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Luo XP, Peng J, Zhou L, Liao H, Jiang XC, Tang X, Tang D, Liu C, Liu JH. Intramedullary administration of tranexamic acid reduces bleeding in proximal femoral nail antirotation surgery for intertrochanteric fractures in elderly individuals: A randomized controlled trial. Chin J Traumatol 2024:S1008-1275(24)00006-3. [PMID: 38429175 DOI: 10.1016/j.cjtee.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Intertrochanteric fractures undergoing proximal femoral nail antirotation (PFNA) surgery are associated with significant hidden blood loss. This study aimed to explore whether intramedullary administration of tranexamic acid (TXA) can reduce bleeding in PFNA surgery for intertrochanteric fractures in elderly individuals. METHODS A randomized controlled trial was conducted from January 2019 to December 2022. Patients aged over 60 years with intertrochanteric fractures who underwent intramedullary fixation surgery with PFNA were eligible for inclusion and grouped according to random numbers. A total of 249 patients were initially enrolled, of which 83 were randomly allocated to the TXA group and 82 were allocated to the saline group. The TXA group received intramedullary perfusion of TXA after the bone marrow was reamed. The primary outcomes were total peri-operative blood loss and post-operative transfusion rate. The occurrence of adverse events was also recorded. Continuous data was analyzed by unpaired t-test or Mann-Whitney U test, and categorical data was analyzed by Pearson Chi-square test. RESULTS The total peri-operative blood loss (mL) in the TXA group was significantly lower than that in the saline group (577.23 ± 358.02 vs. 716.89 ± 420.30, p = 0.031). The post-operative transfusion rate was 30.67 % in the TXA group and 47.95 % in the saline group (p = 0.031). The extent of post-operative deep venous thrombosis and the 3-month mortality rate were similar between the 2 groups. CONCLUSION We observed that intramedullary administration of TXA in PFNA surgery for intertrochanteric fractures in elderly individuals resulted in less peri-operative blood loss and decreased transfusion rate, without any adverse effects, and is, thus, recommended.
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Affiliation(s)
- Xiang-Ping Luo
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China.
| | - Jian Peng
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Ling Zhou
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Hao Liao
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Xiao-Chun Jiang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Xiong Tang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Dun Tang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Chao Liu
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Jian-Hui Liu
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
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Cleveland B, Norling B, Wang H, Gandhi V, Price CL, Borofsky MS, Pais V, Dahm P. Tranexamic acid for percutaneous nephrolithotomy. Cochrane Database Syst Rev 2023; 10:CD015122. [PMID: 37882229 PMCID: PMC10600962 DOI: 10.1002/14651858.cd015122.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings. OBJECTIVES To assess the effects of TXA in individuals with kidney stones undergoing PCNL. SEARCH METHODS We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs). MAIN RESULTS We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm2. We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I2 = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I2 = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I2 = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I2 = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I2 = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I2 = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I2 = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I2 = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I2 = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days. AUTHORS' CONCLUSIONS Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
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Affiliation(s)
- Brent Cleveland
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Brett Norling
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Hill Wang
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Carrie L Price
- Albert S. Cook Library, Towson University, Towson, Maryland, USA
| | - Michael S Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vernon Pais
- Department of Surgery, Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Tripathi V, Rai O, Shaykh N, Patel F, Reddy P. Role of Tranexamic Acid in Palliative Control of Bleeding in End-Stage Head and Neck Cancer: A Case Report. Cureus 2023; 15:e45534. [PMID: 37868581 PMCID: PMC10586072 DOI: 10.7759/cureus.45534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Tumor-related bleeding is a common manifestation of end-stage head and neck cancer, and it can have a significant impact on a patient's quality of life. Tranexamic acid is an anti-fibrinolytic agent that has been shown to effectively control bleeding and reduce the need for transfusions in various hemorrhagic conditions. Here, we present the case of a patient with end-stage head and neck cancer experiencing recurrent episodes of bleeding, who was able to successfully achieve hemostasis after being treated with tranexamic acid. This case report highlights the role of tranexamic acid as a palliation agent that can help control the unpleasant bleeding symptoms of end-stage head and neck cancer and provide a better quality of life for patients.
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Affiliation(s)
- Vanshika Tripathi
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Oshin Rai
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Natalie Shaykh
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Falguni Patel
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Pramod Reddy
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence). It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence). We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect. Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants). All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration). We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2023:S2173-5808(23)00008-1. [PMID: 37031799 DOI: 10.1016/j.nrleng.2020.08.024] [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: 02/17/2020] [Accepted: 08/04/2020] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- César E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA.
| | - Nadxielli Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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Safety and clinical outcomes associated with the routine use of tranexamic acid (TXA) in abdominal-based free flap autologous breast reconstruction — a case control study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02027-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Bouras M, Asehnoune K, Roquilly A. Immune modulation after traumatic brain injury. Front Med (Lausanne) 2022; 9:995044. [PMID: 36530909 PMCID: PMC9751027 DOI: 10.3389/fmed.2022.995044] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/14/2022] [Indexed: 07/20/2023] Open
Abstract
Traumatic brain injury (TBI) induces instant activation of innate immunity in brain tissue, followed by a systematization of the inflammatory response. The subsequent response, evolved to limit an overwhelming systemic inflammatory response and to induce healing, involves the autonomic nervous system, hormonal systems, and the regulation of immune cells. This physiological response induces an immunosuppression and tolerance state that promotes to the occurrence of secondary infections. This review describes the immunological consequences of TBI and highlights potential novel therapeutic approaches using immune modulation to restore homeostasis between the nervous system and innate immunity.
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Affiliation(s)
- Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
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Karanicolas PJ, Lin Y, McCluskey S, Roke R, Tarshis J, Thorpe KE, Ball CG, Chaudhury P, Cleary SP, Dixon E, Eeson G, Moulton CA, Nanji S, Porter G, Ruo L, Skaro AI, Tsang M, Wei AC, Guyatt G. Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial. BMJ Open 2022; 12:e058850. [PMID: 35210348 PMCID: PMC8883280 DOI: 10.1136/bmjopen-2021-058850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched. METHODS AND ANALYSIS This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival. ETHICS AND DISSEMINATION This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT02261415.
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Affiliation(s)
- Paul Jack Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Roke
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elijah Dixon
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gareth Eeson
- Department of Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Geoff Porter
- Department of Surgery, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leyo Ruo
- Department of Surgery, Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
- Deparment of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anton I Skaro
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melanie Tsang
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Thromboelastography is predictive of mortality, blood transfusions, and blood loss in patients with traumatic pelvic fractures: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:345-350. [PMID: 33175987 PMCID: PMC8371986 DOI: 10.1007/s00068-020-01533-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE In patients with traumatic pelvic fractures, thromboelastography (TEG) is a useful tool to rapidly evaluate and identify coagulation disturbances. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss. METHODS A retrospective review at our Level-1 trauma center was conducted to identify Full Trauma Team activations (FTTa) with traumatic pelvic and/or acetabular fractures who were evaluated with a TEG on initial presentation between 2012 and 2016. In-hospital mortality, product transfusion, and hemoglobin changes were analyzed. Subgroup analysis was performed based on pelvic fracture type. RESULTS 141 patients with a mean age of 49.0 ± 20.8 years and mean Injury Severity Score (ISS) of 25.18 ± 12.8 met inclusion criteria. PRBC transfusion occurred in 78.0% of patients; a total of 1486 blood products were transfused. A total of 65 patients (46.1%) underwent operative treatment for the pelvic injuries, and 18 patients (12.7%) required embolization. The overall in-hospital mortality rate was 14.9%. The degree of clot lysis at 30 min (LY30) was significantly associated with blood loss (p < 0.0001), units of packed red blood cells (PRBCs) transfused (p < 0.0001), and mortality rate (p = 0.0002). CONCLUSION Increased fibrinolysis evidenced by an elevated LY30 on initial TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and mortality. Future studies should evaluate the clinical utility of reversing hyperfibrinolysis on initial TEG. LEVEL OF EVIDENCE Prognostic level III.
