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Tworek KB, Ma CH, Opgenorth D, Baig N, Zampieri FG, Basmaji J, Rochwerg B, Lewis K, Kilcommons S, Mehta S, Honarmand K, Stelfox HT, Wilcox ME, Kutsogiannis DJ, Fiest KM, Karvellas CJ, Sligl W, Rewa O, Senaratne J, Sharif S, Bagshaw SM, Lau VI. Nonsteroidal anti-inflammatory drugs for analgesia in intensive care units: a survey of Canadian critical care physicians. Can J Anaesth 2024:10.1007/s12630-024-02800-7. [PMID: 39042215 DOI: 10.1007/s12630-024-02800-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 03/21/2024] [Accepted: 04/03/2024] [Indexed: 07/24/2024] Open
Abstract
PURPOSE Opioids remain the mainstay of analgesia for critically ill patients, but its exposure is associated with negative effects including persistent use after discharge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be an effective alternative to opioids with fewer adverse effects. We aimed to describe beliefs and attitudes towards the use of NSAIDs in adult intensive care units (ICUs). METHODS Our survey of Canadian ICU physicians was conducted using a web-based platform and distributed through the Canadian Critical Care Society (CCCS) email distribution list. We used previously described survey development methodology including question generation and reduction, pretesting, and clinical sensibility and pilot testing. RESULTS We received 115 completed surveys from 321 CCCS members (36%). Nonsteroidal anti-inflammatory drugs use was most described as "rarely" (59 respondents, 51%) with the primary concern being adverse events (acute kidney injury [108 respondents, 94%] and gastrointestinal bleeding [92 respondents, 80%]). The primary preferred analgesic was acetaminophen (75 respondents, 65%) followed by opioids (40 respondents, 35%). Most respondents (91 respondents, 80%) would be willing to participate in a randomized controlled trial examining NSAID use in critical care. CONCLUSIONS In our survey, Canadian critical care physicians did not mention commonly using NSAIDs primarily because of concerns about adverse events. Nevertheless, respondents were interested in further studying ketorolac, a commonly used NSAID outside of the ICU, in critically ill patients.
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Affiliation(s)
- Kimberly B Tworek
- Alberta Health Services, Edmonton, AB, Canada.
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Chen-Hsiang Ma
- Alberta Health Services, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dawn Opgenorth
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network™, Alberta Health Services, Edmonton, AB, Canada
| | - Nadia Baig
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Fernando G Zampieri
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Basmaji
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence & Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sangeeta Mehta
- Sinai Health System, University Health Network, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
| | - H Tom Stelfox
- Sinai Health System, University Health Network, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, University Health Network, Toronto, ON, Canada
| | - Demetrios J Kutsogiannis
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kirsten M Fiest
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Constantine J Karvellas
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Wendy Sligl
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Oleksa Rewa
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Janek Senaratne
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sameer Sharif
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Sean M Bagshaw
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network™, Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Vincent I Lau
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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Al-Khalasi USS, Al-Sarrai Al-Alalawi AKS, Al-Jufaili M, Al-Reesi A, Al-Zakwani I, Al-Asmi MSR, Al-Riyami FB, Vishwakarma R. Atomized Intranasal Ketorolac Versus Intravenous Ketorolac for the Treatment of Severe Renal Colic in the Emergency Department: A Double-Blind, Randomized Controlled Trial. Ann Emerg Med 2024; 83:217-224. [PMID: 37999652 DOI: 10.1016/j.annemergmed.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/25/2023]
Abstract
STUDY OBJECTIVE Atomized intranasal (IN) drug administration offers an alternative to the intravenous (IV) route. We aimed to evaluate the analgesic efficacy of IN versus IV ketorolac in emergency department patients with acute renal colic. METHODS We conducted a double-blind, randomized controlled trial on adult patients (aged 18 to 64 years) with severe renal colic and numerical rating scale pain ratings ≥7.0. They were randomly assigned (1:1) to receive single doses of either IN or IV ketorolac. Our main outcomes were differences in numerical rating scale reduction at 30 and 60 minutes. A 95% confidence interval (CI) was calculated for each mean difference, with a minimum clinically important difference set at 1.3 points. Secondary outcomes included treatment response, adverse events, rescue medications, and emergency department revisits. We analyzed using intention-to-treat. RESULTS A total of 86 and 85 patients with similar baseline characteristics were allocated to the IV and IN groups, respectively. Mean numerical rating scale scores were 8.52 and 8.65 at baseline, 3.85 and 4.67 at 30 minutes, and 2.80 and 3.04 at 90 minutes, respectively. The mean numerical rating scale reduction differences between the IV and IN groups were 0.69 (95% CI -0.08 to 1.48) at 30 minutes and 0.10 (95% CI -0.85 to 1.04) at 60 minutes. There were no differences in secondary outcomes. CONCLUSION Neither IN or IV ketorolac was superior to the other for the treatment of acute renal colic, and both provided clinically meaningful reductions in pain scores at 30 to 60 minutes.
