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Hannigan A, Bumbak P, Brennan-Jones CG, Hintze J. The use of tranexamic acid in paediatric adenotonsillectomy - A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2024; 186:112110. [PMID: 39341021 DOI: 10.1016/j.ijporl.2024.112110] [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: 08/06/2024] [Revised: 09/06/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND Tonsillectomy and adenoidectomy (AT) are two of the most commonly performed ENT procedures in children, with over 500,000 cases performed annually in the United States. Whilst generally considered a safe and well-tolerated operation, it is not without its risks and complications including pain, nausea, anorexia and most importantly bleeding and post-tonsillectomy haemorrhage (PTH). Whilst tranexamic acid (TXA) has a proven benefit in reducing bleeding and transfusion requirements in patients undergoing trauma, spinal and cardiac surgery; the effectiveness, timing and safety of its application in paediatric tonsillectomy has not yet been established. AIMS, OBJECTIVES & SIGNIFICANCE To date, there has been no published systematic review of the literature specifically looking at paediatric patients undergoing AT, despite a massive surge in popularity of the use of TXA perioperatively. The aim of this study is therefore to systematically review the current literature and collate evidence regarding the efficacy and safety of using TXA to reduce bleeding in children undergoing tonsillectomy and/or adenoidectomy. METHODS A structured search of bibliographic databases (MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) was undertaken to retrieve randomised controlled trials, non-randomised case-control studies and ongoing clinical trials that describe the use of TXA in paediatric patients undergoing AT. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: tranexamic acid, bleeding, tonsillectomy, adenoidectomy, paediatrics. To ensure that all relevant data was captured, the search did not contain any restrictions on language or publication time. Data extraction and risk of bias assessment was performed independently and in duplicate. RESULTS This review identified and included a total of eight studies (n = 1315). Five studies reported on the intravenous use of TXA (n = 531) whilst three studies reported on the topical use of TXA (n = 784), and these were analysed separately. The intravenous use of TXA did not reduce intraoperative blood loss significantly (95 % CI: -0.1 to 0.33 p = 0.28) and there was not enough information to analyse the effect on PTH in these studies. Topical TXA led to a significant reduction in both intraoperative blood loss (95 % CI 0.11 to 5.31, p = 0.04) and post operative bleeding rates (RR 0.04, 95 % CI 0.01 to 0.08, P = 0.02). CONCLUSION The results of this systematic review and meta-analysis suggest that TXA administered via the intravenous route does not reduce perioperative bleeding associated with AT in paediatric patients. However, when topical TXA is used intraoperatively at the surgical site in paediatric patients undergoing adenoidectomy alone, there was a significant reduction in both intraoperative blood loss and post operative bleeding. TXA appears to be a safe and well-tolerated drug in the paediatric population with no adverse effects reported in this review. Nevertheless, further large and well-designed randomised controlled trials are needed to investigate the risks and benefits of TXA in paediatric AT with a particular focus on its use topically and in association with newly developed surgical equipment.
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Affiliation(s)
- Amy Hannigan
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia.
| | - Paul Bumbak
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Christopher G Brennan-Jones
- Department of Otolaryngology, Perth Children's Hospital, Perth, Western Australia, Australia; Telethon Kids Institute, The University of Western Australia, Australia; Faculty of Health Sciences, Curtin University, Western Australia, Australia
| | - Justin Hintze
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, USA
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Kirwan MJ, Diltz ZR, Dixon DT, Rivera-Peraza CA, Gammage CJ, Mihalko WM, Harkess JW, Guyton JL, Crockarell JR, Ford MC. The AAHKS Clinical Research Award: Extended Postoperative Oral Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Pilot Study. J Arthroplasty 2024; 39:S13-S17. [PMID: 38430972 DOI: 10.1016/j.arth.2024.02.073] [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] [Received: 12/13/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Perioperative tranexamic acid (TXA) use with total knee arthroplasty (TKA) is widely accepted today. Recently, a few international groups have published on the safety and outcomes of extending TXA use in the postoperative period. Through a double-blinded, randomized control trial (RCT), we aimed to investigate the safety and clinical efficacy of extended postoperative oral TXA use in TKA performed in an American, free-standing ambulatory surgery center (ASC). METHODS Based on a power analysis, 40 patients undergoing primary TKA were randomized into 2 groups: extended oral TXA versus placebo. Both groups received a standard 1g intravenous TXA dose prior to incision and at the time of closure. The extended TXA group received an additional 1.95 g oral TXA dose following ambulation the day of surgery, plus on postoperative days 1,2, and 3. Patients who had a history of venous thromboembolism (VTE) or cancer were excluded. All patients received 81 mg of aspirin twice daily for VTE prophylaxis. Patients were followed on postoperative day 3 and weeks 2 and 6. Paired t-tests determined statistical significance. RESULTS Extended TXA patients showed significantly increased knee flexion at 6 weeks (116.05 versus 106.5, P = .0308), improved VAS at 2 (2.5 versus 3.85, P = .039) and 6 weeks (1.35 versus 2.8, P = .011), and superior KOOS JR at 2 (66.87 versus 60.63, P = .03) and 6 weeks (73.33 versus 62.47, P = .0019) compared to placebo patients. No significant differences were found for changes in hemoglobin levels at any time points. No significant differences were found at 12 weeks for any clinical endpoints. No adverse events were noted in either cohort. CONCLUSIONS When compared to placebo, the extended use of oral TXA in the postoperative period may safely result in improved motion, pain, and functional scores. Further investigation into 1-to-2-year outcomes, as well as the duration and dose of postoperative TXA use is warranted.
