Effect of Spaceflight and Microgravity on the Musculoskeletal System: A Review.

With National Aeronautics and Space Administration's plans for longer distance, longer duration spaceflights such as missions to Mars and the surge in popularity of space tourism, the need to better understand the effects of spaceflight on the musculoskeletal system has never been more present. However, there is a paucity of information on how spaceflight affects orthopaedic health. This review surveys existing literature and discusses the effect of spaceflight on each aspect of the musculoskeletal system. Spaceflight reduces bone mineral density at rapid rates because of multiple mechanisms. While this seems to be recoverable upon re-exposure to gravity, concern for fracture in spaceflight remains as microgravity impairs bone strength and fracture healing. Muscles, tendons, and entheses similarly undergo microgravity adaptation. These changes result in decreased muscle mass, increased tendon laxity, and decreased enthesis stiffness, thus decreasing the strength of the muscle-tendon-enthesis unit with variable recovery upon gravity re-exposure. Spaceflight also affects joint health; unloading of the joints facilitates changes that thin and atrophy cartilage similar to arthritic phenotypes. These changes are likely recoverable upon return to gravity with exercise. Multiple questions remain regarding effects of longer duration flights on health and implications of these findings on terrestrial medicine, which should be the target of future research.

Atraumatic Idiopathic Compartment Syndrome Requiring Emergent Fasciotomy: A Case Report and Literature Review.

A 42-year-old male with no past medical history presented to an emergency room with increasing pain and swelling of his left lower extremity over 48 hours with no preceding trauma. A computed tomography scan demonstrated a hematoma (20 cm × 4 cm × 10 cm) present within the gastrocnemius-soleus complex. Acute compartment syndrome (ACS) was diagnosed clinically, confirmed intraoperatively with an arterial line transducer, and treated with emergent fasciotomy. Extensive workup found no evidence of coagulopathy or source of bleeding. This case presents a patient with ACS secondary to an atraumatic gastrocnemius hematoma discovered in the emergency room with no history of coagulopathies or anticoagulation.

ChatGPT performance on the American Shoulder and Elbow Surgeons maintenance of certification exam.

BACKGROUND: While multiple studies have tested the ability of large language models (LLMs), such as ChatGPT, to pass standardized medical exams at different levels of training, LLMs have never been tested on surgical sub-specialty examinations, such as the American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC). The purpose of this study was to compare results of ChatGPT 3.5, GPT-4, and fellowship-trained surgeons on the 2023 ASES MOC self-assessment exam. METHODS: ChatGPT 3.5 and GPT-4 were subjected to the same set of text-only questions from the ASES MOC exam, and GPT-4 was additionally subjected to image-based MOC exam questions. Question responses from both models were compared against the correct answers. Performance of both models was compared to corresponding average human performance on the same question subsets. One sided proportional z-test were utilized to analyze data. RESULTS: Humans performed significantly better than Chat GPT 3.5 on exclusively text-based questions (76.4% vs. 60.8%, P = .044). Humans also performed significantly better than GPT 4 on image-based questions (73.9% vs. 53.2%, P = .019). There was no significant difference between humans and GPT 4 in text-based questions (76.4% vs. 66.7%, P = .136). Accounting for all questions, humans significantly outperformed GPT-4 (75.3% vs. 60.2%, P = .012). GPT-4 did not perform statistically significantly betterer than ChatGPT 3.5 on text-only questions (66.7% vs. 60.8%, P = .268). DISCUSSION: Although human performance was overall superior, ChatGPT demonstrated the capacity to analyze orthopedic information and answer specialty-specific questions on the ASES MOC exam for both text and image-based questions. With continued advancements in deep learning, LLMs may someday rival exam performance of fellowship-trained surgeons.

Clinical Outcomes of Offset Stem Couplers with or without Cone Augmentation in Revision Total Knee Arthroplasty.

