Practice Advisory on the Appropriate Use of NSAIDs in Primary Care.

Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Self-expanding metallic stents and self-expanding plastic stents in the palliation of malignant oesophageal dysphagia.

Endoluminal stenting has revolutionised the practice of gastrointestinal endoscopy for many years. What started as rigid, inflexible, plastic stents have now evolved into flexible, easy-to-deploy self-expanding stents with a myriad of choices, including covered, partially covered and uncovered types. Many of these also come along with special features including anti-reflux, anti-migration and lasso for stent adjustment and retrieval. Numerous papers with meta-analyses and systemic reviews have without doubt confirmed the efficacy, safety and cost effectiveness of endoluminal stenting in the palliation of malignant obstruction of the oesophagus, stomach, duodenum, colon and the biliary tree. This paper will focus on the use of self-expanding plastic stents (SEPS) as well as self-expanding metallic stents (SEMS) in the palliation of malignant oesophageal obstruction.

Stenting of malignant upper oesophageal obstruction: experience in a regional hospital in Singapore.

Oesophageal stenting for palliation of malignant obstruction with self-expanding metallic stents is undoubtedly well established. Numerous studies have proven it to be safe and easy to perform with good clinical outcomes. However, stenting of the upper oesophagus is still regarded with apprehension, with many endoscopists concerned about cough, significant throat discomfort or intolerable foreign body sensation. Owing to relatively lack of experience of stenting in the upper oesophagus, many patients ended up with feeding jejunostomy instead. Endoscopic laser boring or dilatation of the upper stenotic oesophageal tumour does not seem to be favoured as it is associated with perforation, bleeding, aspiration pneumonia and the need for several sessions of the procedure to achieve and maintain adequate luminal patency.This study aims to discuss the clinical effectiveness of specially designed cervical oesophageal stents for palliation of malignant upper oesophageal obstruction.