Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H)

BACKGROUND

Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid.

METHODS

A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications.

RESULTS

Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months.

CONCLUSIONS

Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Retinoic acid alters the proliferation and survival of the epithelium and mesenchyme and suppresses Wnt/β-catenin signaling in developing cleft palate

Retinoic acid (RA) contributes to cleft palate; however, the cellular and molecular mechanisms responsible for the deleterious effects on the developing palate are unclear. Wnt signaling is a candidate pathway in the cleft palate and is associated with RA in organ development; thus, we aim to investigate whether RA-induced cleft palate also results from altered Wnt signaling. Administration of RA to mice altered cell proliferation and apoptosis in craniofacial tissues by regulating molecules controlling cell cycle and p38 MAPK signaling, respectively. This altered cell fate by RA is a crucial mechanism contributing to 100% incidence of cleft palate. Moreover, Wnt/β-catenin signaling was completely inhibited by RA in the early developing palate via its binding and activation with RA receptor (RAR) and is responsible for RA-induced cleft palate. Furthermore, PI3K/Akt signaling was also involved in actions of RA. Our findings help in elucidating the mechanisms of RA-induced cleft palate.

Association between KCNQ1 genetic variants and QT interval in a Chinese population

AIM

There is a close link between electrocardiographic ventricular repolarization QT parameters and Type 2 diabetes. The aim of the present study was to assess the effects of QT-related and diabetes-related variants in KCNQ1 on QT interval in a Chinese population.

METHODS

We recruited 2415 patients with Type 2 diabetes and 1163 subjects with normal glucose regulation in the present study. QT interval was obtained and the heart rate-corrected QT interval (QTc) was calculated using Bazett's formula. Four single nucleotide polymorphisms in KCNQ1 were selected (rs12296050, rs12576239, rs2237892 and rs2237895) and genotyped.

RESULTS

In participants with normal glucose regulation, the minor allele T of rs12296050 was associated with a 3.46-ms QTc prolongation under an additive model (P = 0.0109, empirical P = 0.0498). In patients with Type 2 diabetes, we did not find any association for the single nucleotide polymorphisms.

CONCLUSIONS

Our findings indicate that KCNQ1 is associated with QT interval in a Chinese population with normal glucose regulation.

Two-step retrograde closed stenting: a novel method for treating canalicular lacerations in Chinese patients

PURPOSE

To evaluate the efficacy of two-step retrograde closed stenting for treating canalicular laceration. methods: Forty-eight consecutive canalicular laceration cases (48 eyes) were randomised and divided into two groups: a one-step group and a two-step group. In the two-step group (23 cases), the first step was performed in the outpatient department and included identifying the medial cut end of the canaliculus and probing under a slit-lamp microscope, followed by a retrograde canalicular stenting assisted by a memory titanium stylet. The second step was canalicular anastomosis, which was performed in the operating room. In the one-step group (25 cases), all of the surgical procedures were performed when preoperative preparations were simultaneously available.

RESULTS

The time elapsed from the doctor visit to the treatment was 4.3 ± 2.4 h in the two-step group and 18.8 ± 6.3 h in the one-step group (P<0.01). The canalicular medial cut ends were found in all cases, but 8.6 ± 3.5 min was needed in the two-step group, and 51.4 ± 24.2 min was needed in the one-step group (P<0.01). The numerical rating scale for pain during surgery was 1.8 ± 1.2 in the two-step group and 5.4 ± 2.2 in the one-step group (P<0.01). One case (2.63%) in the two-step group and nine cases (36%) in the one-step group required other assisted methods to locate the medial cut end (P=0.007). Twenty-one cases (91.3%) in the two-step group and 20 cases (80%) in the one-step group achieved patent lacrimal drainage systems during a 12-month follow-up (P=0.528).

CONCLUSIONS

The two-step canalicular anastomosis method allows an early search for the medial cut end of the canaliculus and improves the chances of finding it; it is also a quicker, less invasive method for treating canalicular lacerations.