Intramedullary stems are often required in patients undergoing revision total knee arthroplasty (rTKA) to achieve stable fixation. Significant bone loss may require the addition of a metal cone to maximize fixation and osteointegration. The purpose of this study was to investigate clinical outcomes in rTKA using different fixation techniques. We conducted a single-institution retrospective review of all patients who received a tibial and femoral stem during rTKA between August 2011 and July 2021. Patients were separated into three cohorts based on fixation construct: press-fit stem with an offset coupler (OS), fully cemented straight (CS) stem, and press-fit straight (PFS) stem. A subanalysis of patients who received tibial cone augmentation was also conducted. A total of 358 patients who underwent rTKA were included in this study, of which 102 (28.5%) had a minimum 2-year follow-up and 25 (7.0%) had a minimum 5-year follow-up. In the primary analysis, 194 patients were included in the OS cohort, 72 in the CS cohort, and 92 in the PFS cohort. When stem type alone was considered, there was no significant difference in rerevision rate (p = 0.431) between cohorts. Subanalysis of patients who received augmentation with a tibial cone demonstrated that OS implants led to significantly higher rates of rerevision compared with the other two stem types (OS: 18.2% vs. CS: 2.1% vs. PFS: 11.1%; p = 0.037). The findings of the present analysis demonstrate that CS and cones in rTKA may provide more reliable long-term outcomes compared with press-fit stems with OS. LEVEL III EVIDENCE: Retrospective Cohort Study.

Impact of a Novel Navigational Technology on Short-Term Patient Outcomes Following Total Knee Arthroplasty A Propensity Matched Cohort Study.

PURPOSE: The use of intraoperative technology is increasing among orthopedic surgeons in the United States. However, there is continued debate as to whether intraoperative technologies provide clinical benefits in patients undergoing total knee arthroplasty (TKA). This study sought to determine whether the use of a novel intraoperative navigation technology produces equivalent or superior short-term outcomes compared to conventional technique. METHODS: Fifty-nine consecutive patients underwent primary TKA with a novel imageless intraoperative navigational technology between October 2019 and January 2020 at a single, urban, orthopedic specialty hospital. A 1:1 cohort propensity matching was performed with patients with similar demographics who underwent primary TKA without the use of technology. Demographics, clinical data, as well as preoperative and 3-month Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) scores were collected. Demographic differences, clinical data, and mean KOOS, JR scores were assessed using chi-squared analysis for categorical variables and independent sample t-test for continuous variables. RESULTS: Upon 1:1 cohort matching, patients in both the navigational cohorts and non-navigational cohorts were statistically similar demographically. Length of stay (2.11 vs. 1.71 days; p = 0.108), surgical time (108.89 vs. 101.19 minutes, p = 0.066), discharge disposition (p = 0.675), 90- day readmissions (4 vs. 4, p = 0.999), and 90-day reoperations (2 vs. 2, p = 0.999) did not statistically differ between the two matched cohorts. Additionally, KOOS, JR scores evaluated between the two cohorts preoperatively (46.06 vs. 45.17, p = 0.836) and at 3-month follow-up (57.63 vs. 55.06, p = 0.580) were similar. CONCLUSION: This study demonstrates that the use of this novel intraoperative navigational technology yields similar short-term TKA results when compared to conventionally performed TKA. Further studies are required to validate new technologies and determine their effect on long-term clinical and patient-reported outcomes.

Can pain be improved with retention of the posterior cruciate ligament during total knee arthroplasty?

PURPOSE: The purpose of the current study was to determine if differences exist between cruciate-retaining (CR) and posterior-stabilized (PS) implant articulations for total knee arthroplasty (TKA) with regards to early post-operative pain. METHODS: We retrospectively reviewed patients who underwent primary TKA, with the same TKA implant design, at our institution between January 2018 and July 2021. Patients were stratified based on whether they received a CR or non-constrained PS (PSnC) articulation and propensity score matched in a 1:1 ratio. A sub-analysis matching patient who received a constrained PS implant (PSC) to those undergoing CR TKA and PSnC TKA was also carried out. Opioid dosages were converted to morphine milligram equivalents (MME). RESULTS: 616 patients after CR TKA were matched 1:1 to 616 patients with a PSnC implant. There were no significant differences between demographic variables. There were no statistically significant differences in opioid usage measured by MME on post-operative day (POD) 0 (p = 0.171), POD1 (p = 0.839), POD2 (p = 0.307), or POD3 (p = 0.138); VAS pain scores (p = 0.175); or 90-day readmission rate for pain (p = 0.654). A sub-analysis of CR versus PSC TKA demonstrated no significant differences in opioid usage on POD0 (p = 0.765), POD1 (p = 0.747), POD2 (p = 0.564), POD3 (p = 0.309); VAS pain scores (p = 0.293); and 90-day readmission rate for pain (p > 0.9). CONCLUSION: Our analysis demonstrated no significant difference in post-operative VAS pain scores and MME usage based on implant. The results suggest that neither the type of articulation or constraint used for primary TKA has a significant impact on immediate post-operative pain and opioid consumption. LEVEL III EVIDENCE: Retrospective Cohort Study.

