No abstract

Implications of prescription opioid use for outcomes after liver transplantation (LT) have not been described. We integrated national transplant registry data with records from a large pharmaceutical claims clearinghouse (2008-2014; n = 29,673). Opioid fills on the waiting list were normalized to morphine equivalents (MEs), and exposure was categorized as follows: > 0-2 ME/day (level 1), > 2-10 ME/day (level 2), > 10-70 ME/day (level 3), and >70 ME/day (level 4). Associations (adjusted hazard ratio [aHR], aHR ) of pretransplant ME level with patient and graft survival over 5 years after transplant were quantified by multivariate Cox regression including adjustment for recipient, donor, and transplant factors, as well as propensity adjustment for opioid use. Overall, 9.3% of recipients filled opioids on the waiting list. Compared with no use, level 3 (aHR 1.28 ) and 4 (aHR 1.52 ) opioid use during listing were associated with increased mortality over 5 years after transplant. These associations were driven by risk after the first transplant anniversary, such that mortality >1-5 years increased in a graded manner with higher use on the waiting list (level 2, aHR, 1.27 ; level 3, aHR, 1.38 ; level 4, aHR, 2.01 ). Similar patterns occurred for graft failure. Of recipients with the highest level of opioids on the waiting list, 65% had level 3 or 4 use in the first year after transplant, including 55% with use at these levels from day 90-365 after transplant. Opioid use in the first year after transplant also bore graded associations with subsequent death and graft loss >1-5 years after transplant. Opioid use history may be relevant in assessing and providing care to LT candidates. Liver Transplantation 23 305-314 2017 AASLD.

Evolving literature suggests that the epidemic of prescription opioid use affects the transplant population. We examined a novel database wherein national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007-2015) to characterize prescription opioid use before and after kidney transplant, and associations (adjusted hazard ratio, aHR ) with death and graft loss. Among 75 430 eligible patients, 43.1% filled opioids in the year before transplant. Use was more common among recipients who were women, white, unemployed, publicly insured, and with longer pretransplant dialysis. Of those with the highest level of pretransplant opioid use, 60% continued high-level use posttransplant. Pretransplant opioid use had graded associations with one-year posttransplant outcomes; the highest-level use predicted 46% increased risk of death (aHR 1.46 ) and 28% increased risk of all-cause graft failure (aHR 1.28 ). Effects of high-level opioid use in the first year after transplant were stronger, predicting twice the risk of death (aHR 2.24 ) and 68% higher all-cause graft failure risk (aHR 1.68 ) over the subsequent year; increased risk persisted over five years. While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.

Overuse injuries are common in recreational and competitive sports as well as in day-to-day activities. The musculotendinous unit comprises the tissue most frequently involved: structural damage to the tendon occurs from repetitive strain and loading, from either endurance or skill activities that require technique and power. The potential for injury is enhanced by a great variety of predisposing intrinsic or extrinsic factors. Tendinous tissue will become fatigued as its basal reparative ability is overwhelmed by repetitive dysfunctional and microtraumatic processes. Tendinitis is the earliest recognisable manifestation of overuse injury: as damage progresses, partial tears and complete ruptures may ensue. The diagnosis of overuse injury rests with identification not only of the affected tendinous unit, but also of the underlying predisposing condition or conditions. Treatment can then proceed with elimination or correction, if possible, of these conditions, together with control of inflammation and programmes of modalities designed to restore the structural and functional integrity of the tendon. Knowledge of overuse problems has grown exponentially in the past 3 decades, as evidenced by the outpouring of scientific and medical literature. Sophisticated analytical techniques, supplementing a sound history and physical examination, have greatly facilitated the diagnosis of overuse problems and allowed the application of scientific therapeutic principles. As the number of participants in recreational activities continues to grow, the application of these techniques in ever more innovative ways holds the greatest promise for the prevention of overuse tendon injuries.

Purpose: With the emergence of new chemotherapies and biologic agents in the treatment of metastatic colorectal cancer (mCRC), the optimal combination and sequencing of these therapies are yet to be determined. This study examined the extent and pattern of chemotherapy and biologic therapy use by line of treatment. Biologic continuation and dose escalation were also examined. Methods:This study used an integrated electronic medical record database of 91 US oncology practices. Records were analyzed for 1,655 adult patients with mCRC who were treated from January 1, 2004 to January 31, 2008 with systemic therapy and could be observed for Ն 3 months beyond their diagnosis of metastatic disease. Combination and sequence of individual drugs and regimens were examined.Results: For first-line therapy, the most common chemotherapy backbone was infused fluorouracil, leucovorin, and oxaliplatin (FOLFOX; 40.5% of patients), and the most common treatment regimen was FOLFOX plus bevacizumab (26.2%). For second-line therapy, fluorouracil, leucovorin, and irinotecan (FOLFIRI) was the most common chemotherapy backbone (25.7%), and FOLFIRI plus bevacizumab was the most common treatment regimen (18.3%). Across the study period, 68.6%, 22%, and 7% of patients received bevacizumab, cetuximab, and panitumumab, respectively. Among 412 patients receiving bevacizumab-containing regimens as first-line therapy who then received second-line therapy, 58% continued receiving bevacizumab, with dose escalation observed in 44%. Conclusion:The most commonly used chemotherapy backbones for mCRC treatment were first-line FOLFOX and second-line FOLFIRI. Bevacizumab was the most frequently administered biologic therapy. Continuation and dose escalation with bevacizumab were frequently observed across lines of therapy.