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Affiliation(s)
- Mateo J Kirwan
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | - Zachary R Diltz
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | | | | | | | - Willliam M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | - James W Harkess
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | - James L Guyton
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | - John R Crockarell
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
| | - Marcus C Ford
- Department of Orthopaedic Surgery and Biomedical Engineering, Health Science Center-Campbell Clinic, University of Tennessee, Memphis, Tennessee
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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [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: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Teng TZJ, Chia AZQ, Gan KF, Tan LHP, Wang Y, Charn TC. A Comparison of Tranexamic Acid in Nasal Versus Sinus Surgeries: a Systematic Review and Meta-Analysis. Indian J Otolaryngol Head Neck Surg 2024; 76:3018-3030. [PMID: 39130301 PMCID: PMC11306473 DOI: 10.1007/s12070-024-04579-x] [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: 01/19/2024] [Accepted: 02/22/2024] [Indexed: 08/13/2024] Open
Abstract
Nasal surgeries (e.g.: rhinoplasties, septoplasties) and sinus surgeries (e.g.: Functional Endoscopic Sinus Surgeries) are common procedures in Otorhinolaryngology. Tranexamic acid (TXA), an antifibrinolytic drug, has been increasingly utilized to reduce hemorrhage recently. While close in proximity anatomically, the bleeding nature of sinus and nasal surgeries may differ. We present the first meta-analysis that has reviewed both nasal and sinus surgery collectively and compares the two. Pubmed, Embase, Cochrane Library and WoS were searched until April 2023. Outcomes of interest include Boezart Scoring, clotting time, postoperative complications and surgical field quality. 27 Studies were assessed, of which 25 studies were evaluated quantitatively. Of the 27 studies, 15 studies involved Sinus surgery while 12 involved Nasal surgery. The use of tranexamic acid was notably beneficial in the evaluation of blood loss, reduction of operating time, surgical field quality and surgeon satisfaction. TXA has proven to be efficacious in both nasal and sinus surgeries to varying degrees. TXA has more effects in sinus surgeries compared to nasal surgeries in objective markers such as reducing blood loss and operating time, but the converse occurs for subjective markers such as surgeon satisfaction scores. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-024-04579-x.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Ministry of Health Holdings, Singapore, Singapore
- Department of Otorhinolaryngology - Head and Neck surgery, Sengkang General Hospital, Singhealth, Singapore
| | | | - Keith Fei Gan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Lydia Hui Peng Tan
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yuxing Wang
- Ministry of Health Holdings, Singapore, Singapore
| | - Tze Choong Charn
- Department of Otorhinolaryngology - Head and Neck surgery, Sengkang General Hospital, Singhealth, Singapore
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Cazes N, Corcostegui SP, Lovi S, Romary E, Desrobert V, Lidzborski L, Derkenne C. Should soldiers take oral tranexamic acid before going into battle? J Trauma Acute Care Surg 2024; 97:S24-S26. [PMID: 38595230 DOI: 10.1097/ta.0000000000004343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT Tranexamic acid is an inexpensive antifibrinolytic treatment that reduces morbidity and mortality in civilian and military trauma patients. It must be administered within 3 hours of the injury, and its efficacy is greater the earlier it is given. It is already used preventively in the civilian environment in a number of indications to reduce bleeding and bleeding-related mortality. We wondered about the potential benefits of preventive oral administration of tranexamic acid prior to an assault for military personnel with a potential risk of injury.
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Affiliation(s)
- Nicolas Cazes
- From the Emergency Department (N.C.), Laveran Army Teaching Hospital, Marseille; Paris Fire Brigade (S.-P.C.); and French Military Health System (S.L., E.R., V.D., L.L., C.D.), Paris, France
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Castro-Delgado R, Garijo-Gonzalo G, Cuartas-Alvarez T. Tranexamic acid needs to be implemented in mass casualty incident protocols. Eur J Trauma Emerg Surg 2024; 50:1931-1933. [PMID: 38801465 PMCID: PMC11458692 DOI: 10.1007/s00068-024-02517-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/30/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Rafael Castro-Delgado
- Faculty of Medicine and Health Sciences, Department of Medicine, University of Oviedo, Julián Clavería, 6, 33006, Oviedo, Spain.
- Health Research Institute of the Principality of Asturias (Research Group On Prehospital Care and Disasters, GIAPREDE), Health Service of the Principality of Asturias (SAMU-Asturias), Oviedo, Spain.