Genome-wide association study in a Chinese population identifies a susceptibility locus for type 2 diabetes at 7q32 near PAX4

AIMS/HYPOTHESIS

Most genetic variants identified for type 2 diabetes have been discovered in European populations. We performed genome-wide association studies (GWAS) in a Chinese population with the aim of identifying novel variants for type 2 diabetes in Asians.

METHODS

We performed a meta-analysis of three GWAS comprising 684 patients with type 2 diabetes and 955 controls of Southern Han Chinese descent. We followed up the top signals in two independent Southern Han Chinese cohorts (totalling 10,383 cases and 6,974 controls), and performed in silico replication in multiple populations.

RESULTS

We identified CDKN2A/B and four novel type 2 diabetes association signals with p < 1 × 10(-5) from the meta-analysis. Thirteen variants within these four loci were followed up in two independent Chinese cohorts, and rs10229583 at 7q32 was found to be associated with type 2 diabetes in a combined analysis of 11,067 cases and 7,929 controls (p meta = 2.6 × 10(-8); OR [95% CI] 1.18 [1.11, 1.25]). In silico replication revealed consistent associations across multiethnic groups, including five East Asian populations (p meta = 2.3 × 10(-10)) and a population of European descent (p = 8.6 × 10(-3)). The rs10229583 risk variant was associated with elevated fasting plasma glucose, impaired beta cell function in controls, and an earlier age at diagnosis for the cases. The novel variant lies within an islet-selective cluster of open regulatory elements. There was significant heterogeneity of effect between Han Chinese and individuals of European descent, Malaysians and Indians.

CONCLUSIONS/INTERPRETATION

Our study identifies rs10229583 near PAX4 as a novel locus for type 2 diabetes in Chinese and other populations and provides new insights into the pathogenesis of type 2 diabetes.

KH902 suppresses high glucose-induced migration and sprouting of human retinal endothelial cells by blocking VEGF and PIGF

AIMS

Vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) are upregulated in many ocular neovascular diseases such as diabetic retinopathy (DR). KH902 is a recombinant fusion protein with its binding ligand taken from the domains of VEGF receptor-1 (VEGFR-1) and VEGF receptor-2 (VEGFR-2) and can bind all VEGF-A isoforms and PlGF. The aim of this study was to investigate the underlying mechanisms of anti-angiogenic effects of KH902.

METHODS

The toxic effect of KH902 on cultured human retinal endothelial cells (HRECs) was measured by Annexin V/PI staining and MTT assay. The concentrations of secreted VEGF and PlGF were measured by ELISA. The migration of HRECs was assessed by scratch wound and transwell assay. The sprouting of HRECs was determined by tube formation assay. The protein levels of Src, p-Src, PI3K, Akt1, p-Akt1, Erk1/2 and p-Erk1/2 were measured by Western blot.

RESULTS

KH902 at the concentrations from 100 ng/ml to 100 µg/ml had no cytotoxicity to cultured HRECs. KH902 bound not only VEGF165, but also PlGF that were secreted by HRECs under high glucose condition. A 500 ng/ml of KH902 significantly suppressed high glucose-induced migration and sprouting of HRECs through downregulating the expression of PI3K and inhibiting the activation of Src, Akt1 and Erk1/2.

CONCLUSION

Our study indicates that KH902 suppresses high glucose-induced migration and sprouting of HRECs through not only binding VEGF, but also PlGF to inhibit the activation of Src-Akt1-Erk1/2 pathway. KH902 is a drug that potentially inhibits angiogenic pathways involving in DR or other ocular neovascular diseases.

Genetic variants of LPIN1 indicate an association with Type 2 diabetes mellitus in a Chinese population

AIMS

Metabolic disorders are independent risk factors for the development of Type 2 diabetes. The aim of the study is to test the association of LPIN1 variants with Type 2 diabetes and clinical characteristics in large samples of the Chinese population.

