TORADOL (ketorolac) linked to Recurrence Prevention
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Been on a walk about...............123 is heavy into researching. She sent me this link. It about Aspirin which is a cox 1 inhibitor in the NSAID family of drugs. The primary focus of this page is to explain inflammation. It's done very well on the lay person level. I keep slipping into medical speak when I try. I was excited when Retsky described it then read it from a lay persons point of view. Realized a dictionary would be needed. If you are interested in inflammation I would suggest you store this web page.
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More info regarding aspirin.....
http://scienceblog.cancerresearchuk.org/2008/05/13/aspirins-a-wonder-drug-but-can-it-prevent-cancer/0 -
Hootie hoo a hyperlink
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Just wanted to share that my mother-in-law had BC surgery yesterday (DCIS with microinvasion) and, with my encouragement, requested Toradol before surgery. I was happy to hear that her anesthesiologist was willing to give it to her, and WAS aware of the studies that have shown it reduces recurrence. We struck out on getting paravertebral nerve block, but at least she got the Toradol.
Meanwhile, I feel like I've been down the rabbit hole (otherwise known as pubmed) for the last 2 weeks. I have about 3 dozen studies about anesthesia and cancer recurrence and I am trying to organize my thoughts about it all. Here are my piles, so far: 1) ketorolac, 2)paravertebral nerve block, 3)propofol, 4)local anesthetic (lidocaine), 5)opioids and opioid blockers, 6)general papers on anesthesia and recurrence
I really feel like anesthesia has a huge impact on recurrence AND overall survival in cancer patients. I wish there could be a rapid movement away from opioid based anesthesia (which may actually drive cancer progression) to NSAIDs and other drugs and procedures that reduce pain and inflammation and shorten recovery time.
I don't even know where to start...I feel like my brain is a pretzel right now!
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Fallleaves,
Please let post when you have your thoughts organized! Thanks for researching!
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Fallleaves. Then it's time to go on a walk about. i.e take a day off, veg, exercise. eat something fattening. Whatever will allow you brain and mind to relax.
I and our lurkers will be here. think possibly tomorrow , the next day, or whenever.
When your brain and mind are whole. Think about loading the studies all in one box. Then maybe we can pull one out at a time and talk about it
Glad it worked out well for your Mom YAY. Interesting on the opiod thing.
Rest. you got Mom taken care of, now you need to take care of you sassy
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Thanks for your comments 123JustMe and Sassy, I appreciate them!
Sassy, do you mean I should just put all the studies into one really long post? (And I like your advice, especially the eating something fattening part!)
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don' t worry about here for at least a couple days. We'll figure it out when you get back. Nursing orders! Hugs sassy
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Wow, fallleaves,,, 3 dozen studies,, you have been busy!0 -
wow wish I would have seen these posts month ago when i was hospitalized for sepsis and an infection in my port I was administered morphine for pain
hoping it didn't cause my cancer to spread I was on chemo during that time0 -
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More information about inflammation and breast cancer.
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123, I have some reservations about that article. Would have to do some digging to satisfy my concerns.
I'll let you do it hahaha Check google keywords "AMA and list all board certified subspecialties" Article says author board certified. Doesn't say from what organization. Could be "The Guy Down The Street College of Poker Players.". Article references a study that had three chemicals tested in one study. Chemicals would have to have clearly substantiated action prior to being tested together. Otherwise, you don't know which chemical is working. Suspect until proof is found. Then a second study with the two drugs. Then a third study and a 4-5-6. Chit 1, then 1&2;1&3; 2.2&3; 3. Yep, 6 studies total before a study with the three in one study. Lol did you follow that
They're is no hyperlinking to the studies. Not an absolute need, but is becoming more common practice. Too many people like you and me saying "Where's the evidenced based material". Article is referring other chemicals beneficial affects without any supporting evidence. It's dropped in info.
This is why I prefer articles on medical/science stuff coming from MEDSCAPE that are doing the play by play on a study. I can trust they are going to review studies well.
Nonscientific purveyors of information have learned the ropes on how to lure in the unsuspecting. Wrap it neat. Refer to studies that don't exist. Direct to a web site that is just as slick. Write a bibliography using other nonscientific articles. All with the help of our local news. In this case Fox news. Maybe a great article telling us good things, but I have some red flags.