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Affiliation(s)
| | | | - Mahmood Al-Jufaili
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Abdullah Al-Reesi
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | - Fatma Bader Al-Riyami
- Emergency Medicine Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | - Ramesh Vishwakarma
- Norwich Clinical Trial Unit, Norwich Medical School, University of East Anglia, United Kingdom
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Pergolizzi JV, Batra A, Schmidt WK. A Randomized Controlled Trial of a Novel Formulation of Ketorolac Tromethamine for Continuous Infusion (NTM-001) in Healthy Volunteers. Adv Ther 2024; 41:659-671. [PMID: 38070041 DOI: 10.1007/s12325-023-02709-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/06/2023] [Indexed: 02/06/2024]
Abstract
INTRODUCTION There is an urgent unmet medical need for a safe, effective, nonopioid analgesic agent for postoperative pain control. METHODS This first-in-man study was designed to explore a data-informed, model-based candidate dosage regimen and safety of a novel formulation of ketorolac tromethamine (NTM-001) delivered as a 12.5-mg intravenous (IV) bolus followed immediately by 3.5 mg/h continuous infusion over 24 h compared versus IV bolus dosing of 30 mg generic ketorolac every 6 h. The study evaluated pharmacokinetic parameters and safety profiles based on a targeted product profile. A graphical overlay method and model-based comparisons were used to assess the concentration-time curve. RESULTS Healthy adults (n = 28, 50% men) received NTM-001 and bolus dosing in an open-label crossover design. Observed plasma concentrations were tightly aligned with predicted values with no outliers. Graphical overlay comparisons showed low between-subject variability and agreed with forecasted concentration-time targets. The pharmacokinetic (PK) base models fit with preliminary PK data from both the NTM-001 and bolus groups with model fit median profiles within 95% prediction limits and no updating of the models. Consistent with serum concentration-time profiles, pain relief scores fell within predicted limits, with initial pain relief scores of NTM-001 slightly above the target profile, likely because the initial serum ketorolac concentrations were somewhat higher than predicted. The 24-h pain relief predicted for NTM-001 based on the area under the median ketorolac pain relief versus time curve was about 6% below that of the pain relief target. Both treatments were well tolerated and no subject withdrew because of adverse events. CONCLUSIONS The PK parameters for NTM-001 and comparator bolus were similar to the modeling targets with no updating of the base model. There were no outliers and little intersubject variability. NTM-001 delivered as a bolus of 12.5 mg IV followed immediately by continuous infusion of 3.5 mg/h using a standard hospital infusion pump may offer an alternative to opioids for acute postoperative pain control.
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Forestell B, Sabbineni M, Sharif S, Chao J, Eltorki M. Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain. Ann Emerg Med 2023; 82:615-623. [PMID: 37178102 DOI: 10.1016/j.annemergmed.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVES Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. METHODS The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. RESULTS This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). CONCLUSION In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Monica Sabbineni
- Department of Medicine, Michael G DeGroote Medical School, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Sharif
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Chao
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver and Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Ma CH, Tworek KB, Kung JY, Kilcommons S, Wheeler K, Parker A, Senaratne J, Macintyre E, Sligl W, Karvellas CJ, Zampieri FG, Kutsogiannis DJ, Basmaji J, Lewis K, Chaudhuri D, Sharif S, Rewa OG, Rochwerg B, Bagshaw SM, Lau VI. Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials. Crit Care Explor 2023; 5:e0938. [PMID: 37396930 PMCID: PMC10309528 DOI: 10.1097/cce.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. STUDY SELECTION Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. DATA EXTRACTION In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. CONCLUSIONS In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.
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Affiliation(s)
- Chen Hsiang Ma
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kimberly B Tworek
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Sebastian Kilcommons
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kathleen Wheeler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Arabesque Parker
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Erika Macintyre
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Wendy Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Constantine J Karvellas
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Demetrios Jim Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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Jaglal R, Nemec EC. What is the analgesic ceiling dose of ketorolac for treating acute pain in the ED? JAAPA 2023; 36:43-44. [PMID: 37097781 DOI: 10.1097/01.jaa.0000923576.90074.2a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT Recent research has suggested that ketorolac has an analgesic ceiling effect, meaning that despite increased dosages, the patient obtains no additional pain relief and is more likely to suffer adverse drug reactions. This article describes the outcomes of these studies and the recommendation to use the lowest possible dose for the shortest time when treating patients with acute pain.
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Affiliation(s)
- Reynold Jaglal
- In the PA program at Sacred Heart University in Fairfield, Conn., Reynold Jaglal is program director, department chair, and a clinical assistant professor, and Eric C. Nemec II is director of research and assessment and a clinical professor. The authors have disclosed no potential conflicts of interest, financial or otherwise
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