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10
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Jiao X, Li M, Li L, Hu X, Guo X, Lu Y. Early Tranexamic Acid in Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2021; 12:721125. [PMID: 34938253 PMCID: PMC8685213 DOI: 10.3389/fneur.2021.721125] [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] [Received: 06/06/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Intracranial hemorrhage (ICH) is a common complication of traumatic brain, in which tranexamic acid has been recommended as an additional therapy to prevent a second bleeding. However, the effect of early administration of tranexamic acid for ICH patients remains controversial. Methods: A systematic search was performed in Cochrane Library, Medline, Embase, and Web of Science. Poor outcome refers to significant hemorrhage growth, new intracranial hemorrhage, new focal cerebral ischaemic lesions, the need for neurosurgery, or death. Study heterogeneity and publication bias were estimated. Results: Seven randomized controlled trials involving 3,192 participants were included in our meta-analysis. Tranexamic acid administration in ICH patients was associated with better outcomes of hematoma expansion (odd ratios [OR] 0.79; 95% confidence interval (CI) CI, 0.67–0.93; I2 = 0%; P = 0.006) and growth of hemorrhagic lesions (weighted mean difference [WMD], −1.97 ml; 95% CI, −2.94 to −1.00; I2 = 14%; P < 0.001) than the placebo. No difference was found between the mortality, poor outcome, neurosurgical intervention, new bleeding, and the duration of hospital stay. Moreover, no publication bias was found. Conclusion: Our analysis reveals that the early treatment with tranexamic acid can significantly reduce the incidence of hematoma expansion and the volume of hemorrhagic lesion, but does not exert considerable effects on mortality, poor outcome, neurosurgery, rebleeding, and the duration of stay.
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Affiliation(s)
- Xu Jiao
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mingfei Li
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lulu Li
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyu Hu
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaohui Guo
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yun Lu
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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11
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Gibson BHY, Wollenman CC, Moore-Lotridge SN, Keller PR, Summitt JB, Revenko AR, Flick MJ, Blackwell TS, Schoenecker JG. Plasmin drives burn-induced systemic inflammatory response syndrome. JCI Insight 2021; 6:154439. [PMID: 34877937 PMCID: PMC8675186 DOI: 10.1172/jci.insight.154439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Severe injuries, such as burns, provoke a systemic inflammatory response syndrome (SIRS) that imposes pathology on all organs. Simultaneously, severe injury also elicits activation of the fibrinolytic protease plasmin. While the principal adverse outcome of plasmin activation in severe injury is compromised hemostasis, plasmin also possesses proinflammatory properties. We hypothesized that, following a severe injury, early activation of plasmin drives SIRS. Plasmin activation was measured and related to injury severity, SIRS, coagulopathy, and outcomes prospectively in burn patients who are not at risk of hemorrhage. Patients exhibited early, significant activation of plasmin that correlated with burn severity, cytokines, coagulopathy, and death. Burn with a concomitant, remote muscle injury was employed in mice to determine the role of plasmin in the cytokine storm and inflammatory cascades in injured tissue distant from the burn injury. Genetic and pharmacologic inhibition of plasmin reduced the burn-induced cytokine storm and inflammatory signaling in injured tissue. These findings demonstrate (a) that severe injury-induced plasmin activation is a key pathologic component of the SIRS-driven cytokine storm and SIRS-activated inflammatory cascades in tissues distant from the inciting injury and (b) that targeted inhibition of plasmin activation may be effective for limiting both hemorrhage and tissue-damaging inflammation following injury.
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Affiliation(s)
| | - Colby C Wollenman
- School of Medicine.,Department of Orthopaedic Surgery, Vanderbilt University Medical Center
| | - Stephanie N Moore-Lotridge
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center.,Vanderbilt Center for Bone Biology
| | | | - J Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center; and.,Vanderbilt University Medical Center Burn Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Alexey R Revenko
- IONIS Pharmaceuticals Pulmonary and Oncology Drug Discovery, Carlsbad, California, USA
| | - Matthew J Flick
- Department of Pathology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA.,University of North Carolina Blood Research Center, Chapel Hill, North Carolina, USA
| | - Timothy S Blackwell
- Department of Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA.,Division of Pulmonary and Critical Care
| | - Jonathan G Schoenecker
- Department of Pharmacology.,Department of Orthopaedic Surgery, Vanderbilt University Medical Center.,Vanderbilt Center for Bone Biology.,Department of Pathology, Microbiology, and Immunology; and.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Lima LPDST, Santos PRS, Martins HJ, Rodrigues DADS, Silva LM, Libardi MBO, Azevedo NAM. Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report. Air Med J 2021; 40:359-362. [PMID: 34535245 DOI: 10.1016/j.amj.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/28/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
This study describes the use of tranexamic acid associated with other measures in the initial approach to contain bleeding in a situation of hemorrhagic shock in a trauma patient. The case describes the care of a young man with multiple thorax punctures by a melee weapon, quickly progressing to a condition of severe shock, in addition to the action of a helicopter emergency medical team supporting the patient's transportation from a low-complexity emergency care unit to a specialized unit.
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Affiliation(s)
- Lilyan Paula de Sousa Teixeira Lima
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Paulo Regis Souza Santos
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Herberth Jessie Martins
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Daniel Augusto de Souza Rodrigues
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Larissa Michetti Silva
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Trauma Center of the Federal District, Brasília, Brazil.
| | - Mônica Beatriz Ortolan Libardi
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
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13
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Aprato A, Nardi M, Arduini M, Bove F, Branca Vergano L, Capitani D, Casiraghi A, Cavanna M, Cominetti G, Commessatti M, Favuto M, Ferreli A, Fino A, Gulli S, Lamponi F, Massè A, Mezzadri U, Monesi M, Oransky M, Pannella A, Santolini F, Stella M, Tigani D, Zoccola K, Rocca G. Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021290. [PMID: 34487106 PMCID: PMC8477087 DOI: 10.23750/abm.v92i4.9856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 11/25/2022]
Abstract
Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.
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Affiliation(s)
| | - Michele Nardi
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino.
| | - Mario Arduini
- Policlinico Tor Vergata, Viale Oxford, 81, 00133, Roma.
| | | | | | | | | | | | - Gabriele Cominetti
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino.
| | | | - Marco Favuto
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino.
| | | | - Alberto Fino
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino.
| | | | | | - Alessandro Massè
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino.
| | | | | | | | | | | | | | | | - Kristijan Zoccola
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino.
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14
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Myers SP, Neal MD. Venous thromboembolism after tranexamic acid administration: legitimate risk or statistical confounder? ANZ J Surg 2021; 90:425-426. [PMID: 32339430 DOI: 10.1111/ans.15670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Sara P Myers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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15
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Yamakawa Y, Morioka M, Negoto T, Orito K, Yoshitomi M, Nakamura Y, Takeshige N, Yamamoto M, Takeuchi Y, Oda K, Jono H, Saito H. A novel step-down infusion method of barbiturate therapy: Its safety and effectiveness for intracranial pressure control. Pharmacol Res Perspect 2021; 9:e00719. [PMID: 33617150 PMCID: PMC7899213 DOI: 10.1002/prp2.719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/22/2020] [Indexed: 11/28/2022] Open
Abstract
Intracranial pressure (ICP) has to be maintained quite constant, because increased ICP caused by cerebrovascular disease and head trauma is fatal. Although controlling ICP is clinically critical, only few therapeutic methods are currently available. Barbiturates, a group of sedative-hypnotic drugs, are recognized as secondary treatment for controlling ICP. We proposed a novel "step-down infusion" method, administrating barbiturate (thiamylal) after different time point from the start of treatment under normothermia, at doses of 3.0 (0-24 h), 2.0 (24-48 h), 1.5 (48-72 h), and 1.0 mg/kg/h (72-96 h), and evaluated its safety and effectiveness in clinical. In 22 patients with severe traumatic brain injury or severe cerebrovascular disease (Glasgow coma scale ≤8), thiamylal concentrations and ICP were monitored. The step-down infusion method under normothermia maintained stable thiamylal concentrations (<26.1 µg/ml) without any abnormal accumulation/elevation, and could successfully keep ICP <20 mmHg (targeted management value: ICP <20 mmHg) in all patients. Moreover the mean value of cerebral perfusion pressure (CPP) was also maintained over 65 mmHg during all time course (targeted management value: CPP >65 mmHg), and no threatening changes in serum potassium or any hemodynamic instability were observed. Our novel "step-down infusion" method under normothermia enabled to maintain stable, safe thiamylal concentrations to ensure both ICP reduction and CPP maintenance without any serious side effects, may provide a novel and clinically effective treatment option for patients with increased ICP.
