J. R. Laporte

Upper gastrointestinal bleeding in relation to previous use of analgesics and non-steroidal anti-inflammatory drugs

Abstract To assess the risk of upper gastrointestinal bleeding associated with the use of individual non-narcotic analgesics and non-steroidal anti-inflammatory drugs (NSAI Ds), a multicentre study of 875 cases of upper gastrointestinal bleeding and 2682 hospital controls was done. With control for confounding factors, the overall odds ratio estimate for aspirin taken at least once during the week before the first symptom was 7·2 (95% confidence interval 5·4-9·6). Non-aspirin NSAIDs associated with upper gastrointestinal bleeding were diclofenac (7·9 [4·3-14·6]), indomethacin (4·9 [2·0-12·2]), naproxen (6·5 [2·2-19·6]), and piroxicam (19·1 [8·2-44·3]). Paracetamol, propyphenazone, and dipyrone did not increase the risk. A previous history of gastrointestinal bleeding or peptic ulcer did not greatly affect odds ratio estimates, which differed according to sex and were higher for younger than for older patients. However, the incidence of upper gastrointestinal bleeding was higher among the elderly.

Oral antispastic drugs in nonprogressive neurologic diseases: A systematic review

Objective: To assess the efficacy of oral drugs in the treatment of spasticity in patients with nonprogressive neurologic disease (NPND). Methods: Systematic review of double-blind randomized controlled trials of antispastic oral drugs in the treatment of spasticity in NPND. Data sources: Electronic MEDLINE, PubMed, Cochrane Library, and hand searches. Results: Twelve studies (469 patients) were included (6 on stroke, 3 on spinal cord diseases, and 3 on cerebral palsy). Tizanidine was assessed in four trials (276 patients, 142 exposed), dantrolene in four (103, 93), baclofen in three (70, 55), diazepam in two (127, 76), and gabapentin in one (28, all exposed). Most trials were of small size, of short duration, and their methodologic quality was inadequate. Ten trials were controlled with placebo and only two were direct comparisons between drugs. Efficacy outcome variables were heterogeneous. Only four reports described the magnitude of the antispastic effect. The incidence of adverse drug effects (drowsiness, sedation, and muscle weakness) was high. Conclusion: Evidence on the efficacy of oral antispastic drugs in NPND is weak and does not include evaluation of patients’ quality of life. If any, efficacy is marginal. Adverse drug reactions were common. Better methodologic instruments are needed for the evaluation of antispastic treatment.

Utilization of antihypertensive drugs in certain European countries

SummaryThe consumption of various groups of antihypertensive drugs in Spain during the period 1977–1981 has been measured by the DDD method. The total consumption of the drugs did not change much during this time. Combinations of thiazides with other hypotensives accounted for more than half the total antihypertensive drugs used. The consumption of rauwolfia and its derivatives, and of dihydralazine, was higher than of β-blockers and methyldopa. Total consumption of antihypertensives in 1981 was 37.5 DDDs/1 000 inhab/day, which was much lower than in Denmark (136.6 DDDs/1 000 inhab/day), Finland (114.5), Iceland (92.2), Norway (89.4) and Sweden (138.7). Wide qualitative differences between countries were also identified. Although other factors may play a role, it is suggested that these striking differences may be due to differences in general health policy and in the pharmaceutical markets.

Trends of prescribing patterns for the secondary prevention of myocardial infarction over a 13-year period

AbstractObjective: The efficacy of β-adrenergic blocking agents and acetylsalicylic acid in the secondary prevention of myocardial infarction has been well recognized since the beginning of the 1980s. In a previous paper, however, we reported a lower than expected use of these drugs during the period 1982–1988. In 1989 the results of this survey were presented and discussed with the prescribing physicians. In the present paper we describe the prescription patterns for the same indication and in the same centre over the following 6 years (1989–1994). We also describe the use of angiotensin-converting enzyme (ACE) inhibitors, for which efficacy in certain subgroups has been recently shown. Methods: Random samples of patients discharged from our hospital between 1989 and 1994 with a diagnosis of acute myocardial infarction with Q-wave were studied. Information about diagnoses, other clinical variables and treatments prescribed at discharge was obtained from the hospital discharge forms. The results were compared with those obtained in the previous study. Results: We studied 514 patients (80% men) with a median age of 59 years (range 31–89). The proportions of patients prescribed β-adrenergic blocking agents and acetylsalicylic acid increased from 34% and 28%, respectively, in 1986–1988, to 62% and 75% in 1989–1991. In 1994 they had reached a steady state (63% and 71%). In addition, a continued decrease in the use of calcium channel blockers was noted, from 36% in 1986–1988 to 17% in 1994. The increase in the prescription of β-adrenergic blocking agents was especially remarkable in the subgroups for which a larger underuse was recorded in the previous study, such as the elderly. The proportion of patients prescribed an ACE inhibitor increased from 14% in 1989–1991 to 23% in 1994. In a multivariate analysis the prescription of ACE inhibitors was associated with female gender, hypertension during admission, heart failure during admission, and previous myocardial infarction. A substantial increase in the prescription of β-adrenergic blocking agents and acetylsalicylic acid and a decrease in the prescription of calcium channel blockers was recorded between 1982 and 1994. The prescription rate of β-adrenergic blocking agents has increased substantially in certain subgroups where underuse had been previously recorded. Most of the changes occurred in 1989–1991, and reached a steady state in 1994. In 1994 an increase in the prescription of ACE inhibitors was also recorded.