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Lol! I follow you captain! I guess my point is why as women with breast cancer are we not demanding a scientific study on the effect of NSAIDS on breast cancer! Crazy to have such an affordable medication available and not test the theory being presented....
http://cebp.aacrjournals.org/content/19/4/1033.short0 -
123, If you want to have some fun this is how to do it. Absolutely immerse yourself in all of Forgets and Retsky's published works. Then call them and ask "What's up?". Serious, I have done it maybe a half dozen or more times since 1980. It's very cool. Very.
The first phone call dramatically changed the course of my life.
If you decide to do it. I'll help prep you for the call. Great fun. Honest.
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Retsky defined in his first publication listed here how to do the study in his conclusion. The TNBC group. Problem with that is if the eveidence so strongly supports the use, how with someone's life in the balance do you withhold the drug? I know studies are done this way all the time, but I have difficulty with it.
Yoohoo SpecialK if you are lurking can you pop in and share your story of the vaccine study you were in? I still remember well our talk when you started into that study. You explained the process well and how they're is a "Do No Harm" approach.
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123, these two have some promise. One was a controlled trial. The other I'll let you look at and tell me
Aspirin and Serum Estrogens in Postmenopausal Women: A Randomized Controlled Clinical Trial Cancer Prev Res September 1, 2014 7:9 906-912Recent Prediagnostic Aspirin Use, Lymph Node Involvement, and 5-Year Mortality in Women with Stage I-III Breast Cancer: A Nationwide Population-Based Cohort Study Cancer Res. August 1, 2014 74:15 4065-40770 -
123, favor please
would you look for the companion article on Retsky's study on Medscape. Not sure what was up with my computer. Everytime I tried to search their after a certain point my computer locked up. 0 -
Sas, which companion article? Can't find anything by Retsky on Medscape....0
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123, thanks, It won't be by Retsky it will be by someone else that is writing a review about his study. They review it and put the findings in language that is understandable by the non research kind. Like us
This is in the topic box. It's an ARTICLE about Forget's study and then Forget's STUDY. The article is the author interpretation of the study. They generally talk about the strength and weaknesses of the study, whether they're was bias, are the conclusions well drawn from the study.
"This link is to an article about the Forget et al study, 2010 patient cohort 327
http://www.medscape.com/viewarticle/723293
Forget et all study----this will be/ is a landmark study
http://www.ncbi.nlm.nih.gov/pubmed/20435950 "
These types of articles can be found in several ways. 1. on the page the original abstract appears it may be listed to the side. Pubmed, Plos, Medscape 2. same thing on the NIH site. 3. sometimes in the google pull.
Not sure when I figured this out, but it's been a really long time. It's very useful to know this. I didn't learn it in school. Often I'll read the article before the study. It gives me sense of what the study is going to say. Depending on why I want to know the material, determines how I approach the study. Studies can be abysmal to read. All those stats etc. Abstracts are generally easy compared to the full study. But again it goes back to the reason for learning the material. Full studies can be great, bad, anywhere in between. Part of what I do when I read a full study, is look at it from a peer review approach. Are the researchers biased, even though every study includes a description of the parameters to prevent bias. Pisses me off when studies get by peer review and they are biased. Worse, if a bad study then influences practices, beliefs, treatments, laws etc., we all loose.
In the old days pre-computers, it was tough slugging out the info from journals and card catalogues in the library. We are so pampered now.
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123, In the old days the controls on studies by the journals they were published in was immense. For medicine, The New England Journal of Medicine was the most prestigious journal. A study published there was considered to go through the most rigorous peer review. They're many very good journals. With the explosion of knowledge in the last 4 decades, journals developed to publish the studies and articles of particular subgroups. With the advent of the computer, studies get published online. Making sure the science and review is there is getting harder too do.
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Well, I'm finally back. I hope you don't feel like I am hijacking this thread, Sassy, but I feel like we need to take a comprehensive look at anesthesia and how it affects BC. I'm going to start with the overview articles I've read that cover all forms of cancer, and then post separately with articles on specific topics (ketorolac, paravertebral nerve block, propofol, opioids, etc.) I apologize if my thinking is scattered. I've been doing this while my sons were playing "Modern Warfare 2"!