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Affiliation(s)
- Yukako Yamakawa
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Motohiro Morioka
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Tetsuya Negoto
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Kimihiko Orito
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Munetake Yoshitomi
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Yukihiko Nakamura
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Nobuyuki Takeshige
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Masafumi Yamamoto
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Yasuharu Takeuchi
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Kazutaka Oda
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hirofumi Jono
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hideyuki Saito
- Department of PharmacyKumamoto University HospitalKumamotoJapan
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16
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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17
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Yokobori S, Yatabe T, Kondo Y, Kinoshita K. Efficacy and safety of tranexamic acid administration in traumatic brain injury patients: a systematic review and meta-analysis. J Intensive Care 2020; 8:46. [PMID: 32637122 PMCID: PMC7333334 DOI: 10.1186/s40560-020-00460-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/11/2020] [Indexed: 12/29/2022] Open
Abstract
Background The exacerbation of intracranial bleeding is critical in traumatic brain injury (TBI) patients. Tranexamic acid (TXA) has been used to improve outcomes in TBI patient. However, the effectiveness of TXA treatment remains unclear. This study aimed to assess the effect of administration of TXA on clinical outcomes in patients with TBI by systematically reviewing the literature and synthesizing evidence of randomized controlled trials (RCTs). Methods MEDLINE, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi (ICHUSHI) Web were searched. Selection criteria included randomized controlled trials with clinical outcomes of adult TBI patients administered TXA or placebo within 24 h after admission. Two investigators independently screened citations and conducted data extraction. The primary “critical” outcome was all-cause mortality. The secondary “important” outcomes were good neurological outcome rates, enlargement of bleeding, incidence of ischemia, and hemorrhagic intracranial complications. Random effect estimators with weights calculated by the inverse variance method were used to report risk ratios (RRs). Results A total of 640 records were screened. Seven studies were included for quantitative analysis. Of 10,044 patients from seven of the included studies, 5076 were randomly assigned to the TXA treatment group, and 4968 were assigned to placebo. In the TXA treatment group, 914 patients (18.0%) died, while 961 patients (19.3%) died in the placebo group. There was no significant difference between groups (RR, 0.93; 95% confidence interval, 0.86–1.01). No significant differences between the groups in other important outcomes were also observed. Conclusions TXA treatment demonstrated a tendency to reduce head trauma-related deaths in the TBI population, with no significant incidence of thromboembolic events. TXA treatment may therefore be suggested in the initial TBI care.
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Affiliation(s)
- Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kosaku Kinoshita
- Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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18
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Abstract
Neurosurgical procedures are unique in that the best monitoring modality is the neurologic examination and the most important sign includes an intact mental status. Anesthesiologists play a vital role in medical management of neurosurgical emergencies. The authors discuss the important management strategies for these emergencies, including increased intracranial pressure and impending brain herniation, acute alteration of mental status, status epilepticus, and trauma to cervical spine. The key is to maintain cerebral and spinal cord perfusion pressure at all times to salvage neuronal recovery.
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Affiliation(s)
- Shilpa Rao
- Department of Anesthesiology, Yale School of Medicine and Yale New Haven Hospital, 333 Cedar Street, TMP 3, PO Box 208051, New Haven, CT 06520-8051, USA.
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic Foundation, 9500 Euclid Avenue # E31, Cleveland, OH 44195, USA
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19
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Davis S, Nawab A, van Nispen C, Pourmand A. The Role of Tranexamic Acid in the Management of an Acutely Hemorrhaging Patient. Hosp Pharm 2020; 56:350-358. [PMID: 34381274 DOI: 10.1177/0018578720906613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Acute hemorrhage, both traumatic and nontraumatic, leads to significant morbidity and mortality, both in the United States and globally. Traditional treatment of acute hemorrhage is focused on hemostasis and blood product replacement. Tranexamic acid is an antifibrinolytic agent that may reduce acute hemorrhage through inhibition of plasminogen. Newer research suggests that coagulopathy, specifically fibrinolysis, may contribute significantly to the pathology of acute hemorrhage. Methods: We searched the PubMed database for relevant articles from 2000 to 2018 for the terms "tranexamic acid," "TXA," "antifibrinolytic," "hyperfibrinolysis," and "coagulopathy." Our search was limited to studies published in the English language. Results: A total of 53 studies were included in this review. These articles suggest a potential role for tranexamic acid in the management of acute intracranial hemorrhage, epistaxis, hematuria, postpartum hemorrhage, gastrointestinal hemorrhage, and trauma-related hemorrhage. A theoretical risk of thrombotic events following tranexamic acid use exists, though large clinical trials suggest this risk remains exceedingly small. Conclusions: Recent studies suggest a mortality benefit with tranexamic acid following acute hemorrhage. First responders such as emergency medical technicians and emergency department clinicians should consider tranexamic acid as an adjunct therapy in the management of acute, severe traumatic and nontraumatic hemorrhage.
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Affiliation(s)
- Steven Davis
- The George Washington University, Washington, DC, USA
| | - Aria Nawab
- The George Washington University, Washington, DC, USA
| | | | - Ali Pourmand
- The George Washington University, Washington, DC, USA
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20
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Gibbs VN, Champaneria R, Novak A, Doree C, Palmer AJR, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation of hip, pelvic and long bone fractures: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Victoria N Gibbs
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Rita Champaneria
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Alex Novak
- John Radcliffe Hospital; Emergency Department; Headley Way Oxford Oxon UK OX39DU
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Antony JR Palmer
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; Botnar Research Centre Oxford Oxfordshire UK OX3 7LD
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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Song YJ, Dai CX, Li M, Cui MM, Ding X, Zhao XF, Wang CL, Li ZL, Guo MY, Fu YY, Wen XR, Qi DS, Wang YL. The potential role of HO-1 in regulating the MLK3-MKK7-JNK3 module scaffolded by JIP1 during cerebral ischemia/reperfusion in rats. Behav Brain Res 2019; 359:528-535. [PMID: 30412737 DOI: 10.1016/j.bbr.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 11/03/2018] [Accepted: 11/05/2018] [Indexed: 01/01/2023]
Abstract
Heme oxygenase (HO-1), which may be induced by Cobaltic protoporphyrin IX chloride (CoPPIX) or Rosiglitazone (Ros), is a neuroprotective agent that effectively reduces ischemic stroke. Previous studies have shown that the neuroprotective mechanisms of HO-1 are related to JNK signaling. The expression of HO-1 protects cells from death through the JNK signaling pathway. This study aimed to ascertain whether the neuroprotective effect of HO-1 depends on the assembly of the MLK3-MKK7-JNK3 signaling module scaffolded by JIP1 and further influences the JNK signal transmission through HO-1. Prior to the ischemia-reperfusion experiment, CoPPIX was injected through the lateral ventricle for 5 consecutive days or Ros was administered via intraperitoneal administration in the week prior to transient ischemia. Our results demonstrated that HO-1 could inhibit the assembly of the MLK3-MKK7-JNK3 signaling module scaffolded by JIP1 and could ultimately diminish the phosphorylation of JNK3. Furthermore, the inhibition of JNK3 phosphorylation downregulated the level of p-c-Jun and elevated neuronal cell death in the CA1 of the hippocampus. Taken together, these findings suggested that HO-1 could ameliorate brain injury by regulating the MLK3-MKK7-JNK3 signaling module, which was scaffolded by JIP1 and JNK signaling during cerebral ischemia/reperfusion.