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain.
| | - Gracia Garijo-Gonzalo
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
- Emergencias Osakidetza. Vasc Country, Madrid, Spain
| | - Tatiana Cuartas-Alvarez
- Health Research Institute of the Principality of Asturias (Research Group On Prehospital Care and Disasters, GIAPREDE), Health Service of the Principality of Asturias (SAMU-Asturias), Oviedo, Spain
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
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Roberts I. Urgent action needed on prehospital tranexamic acid in trauma. Emerg Med J 2024; 41:450-451. [PMID: 38876769 PMCID: PMC11287549 DOI: 10.1136/emermed-2024-214194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/22/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Ian Roberts
- Nutrition and Public Health Intervention Research Unit, London School of Hygiene & Tropical Medicine, London, UK
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Qureshi S, Alavi SE, Mohammed Y. Microsponges: Development, Characterization, and Key Physicochemical Properties. Assay Drug Dev Technol 2024; 22:229-245. [PMID: 38661260 DOI: 10.1089/adt.2023.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Microsponges are promising drug delivery carriers with versatile characteristics and controlled release properties for the delivery of a wide range of drugs. The microsponges will provide an optimized therapeutic effect, when delivered at the site of action without rupturing, then releasing the cargo at the predetermined time and area. The ability of the microsponges to effectively deliver the drug in a controlled manner depends on the material composition. This comprehensive review entails knowledge on the design parameters of an optimized microsponge drug delivery system and the controlled release properties of microsponges that reduces the side effects of drugs. Furthermore, the review delves into the fabrication techniques of microsponges, the mechanism of drug release from the microsponges, and the regulatory requirements of the U.S. Food and Drug Administration (FDA) for the successful marketing of microsponge formulation. The review also examines the patented formulations of microsponges. The prospects of these sophisticated drug delivery systems for improved clinical outcomes are highlighted.
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Affiliation(s)
- Sundus Qureshi
- Department of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Seyed Ebrahim Alavi
- Frazer Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Yousuf Mohammed
- Frazer Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, The University of Queensland, Brisbane, Australia
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Zhao Y, Zhang C, Zhang Y, Li R, Xie T, Bai L, Chen H, Rui Y. Efficacy and Safety of Orally and Intravenously Administration of Tranexamic Acid in Patients with Elderly Femoral Neck Fracture. Orthop Surg 2024; 16:1581-1591. [PMID: 38766813 PMCID: PMC11216831 DOI: 10.1111/os.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE For elderly femoral neck fracture patients, anemia is one of the most common complications, increasing the risk of postoperative adverse events. Tranexamic acid (TXA) has been widely applied to the perioperative blood management. However, the optimal route of TXA administration in elderly femoral neck fracture remains unclear. The aim of this study is to evaluate the efficacy and safety of oral and intravenous (IV) application of TXA in elderly patients with femoral neck fracture undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA). METHODS All elderly patients aged over 65 years old diagnosed with femoral neck fracture admitted to the trauma orthopedics from August 1, 2020 to February 28, 2022 were enrolled in this prospective cohort study. Participants were divided into three groups: oral group: TXA 2g orally 2 h before incision; IV group: intravenous infusion of TXA 1g 15 min before incision; and control group: usual hemostatic method. The primary outcomes were total blood loss, allogeneic transfusion rate, and postoperative thromboembolic events. SPSS 23.0 (IBM, Armonk, NY, USA) was used for statistical analysis, and p ≤ 0.05 was considered statistically significant. RESULTS A total of 100 patients were enrolled, including 32 cases in the oral group, 34 cases in the IV group and 34 cases in the control group. Compared with the control group, the total perioperative blood loss in the oral and IV groups was significantly decreased (763.92 ± 358.64 mL vs 744.62 ± 306.88 mL vs 1250.60 ± 563.37 mL, p = 0.048). No significant difference was identified between the oral and IV groups (p = 0.970). The rate of allogeneic transfusion was lower in the oral and IV groups than in the control group, but the difference had no statistical significant (6 vs 5 vs 12, p = 0.108), However, subgroup analysis showed that the IV and oral groups in patients who underwent THA have significant lower transfusion rate compared with the control group (1 vs 3 vs 7, p = 0.02). During 6 months follow-up, no thromboembolic events were identified. Two patients (one from the oral group and one from the control group) died of respiratory failure. The cost of blood management from the oral group was significantly lower than IV (p < 0.001) and control groups (p = 0.009). CONCLUSION Elderly patients with femoral neck fracture undergoing THA can benefit from both IV and oral administration of tranexamic acid. The results of these two administration routes are similar in safety and effectiveness. A similar tendency was observed in patients undergoing HA. Oral TXA is more cost-benefit compared with intravenous applications.
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Affiliation(s)
- Ya‐kuan Zhao
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- The Fourth Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Cheng Zhang
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Yuan‐wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Ru‐ya Li
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Li‐yong Bai
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Handan First HospitalHandanChina
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Yun‐feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
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Kolasiński J, Reysner T, Kolenda M, Kołacz S, Domagalska M. A systematic review and meta-analysis of systematic and topical tranexamic acid administration in aesthetic plastic surgery. Perioper Med (Lond) 2024; 13:52. [PMID: 38831387 PMCID: PMC11149283 DOI: 10.1186/s13741-024-00406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Tranexamic acid has been widely used in plastic surgery. However, its efficacy has yet to be fully established. This meta-analysis aimed to determine its effectiveness in aesthetic plastic surgery. METHODS Following PRISMA guidelines, we conducted a meta-analysis of prospective randomised clinical trials that compared the effects of topical or systematic administration of tranexamic acid versus the control group in aesthetic plastic surgeries. The study was registered on the International Register of Systematic Reviews (PROSPERO) and is available online ( www.crd.york.uk/prospero , CRD42023492585). RESULTS Eleven studies encompassing 960 patients were included for the synthesis after critical evaluation. Systematic (MD - 18.05, 95% Cl, - 22.01, - 14.09, p < 0.00001) and topical (MD - 74.93, 95% Cl, - 88.79, - 61.07, p < 0.00001) administration of tranexamic acid reduced total blood loss. Topical tranexamic acid reduced drainage output (p < 0.0006). CONCLUSION Tranexamic acid reduced blood loss in aesthetic plastic surgery. More strictly defined RCTs, using high-quality methodology, are needed to evaluate the advantages and disadvantages of tranexamic acid in aesthetic plastic surgery.