Anyway, here goes:
Surgery is often necessary for the removal of cancer, but it also causes inflammation and immunosuppression, which are linked (inflammation can lead to immunosuppression). Anesthesia may contribute to these effects or attenuate them. Here's what I've found so far (excuse the strange bolding---it didn't copy the way I wanted)
Good overview articles
Effect of anaesthetic technique and other perioperative factors on cancer recurrence
Really good article that covers the effects of a lot of different anesthesia drugs, and regional anesthesia on long term outcome and gives a good overview of the metastatic process. A few highlights:
"Surgery can inhibit important host defences and promote the development of metastases. Anaesthetic technique and drug choice can interact with the cellular immune system and effect long-term outcome."
"Tumour cells that survive (immune defences) will become trapped in the capillary beds of distant organs, extravasate, proliferate, and ultimately develop their own blood supply. The mediators of this process of angiogenesis include vascular epidermal growth factor (VEGF) and prostaglandin E2 (PGE2)."
"Animal studies have shown that stress-induced reduction of NK cell activity can cause enhanced tumour development."
"Natural killer (NK) cells are the primary defence against cancer cells. Animal studies have shown that stress-induced reduction in NK cell activity can cause enhanced tumour development."
This article also looks at NSAIDS: "Non-steroidal anti-inflammatory drugs inhibit prostaglandin sythesis via the inhibition of the COX enzyme. Tumour cells have been shown to secrete prostaglandins, and this may be a mechanism to evade host cell-mediated immunity. COX-2 inhibitors have anti-tumour and anti-angiogenic properties in a rat model. Breast cancer cells over-express COX-2. Women on long-term COX-2 inhibitors may have a lower incidence of breast cancer. " (However, a phase III trial of an aromatase inhibitor combined with celecoxib in women with advanced breast cancer did not result in a significant advantage to the aromatase inhibitor alone.)
http://bja.oxfordjournals.org/content/105/2/106.full
(Snyder, 2010)
Cancer recurrence after surgery: direct and indirect effects of anesthestic agents
"Despite meticulous surgical technique including minimal handling of the neoplasm, surgical resection of tumors causes measurable release of cancerous cells into the circulation. In addition to this seeding effect, undetectable micrometastases may already exist even in localized disease."
"Natural killer (NK) cells, a subset of the CMI (cell-mediated immune) system are of key importance to this phenomenon. These are MHC-independent cytotoxic lymphocytes that are uniquely able to detect and destroy circulating tumor cells and micrometastases. Intratumoral NK-cell levels have a prognostic significance in a range of neoplasms."
"Melamed et al. investigated the effects of propofol, thiopental, ketamine and halothane: all agents reduced the number of circulating NK-cells and all except propofol depressed NK-cell cytotoxicity (to cancer cells). Ketamine has notable adrenergic activity and is profoundly immunosuppressive."
"Opioids are widely used in anesthesia to provide both intra- and postoperative pain relief. Although undoubtedly efficacious analgesics, there is growing evidence of their potential for exerting negative consequences in those undergoing surgery. Administration of morphine to mice in clinically relevant doses leads to increased angiogenesis and growth of breast tumors."
"...morphine has been demonstrated to reduce NK-cell activity in a dose-dependent fashion in rats and also reduces NK-activity following intravenous administration in humans, the effects persisting 24 hr. after the cessation of the infusion." (However, in other studies morphine acted to promote apoptosis and cell death, and lessened the tumor promoting effect of surgery)
"Although inhalational anesthestics and opioids appear to negatively affect immune parameters, growing evidence suggests the use of RA (regional anesthesia) lessens the immunosuppressive burden of surgery."
"...regional anesthesia reduces intra- and postoperative opioid requirement. By reducing opiate-induced immunosuppression, RA may also abrogate opiate-induced NK-cell suppression."
http://onlinelibrary.wiley.com/doi/10.1002/ijc.26448/pdf
(Tavare, 2011)
The effects of anesthesia on tumor progression
"Retrospective studies suggest that regional anesthesia reduces the risk of tumor metastasis and recurrence. This benefit may be due to the attenuation of immunosuppression by regional anesthesia. On the other hand, accumulating evidence points to a direct role of anesthetics in tumor progression. A variety of malignancies exhibit increased activity of voltage-gated sodium channels. Blockade of these channels by local anesthetics may help inhibit tumor progression. Opioids promote angiogenesis, cancer cell proliferation and metastasis."
"Except propofol, volatile anesthetics and intravenous anesthetics are known to depress all aspects of immunity system. This depression augments the surgically-induced immunosuppression."