Caffeine, tobacco, alcohol and drug consumption among medical students in Barcelona

SummaryA survey of medical students was conducted at the Universitat Autònoma de Barcelona in 1974. Out of 1029 students, 808 present at lectures (78.5%) returned properly completed questionnaires. These showed that mean caffeine consumption was 8.3 g per month and increased with the length of stay at the university. Tobacco consumption (general mean, 190 cigarettes per month, 216 for males and 150 for females) and alcohol consumption (8.8 litres/year for males and 4.1 litres/year for females) also increased with time spent at university. Alcohol consumption was not as high as in the general population. Amphetamine consumption was very high (22% of students had taken amphetamines on more than one occasion in the six months prior to the survey). Marihuana and hashish were by far the most commonly used drugs (9.6%), the use of these drugs being much less common than at other European universities. The use of “harder” drugs was very limited. Appraisal of alcohol, tobacco and amphetamine abuse is necessary, since the authorities have not employed adequate measures to stop or limit them.

Topical heparin for the treatment of acute superficial phlebitis secondary to indwelling intravenous catheter A double-blind, randomized, placebo-controlled trial

AbstractObjective: To assess the clinical efficacy of a topical gel containing 1000 IU · g−1 of heparin, applied three times daily for a maximal period of 7 days to patients with acute superficial phlebitis secondary to indwelling intravenous catheter. Methods: A Double-blind, randomized, placebo-controlled study was conducted in one of the internal medicine wards of a tertiary General Hospital in Barcelona, Spain. Inpatients of both genders over 18 years of age that developed superficial phlebitis and gave informed consent were included in the study. The sample size estimation was 132 patients. Sixty-six patients were allocated to each group. There were five protocol deviations and 24 withdrawals in the intervention group, and one protocol deviation and 25 withdrawals in the control group. Consequently, 37 patients in the intervention group and 40 in the control group completed the trial. The main outcome measure was the disappearance of the symptoms and signs of superficial phlebitis. Clinical course, investigators global impression and adverse events were also recorded. Results: According to the intention-to-treat analysis, after treatment for 7 days superficial phlebitis healed in 27 of the 61 patients (44.3%) who received topical heparin, and in 17 of the 65 patients (26.1%) receiving placebo, giving a relative risk [95% confidence interval (CI)] of 1.69 (1.03–2.78). This indicates that six patients (95% CI, 3–72) have to be treated in order to induce one additional healing. The clinical course and the overall clinical impression were similar in both groups. One patient treated with topical heparin developed mild urticaria. Conclusion: Topical heparin is safe and effective for the treatment of superficial phlebitis secondary to indwelling intravenous catheter.

Impact of analgesic drug-use guidelines for the management of postoperative pain: a drug utilization study.

OBJECTIVE Postoperative pain is inadequately treated in many surgical settings. The present study evaluates the impact of analgesic drug-use guidelines in the management of postoperative pain. PATIENTS AND METHODS A prospective drug utilization study was carried out in 3 stages in a traumatology, orthopedic and rehabilitation tertiary hospital. The first stage, aimed at describing the patterns of use of analgesic strategies in the management of postoperative pain, identified habits, practices and misconceptions regarding this therapeutic area. After this, an ad hoc representative institutional working group agreed on analgesic drug-use guidelines for the management of postoperative pain. These were then published, presented and discussed with surgeons and nurses. After the guidelines had been implemented, their impact was evaluated in terms of the analgesics used, their dosage and their administration schedule. RESULTS 101 patients were studied before the implementation of the guidelines and 108 patients after. Patients receiving opiate analgesics during the immediate postoperative period increased from 70-94% (p < 0.05). First-choice analgesics used according to the guidelines increased from 40-89% of choices after the implementation of the guidelines (p < 0.05). Administration of analgesics at regular predetermined intervals increased from 45-58% of medical orders, but this increase was not statistically significant (p = 0.07). Prescription of analgesics at adequate doses increased from 67-87% (p < 0.05). CONCLUSION Education on the treatment of postoperative pain is made up of several messages including the drug of choice and dose regimen. Prescribers seemed more receptive to a change in drug rather than issues related to the correct dose regimen. More research is needed to assess how educational activities can improve the management of postoperative pain.

Rifampicin in tuberculous meningitis: a retrospective assessment.

SummaryTo shed some light on the potential value of rifampicin in the treatment of tuberculous meningitis (TBM) in adults, a retrospective analysis has been made of 143 medical records from 4 hospitals for the period 1967–80. Treatment of TBM with rifampicin and other antituberculous drugs in combination (Group B) was compared to other regimes which did not include rifampicin (Group A). There were 64 patients in Group B and 79 in Group A. The two groups of patients did not differ significantly in their prognostic characteristics. The total mortality was 14.7%: it was higher among patients not treated with rifampicin (24%; Group A) than amongst those given rifampicin (3.1%; Group B; x2=10.74; p<0.005). The difference was also statistically significant (x2=6.88; p<0.01) if patients who died during the first 48 h after the institution of treatment were excluded. No significant difference in mortality rate was found when patients treated with rifampicin plus isoniazid (INH) 8–10 mg/kg (1 death out of 41 patients) were compared to patients treated with INH 15 mg/kg (2 deaths out of 20 patients). Neurological sequelae recorded during a 6 month follow-up period were more severe among patients not treated with rifampicin.

The value of the case—control approach for the evaluation of the risk of upper gastrointestinal bleeding associated with the previous use of non-steroidal anti-inflammatory drugs

Several studies have reported an association between upper gastrointestinal bleeding (UGIB) and the previous use of acetylsalicylic acid (ASA) [1–11] or non-steroidal anti-inflammatory drugs (NSAIDs) as a whole [12–14]. However, specific estimates for individual drugs are not available because the lower prevalence of use of each individual NSAID — compared with that of ASA — limits the statistical power of any analytical study designed to quantify individual risks.