METHODS

In the first stage, 15 single nucleotide polymorphisms within the LPIN1 region were selected and genotyped in 3700 Chinese Han participants. In the second stage, the single nucleotide polymorphisms showing significant association or trends towards association were genotyped in an additional 3122 samples for replication. Meta-analyses and genotype-phenotype association studies were performed after combining the data from the two stages.

RESULTS

In the first stage, we detected that rs16857876 was significantly associated with Type 2 diabetes with an odds ratio of 0.806 (95% CI 0.677-0.958, P = 0.015), while rs11695610 showed a trend with Type 2 diabetes (odds ratio 0.846, 95% CI 0.709-1.009, P = 0.062). In the second stage, a similar effect of rs11695610 on Type 2 diabetes was observed (odds ratio 0.849, 95% CI 0.700-1.030, P = 0.096). The meta-analyses combining the information from the two stages showed a significant effect of rs11695610 on Type 2 diabetes with an odds ratio of 0.847 (95% CI 0.744-0.965, P = 0.012). Finally, the phenotype-genotype association analyses showed that rs11695610 was associated with 2-h plasma glucose (P = 0.040) and triglyceride levels (P = 0.034).

CONCLUSIONS

Our data implied that common single nucleotide polymorphisms within the LPIN1 region were associated with Type 2 diabetes and metabolic traits in the Chinese population.

Abstract P4-01-11: Clinical Findings and Outcomes from MRI Staging of Breast Cancer in a Diverse Population

Background: Staging breast MRI can detect occult breast cancers in 1–10% of newly diagnosed patients. The performance of MRI, impact of patient factors, and resulting surgical management in underserved and diverse populations has not been well studied.

Methods We performed a retrospective analysis of consecutive patients with newly diagnosed in situ or invasive breast cancer (2006–2011) who had a preoperative staging MRI seen at our Centers that cares for an underserved and minority population. IRB approval was obtained to extract demographic and clinicopathological data, imaging studies and surgical treatment. Non-index lesions (NIL) were defined as those in breast or axillary nodes not known to be malignant or presenting with clinical, mammographic or ultrasound findings, in a different quadrant and given an MRI BIRADS score of 4 or 5. Occult cancers (OC) were those lesions found by biopsy or surgery to be invasive or in situ cancer. Logistic regression was used to examine the association between the probability of a NIL or OC and patients characteristics. Statistical computation was performed using STATA.

Results: Among 678 patients, 144 (21%) had a total of 171 NIL identified by MRI; 67 (9.8%) were ipsilateral, 44 (6.5%) contralateral and 24(3.5%)axillary nodes. 57 patients (8.4%) had a total of 62 OCs detected −34 (5%) ipsilateral, 8(1.2%) contralateral, and 9(1.3%) axillary nodes of which 49 (7.2%) were invasive and 8 (1.2%) in situ. 40% of patients with NILs were confirmed as OCs.

Hsp110 expression changes in rat primary myocardial cells exposed to heat stress in vitro

We investigated and described the kinetics of heat shock protein (Hsp) 110 expression and distribution in rat primary myocardial cells exposed to heat stress in vitro. After incubation at 37°C for 72 h, myocardial cells were heat stressed at 42°C for 0, 10, 20, 40, 60, 120, 240, 360, and 480 min. Significant increases in aspartate transaminase, lactate dehydrogenase, and creatine kinase enzymatic activities in the myocardial cell culture media were observed during heat stress, suggesting that the integrity of the myocardial cells was altered. Immunocytochemical analysis revealed that the expressed Hsp110 was constitutively localized in the cytoplasm and in the nuclei in small amounts characterized by a granular pattern. Nuclear Hsp110 levels increased significantly after 240 min of heat stress compared with levels in the control. The overall levels of Hsp110 expression increased significantly after 20 min. After 240 min, Hsp110 levels were approximately 1.2-fold higher than those in the control. Increasing levels of hsp110 messenger RNA detected using real-time quantitative polymerase chain reaction were observed after 20 min of heat stress, and the levels peaked with a 10-fold increase after 240 min of heat stress. These results indicate that the expression of Hsp110 in primary myocardial cells in vitro is sensitive to hyperthermic stress and that Hsp110 is involved in the potential acquisition of thermotolerance after heat stress. Therefore, Hsp110 might play a fundamental role in opposing and alleviating heat-induced damage caused by hyperthermic stress in primary myocardial cells.