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Affiliation(s)
| | - Tomasz Reysner
- Department of Palliative Medicine, Poznan University of Medical Sciences, 61-245, Poznań, Poland
| | | | - Szymon Kołacz
- Kolasinski Clinic, Hair Clinic Poznan, 62-020, Swarzędz, Poland
| | - Małgorzata Domagalska
- Department of Palliative Medicine, Poznan University of Medical Sciences, 61-245, Poznań, Poland.
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Poursalehian M, Tajvidi M, Ghaderpanah R, Soleimani M, Hashemi SM, Kachooei AR. Efficacy and Safety of Oral Tranexamic Acid vs. Other Routes in Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis. JBJS Rev 2024; 12:01874474-202406000-00003. [PMID: 38889241 DOI: 10.2106/jbjs.rvw.23.00248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Total joint arthroplasty (TJA) is often associated with significant blood loss, leading to complications such as acute anemia and increased risk of infection and mortality. Tranexamic acid (TXA), an antifibrinolytic agent, has been recognized for effectively reducing blood loss during TJA. This systematic review and network meta-analysis aims to evaluate the efficacy and safety of oral TXA compared with other administration routes in TJA. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Embase, and Web of Science, focusing on randomized clinical trials involving oral TXA in TJA. The studies were assessed for quality using the Cochrane risk assessment scale. Data synthesis involved network meta-analyses, comparing outcomes including hemoglobin drop, estimated blood loss (EBL), transfusion rate, and deep vein thrombosis (DVT) rate. RESULTS Our comprehensive literature search incorporated 39 studies with 7,538 participants, focusing on 8 TXA administration methods in TJA. The combination of oral and intra-articular (oral + IA) TXA markedly reduced hemoglobin drop more effectively than oral, intravenous (IV), and IA alone, but the difference was not significant. Oral + IA TXA significantly reduced EBL more effectively than oral + IV, IA + IV, and oral, IV, and IA alone. Perioperative transfusion rates with oral + IA TXA was significantly lower than that of oral, IA, and IV alone. The DVT rate with oral + IA was significantly lower than that with all other routes, including oral + IV, IA + IV, and oral, IA, and IV alone. CONCLUSION Oral TXA, particularly in combination with IA administration, demonstrates significantly higher efficacy in reducing blood loss and transfusion rates in TJA, with a safety profile comparable with that of other administration routes. The oral route, offering lower costs and simpler administration, emerges as a viable and preferable option in TJA procedures. LEVEL OF EVIDENCE Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mohammad Poursalehian
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Tajvidi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Rezvan Ghaderpanah
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Melika Hashemi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Zhang Y, Zhao W, Hu M, Liu X, Peng Q, Meng B, Yang S, Feng X, Zhang L. The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Percutaneous Endoscopic Interlaminar Diskectomy: A Retrospective Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:280-287. [PMID: 37586408 DOI: 10.1055/s-0043-1769127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is safe and effective in preventing bleeding during spinal surgery. However, there is currently no relevant research on the efficacy and safety of adding TXA to the saline irrigation fluid in percutaneous endoscopic interlaminar diskectomy (PEID). This study aimed to evaluate the efficacy and safety of topical saline irrigation with TXA for PEID in the treatment of lumbar disk herniation. METHODS In this single-center, retrospective cohort study, patients who underwent PEID for L5-S1 lumbar disk herniation were included and allocated to two groups according to whether they had been administered TXA. PEID was performed with saline irrigation fluid containing 0.33 g of TXA per 1 L of saline in the TXA group (n = 38). In the control group (n = 51), the saline irrigation fluid was injected with the same volume of normal saline. All PEIDs were performed by the same spine surgery team. The hidden blood loss (HBL), intraoperative blood loss (IBL), total blood loss (TBL), amount of fluid used, operation time, visual clarity, hospital stay, blood transfusion rate, coagulation index, and complication rate were compared between the two groups. RESULTS The TBL, HBL, and IBL in the TXA group were significantly lower than those of the control group. The postoperative hemoglobin in the TXA group was significantly higher than that of the control group. Visual clarity was significantly better and the operation time was significantly shorter in the TXA group. However, there was no significant difference in postoperative hematocrit, blood coagulation function, amount of fluid used, blood transfusion rate, and perioperative complications between the two groups. CONCLUSION In PEID, the addition of TXA to topical saline irrigating fluid can significantly reduce the HBL, IBL, and TBL. The addition of TXA to topical saline irrigating fluid can improve visual clarity in the surgery and reduce operation time, but it does not change the coagulation function or the complication rate.