"Anesthetics act on neoplasms both directly and indirectly. Past studies have been focused more on the indirect aspect, the immune suppression . Recently, growing evidence demonstrates that anesthetics directly regulate tumor molecular and cell biology."
"A good approach is to avoid regimens that are potentially harmful and favor these potentially beneficial. The former includes volatile anesthetics, systemic opioids, and ketamine; while the latter includes regional block, local anesthetics, and propofol. In addition, multidisciplinary strategies need to be implemented to reduce perioperative stress."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601457/#b58
(Mao, 2013)The perioperative period and promotion of cancer metastasis: New outlooks on mediating mechanisms and immune involvement
"A recent epidemiological historical study had compared two databases of breast cancer patients, showing that while untreated patients exhibited only one peak of mortality 3–4 years after diagnosis, operated patients showed an additional distinct peak at 7–8 years after surgery, suggesting that beside its important beneficial outcomes, surgery may indeed have long-term deleterious effects."
"Opiate administration, and endogenously secreted opioids in response to nociception, were shown to facilitate tumor proliferation, promote tumor angiogenesis, and enhance tumor blood supply through nitric-oxide (NO) release. Opiates were also shown to suppress NK and phagocytic activity, the production of antibodies, and the release of pro-CMI cytokines." (Although at lower doses opiates have beneficial effects)
In comparing general anesthesia (GA) to regional anesthesia (RA), "several experimental studies in humans have recently shown that the GA approach as a whole can directly affect the malignant tissue and promote its growth. In two studies, breast cancer patients were randomly assigned to undergo either GA or RA. Only the GA approach (which includes opiate administration) was shown to directly increase serum levels of VEGF , MMP-3, and MMP-9. In another study, sera taken from patients who were randomly allocated to undergo GA, rather than RA, promoted the in vitro proliferation of a breast cancer cell line). Other studies have reported that the use of RA had resulted in a reduced perioperative stress response, and spared postoperative immunity."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423506/
(Neeman, 2013)Anesthetic Techniques and Cancer Recurrence after Surgery
"Anesthesia technique could differentially affect cancer recurrence in oncologic patients undergoing surgery, due to immunosuppression, stimulation of angiogenesis, and dissemination of residual cancer cells. Data support the use of intravenous anesthetics, such as propofol anesthesia, thanks to antitumoral protective effects inhibiting cyclooxygenase 2 and prostaglandins E2 in cancer cells, and stimulation of immunity response; a restriction in the use of volatile anesthetics; restriction in the use of opioids as they suppress humoral and cellular immunity, and their chronic use favors angiogenesis and development of metastases; use of locoregional anesthesia compared with general anesthesia, as locoregional appears to reduce cancer recurrence after surgery. However, these findings must be interpreted cautiously as there is no evidence that simple changes in the practice of anesthesia can have a positive impact on postsurgical survival of cancer patients."
http://www.hindawi.com/journals/tswj/2014/328513/
(Fodale, 2014)
Are we causing the recurrence-impact of perioperative period on long-term cancer prognosis: Review of currrent evidence and practice
This review gives a good explanation of the immune system and pro and anti-inflammatory cytokines, then looks at the effects of intavenous agents, barbituates, propofol, midazolam, ketamine, volatile agents, opioids, NSAIDS/COX-2 inhibitors, local and regional anesthesia, steroids and statins, and other perioperative factors.
"On reviewing the current literature, we can suggest to modify our practice more towards preoperative anxiolysis, use of 'safer' drugs like propofol, tramadol, NSAIDS, and use of regional anesthesia wherever possible along with adequate pain control. In our institute, which caters to approximately 7,000 oncosurgeries a year, we are trying to follow the same and are in the process of formulating a comprehensive institutional oncoanesthesia protocol based on current evidences. Whether these will help our patients, only data from long-term follow-up reports will tell."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC400963...
(Das, 2014)
Anesthesia and cancer recurrence: What is the evidence?