Association between KCNQ1 genetic variants and obesity in Chinese patients with type 2 diabetes

AIMS/HYPOTHESIS

There is evidence of overlap between susceptibility loci for type 2 diabetes and obesity. The aim of this study is to explore the association between the established type 2 diabetes locus KCNQ1 and obesity in Han Chinese.

METHODS

We recruited 6,667 and 6,606 diabetic case-control samples from Shanghai and Hong Kong, respectively. Of the samples, 7.5% and 6.3% were excluded because of genotyping failure or data missing in the association analyses of rs2237892 and rs2237895 with obesity/BMI, respectively.

RESULTS

We found that rs2237892 was associated with lower BMI and lower incidence of overweight/obesity in diabetic patients from Hong Kong (BMI, β = -0.0060 per diabetes risk C allele for log(10)BMI [95% CI -0.0088, -0.0032; p = 2.83 × 10(-5)]; overweight/obesity, OR 0.880 for C allele [95% CI 0.807, 0.960; p = 0.004]) and in the meta-analysis of cases from the two regions (BMI, combined β = -0.0048 per C allele for log(10)BMI [95% CI -0.0070, -0.0026; p = 2.20 × 10(-5)]; overweight/obesity, combined OR 0.890 for C allele [95% CI 0.830, 0.955; p = 0.001]). rs2237895 was also related to decreased BMI (combined β = -0.0042 per diabetes risk C allele for log(10)BMI [95% CI -0.0062, -0.0022; p = 4.30 × 10(-5)]). A significant association with waist circumference was detected for rs2237892 in the pooled analyses (β = -0.0026 per C allele for log(10)[waist circumference] [95% CI -0.0045, -0.0007; p = 0.007]). However, neither an association with the risk of being overweight or obese nor associations with quantitive traits were detected for rs2237892 or rs2237895 in controls.

CONCLUSION

Our findings indicate that KCNQ1 is associated with obesity in Chinese patients with type 2 diabetes.

Physiological consequences of the salmon louse (Lepeophtheirus salmonis) on juvenile pink salmon (Oncorhynchus gorbuscha): implications for wild salmon ecology and management, and for salmon aquaculture

Pink salmon, Oncorhynchus gorbuscha, are the most abundant wild salmon species and are thought of as an indicator of ecosystem health. The salmon louse, Lepeophtheirus salmonis, is endemic to pink salmon habitat but these ectoparasites have been implicated in reducing local pink salmon populations in the Broughton Archipelago, British Columbia. This allegation arose largely because juvenile pink salmon migrate past commercial open net salmon farms, which are known to incubate the salmon louse. Juvenile pink salmon are thought to be especially sensitive to this ectoparasite because they enter the sea at such a small size (approx. 0.2 g). Here, we describe how 'no effect' thresholds for salmon louse sublethal impacts on juvenile pink salmon were determined using physiological principles. These data were accepted by environmental managers and are being used to minimize the impact of salmon aquaculture on wild pink salmon populations.

Effects of intravitreal injection of KH902, a vascular endothelial growth factor receptor decoy, on the retinas of streptozotocin-induced diabetic rats

AIMS

KH902 is a fusion protein that can bind vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) through its binding ligand taken from the domains of VEGF receptor 1 and VEGF receptor 2 (VEGFR2). This study was to investigate the effects of intravitreal injection of KH902 on the retinas of streptozotocin-induced diabetic rats.