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Affiliation(s)
- Yu Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Wenjie Zhao
- Graduate School of Dalian Medical University, Dalian, China
| | - Man Hu
- Graduate School of Dalian Medical University, Dalian, China
| | - Xin Liu
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Qing Peng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Bo Meng
- Graduate School of Dalian Medical University, Dalian, China
| | - Sheng Yang
- Graduate School of Dalian Medical University, Dalian, China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
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13
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Faraoni D, Fenger-Eriksen C. Dosing of tranexamic acid in trauma. Curr Opin Anaesthesiol 2024; 37:125-130. [PMID: 38390911 DOI: 10.1097/aco.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile. RECENT FINDINGS A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects. SUMMARY The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric. Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian Fenger-Eriksen
- Department of Anesthesiology and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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14
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Piette N, Beck F, Carella M, Hans G, Maesen D, Kurth W, Lecoq JP, Bonhomme VL. Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial. Eur J Anaesthesiol 2024; 41:217-225. [PMID: 38214552 DOI: 10.1097/eja.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Oral as compared to intravenous tranexamic acid (TXA) is an attractive option, in terms of cost and safety, to reduce blood loss and transfusion in total hip arthroplasty. Exclusion criteria applied in the most recent randomised trials may have limited the generalisability of oral tranexamic acid in this indication. Larger and more inclusive studies are needed to definitively establish oral administration as a credible alternative to intravenous administration. OBJECTIVES To assess the noninferiority of oral to intravenous TXA at reducing intra-operative and postoperative total blood loss (TBL) in primary posterolateral approached total hip arthroplasty (PLTHA). DESIGN Noninferiority, single centre, randomised, double-blind controlled study. SETTING Patients scheduled for primary PLTHA. Data acquisition occurred between May 2021 and November 2022 at the University Hospital of Liège, Belgium. PATIENTS Two hundred and twenty-eight patients, randomised in a 1 : 1 ratio from a computer-generated list, completed the trial. INTERVENTIONS Administration of 2 g of oral TXA 2 h before total hip arthroplasty and 4 h after incision (Group oral) was compared to the intravenous administration of 1 g of TXA 30 min before surgery and 4 h after incision (Group i.v.). MAIN OUTCOME MEASURES TBL (measured intra-operative and drainage blood loss up to 48 h after surgery, primary outcome), decrease in haemoglobin concentration, D-Dimer at day 1 and day 3, transfusion rate (secondary outcomes). RESULTS Analyses were performed on 108 out of 114 participants (Group i.v.) and 104 out of 114 participants (Group oral). Group oral was noninferior to Group i.v. with regard to TBL, with a difference between medians (95% CI) of 35 ml (-103.77 to 33.77) within the noninferiority margins. Median [IQR] of estimated TBL was 480 ml [350 to 565] and 445 ml [323 to 558], respectively. No significant interaction between group and time was observed regarding the evolution of TBL and haemoglobin over time. CONCLUSIONS TXA as an oral premedication before PLTHA is noninferior to its intravenous administration regarding peri-operative TBL. TRIAL REGISTRATION European Clinical Trial Register under EudraCT-number 2020-004167-29 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-004167-29/BE ).
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Affiliation(s)
- Nicolas Piette
- From the Department of Anaesthesia and Intensive Care Medicine (NP, FB, MC, GH, J-PL, VLB), Department of Clinical Pharmacy (DM), Department of Locomotor System Surgery, Liege University Hospital (WK), Inflammation and Enhanced Rehabilitation Laboratory (Regional Anaesthesia and Analgesia), GIGA-I3 Thematic Unit (NP, MC, J-PL), Anaesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium (FB, VLB)
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15
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Marangoni D, Gemito A, Milan S, Tognetto D. Oral tranexamic acid for acute management of active bleeding from iris microhemangiomatosis: A case report. Am J Ophthalmol Case Rep 2024; 33:102000. [PMID: 38318444 PMCID: PMC10839555 DOI: 10.1016/j.ajoc.2024.102000] [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: 07/19/2023] [Revised: 12/24/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
Purpose to report a case of active intraocular bleeding caused by iris microhemangiomatosis managed with oral tranexamic acid. Observations an 80-year-old male was referred to our emergency department for acute intraocular bleeding. Eye exam showed filiform bleeding arising from a cluster of vascular tufts at the upper pupillary margin, which was consistent with a diagnosis of iris microhemangiomatosis. The bleeding had started 6 hours before and could not be halted by conservative maneuvers such as ocular compression and application of sympathomimetic drops. Oral tranexamic acid 500 mg was administered and led to prompt resolution of the hemorrhage within 60 minutes. The patient was monitored for 3 months and showed no recurrence of the hemorrhage. Conclusion and importance oral tranexamic acid may represent a viable option to manage active intraocular bleeding from iris microhemangiomatosis, facilitating rapid hemorrhage resolution.
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Affiliation(s)
- Dario Marangoni
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Antonio Gemito
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Serena Milan
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Daniele Tognetto
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
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16
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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17
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Hersh AR, Carroli G, Hofmeyr GJ, Garg B, Gülmezoglu M, Lumbiganon P, De Mucio B, Saleem S, Festin MPR, Mittal S, Rubio-Romero JA, Chipato T, Valencia C, Tolosa JE. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes. Am J Obstet Gynecol 2024; 230:S1046-S1060.e1. [PMID: 38462248 DOI: 10.1016/j.ajog.2022.11.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 03/12/2024]
Abstract
The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.