The effect of reduced bone mineral density on elective total hip arthroplasty outcomes.

INTRODUCTION: Reduced bone mineral density (BMD) and disruption of normal bony architecture are the characteristics of osteopenia and osteoporosis and in patients undergoing total hip arthroplasty (THA) may cause failure of trabecular ingrowth. The purpose of this study is to evaluate the impact of reduced BMD on outcomes following primary elective THA. METHODS: A retrospective chart review of 650 elective THAs with a DEXA scan in their electronic health record (EHR) from 2011 to 2020 was conducted at an urban, academic center and a regional, health center. Patients were separated into three cohorts based on their t-score and the World Health Organizations definitions: normal (t-score ≥ - 1), osteopenia (t-score < - 1.0 and > - 2.5), and osteoporosis (t-score ≤ - 2.5). Demographic and outcome data were assessed. Subsidence was assessed for patients with non-cemented THAs. Regression models were used to account for demographic differences. RESULTS: 650 elective THAs, of which only 11 were cemented, were included in the study. Patients with osteopenia and osteoporosis were significantly older than those without (p = 0.002 and p < 0.0001, respectively) and had a lower BMI (p < 0.0001 and p < 0.0001, respectively). PFx was significantly greater in patients with osteoporosis when compared to those with normal BMD (6.5% vs. 1.0%; p = 0.04). No such difference was found between osteoporotic and osteopenic patients. The revision rate was significantly higher for osteoporotic patients than osteopenic patients (7.5% vs. 1.5%; p = 0.04). No such difference was found between the other comparison groups. CONCLUSION: Patients with osteoporosis were older with reduced BMI and had increased PFx after non-cemented elective THA. Understanding this can help surgeons formulate an appropriate preoperative plan for the treatment of patients with osteoporotic bone undergoing elective THA.

Impact of preoperative opioid use on patient-reported outcomes following primary total knee arthroplasty.

PURPOSE: The previous literature suggests that 25-30% of patients who undergo total knee arthroplasty (TKA) are using opioids prior to their surgery. This study aims to investigate the effect of preoperative opioid use on clinical outcomes and patient-reported outcome measures (PROMs) following TKA. METHODS: We retrospectively reviewed 329 patients who underwent primary TKA from 2019 to 2020, answered the preoperative opioid survey, and had available PROMs. Patients were stratified into two groups based on whether they were taking opioids preoperatively or not: 26 patients with preoperative opioid use (8%) and 303 patients without preoperative opioid use (92%) were identified. Demographics, clinical data, and PROMs [Forgotten Joint Score (FJS-12), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), and Veterans RAND-12 Physical and Mental components (VR-12 PCS and MCS)] were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Outcomes were compared using multilinear regression analysis, controlling for demographic differences. RESULTS: Preoperative opioid users had a significantly longer length-of-stay (2.74 vs. 2.10; p = 0.010), surgical time (124.65 vs. 105.69; p < 0.001), and were more likely to be African-American (38.5 vs. 14.2%; p = 0.010) compared to preoperative opioid-naive patients. Postoperative FJS-12 did not statistically differ between the two groups. While preoperative KOOS, JR scores were significantly lower for preoperative opioid users (41.10 vs. 46.63; p = 0.043), they did not significantly differ postoperatively. Preoperative VR-12 PCS did not statistically differ between the groups; however, both 3-month (33.87 vs. 38.41; p = 0.049) and 1-year (36.01 vs. 44.73; p = 0.043) scores were significantly lower for preoperative opioid users. Preoperative VR-12 MCS was significantly lower for preoperative opioid users (46.06 vs. 51.06; p = 0.049), though not statistically different postoperatively. CONCLUSION: At 8%, our study population had a lower percentage of opioid users than previously reported in the literature. Preoperative opioid users had longer operative times and length of stay compared to preoperatively opioid-naive patients. While both cohorts achieved similar clinical benefits following TKA, preoperative opioid users reported lower postoperative scores with respect to VR-12 PCS scores. LEVEL III EVIDENCE: Retrospective Cohort.

