the SA patients compared with the non-SA patients (6% versus 2%, respectively). However, SA ethnicity was not an independent predictor of one-year adverse cardiovascular outcomes. CONCLUSIONS The present study demonstrated an increased prevalence of diabetes mellitus among the SA patients with ACS compared with non-SA patients. SA patients had increased one-year mortality compared with non-SA patients. However, SA ethnicity was not an independent predictor of one-year mortality and coronary intervention.

Concordance with guideline recommendations: previous and more recent nonsteroidal anti-inflammatory drug prescriptions in Quebec, Canada.

Clinical practice guidelines for appropriate nonsteroidal anti‐inflammatory drug (NSAID) utilisation focus on preventing NSAID‐related gastrointestinal (GI), cardiovascular (CV), congestive heart failure (CHF) and renal adverse events. We compared concordance of NSAID prescriptions with clinical practice guideline recommendations in Quebec, pre and post rofecoxib withdrawal from market.

Use of Nonsteroidal Antiinflammatory Drugs: Is There a Change in Patient Risk Profile After Withdrawal of Rofecoxib?

Objective. Use of traditional nonsteroidal antiinflammatory drugs (tNSAID) increased after rofecoxib withdrawal. tNSAID use is associated with increased gastrointestinal (GI) toxicity and cardiovascular (CV) risk similar to celecoxib. The objective of our study was to describe changes in celecoxib and tNSAID use regarding GI and CV risk and congestive heart failure (CHF) and renal risk that occurred in Quebec, Canada, between April 2005–March 2007 (the post-period) compared to April 2002–March 2004 (the pre-period). Methods. Data were obtained from the provincial health insurance agency. All NSAID users ≥ 50 years of age were considered. Results. Celecoxib use decreased by 23% (coxib 61%) while that of tNSAID doubled. In both periods, celecoxib users were older and included more women, and they suffered more frequently from arthritis. Users of celecoxib were more likely to have higher level of GI risk: post-period odds ratios compared to low GI risk, very high 1.79 (95% CI 1.63, 1.97), high 1.76 (95% CI 1.71, 1.81), and moderate 1.30 (95% CI 1.27, 1.33); similar results were observed in the pre-period. Celecoxib users had higher CV risk levels in the pre-period: OR compared to low CV risk, very high 1.13 (95% CI 1.08, 1.19), high 1.24 (95% CI 1.20, 1.29), and moderate 1.16 (95% CI 1.14, 1.19); and in the post-period, very high 0.85 (95% CI 0.81, 0.89), high 1.13 (95% CI 1.10, 1.16), and moderate 1.15 (95% CI 1.12, 1.17). CHF and renal risk factors did not play an important role in the choice of NSAID in either period. Conclusion. Current NSAID use differs from that prior to 2004. Coxib utilization decreased substantially and patients at high CV risk seem less likely to receive celecoxib, while those at high GI risk seem more likely to receive it.

Mortality and readmission rates after hospitalization for upper and lower gastrointestinal events in Quebec, Canada.

Goals: We determined yearly rates of upper and lower gastrointestinal (GI) hospitalizations in Quebec, Canada and compared the 1-year readmission and mortality risks among those discharged from lower versus upper GI hospitalizations. Background: The burden of serious upper and lower GI events is substantial. Study: Demographic, medical, pharmaceutical, and hospital records were used in a retrospective cohort study to assess risks of mortality and hospital readmission for upper and lower GI events among patients 50 years and older during 1998 to 2006. Results: Among included 39,771 GI hospitalizations, 5238 were from 1998 to 1999, and 5050 from 2005 to 2006. Rates of upper GI hospitalizations decreased in the study period, whereas that of lower GI events did not change. The risk of in-hospital mortality was higher in patients with small bowel versus upper GI events [odds ratio 2.11; 95% confidence interval (CI), 1.81-2.47] and lower in patients with colon/rectal events 0.30 (0.25-0.36). One-year mortality risk after discharge was lower in patients with lower versus upper GI events (small bowel hazard ratio 0.81; 95% CI, 0.70-0.93; and colon/rectal: 0.77; 95% CI, 0.71-0.83). Compared to upper GI events, the risk of hospital readmission was higher in those with small bowel 1.53 (1.19-1.97) and similar in those with colon/rectal events 1.12 (0.96-1.31). Conclusions: The risk of upper GI events may be decreasing, but remains over 3 times as high as that of lower GI events and among those admitted for GI events, about 80% of in-hospital mortality occurred in those with upper GI problems. Although GI events in the small bowel are less frequent than those in upper or lower GI tract, they are the most severe and are associated with higher risks of mortality and hospital readmissions.

Cost of Ulcerative Colitis in Quebec, Canada: A Retrospective Cohort Study

Background: Ulcerative colitis (UC) is associated with significant health care utilization and costs. We assessed UC direct medical costs in Quebec, Canada, in 2 time periods (1998–2004 and 2005–2011) and determined changes over time. Methods: Because the introduction of anti–tumor necrosis factor &agr; may have influenced the UC cost, we used the Quebec health services administrative databases and the same inclusion criteria to create 2 separate UC cohorts, before (1998–2004) and after (2005–2011) anti–tumor necrosis factor &agr; introduction. Results: The postcohort included 801 patients and the precohort 716 patients. Overall, cohorts were predominately women and were comparable in terms of patients demographics and comorbidities. Corticosteroid use, emergency department visits and hospitalizations for colectomies, and other gastrointestinal disorders were fewer in the postcohort versus precohort. The median daily cost (interquartile range) was

Discrepancy among observational studies: example of naproxen-associated adverse events.

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Risks of Suicide and Poisoning Among Elderly Patients Prescribed Selective Serotonin Reuptake Inhibitors : A Retrospective Cohort Study

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