Summarizes the studies on the effect of anesthesia on various cancers, and points out a lack of randomized controlled trials. But the authors come to a conservative conclusion: "Thus, while the basic science literature does point towards a potential effect of anesthetic technique on cancer outcomes, current data do not call for a drastic change int he perioperative management of cancer patients."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009629/
(Divatia, 2014)
Improving patient outcomes through state-of-the-art pain control in breast cancer surgery"A multimodal analgesic regimen that consists of 2 or more nonopioid medications and is initiated in the preoperative phase and continued during the intraoperative and acute postoperative phases may provide the best patient outcomes. These nonopioid medications include, but are not limited to, local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs, antiepileptics, alpha-2-adrenergic antagonists, N-methyl-D-aspartate antagonists, and glucocorticoids. This multimodal approach can be a stand-alone protocol or a part of a more comprehensive enhanced recovery after surgery (ERAS) protocol" - See more at: http://www.gotoper.com/publications/ajho/2015/2015...
(Hutchins, 2015)
Cancer surgery: how may anesthesia influence outcome?
"Surgery is the main treatment for potentially curable solid tumors, but most cancer-related deaths in patients who have received previous surgical treatment are caused by metastatic disease. There is increasing evidence that anesthetic technique has the potential to affect long-term outcome after cancer surgery."
"Inhaled anesthetics induce immunosuppression and activate inflammatory cascade activation, whereas propofol has a protective action. Opioids might promote cancer recurrence and metastasis. In vitro and in vivo studies have demonstrated that local anesthetics inhibit proliferation and migration of cancer cells and induce apoptosis."
"Anesthesiologists should follow current best clinical practice and include all strategies that effectively decrease pain and attenuate stress. Regional anesthesia and multimodal analgesia, adding anti-inflammatory drugs, play an unquestionable role in the control of perioperative pain and may improve recurrence-free survival.
http://www.ncbi.nlm.nih.gov/pubmed/25769963
(Cassinello, 2015)
What is being done nowThe Mayo Clinic has been using "enhanced recovery pathways" that are meant to help patients recover more quickly and need less opioid painkillers. That involves: preoperative analgesics to help prevent pain , nonsteroidal anti-inflammatories (don't know if they use as ketorolac), use of nerve-numbing agent liposomal bupivacaine in the surgical site during surgery, avoiding postoperative opioids, giving preventive nausea treatment, resuming food and walking soon after surgery, and avoiding routine intensive care unit monitoring
(http://www.sciencedaily.com/releases/2014/03/140303143345.htm)
"Non-opiate surgical anesthesia: a paradigm shift?"
This includes a non-opiate surgical protocal developed by one of the authors of the Forget study. It involves clonidine, ketamine (bad), but at low dose, and with esmolol, which is a beta-adrenergic, and counteracts ketamine's immunosuppressiveness.http://publicationslist.org/data/jan.mulier/ref-37...
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falls, you seem rested and energized. YAY go girl! threads need to wander where the info leads. I'm thrilled you are here.
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Thanks so much, Sassy! I am off to help Number 1 son try and get in-state tuition (University of Washington). Will post more later!
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Getting back to Ketorolac... here are a few older studies that I thought were interesting. This first one is a rat study.
1) Perioperative immunomodulation in cancer surgery
"Despite undergoing a curative resection, many patients with colorectal cancer will develop and die of metastatic disease. It has been shown clinically and experimentally that surgery causes a transient period of immunosuppression, and it is postulated that this may encourage both the implantation of surgically disseminated tumor cells and the growth of existing micrometastases. The present study used natural killer cell cytotoxicity (NKCC) and tumor burden to evaluate perioperative modulation of immunocompetence in a murine model. We measured NKCC and tumor burden responses to a standardized surgical stress (SSS) alone, and to either morphine sulfate (MS) (15 mg/kg subcutaneously x 4 doses), ketorolac (a prostaglandin synthetase--prostaglandin E2--inhibitor) (2.5 mg/kg subcutaneously x 4 doses), or interleukin 2 (2,000 units intraperitoneally x 3 doses) administration with the SSS. In this model, we found that both low-dose interleukin-2 (IL-2) and ketorolac reversed the NKCC suppression associated with surgery, whereas morphine resulted in further depression of NKCC. In addition, IL-2 significantly decreased tumor incidence, whereas continuous MS exposure markedly increased tumor burden after surgery. These data suggest that IL-2 and ketorolac may be effective agents for the restoration of perioperative immune competence, whereas the use of continuous morphine might have significant deleterious effects."
http://www.ncbi.nlm.nih.gov/pubmed/8311130
(Colacchio, 1994)
Very interesting that keterolac reversed the NKCC suppression from surgery, and IL-2 did that AND reduced tumor incidence (!), while morphine depressed NKCC and increased tumor burden.