The effect of losartan on range of motion and rates of manipulation in total knee arthroplasty: a retrospective matched cohort study.

INTRODUCTION: Arthrofibrosis remains a common cause of patient dissatisfaction and reoperation after total knee arthroplasty (TKA). Losartan is an angiotensin receptor blocker (ARB) with inhibitory effects on transforming growth factor beta, previously implicated in tissue repair induced fibrosis, and has been studied to prevent stiffness following hip arthroscopy. This study aimed to evaluate pre- and postoperative range of motion (ROM) and the incidence of manipulation under anesthesia (MUA) following primary TKA in patients taking Losartan preoperatively for hypertension. MATERIALS AND METHODS: A retrospective review of 170 patients from 2012 to 2020 who underwent a primary, elective TKA and were prescribed Losartan at least three months prior to surgery. All patients who were prescribed Losartan and had a preoperative and postoperative ROM in their chart were included and were matched to a control group of patients who underwent TKA and had no Losartan prescription. ROM, MUA, readmissions, reoperations, and revisions were assessed using chi-square and independent sample t tests. RESULTS: Seventy-nine patients met the inclusion criteria. Preoperative ROM was similar between patients on Losartan and the control group (103.59° ± 16.14° vs. 104.59° ± 21.59°, respectively; p = 0.745). Postoperative ROM and ΔROM were greater for patients prescribed Losartan (114.29° ± 12.32° vs. 112.76° ± 11.65°; p = 0.429 and 10.57° ± 14.95° vs. 8.17° ± 21.68°; p = 0.422), though this difference did not reach statistical significance. There was no difference in readmission, rate of manipulation for stiffness, or all-cause revision rates. CONCLUSION: In this study, we found that the use of Losartan did not significantly improve postoperative ROM, reduce MUA or decrease revision rates. Further prospective studies using Losartan are required to elucidate the potential effects on ROM and incidence of arthrofibrosis requiring MUA. LEVEL III EVIDENCE: Retrospective cohort study.

Patient Acceptable Symptom State for the Forgotten Joint Score in Primary Total Knee Arthroplasty.

BACKGROUND: In order to better understand the clinical benefits of total knee arthroplasty (TKA) and improve the interpretability of the Forgotten Joint Score (FJS-12), the establishment of a meaningful change in score is necessary. The purpose of this study is to determine the threshold of the FJS-12 for detecting the patient acceptable symptom state (PASS) following primary TKA. METHODS: We retrospectively reviewed all patients who underwent elective, primary TKA and answered both the FJS-12 and the Knee Injury Osteoarthritis Outcome Survey, Joint Replacement KOOS, JR surveys 1-year postoperatively. The questionnaires were administered via a web-based electronic application. KOOS, JR score was used as the anchor. The anchor for PASS calculation should relate pain, physical function, and patient satisfaction. Two statistical methods were employed: (1) the receiver operating characteristic (ROC) curve point; (2) 75th percentile of the cumulative percentage curve of patients who had the KOOS, JR score difference larger than the cut-off value. RESULTS: This study included 457 patients. The mean 1-year FJS-12 score was 42.6 ± 27.8. The mean 1-year KOOS, JR score was 68.0 ± 17.2. A high positive correlation between FJS-12 and KOOS, JR was found (r = 0.72, P < .001) making the KOOS, JR a valid external anchor. The threshold score of the FJS-12 which maximized the sensitivity and specificity for detecting a PASS was 33.3 (AUC = 0.78, 95% CI [0.74, 0.83]). The cut-off value computed with the 75th percentile approach was 77.1 (95% CI [73.9, 81.5]). CONCLUSION: The PASS threshold for the FJS-12 was 33.3 and 77.1 at 1-year follow-up after primary TKA using the receiver operating characteristic (ROC) curve and 75th percentile approaches, respectively. These values can be used to assess the successful achievement of a forgotten joint. LEVEL III EVIDENCE: Retrospective Cohort Study.