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Affiliation(s)
- Alyssa R Hersh
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia.
| | | | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana; University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; Walter Sisulu University, Mthatha, South Africa
| | - Bharti Garg
- Oregon Health & Science University, Portland, OR
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Montevideo, Uruguay
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mario Philip R Festin
- Department of Obstetrics and Gynecology, College of Medicine, University of the Philippines, Manila, Philippines
| | | | | | - Tsungai Chipato
- Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Catalina Valencia
- FUNDARED-MATERNA, Bogotá, Colombia; Medicina Fetal SAS, Medellin, Colombia
| | - Jorge E Tolosa
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia; St. Luke's University Health Network, Bethlehem, PA
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18
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Xie J, Huang Q, Huang Z, Wang F, Liu J, Tian H, Huang W, Pei F. High dose of tranexamic acid infusion in primary total knee arthroplasty: A randomized multicenter clinical trail. Chin Med J (Engl) 2024; 137:359-361. [PMID: 38214305 PMCID: PMC10836875 DOI: 10.1097/cm9.0000000000002952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Fei Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Jun Liu
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Hua Tian
- Department of Orthopaedic Surgery, Peking University Third Hospital, Haidian District, Beijing 100191, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing 400016, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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19
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Eisinger EC, Forsythe L, Joergensen S, Murali S, Cannon JW, Reilly PM, Kim PK, Kaufman EJ. Thromboembolic Complications Following Perioperative Tranexamic Acid Administration. J Surg Res 2024; 293:676-684. [PMID: 37839099 DOI: 10.1016/j.jss.2023.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The antifibrinolytic tranexamic acid (TXA) may reduce death in trauma; however, outcomes associated with TXA use in patients without proven hyperfibrinolysis remain unclear. We analyzed the associations of empirically administered TXA, hypothesizing that TXA use would correlate to lower transfusion totals but increased thromboembolic complications. METHODS This retrospective cohort study compared trauma patients started on massive transfusion protocol at a Level I trauma center from 2016 to 2021 who either did or did not receive TXA. Our primary outcome was in-hospital mortality. Venous thromboembolism (VTE; pulmonary embolism or deep vein thrombosis), transfusion volumes, and coagulation measures were considered secondarily. Descriptive statistics, univariate analyses, and multivariable logistic regression were used to evaluate differences in outcomes. RESULTS TXA patients presented with lower systolic blood pressure (100 versus 119.5 mmHg, P = 0.009), trended toward higher injury severity (ISS of 25 versus 20, P = 0.057), and were likelier to have undergone thoracotomy or laparotomy (89 versus 71%, P = 0.002). After adjusting for age, mechanism, presenting vitals, and operation, TXA was not significantly associated with mortality or VTE. TXA patients had larger volumes of packed red blood cells, platelets, and plasma transfused within 4- and 24-h (P ≤ 0.002). No differences in clot stability, captured via thromboelastography, were noted. CONCLUSIONS Despite no differences in mortality or VTE between patients who did and did not receive TXA, there were significant differences in transfusion totals. TXA patients had worse presenting physiology and likely had more severe bleeding. This absence of adverse outcomes supports TXA's safety. Nevertheless, further inquiry into the precise mechanism of TXA may help guide its empiric use, allowing for more targeted application.
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Affiliation(s)
- Ella C Eisinger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Liam Forsythe
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Shyam Murali
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick K Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Koster A, Hulde N, Deutsch MA, Gummert JF, von Dossow V, Zittermann A. The Efficacy and Safety of a Low-Dose Tranexamic Acid Bolus-Only Protocol Compared with the Moderate-Dose Protocol in Valvular Heart Surgery. Thorac Cardiovasc Surg 2024; 72:55-58. [PMID: 36657457 DOI: 10.1055/s-0042-1760205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In 873 propensity score-matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement.
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Affiliation(s)
- Andreas Koster
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Nikolai Hulde
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Marcus-Andre Deutsch
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Vera von Dossow
- Institute for Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
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21
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Abdallah Z, Staibano P, Zhou K, Khalife S, Nguyen TBV, Sommer DD. Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:2187-2204. [PMID: 37259887 DOI: 10.1002/alr.23203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.