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Affiliation(s)
- Yuan-Jian Song
- Jiangsu Key Laboratory of Brain Disease Bioinformatics, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China; Department of Genetics, Research Facility Center for Morphology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Chun-Xiao Dai
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Man Li
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Miao-Miao Cui
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Xin Ding
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Xiao-Fang Zhao
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Cai-Lin Wang
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Zhen-Ling Li
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Meng-Yuan Guo
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Yan-Yan Fu
- Jiangsu Key Laboratory of Brain Disease Bioinformatics, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China; Department of Genetics, Research Facility Center for Morphology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Xiang-Ru Wen
- Jiangsu Key Laboratory of Brain Disease Bioinformatics, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China; School of Basic Education Science, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China.
| | - Da-Shi Qi
- Jiangsu Key Laboratory of Brain Disease Bioinformatics, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China; Department of Genetics, Research Facility Center for Morphology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China.
| | - Yu-Lan Wang
- Jiangsu Key Laboratory of Brain Disease Bioinformatics, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China; Department of Anatomy, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China.
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Hong X, Lin J, Gu W. Risk factors and therapies in vascular diseases: An umbrella review of updated systematic reviews and meta‐analyses. J Cell Physiol 2018; 234:8221-8232. [PMID: 30317627 DOI: 10.1002/jcp.27633] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/27/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Xing‐yu Hong
- Department of Vascular Surgery China‐Japan Union Hospital of JiLin University ChangChun China
| | - Jie Lin
- Department of Vascular Surgery China‐Japan Union Hospital of JiLin University ChangChun China
| | - Wei‐wei Gu
- Department of Hepatopancreatobility Surgery China‐Japan Union Hospital of JiLin University ChangChun China
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Synnot A, Bragge P, Lunny C, Menon D, Clavisi O, Pattuwage L, Volovici V, Mondello S, Cnossen MC, Donoghue E, Gruen RL, Maas A. The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map. PLoS One 2018; 13:e0198676. [PMID: 29927963 PMCID: PMC6013193 DOI: 10.1371/journal.pone.0198676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). METHODS We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). FINDINGS We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. CONCLUSION A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.
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Affiliation(s)
- Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Consumers and Communication, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Carole Lunny
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke’s Hospital; Queens’ College, Cambridge, United Kingdom
| | - Ornella Clavisi
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- MOVE: Muscle, Bone and Joint Health Ltd, Melbourne, Victoria, Australia
| | - Loyal Pattuwage
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Maryse C. Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma Donoghue
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Russell L. Gruen
- Nanyang Technical University, Singapore
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Definition of Traumatic Brain Injury, Neurosurgery, Trauma Orthopedics, Neuroimaging, Psychology, and Psychiatry in Mild Traumatic Brain Injury. Neuroimaging Clin N Am 2018; 28:1-13. [DOI: 10.1016/j.nic.2017.09.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Flaherty K, Bath PM, Dineen R, Law Z, Scutt P, Pocock S, Sprigg N. Statistical analysis plan for the 'Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage' (TICH-2) trial. Trials 2017; 18:607. [PMID: 29262841 PMCID: PMC5738041 DOI: 10.1186/s13063-017-2341-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/09/2017] [Indexed: 11/10/2022] Open
Abstract
RATIONALE Aside from blood pressure lowering, treatment options for intracerebral haemorrhage remain limited and a proportion of patients will undergo early haematoma expansion with resultant significant morbidity and mortality. Tranexamic acid (TXA), an anti-fibrinolytic drug, has been shown to significantly reduce mortality in patients, who are bleeding following trauma, when given rapidly. TICH-2 is testing whether TXA is effective at improving outcome in spontaneous intracerebral haemorrhage (SICH). METHODS AND DESIGN TICH-2 is a pragmatic, phase III, prospective, double-blind, randomised placebo-controlled trial. Two thousand adult (aged ≥ 18 years) patients with an acute SICH, within 8 h of stroke onset, will be randomised to receive TXA or the placebo control. The primary outcome is ordinal shift of modified Rankin Scale score at day 90. Analyses will be performed using intention-to-treat. RESULTS This paper and its attached appendices describe the statistical analysis plan (SAP) for the trial and were developed and published prior to database lock and unblinding to treatment allocation. The SAP includes details of analyses to be undertaken and unpopulated tables which will be reported in the primary and key secondary publications. The database will be locked in early 2018, ready for publication of the results later in the same year. DISCUSSION The SAP details the analyses that will be done to avoid bias arising from prior knowledge of the study findings. The trial will determine whether TXA can improve outcome after SICH, which currently has no definitive therapy. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN93732214 . Registered on 17 January 2013.
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Affiliation(s)
- Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Robert Dineen
- Imaging Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zhe Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - on behalf of the TICH-2 investigators
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
- Imaging Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
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27
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Marehbian J, Muehlschlegel S, Edlow BL, Hinson HE, Hwang DY. Medical Management of the Severe Traumatic Brain Injury Patient. Neurocrit Care 2017; 27:430-446. [PMID: 28573388 PMCID: PMC5700862 DOI: 10.1007/s12028-017-0408-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Severe traumatic brain injury (sTBI) is a major contributor to long-term disability and a leading cause of death worldwide. Medical management of the sTBI patient, beginning with prehospital triage, is aimed at preventing secondary brain injury. This review discusses prehospital and emergency department management of sTBI, as well as aspects of TBI management in the intensive care unit where advances have been made in the past decade. Areas of emphasis include intracranial pressure management, neuromonitoring, management of paroxysmal sympathetic hyperactivity, neuroprotective strategies, prognostication, and communication with families about goals of care. Where appropriate, differences between the third and fourth editions of the Brain Trauma Foundation guidelines for the management of severe traumatic brain injury are highlighted.
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Affiliation(s)
- Jonathan Marehbian
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care, and Surgery, University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
| | - Brian L Edlow
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, 55 Fruit Street - Lunder 650, Boston, MA, 02114, USA
| | - Holly E Hinson
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA.
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Abstract
Traumatic brain injury remains a serious public health problem, causing death and disability for millions. In order to maximize outcomes in the face of a complex injury to a complex organ, a variety of advanced neuromonitoring techniques may be used to guide surgical and medical decision-making. Because of the heterogeneity of injury types and the plethora of treatment confounders present in this patient population, the scientific study of specific interventions is challenging. This challenge highlights the need for a firm understanding of the anatomy and pathophysiology of brain injuries when making clinical decisions in the intensive care unit.
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Attenuation of hemorrhage-associated lung injury by adjuvant treatment with C23, an oligopeptide derived from cold-inducible RNA-binding protein. J Trauma Acute Care Surg 2017; 83:690-697. [PMID: 28930962 DOI: 10.1097/ta.0000000000001566] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Hemorrhagic shock (HS) is an important cause of mortality. HS is associated with an elevated incidence of acute lung injury and acute respiratory distress syndrome, significantly contributing to HS morbidity and mortality. Cold-inducible RNA-binding protein (CIRP) is released into the circulation during HS and can cause lung injury. C23 is a CIRP-derived oligopeptide that binds with high affinity to the CIRP receptor and inhibits CIRP-induced phagocyte secretion of TNF-α. This study was designed to determine whether C23 is able to attenuate HS-associated lung injury. METHODS C57BL/6 mice were subjected to controlled hemorrhage leading to a mean arterial pressure of 25 ± 3 mm Hg for 90 minutes. Mice were then volume-resuscitated for 30 minutes with normal saline solution alone (vehicle) or plus adjuvant treatment with C23 (8 mg/kg BW). At 4.5 hours after resuscitation, the blood and lungs were harvested. RESULTS Serum levels of organ injury markers lactate dehydrogenase, aspartate aminotransferase were significantly elevated in hemorrhaged mice receiving vehicle and were reduced by 51.3% and 52.2% in mice adjuvantly treated with C23, respectively. Similarly, lung mRNA levels of IL-1β, TNF-α, and IL-6, and lung myeloperoxidase activity were elevated after HS and reduced by 66.1%, 54.4%, 69.7%, and 24.3%, respectively, in mice treated with C23. Adjuvant treatment with C23 also decreased the lung histology score by 33.9%, lung extravasation of albumin carrying Evans blue dye by 36.8%, and the protein level of intercellular adhesion molecule-1, and indicator of vascular endothelial cell activation, by 40.3%. CONCLUSION Together, these results indicate that adjuvant treatment with the CIRP-derived oligopeptide C23 is able to improve lung inflammation and vascular endothelial activation secondary to HS, lending support to the development of CIRP-targeting adjuvant treatments to minimize lung injury after HS.