METHODS

Two weeks after induction of diabetes, the left eyes of diabetic rats in each group received an intravitreal injection of phosphate-buffered saline (PBS), Avastin or KH902 solution, respectively. Four weeks after intravitreal injection, retinal electrophysiological function and the integrity of inner blood retinal barrier (iBRB) were measured by electroretinogram and Evans blue perfusion. The protein levels of VEGF signal pathway were assayed by western blot. The expression and distribution of claudin-5 and occludin were analysed by double immunofluorescent staining under confocal microscope. The expression of VEGFR2 and PlGF was measured by immunohistochemistry.

RESULTS

Four weeks after intravitreal injection, KH902-treated rats had better retinal electrophysiological function, less retinal vessel leakage and lower levels of VEGFR2, PI3K, AKT, p-AKT, p-ERK and p-SRC than PBS or Avastin-treated rats. The distribution of claudin-5 and occludin in the retinal vessels of diabetic rats treated by KH902 was smoother and more uniform than those of diabetic rats treated by PBS or Avastin. The expression of PlGF and VEGFR2 in KH902-treated rats was decreased compared with those in PBS or Avastin-treated rats.

CONCLUSIONS

KH902 could improve retinal electrophysiological function and inhibit the breakdown of iBRB by inhibiting the expression of VEGFR2, PlGF and PI3K, and the activation of SRC, AKT and ERK.

SU-E-T-147: Film Dosimetry Verification for TSE Using An Epson Scanner

PURPOSE

To commission and verify an Epson scanner for film dosimetry for total skin electron beam therapy (TSEB).

METHODS

Use data from an IBA PPC40 parallel-plate ion chamber and Sun Nuclear QED skin diode detectors as standard; we have made comparisons to the film measurement using Kodak XV films. Hurter-Driffield (HD) curve are established for 6 MeV total skin electron beams at a source-to-surface distance (SSD) of 5 m. Also HD curves are built for 6 MeV at a 100 cm SSD. Dose profiles for a series of oblique incident large electron fields are measured using the film for approximately 80 cGy dose delivered at the peak. The film is then scanned using two scanners, an Epson expression 10000 XL and a Vidar VXR-16 Dosimetry Pro. The optimal scanning conditions (e.g., dot per pixel size, internal color correction scheme) are chosen for the Epson scanner. Matlab is then used to analyze the optical density (OD) of the scanned films. A transmission densitometer made by Tobias Associates transmission is used to analyze the films to give a classical standard.

RESULTS

The analysis of the Epson scanner is presented in two forms: one with and one without the HD correction from the established HD curve. The error analysis gives an uncertainty of 5% without the HD correction. An improved result of approximately 3% is found when an HD correction is applied to the analysis.

CONCLUSIONS

A simple Epson scanner satisfies the commissioning standards for TSEB when an HD curve correction is applied.

Diagnostic accuracy of rapid phIGFBP-I assay for predicting preterm labor in symptomatic patients

OBJECTIVE

To estimate sensitivity, specificity, positive and negative predictive values (PPV, NPV) of insulin-like growth factor binding protein-1 (phIGFBP-1) test in predicting preterm delivery in women with symptoms of preterm labor. Secondary objectives were to compare test characteristics of the phIGFBP-1 and fetal fibronectin (fFN) tests.

STUDY DESIGN

Labor and delivery units in two Calgary hospitals. Subjects were 349 women with suspected labor between 24 and 35 weeks gestational age (GA). Women had cervical phIGFBP-1 test +/- and fFN testing. Sensitivity, specificity, PPV and NPV were estimated. Primary outcome was birth <37 weeks GA.

RESULT

Sensitivity of phIGFBP-1 test for delivery <37 weeks was 0.39; specificity, 0.76; PPV, 0.24; NPV, 0.86. NPV of phIGFBP-1 did not differ greatly from that of fFN testing (0.88).

CONCLUSION

NPV did not differ between phIGFBP-1 and fFN for delivery <37 weeks. Neither test improves on pretest probability of delivery <37 weeks, so clinicians must decide whether the use of either test is justified.