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Affiliation(s)
- Zahra Abdallah
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Phillip Staibano
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kelvin Zhou
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khalife
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas B V Nguyen
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Doron D Sommer
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
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22
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Javeed SS, Altawili MA, Almubarak LNA, Alaodah SA, Alqarni MMA, Odeh OI, Asiri MAB, Alotaibi RAM, Alshammari AAA, Alqutayfi ZAM, Altemani OSD, Al Gharban DAM, Zafar ZA. The Effectiveness of Prehospital Administration of Tranexamic Acid in Reducing Mortality in Trauma Patients: An Overview. Cureus 2023; 15:e49784. [PMID: 38161561 PMCID: PMC10757764 DOI: 10.7759/cureus.49784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic drug that reduces bleeding by inhibiting plasminogen activation and fibrin clot degradation. Its role in prehospital trauma management remains unclear. This article aims to systematically review the current evidence on the effect of prehospital TXA administration on mortality in adult and pediatric trauma patients. A literature search was conducted of PubMed, Web of Science, Scopus, and Cochrane databases from March 2023 to August 2023 for studies evaluating the impact of prehospital TXA use on trauma mortality. Inclusion criteria were articles published in the English language in the past 20 years focusing on clinical outcomes of prehospital TXA administration. Data on all-cause mortality, thromboembolic events, and time to TXA administration were extracted. In adult trauma, prehospital TXA appears to reduce early all-cause mortality when given within three hours of injury without increasing thromboembolic risks. Some studies found decreased delayed mortality, while others found no difference. In pediatric trauma, preliminary evidence suggests TXA may lower in-hospital mortality in hemodynamically unstable patients, though higher doses may increase seizure risk. Early prehospital administration of TXA within three hours of adult trauma may reduce mortality through improved hemorrhage control. Potential benefits in pediatric trauma warrant further investigation, balancing efficacy against safety risks such as seizures from high doses. Well-designed randomized trials are needed to validate optimal TXA dosing strategies across age groups and injury severity levels.
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Affiliation(s)
- Syed S Javeed
- Emergency Medicine, King Salman Armed Forces Hospital, Tabuk, SAU
| | | | | | | | | | - Omar I Odeh
- Medical School, King Saud University College of Medicine, Riyadh, SAU
| | | | | | | | | | | | | | - Zohair A Zafar
- General Practice, Al-Awali Primary Health Care Center, Makkah, SAU
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Gluyas-Harris J, McConnell D. Cost of the Defence Medical Services Patient Group Directive for a 10-minute tranexamic acid (TXA) infusion in trauma: a bolus is safe and saves lives. BMJ Mil Health 2023:e002471. [PMID: 37973370 DOI: 10.1136/military-2023-002471] [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: 05/18/2023] [Accepted: 10/21/2023] [Indexed: 11/19/2023]
Abstract
Tranexamic acid (TXA) is a life-saving drug that reduces the risk of death from haemorrhage. Intervention is time critical with benefit decreasing with delayed administration. The current Joint Service Publication Patient Group Directive (PGD) for giving TXA during the tactical field care phase of the operational patient care pathway specifies it is given over 10 min via intravenous infusion based on TXA's Summary of Product Characteristics. This paper aims to explore the risks of administering TXA as a bolus rather than a 10-minute infusion. There is little evidence to support the risk of quoted adverse events from bolus administration of TXA, good-quality evidence for the mortality benefit of early administration and some evidence that bolus dosing is safe. The Defence Medical Service should consider a default PGD of rapid TXA administration to maximise mortality benefit.
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Affiliation(s)
| | - D McConnell
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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24
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Han C, Liu M, Lian X, Sun T, Yan S, Bai X, Gan D, Leng B, Qiu Y, Ren Y. Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis. J Shoulder Elbow Surg 2023; 32:2389-2399. [PMID: 37468032 DOI: 10.1016/j.jse.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Although tranexamic acid (TXA) is being increasingly used in orthopedic arthroplasty and lower-extremity arthroscopic procedures, its use in arthroscopic rotator cuff repair (ARCR) is less widely reported. The aim of this study was to evaluate the clinical effectiveness and safety of TXA administration in ARCR. METHODS A systematic review and meta-analysis of randomized controlled trials was performed to compare clinical outcomes in patients who underwent ARCR with or without TXA. Literature was retrieved using the Cochrane Library, MEDLINE, PubMed, and Embase electronic databases. The primary outcome of this study was visual clarity. Secondary outcomes contained total operative time, postoperative pain score, amount of blood loss, shoulder swelling (change in shoulder circumference), volume of irrigation fluid, number of adjustments of the pump pressure for irrigation, and adverse cardiovascular events. RESULTS Seven studies (3 and 4 with level I and II evidence, respectively), which included 272 and 265 patients who underwent arthroscopy with and without TXA, respectively, met the eligibility criteria. Pooled analysis showed significant improvements in visual clarity (mean difference, 9.10%; 95% CI, 4.05-14.15; P = .0004) and total operative time (mean difference, -11.24 minute; 95% CI, -19.90 to -2.57) associated with perioperative TXA application. None of the trials reported adverse events and complications associated with TXA. CONCLUSION The best available evidence indicates that TXA administration could significantly improve arthroscopic visual clarity and effectively save operative time in ARCR without increasing the incidence of adverse events. Furthermore, the optimal dose, route, and timing of TXA application in ARCR surgery remains to be validated by future high-level evidence studies.
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Affiliation(s)
- Changxu Han
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Ming Liu
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xin Lian
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Tao Sun
- Emergency Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shengjuan Yan
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xianming Bai
- Spine Surgery Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Dige Gan
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Bing Leng
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Yi Qiu
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
| | - Yizhong Ren
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
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Cazes N, Briquet A, Delcasso B. IV or Nebulized Tranexamic Acid for Hemoptysis: Can We Stop There? Chest 2023; 164:e159. [PMID: 37945203 DOI: 10.1016/j.chest.2023.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Nicolas Cazes
- Bataillon de marins-pompiers de Marseille, Laveran Army Teaching Hospital, Marseille, France.