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Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in patients with trauma. Management strategies must focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow. CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both. The goal should be euvolemia and avoidance of hypotension. Other factors that deserve important consideration in the acute management of patients with TBI are venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization.
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Affiliation(s)
- Michael A. Vella
- Chief Resident in General Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Medical Center North, CCC-4312, 1161 21st Avenue South, Nashville, TN 37232-2730,
| | - Marie Crandall
- Professor of Surgery, Division of Acute Care Surgery, Department of Surgery, University of Florida, Jacksonville, 655 West 8th Street, Jacksonville, FL 32209,
| | - Mayur B. Patel
- Assistant Professor of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Section of Surgical Sciences, Center for Health Services Research, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 21 Avenue South, Medical Arts Building, Suite 404, Nashville, TN 37212,
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31
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Pinto MA, Silva JGD, Chedid AD, Chedid MF. USE OF TRANEXAMIC ACID IN TRAUMA PATIENTS: AN ANALYSIS OF COST-EFFECTIVENESS FOR USE IN BRAZIL. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:282-286. [PMID: 28076488 PMCID: PMC5225873 DOI: 10.1590/0102-6720201600040017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/16/2016] [Indexed: 11/30/2022]
Abstract
Introduction: Use of tranexamic acid (TXA) in trauma has been the subject of growing interest by researchers and health professionals. However, there are still several open questions regarding its use. In some aspects medical literature is controversial. The points of disagreement among experts include questions such as: Which patients should receive TXA in trauma? Should treatment be performed in the pre-hospital environment? Is there any need for laboratory parameters before starting TXA treatment? What is the drug safety profile? The main issue on which there is still no basis in literature is: What is the indication for treatment within massive transfusion protocols? Objective: Answer the questions proposed based on critical evaluation of the evidence gathered so far and carry out a study of cost-effectiveness of TXA use in trauma adapted to the Brazilian reality. Methods: A literature review was performed through searching Pubmed.com, Embase and Cab Abstract by headings "tranexamic AND trauma", in all languages, yielding 426 articles. Manuscripts reporting on TXA utilization for elective procedures were excluded, remaining 79 articles. Fifty-five articles were selected, and critically evaluated in order to answer study questions. The evaluation of cost effectiveness was performed using CRASH-2 trial data and Brazilian official population data. Results: TXA is effective and efficient, and should be administered to a wide range of patients, including those with indication evaluated in research protocols and current indication criteria for TXA should be expanded. As for the cost-effectiveness, the TXA proved to be cost-effective with an average cost of R$ 61.35 (currently US$16) per year of life saved. Conclusion: The use of TXA in trauma setting seems to be effective, efficient and cost-effective in the various groups of polytrauma patients. Its use in massive transfusion protocols should be the subject of further investigations.
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Affiliation(s)
- Marcelo A Pinto
- Division of General and Trauma Surgery, Hospital de Pronto Socorro Municipal de Porto Alegre.,Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
| | - Jair G da Silva
- Division of General and Trauma Surgery, Hospital de Pronto Socorro Municipal de Porto Alegre.,Kidney Transplantation Group, Hospital Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Aljamir D Chedid
- Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
| | - Marcio F Chedid
- Division of Gastrointestinal Surgery and Liver and Pancreas Transplantation, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul
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Czosnyka M, Pickard J, Steiner L. Principles of intracranial pressure monitoring and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:67-89. [DOI: 10.1016/b978-0-444-63600-3.00005-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
BACKGROUND Haemoptysis is a common pathology around the world, occurring with more frequency in low-income countries. It has different etiologies, many of which have infectious characteristics. Antifibrinolytic agents are commonly used to manage bleeding from different sources, but their usefulness in pulmonology is unclear. OBJECTIVES To evaluate the effectiveness and safety of antifibrinolytic agents in reducing the volume and duration of haemoptysis in adult and paediatric patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, EMBASE and LILACS for publications that describe randomized controlled trials (RCTs) of antifibrinolytic therapy in patients presenting with haemoptysis. We also performed an independent search in MEDLINE for relevant trials not yet included in CENTRAL or DARE. Searches are up to date to the 19th September 2016. We conducted electronic and manual searches of relevant national and international journals. We reviewed the reference lists of included studies to locate relevant randomized controlled trials (RCTs). An additional search was carried out to find unpublished RCTs. SELECTION CRITERIA We included RCTs designed to evaluate the effectiveness and safety of antifibrinolytic agents in reducing haemoptysis in adult and paediatric patients of both genders presenting with haemoptysis of any etiology and severity. The intervention of interest was the administration of antifibrinolytic agents compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS All reviewers independently assessed methodological quality and extracted data tables pre-designed for this review. MAIN RESULTS The electronic literature search identified 1 original study that met the eligibility criteria. One unpublished study was also identified through manual searches. Therefore two randomized controlled trials met the inclusion criteria: Tscheikuna 2002 (via electronic searches) and Ruiz 1994 (via manual searches). Tscheikuna 2002, a double-blind RCT performed in Thailand, evaluated the effectiveness of tranexamic acid (TXA, an antifibrinolytic agent) administered orally in 46 hospital in- and outpatients with haemoptysis of various etiologies. Ruiz 1994, a double-blind RCT performed in Peru, evaluated the effectiveness of intravenous TXA in 24 hospitalised patients presenting with haemoptysis secondary to tuberculosis.Pooled together, results demonstrated a significant reduction in bleeding time between patients receiving TXA and patients receiving placebo with a weighted mean difference (WMD) of -19.47 (95% CI -26.90 to -12.03 hours), but with high heterogeneity (I² = 52%). TXA did not affect remission of haemoptysis evaluated at seven days after the start of treatment. Adverse effects caused by the drug's mechanism of action were not reported. There was no significant difference in the incidence of mild side effects between active and placebo groups (OR 3.13, 95% CI 0.80 to 12.24). AUTHORS' CONCLUSIONS There is insufficient evidence to judge whether antifibrinolytics should be used to treat haemoptysis from any cause, though limited evidence suggests they may reduce the duration of bleeding.
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Affiliation(s)
- Gabriela Prutsky
- Mayo ClinicKnowledge and Evaluation Research Unit200 First Street SWRochesterMinnesotaUSAMN 55905
- CONEVID, Unidad de conocimiento y evidencia, Cayetano Heredia Peruvian UniversityLimaPeru
| | - Juan Pablo Domecq
- CONEVID, Unidad de conocimiento y evidencia, Cayetano Heredia Peruvian UniversityLimaPeru
- Henry Ford Health SystemDepartment of Internal MedicineDetroitMichiganUSA48202
| | - Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaPeru
| | - Roberto Accinelli
- Departamento de Medicina, Universidad Peruana Cayetano Heredia and Hospital Nacional Cayetano HerediaLaboratorio de Respiración of the Instituto de Investigaciones de la AlturaAv. Honorio Delgado 262 SMPLimaPeru
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Abstract
Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.
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Morita T, Shibuta S, Kosaka J, Fujino Y. Thiopental sodium preserves the responsiveness to glutamate but not acetylcholine in rat primary cultured neurons exposed to hypoxia. J Neurol Sci 2016; 365:126-31. [PMID: 27206889 DOI: 10.1016/j.jns.2016.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/17/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
Although many in vitro studies demonstrated that thiopental sodium (TPS) is a promising neuroprotective agent, clinical attempts to use TPS showed mainly unsatisfactory results. We investigated the neuroprotective effects of TPS against hypoxic insults (HI), and the responses of the neurons to l-glutamate and acetylcholine application. Neurons prepared from E17 Wistar rats were used after 2weeks in culture. The neurons were exposed to 12-h HI with or without TPS. HI-induced neurotoxicity was evaluated morphologically. Moreover, we investigated the dynamics of the free intracellular calcium ([Ca(2+)]i) in the surviving neurons after HI with or without TPS pretreatment following the application of neurotransmitters. TPS was neuroprotective against HI according to the morphological examinations (0.73±0.06 vs. 0.52±0.07, P=0.04). While the response to l-glutamate was maintained (0.89±0.08 vs. 1.02±0.09, P=0.60), the [Ca(2+)]i response to acetylcholine was notably impaired (0.59±0.02 vs. 0.94±0.04, P<0.01). Though TPS to cortical cultures was neuroprotective against HI morphologically, the [Ca(2+)]i response not to l-glutamate but to acetylcholine was impaired. This may partially explain the inconsistent results regarding the neuroprotective effects of TPS between experimental studies and clinical settings.