Tourniquet Use Is Associated With Reduced Blood Loss and Fewer Reoperations in Aseptic Revision Total Knee Arthroplasty.

BACKGROUND: Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA. METHODS: We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011 to 2020. Patients were separated into 2 cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss, change in hemoglobin, surgical time, length of stay, reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores. RESULTS: Of the 1212 patients included, 1007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (standard deviation 33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through estimated blood loss (224.1 vs 325.1 mL, P < .001) and change in preoperative to postoperative hemoglobin (1.75 vs 2.04 g/dL, P < .001). There were no statistical differences in surgical time (P = .267) and length of stay (P = .206) between the 2 groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5% vs 15.0%, P = .038). Delta improvement in KOOS, JR scores from baseline to 3 months postoperatively did not statistically differ between the 2 cohorts (P = .560). CONCLUSION: Although delta improvements in KOOS, JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did. LEVEL III EVIDENCE: Retrospective Cohort Study.

Does Retention of the Posterior Cruciate Ligament Lead to a More "Forgotten Joint" Following Total Knee Arthroplasty?

INTRODUCTION: Posterior cruciate ligament (PCL) retention may impact a patient's awareness of their artificial joint following primary total knee arthroplasty (pTKA) due to increased proprioception and more native knee kinematics. Therefore, the purpose of this study was to investigate whether cruciate-retaining (CR) or posterior-stabilized (PS) implants influence the Forgotten Joint Score (FJS-12) following pTKA. METHODS: We retrospectively reviewed all patients who underwent pTKA with a CR or PS implant at our institute between October 2017 and March 2021. Of the 6,258 patients identified, 5,587 did not have recorded FJS-12 scores at either three months, one year, or two years postoperatively nor a Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) preoperatively, three months, or one year postoperatively, and these were considered lost to follow up. Thus, a total of 671 cases were identified and subsequently stratified into two cohorts based on whether they received a CR (n=236, 35%) or PS (n=435, 65%) implant. Patients who received PS implants were further divided into constrained (CoN) and non-constrained (NCoN) liner cohorts. Multivariable linear regression analysis was used to compare patient-reported outcome (PRO) scores. RESULTS: There were no significant differences in PRO scores between CR and PS implants at any time point. Patients in the CoN (n=74) cohort had significantly higher FJS-12 scores at one year (CoN: 56.31 + 25.34 vs NCoN: 42.24 + 27.00, p=0.001) and two years (CoN: 58.52 + 33.71 vs NCoN: 46.97 + 27.44, p=0.013) postoperatively compared to patients in the NCoN (n=361) cohort. CONCLUSION: Although our analysis demonstrated significant differences in FJS-12 scores at one and two years postoperatively depending upon the liner constraint, there were no significant differences in FJS-12 scores between CR and PS implants. Therefore, while retention of the PCL does not impact patient awareness of their artificial joint, the level of liner constraint may influence outcomes if the PCL is sacrificed.

Effect of Marital Status on Outcomes Following Total Joint Arthroplasty.

INTRODUCTION: The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences. RESULTS: This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort. CONCLUSION: Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Does the Use of Intraoperative Technology Yield Superior Patient Outcomes Following Total Knee Arthroplasty?