and
2)Ketorolac. A reappraisal of it's pharmacodynamic and pharmacokinetic properties and therapeutic use in pain management
"After major abdominal, orthopaedic or gynaecological surgery or ambulatory laparoscopic or gynaecological procedures, ketorolac provides relief from mild to severe pain in the majority of patients and has similar analgesic efficacy to that of standard dosages of morphine and pethidine (meperidine) as well as less frequently used opioids and other NSAIDs. The analgesic effect of ketorolac may be slightly delayed but often persists for longer than that of opioids. Combined therapy with ketorolac and an opioid results in a 25 to 50% reduction in opioid requirements, and in some patients this is accompanied by a concomitant decrease in opioid-induced adverse events, more rapid return to normal gastrointestinal function and shorter stay in hospital."
"Subcutaneous administration of ketorolac reduces pain in patients with cancer and seems particularly beneficial in pain resulting from bone metastases."
http://www.ncbi.nlm.nih.gov/pubmed/9010653
So, it seems the advantage of ketorolac is that it both preserves immune system functioning, and reduces the need for opioids (in addition to it's anti-inflammatory action).
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Okay we are off.........Always good to look at the history of drugs or anything. Always. Now the old is in line with the new, except 'other opiods'. Meperidine has been out of favor since around 2005. Morphine and dilaudid are the drugs of choice for the last ten years at least. No clue how much Dilaudid is used intraoperatively. Used widely post-op. Doesn't mention Fentanyl's grand daddy drug Sufentanil. (that's not a good description, but it work's for me). Sufentanil is 500 times more potent than Fentanyl(wiki). It figures into Forget's study and is used world wide as an anesthetic agent. Starting to tread water here...........the point is?
Drugs have additive properties and drugs can potentiate their individual properties
Drug 1 + drug 2+= 2(additive) Sorry, perhaps aspirin and caffeine. Can't think of anything right now(see potentiated)
drug 1 + drug 2 + =4 (potentiated--the sum of their effect is greater than their individual effect) For example, oxycodone + acetominophen give > pain relief than do the individual drugs. Mostly, when adding drugs together we look for potentiated affects.
When drugs potentiate each other an advantage is you can use a smaller amount of each drug to accomplish the same effect.
Back in discussing anesthesia, I described anesthesia as being a smorgasboard. A little of this, and a little of that, and maybe some more of this and that. By choosing drugs that potentiate each other, less of each can be used. When you use a lesser amount of any drug, that reduces the side effects of that particular drug.
TIVA was brought forward as a name associated with this. Total IntraVenous Anesthesia. By exclusion the gases Halothane/fluothane etc are omitted(good). I came into in the 70's, TIVA in it's earliest form i.v. push, was being used progressively as the gases were considered dangerous to patient and staff. Used as necessary, but the trend was to avoid them b/c of side effects. We never used TIVA term. Not sure when it became TIVA. In time, machines that could be calibrated for delivery of drugs were introduced in the 90's(where I worked, earlier at bigger centers).
The precise delivery of the newer machines is key. A little of this , a little of that. The smorgasboard was the same
.Bottom line you put Toradol together with an opiod, the affect is potentiated as evidenced by that 90's study of a 25-50% reduction in the use of opiods....................
Falls. Now possibly brain dead
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Sassy, I can tell already I'm going to have a hard time keeping up with you! Just want you to know I'm going to be away for the weekend (following the footsteps of Lewis and Clark), but am looking forward to plowing through some of these studies with you when I get back. Hope you have a good weekend!
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falls,have a good weekend. Left off the. "Lol" on that last post. Makes it sound " hands on hips " noisy. Sorry. (took it out)
That article gives us a reference point in time for the beginning of our work. That's good. I have computer problems again. My tech buddy has control of the lap top.
Have a good weekend
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Great stuff, wow!
I am copying some of this and sending it to my oncologist and surgeon. If something simple like a drug choice can affect someone's outcome, then the information needs to be looked at!
It gets the timeline for keterolac back a bit from what I found a few weeks ago in PubMed.
I still have some recon work that I have been worried about completing...every time I say that anasthesia suppresses the immune system I get blasted around these boards, lol.
I don't need nipples as much as I need to be here for my 3 kids!
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geewhiz, people blast you? Well stay here with us. Always nice to talk with people that like learning. Works up those little brain cells Coffee always on.
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