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Affiliation(s)
- Tomotaka Morita
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Satoshi Shibuta
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Jun Kosaka
- Center for Medical Science, International University of Health and Welfare, 2600-1 Kita-Kanemaru, Ohtawara, Tochigi 324-8501, Japan.
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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Nishijima DK, Monuteaux MC, Faraoni D, Goobie SM, Lee L, Galante J, Holmes JF, Kuppermann N. Tranexamic Acid Use in United States Children's Hospitals. J Emerg Med 2016; 50:868-874.e1. [PMID: 27017532 DOI: 10.1016/j.jemermed.2016.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/13/2016] [Accepted: 02/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of tranexamic acid (TXA) use for trauma and other conditions in children is unknown. OBJECTIVES The objective of this study was to describe the use of TXA in United States (US) children's hospitals for children in general, and specifically for trauma. METHODS We conducted a secondary analysis of a large, administrative database of 36 US children's hospitals. We included children <18 years of age who received TXA (based on pharmacy charge codes) between 2009 and 2013. Patients were grouped into the following diagnostic categories: trauma, congenital heart surgery, scoliosis surgery, craniosynostosis/craniofacial surgery, and other, based on the International Classification of Diseases, Ninth Revision principal procedure and diagnostic codes. TXA administration and dosage, in-hospital clinical variables, and diagnostic and procedure codes were documented. RESULTS A total of 35,478 pediatric encounters with a TXA charge were included in the study cohort. The proportions of children who received TXA were similar across the years 2009 to 2013. Only 110 encounters (0.31%) were for traumatic conditions. Congenital heart surgery accounted for more than one-half of the encounters (22,863; 64%). Overall, the median estimated weight-based dose of TXA was 22.4 mg/kg (interquartile range, 7.3-84.9 mg/kg). CONCLUSIONS We identified a wide frequency of use and range of doses of TXA for several diagnostic conditions in children. The use of TXA among injured children, however, appears to be rare despite its common use and efficacy among injured adults. Additional work is needed to identify appropriate indications for TXA and provide dosage guidelines among children with a variety of conditions, including trauma.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Michael C Monuteaux
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lois Lee
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph Galante
- Division of Trauma and Emergency Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, California
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California
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Panteli M, Pountos I, Giannoudis PV. Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma Emerg Surg 2015; 42:303-10. [PMID: 26660675 PMCID: PMC4886148 DOI: 10.1007/s00068-015-0613-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
Severe trauma and massive haemorrhage represent the leading cause of death and disability in patients under the age of 45 years in the developed world. Even though much advancement has been made in our understanding of the pathophysiology and management of trauma, outcomes from massive haemorrhage remain poor. This can be partially explained by the development of coagulopathy, acidosis and hypothermia, a pathological process collectively known as the “lethal triad” of trauma. A number of pharmacological adjuncts have been utilised to stop bleeding, with a wide variation in the safety and efficacy profiles. Antifibrinolytic agents in particular, act by inhibiting the conversion of plasminogen to plasmin, therefore decreasing the degree of fibrinolysis. Tranexamic acid, the most commonly used antifibrinolytic agent, has been successfully incorporated into most trauma management protocols effectively reducing mortality and morbidity following trauma. In this review, we discuss the current literature with regard to the management of haemorrhage following trauma, with a special reference to the use of pharmacological adjuncts. Novel insights, concepts and treatment modalities are also discussed.
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Affiliation(s)
- M Panteli
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| | - I Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Piggott RP, Leonard M. Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery? Ir J Med Sci 2015; 185:29-34. [PMID: 26560109 DOI: 10.1007/s11845-015-1375-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 10/17/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pelvic and acetabular fractures are rare, complex injuries associated with significant morbidity. Fixation of these injuries requires major orthopaedic surgery which in itself is associated with substantial blood loss owing to the extensile operative approach and prolonged operating time required to address the complex fracture anatomy. In order to reduce morbidity, a multifactor approach to blood conservation must be adopted. CURRENT ROLE OF ANTIFIBRINOLYTICS IN ORTHOPAEDIC SURGERY The use of antifibrinolytics to reduce operative blood loss is well documented in many surgical specialties, including orthopaedic surgery. Elective spinal surgery and joint arthroplasty have benefited from the introduction of antifibrinolytics; however, their role in trauma and fracture surgery is not fully defined. Pelvic and acetabular fracture surgery would benefit from further investigation on the benefit and safety of these agents. CONCLUSION Routine use cannot be recommended at this time but agents may be considered on a case-specific basis.
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Affiliation(s)
- R P Piggott
- Department of Trauma and Orthopaedics, The National Centre for the Treatment of Pelvic and Acetabular Fractures, The Adelaide and Meath Hospital Dublin, Incorporating The National Children's Hospital (AMNCH), Tallaght, Dublin 24, Ireland.
| | - M Leonard
- Department of Trauma and Orthopaedics, The National Centre for the Treatment of Pelvic and Acetabular Fractures, The Adelaide and Meath Hospital Dublin, Incorporating The National Children's Hospital (AMNCH), Tallaght, Dublin 24, Ireland
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Coagulation Parameters and Risk of Progressive Hemorrhagic Injury after Traumatic Brain Injury: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:261825. [PMID: 26457298 PMCID: PMC4589576 DOI: 10.1155/2015/261825] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/03/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022]
Abstract
Intracranial hemorrhage (ICH) after traumatic brain injury (TBI) commonly increases in size and coagulopathy has been implicated in such progression. Our aim is to perform a meta-analysis to assess their relationship. Cochrane library, PubMed, and EMBASE were searched for literatures. Pooled effect sizes and 95% confidential intervals (CIs) were calculated using random-effects model. We included six studies, involving 1700 participants with 540 progressive hemorrhagic injuries (PHIs). Our findings indicate that PT, D-dimer level, and INR value are positively associated with the risk of PHI. Higher level of PLT and Fg seemed to suggest a lower risk of PHI. Among these parameters, higher D-dimer level and INR value would possess more powerful strength in predicting PHI.