INTRODUCTION: There is debate regarding whether the use of computer-assisted technology, such as navigation and robotics, has any benefit on outcomes or patient-reported outcome measures (PROMs) following total knee arthroplasty (TKA). This study aims to report on the association between intraoperative use of technology and outcomes in patients who underwent primary TKA. METHODS: We retrospectively reviewed 7096 patients who underwent primary TKA from 2016-2020. Patients were stratified depending on the technology utilized: navigation, robotics, or no technology. Patient demographics, clinical data, Forgotten Joint Score-12 (FJS), and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) were collected at various time points up to 1-year follow-up. Demographic differences were assessed with chi-square and ANOVA. Clinical data and PROMs were compared using univariate ANCOVA, controlling for demographic differences. RESULTS: A total of 287(4%) navigation, 367(5%) robotics, and 6442(91%) manual cases were included. Surgical-time significantly differed between the three groups (113.33 vs 117.44 vs 102.11; P < .001). Discharge disposition significantly differed between the three groups (P < .001), with more manual TKA patients discharged to a skilled nursing facility (12% vs 8% vs 15%; P < .001) than those who had technology utilized. FJS scores did not statistically differ at three-months (P = .067) and one-year (P = .221). We found significant statistical differences in three-month KOOS, JR scores (59.48 vs 60.10 vs 63.64; P = .001); however, one-year scores did not statistically differ between all groups (P = .320). CONCLUSION: This study demonstrates shorter operative-time in cases with no utilization of technology and clinically similar PROMs associated with TKAs performed between all modalities. While the use of technology may aid surgeons, it has not currently translated to better short-term outcomes. LEVEL III EVIDENCE: Retrospective Cohort.

Risks of Cardiovascular Disease and Beyond in Prescription of Nonsteroidal Anti-Inflammatory Drugs.

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, naproxen, diclofenac, and ibuprofen, as well as selective cyclooxygenase 2 inhibitors such as celecoxib. Their use is common, as well as their side effects which cause 100 000 hospitalizations and 17 000 deaths annually. Recently, the US Food and Drug Administration strengthened its warning about the risks of cardiovascular disease (CVD) attributed to nonaspirin NSAIDs. METHODS: When the sample size is large, randomization provides control of confounding not possible to achieve with any observational study. Further, observational studies and, especially, claims data have inherent confounding by indication larger than the small to moderate effects being sought. RESULTS: While trials are necessary, they must be of sufficient size and duration and achieve high compliance and follow-up. Until then, clinicians should remain uncertain about benefits and risks of these drugs. Conclusions: Since the totality of evidence remains incomplete, health-care providers should consider all these aforementioned benefits and risks, both CVD and beyond, in deciding whether and, if so, which, NSAID to prescribe. The factors in the decision of whether and, if so, which NSAID to prescribe for relief of pain from inflammatory arthritis should not be limited to risks of CVD or gastrointestinal side effects but should also include potential benefits including improvements in overall quality of life resulting from decreases in pain or impairment from musculoskeletal pain syndromes. The judicious individual clinical decision-making about the prescription of NSAIDs to relieve pain based on all these considerations has the potential to do much more good than harm.

Underutilization of Aspirin in Patients With Advanced Colorectal Polyps.

BACKGROUND: Colorectal cancer is the third-most common cause of cancer deaths in the United States, and advanced colorectal polyps are a major risk factor. Although there are no large-scale individual trials designed a priori to test the hypothesis, in meta-analyses of trials in primary prevention of cardiovascular disease, aspirin reduces risk of colorectal cancer. The US Preventive Services Task Force used a microsimulation model, including baseline risk factors, and concluded that aspirin reduces risk of colorectal cancer by 40%. Their guidelines suggest that without a specific contraindication, clinicians should routinely prescribe aspirin to patients with advanced colorectal polyps. METHODS: Written informed consent was obtained, and brief telephone interviews were conducted by trained interviewers for 84 men and women with biopsy-proven advanced colorectal polyps from 55 clinical practices. RESULTS: Of the 84, 39 (46.4%) were men. The mean age was 66 with a range from 41 to 91 years. Among the 84, 36 (42.9%) reported taking aspirin. CONCLUSIONS: These data suggest underutilization of aspirin by patients with advanced colorectal polyps. These data pose major challenges that require multifactorial approaches by clinicians and their patients, which include therapeutic lifestyle changes, adjunctive drug therapies, and screening. Lifestyle changes include treating overweight status and obesity and engaging in regular physical activity; adjunctive drug therapies include aspirin. These multifactorial approaches will be necessary to achieve the most good for the most patients with regard to prevention, as well as, early diagnosis and treatment of colorectal cancer in patients with advanced colorectal polyps.