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Ker K, Roberts I. Exploring redundant research into the effect of tranexamic acid on surgical bleeding: further analysis of a systematic review of randomised controlled trials. BMJ Open 2015; 5:e009460. [PMID: 26303335 PMCID: PMC4550739 DOI: 10.1136/bmjopen-2015-009460] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We examined whether apparent redundancy in a cumulative meta-analysis of trials is justified by concern about bias, random error or generalisability of the results. DESIGN Cumulative meta-analysis, risk of bias assessment, trial sequential analysis, description of study participants over time and a review of rationales for conducting trials. DATA SOURCE 126 randomised trials included in a systematic review assessing of tranexamic acid on blood transfusion in surgery. RESULTS The cumulative meta-analysis including all trials shows that the pooled estimate first reached statistical significance after the second trial in 1993. When the analysis was limited to the 38 high-quality trials and adjusted to account for potential systematic and random errors, the uncertainty was resolved after the 22nd trial in 2008. When the analysis was restricted to the two high-quality, prospectively registered trials, the cumulative z-curve crossed p=0.05 but not the monitoring boundary, suggesting an early potentially spurious statistically significant result. As precision of the pooled estimate increased, the number of trials initiated increased, although trial activity appeared to move to other surgery types. Most (62%) reports cited at least one systematic review. Of 118 reports examined, concern about generalisability was the reason for initiating the trial in 60%. Other reasons were to address a question other than the effect on bleeding (26%) and to confirm previously observed results (4%). Unawareness of previous research was apparent in 4% trials, while the rationale was unclear in 3%. CONCLUSIONS Our results indicate that poor quality is a more important cause of redundant research than the failure to review existing evidence. Concerns about generalisability of results is the main motivation for new trials. Contrary to previous claims, our results suggest that systematic reviews showing treatment effects can stimulate an increase in trial activity rather than reduce it.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Abstract
BACKGROUND Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. OBJECTIVES To assess the effect of antifibrinolytic drugs in patients with acute traumatic injury. SEARCH METHODS We ran the most recent search in January 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), PubMed and clinical trials registries. SELECTION CRITERIA Randomised controlled trials of antifibrinolytic agents (aprotinin, tranexamic acid [TXA], epsilon-aminocaproic acid and aminomethylbenzoic acid) following acute traumatic injury. DATA COLLECTION AND ANALYSIS From the results of the screened electronic searches, bibliographic searches, and contacts with experts, two authors independently selected trials meeting the inclusion criteria, and extracted data. One review author assessed the risk of bias for key domains.Outcome measures included: mortality at end of follow-up (all-cause); adverse events (specifically vascular occlusive events [myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism] and renal failure); number of patients undergoing surgical intervention or receiving blood transfusion; volume of blood transfused; volume of intracranial bleeding; brain ischaemic lesions; death or disability.We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach. MAIN RESULTS Three trials met the inclusion criteria.Two trials (n = 20,451) assessed the effect of TXA. The larger of these (CRASH-2, n = 20,211) was conducted in 40 countries and included patients with a variety of types of trauma; the other (n = 240) restricted itself to those with traumatic brain injury (TBI) only.One trial (n = 77) assessed aprotinin in participants with major bony trauma and shock.The pooled data show that antifibrinolytic drugs reduce the risk of death from any cause by 10% (RR 0.90, 95% CI 0.85 to 0.96; P = 0.002) (quality of evidence: high). This estimate is based primarily on data from the CRASH-2 trial of TXA, which contributed 99% of the data.There is no evidence that antifibrinolytics have an effect on the risk of vascular occlusive events (quality of evidence: moderate), need for surgical intervention or receipt of blood transfusion (quality of evidence: high). There is no evidence for a difference in the effect by type of antifibrinolytic (TXA versus aprotinin) however, as the pooled analyses were based predominantly on trial data concerning the effects of TXA, the results can only be confidently applied to the effects of TXA. The effects of aprotinin in this patient group remain uncertain.There is some evidence from pooling data from one study (n = 240) and a subset of data from CRASH-2 (n = 270) in patients with TBI which suggest that TXA may reduce mortality although the estimates are imprecise, the quality of evidence is low, and uncertainty remains. Stronger evidence exists for the possibility of TXA reducing intracranial bleeding in this population. AUTHORS' CONCLUSIONS TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.
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Affiliation(s)
- Katharine Ker
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 186Keppel StreetLondonUKWC1E 7HT
| | - Ian Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 186Keppel StreetLondonUKWC1E 7HT
| | - Haleema Shakur
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
| | - Tim J Coats
- University of LeicesterEmergency Medicine Academic GroupInfirmary SquareLeicesterUKLE1 5WW
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Bridges EJ, McNeill MM. Trauma resuscitation and monitoring: military lessons learned. Crit Care Nurs Clin North Am 2015; 27:199-211. [PMID: 25981723 DOI: 10.1016/j.cnc.2015.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Over the past 13 years, the military health care system has made improvements that are associated with an unprecedented survival rate for severely injured casualties. Monitoring for indications of deterioration as the critically injured patient moves across the continuum of care is difficult given the limitations of routinely used vital signs. Research by both military and civilian researchers is revolutionizing monitoring, with an increased focus on noninvasive, continuous, dynamic measurements to provide earlier, more sensitive indications of the patient's perfusion status.
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Affiliation(s)
- Elizabeth J Bridges
- Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Box 357266, Seattle, WA 98195, USA.
| | - Margaret M McNeill
- University of Washington Medical Center, Seattle, WA, USA; Department of Professional and Clinical Development, Frederick Memorial Hospital, 400 West Seventh Street, Frederick, MD 21701, USA
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Abstract
Haemorrhage remains a major cause of potentially preventable deaths. Rapid transfusion of large volumes of blood products is required in patients with haemorrhagic shock which may lead to a unique set of complications. Recently, protocol based management of these patients using massive transfusion protocol have shown improved outcomes. This section discusses in detail both management and complications of massive blood transfusion.
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Affiliation(s)
- Vijaya Patil
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Madhavi Shetmahajan
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Low-, medium- and high-dose steroids with or without aminocaproic acid in adult hematopoietic SCT patients with diffuse alveolar hemorrhage. Bone Marrow Transplant 2014; 50:420-6. [PMID: 25531284 DOI: 10.1038/bmt.2014.287] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/31/2014] [Accepted: 11/07/2014] [Indexed: 02/08/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a poorly understood complication of transplantation carrying a high mortality. Patients commonly deteriorate and require intensive care unit (ICU) admission. Treatment with high-dose steroids and aminocaproic acid (ACA) has been suggested. The current study examined 119 critically ill adult hematopoietic transplant patients treated for DAH. Patients were subdivided into low-, medium- and high-dose steroid groups with or without ACA. All groups had similar baseline characteristics and severity of illness scores. Primary objectives were 30, 60, 100 day, ICU and hospital mortality. Overall mortality (n=119) on day 100 was high at 85%. In the steroids and ACA cohort (n=82), there were no significant differences in 30, 60, 100, day, ICU and hospital mortality between the dosing groups. In the steroids only cohort (n=37), the low-dose steroid group had a lower ICU and hospital mortality (P=0.02). Adjunctive treatment with ACA did not produce differences in outcomes. In the multivariate analysis, medium- and high-dose steroids were associated with a higher ICU mortality (P=0.01) as compared with the low-dose group. Our data suggest that treatment strategies may need to be reanalyzed to avoid potentially unnecessary and potentially harmful therapies.
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Bunn F, Trivedi D, Alderson P, Hamilton L, Martin A, Iliffe S. The impact of Cochrane Systematic Reviews: a mixed method evaluation of outputs from Cochrane Review Groups supported by the UK National Institute for Health Research. Syst Rev 2014; 3:125. [PMID: 25348511 PMCID: PMC4238314 DOI: 10.1186/2046-4053-3-125] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/13/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There has been a growing emphasis on evidence-informed decision-making in health care. Systematic reviews, such as those produced by the Cochrane Collaboration, have been a key component of this movement. The UK National Institute for Health Research (NIHR) Systematic Review Programme currently supports 20 Cochrane Review Groups (CRGs). The aim of this study was to identify the impacts of Cochrane reviews published by NIHR-funded CRGs during the years 2007-2011. METHODS We sent questionnaires to CRGs and review authors, interviewed guideline developers and used bibliometrics and documentary review to get an overview of CRG impact and to evaluate the impact of a sample of 60 Cochrane reviews. We used a framework with four categories (knowledge production, research targeting, informing policy development and impact on practice/services). RESULTS A total of 1,502 new and updated reviews were produced by the 20 NIHR-funded CRGs between 2007 and 2011. The clearest impacts were on policy with a total of 483 systematic reviews cited in 247 sets of guidance: 62 were international, 175 national (87 from the UK) and 10 local. Review authors and CRGs provided some examples of impact on practice or services, for example, safer use of medication, the identification of new effective drugs or treatments and potential economic benefits through the reduction in the use of unproven or unnecessary procedures. However, such impacts are difficult to objectively document, and the majority of reviewers were unsure if their review had produced specific impacts. Qualitative data suggested that Cochrane reviews often play an instrumental role in informing guidance, although a poor fit with guideline scope or methods, reviews being out of date and a lack of communication between CRGs and guideline developers were barriers to their use. CONCLUSIONS Health and economic impacts of research are generally difficult to measure. We found that to be the case with this evaluation. Impacts on knowledge production and clinical guidance were easier to identify and substantiate than those on clinical practice. Questions remain about how we define and measure impact, and more work is needed to develop suitable methods for impact analysis.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK.
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Lord JM, Midwinter MJ, Chen YF, Belli A, Brohi K, Kovacs EJ, Koenderman L, Kubes P, Lilford RJ. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet 2014; 384:1455-65. [PMID: 25390327 PMCID: PMC4729362 DOI: 10.1016/s0140-6736(14)60687-5] [Citation(s) in RCA: 467] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Improvements in the control of haemorrhage after trauma have resulted in the survival of many people who would otherwise have died from the initial loss of blood. However, the danger is not over once bleeding has been arrested and blood pressure restored. Two-thirds of patients who die following major trauma now do so as a result of causes other than exsanguination. Trauma evokes a systemic reaction that includes an acute, non-specific, immune response associated, paradoxically, with reduced resistance to infection. The result is damage to multiple organs caused by the initial cascade of inflammation aggravated by subsequent sepsis to which the body has become susceptible. This Series examines the biological mechanisms and clinical implications of the cascade of events caused by large-scale trauma that leads to multiorgan failure and death, despite the stemming of blood loss. Furthermore, the stark and robust epidemiological finding--namely, that age has a profound influence on the chances of surviving trauma irrespective of the nature and severity of the injury--will be explored. Advances in our understanding of the inflammatory response to trauma, the impact of ageing on this response, and how this information has led to new and emerging treatments aimed at combating immune dysregulation and reduced immunity after injury will also be discussed.
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Affiliation(s)
- Janet M Lord
- MRC-ARUK Centre for Musculoskeletal Ageing Research, School of Immunity and Infection, University of Birmingham, Birmingham, UK; NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - Mark J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; School of Health and Population Sciences, University of Birmingham, Birmingham, UK; Division of Health Sciences, University of Warwick, Coventry, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; Neurotrauma and Neurodegeneration Section, University of Birmingham, Birmingham, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Elizabeth J Kovacs
- Loyola University Chicago Health Sciences Campus, Stritch School of Medicine, Department of Surgery, Burn and Shock Trauma Institute, Maywood, IL, USA
| | - Leo Koenderman
- University Medical Centre Utrecht, Department of Respiratory Medicine, Utrecht, Netherlands
| | - Paul Kubes
- University of Calgary, Department of Physiology and Pharmacology, Calvin Phoebe and Joan Snyder Institute for Chronic Disease, Calgary, Canada
| | - Richard J Lilford
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK; Division of Health Sciences, University of Warwick, Coventry, UK.
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HEESEN M, BÖHMER J, KLÖHR S, ROSSAINT R, VAN DE VELDE M, DUDENHAUSEN JW, STRAUBE S. Prophylactic tranexamic acid in parturients at low risk for post-partum haemorrhage: systematic review and meta-analysis. Acta Anaesthesiol Scand 2014; 58:1075-85. [PMID: 25069636 DOI: 10.1111/aas.12341] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 11/26/2022]
Abstract
Tranexamic acid is effective in reducing blood loss during various types of surgery and after trauma. No compelling evidence has yet been presented for post-partum haemorrhage. A systematic literature search of relevant databases was performed to identify trials that assessed blood loss and transfusion incidence after tranexamic acid administration for post-partum haemorrhage. The random effects model was used for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs). Seven trials with a low risk of bias comparing tranexamic acid vs. placebo with a total of 1760 parturients were included in our systematic review and meta-analysis. Blood loss was significantly lower after tranexamic acid use (WMD -140.29 ml, 95% CI -189.64 to -90.93 ml; P<0.00001). Tranexamic acid reduced the risk for blood transfusions (RR 0.34, 95% CI 0.20-0.60, P=0.0001). The incidence of transfusions in the placebo group varied between 1.4% and 33%. When omitting the two trials with the highest incidence of transfusions, the RR was no longer significant. Additional uterotonics were necessary in the placebo groups; gastrointestinal adverse events were more common after tranexamic acid use. Only four cases of thrombosis were found, two each in the tranexamic acid and control groups. Tranexamic acid effectively reduced post-partum blood loss; the effect on the incidence of blood transfusions requires further studies. Only few trials observed adverse events including thromboembolic complications and seizures.
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Affiliation(s)
- M. HEESEN
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - J. BÖHMER
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - S. KLÖHR
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - R. ROSSAINT
- Department of Anaesthesia; University Hospital Aachen; Aachen Germany
| | - M. VAN DE VELDE
- Department of Anaesthesia; Universitair Zieckenhuis Leuven; Leuven Belgium
| | - J. W. DUDENHAUSEN
- Weill Cornell Medical College; Sidra Medical and Research Center; Charite University Medicine Berlin; Doha Qatar
| | - S. STRAUBE
- Department of Occupational, Social and Environmental Medicine; University Medical Center Göttingen; Göttingen Germany
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Zehtabchi S, Abdel Baki SG, Falzon L, Nishijima DK. Tranexamic acid for traumatic brain injury: a systematic review and meta-analysis. Am J Emerg Med 2014; 32:1503-9. [PMID: 25447601 DOI: 10.1016/j.ajem.2014.09.023] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/19/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical benefit in trauma patients with severe bleeding, but its effectiveness in patients with traumatic brain injury (TBI) is unclear. We conducted a systematic review to evaluate the following research question: In ED patients with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA compared to placebo improve patients' outcomes? METHODS MEDLINE, EMBASE, CINAHL, and other databases were searched for randomized controlled trial (RCT) or quasi-RCT studies that compared the effect of TXA to placebo on outcomes of TBI patients. The main outcomes of interest included mortality, neurologic function, hematoma expansion, and adverse effects. We used "Grading quality of evidence and strength of recommendations" to assess the quality of trials. Two authors independently abstracted data using a data collection form. Results from studies were pooled when appropriate. RESULTS Of 1030 references identified through the search, 2 high-quality RCTs met inclusion criteria. The effect of TXA on mortality had a pooled relative risk of 0.64 (95% confidence interval [CI], 0.41-1.02); on unfavorable functional status, a relative risk of 0.77 (95% CI, 0.59-1.02); and on ICH progression, a relative risk of 0.76 (95% CI, 0.58-0.98). No serious adverse effects (such as thromboembolic events) associated with TXA group were reported in the included trials. CONCLUSION Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA and a nonstatistically significant improvement of clinical outcomes in ED patients with TBI. Further evidence is required to support its routine use in patients with TBI.
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Affiliation(s)
- Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY.
| | - Samah G Abdel Baki
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY.
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY.
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50
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Verma A, Kole T. International normalized ratio as a predictor of mortality in trauma patients in India. World J Emerg Med 2014; 5:192-5. [PMID: 25225583 DOI: 10.5847/wjem.j.issn.1920-8642.2014.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/19/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhage is the second leading cause of death in trauma patients preceded only by traumatic brain injury. But hemorrhagic shock is the most common cause of preventable death within 6 hours of admission. Traumatic coagulopathy is a hypocoagulable state that occurs in the most severely injured. International normalized ratio (INR) and its relationship with trauma mortality have not been studied specifically. This study aimed to establish a predictive value of INR for trauma-related mortality. METHODS A total of 99 trauma patients aged 18-70 years were included in the study. Their INR was determined and patient progression was followed up till death/discharge. According to previous retrospective studies, the cutoff value for INR in our study was kept at 1.5. RESULTS The total mortality rate of the patients was 16.16% (16/99). The mean INR was 1.45 with a SD of 1.35. INR was deranged in a total of 14 patients (14.14%). Of these patients, 11 died (78.57%) and 3 survived. INR was deranged in 11 (68.75%) of the 16 patients who died, but 5 deaths (31.25%) had normal INR values. The sensitivity of INR was 69% (95%CI 41%-88%) and the specificity 96% (95%CI 90%-99%). The diagnostic accuracy of INR was 92% (95%CI 85%-96%). Positive predictive value and negative predictive value were 79% (95%CI 49%-95%) and 94% (95%CI 87%-98%), respectively. CONCLUSION Our results showed that INR is a good predictor of mortality in trauma patients.
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Affiliation(s)
- Ankur Verma
- Department of Emergency Medicine, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain, India
| | - Tamorish Kole
- Department of Emergency Medicine, Max Hospital, Saket, New Delhi 110017, India
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