| | - Anaïs Briquet
- Pulmonology Department, Laveran Army Teaching Hospital, Marseille, France
| | - Benjamine Delcasso
- Pulmonology Department, Laveran Army Teaching Hospital, Marseille, France
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26
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Gopinath B, Mishra PR. Response. Chest 2023; 164:e160. [PMID: 37945204 DOI: 10.1016/j.chest.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Bharath Gopinath
- All India Institute of Medical Sciences, New Delhi, Delhi, India
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Nejat MH, Khayami A, Daliri M, Ebrahimzadeh MH, Sadeghi M, Moradi A. Does tranexamic acid diminish hemorrhage and pain in open elbow arthrolysis? a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:795. [PMID: 37803371 PMCID: PMC10557324 DOI: 10.1186/s12891-023-06835-7] [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] [Received: 05/29/2023] [Accepted: 08/26/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND/OBJECTIVE Effective hemostasis has the potential to reduce inflammation and pain, leading to potential benefits in the early rehabilitation of patients who undergo elbow arthrolysis. In the present study, we aim to assesse the effects of tranexamic acid (TXA) on elbow arthrolysis postoperative blood loss, patients' pain perception according to the visual analog scale (VAS), elbow range of motion (ROM), and complications. METHODS We systematically searched PubMed, Web of Science, SCOPUS, and Cochrane Library. We included controlled trials, either randomized (RCT) or non-randomized studies of intervention (NRSI) comparing the effects of intravenous tranexamic acid (TXA) treatment with placebo/no treatment on postoperative blood loss, pain VAS score, elbow ROM, and complications, in patients who underwent open or closed elbow arthrolysis surgery. RESULTS One RCT, and three NRSIs met eligibility criteria. The meta-analysis determined that tranexamic acid application reduced drain output 34 mm on average (WMD: -34.00; 95% CI: -49.45, -18.55). There was a discrepancy among included articles in terms of intra-operative blood loss; although the study with the largest sample size (291 and 296 patients in the case and control groups, respectively) reported reduced intra-operative blood loss in patients who received TXA. The pooled estimation for the pain VAS score on the first day post-operatively indicates a reduction in pain among patients in the TXA group (WMD: -0.82; 95% CI: -1.36, -0.28). Results for ROM, and complications' rate such as hematoma and ulnar nerve palsy were not different between the two groups. CONCLUSION TXA may be beneficial to reduce elbow arthrolysis bleeding volume. However, it dose not seem to affect final elbow ROM and patients' pain score. Further high-quality clinical trials are needed to draw a robust conclusion on this topic.
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Affiliation(s)
- Mohammad Hadi Nejat
- Orthopedics Research Center, Ghaem hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhosein Khayami
- Orthopedics Research Center, Ghaem hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahla Daliri
- Orthopedics Research Center, Ghaem hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad H Ebrahimzadeh
- Orthopedics Research Center, Ghaem hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoumeh Sadeghi
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Moradi
- Orthopedics Research Center, Ghaem hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
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Lam T, Medcalf RL, Cloud GC, Myles PS, Keragala CB. Tranexamic acid for haemostasis and beyond: does dose matter? Thromb J 2023; 21:94. [PMID: 37700271 PMCID: PMC10496216 DOI: 10.1186/s12959-023-00540-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.
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Affiliation(s)
- Tammy Lam
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne VIC, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia.
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Shakur-Still H, Roberts I, Grassin-Delyle S, Chaudhri R, Geer A, Arribas M, Lamy E, Mansukhani R, Lubeya MK, Javaid K, Kayani A, Israr N, Mazhar SB, Urien S, Bouazza N, Foissac F, Prowse D, Carrington L, Barrow C, Onandia JG, Balogun E. Alternative routes for tranexamic acid treatment in obstetric bleeding (WOMAN-PharmacoTXA trial): a randomised trial and pharmacological study in caesarean section births. BJOG 2023; 130:1177-1186. [PMID: 37019443 DOI: 10.1111/1471-0528.17455] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/08/2023] [Accepted: 03/03/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE To examine the safety, efficacy and pharmacology of intravenous (IV), intramuscular (IM) and oral tranexamic acid (TXA) use in pregnant women. DESIGN Randomised, open-label trial. SETTING Hospitals in Pakistan and Zambia. POPULATION Women giving birth by caesarean section. METHODS Women were randomised to receive 1 g IV, 1 g IM, 4 g oral TXA or no TXA. Adverse events in women and neonates were recorded. TXA concentration in whole blood was measured and the concentrations over time were examined with population pharmacokinetics. The relationship between drug exposure and D-dimer was explored. The trial registration is NCT04274335. MAIN OUTCOME MEASURES Concentration of TXA in maternal blood. RESULTS Of the 120 women included in the randomised safety study, there were no serious maternal or neonatal adverse events. TXA concentrations in 755 maternal blood and 87 cord blood samples were described by a two-compartment model with one effect compartment linked by rate transfer constants. Maximum maternal concentrations were 46.9, 21.6 and 18.1 mg/L for IV, IM and oral administration, respectively, and 9.5, 7.9 and 9.1 mg/L in the neonates. The TXA response was modelled as an inhibitory effect on the D-dimer production rate. The half-maximal inhibitory concentration (IC50 ) was 7.5 mg/L and was achieved after 2.6, 6.4 and 47 minutes with IV, IM and oral administration of TXA, respectively. CONCLUSIONS Both IM and oral TXA are well tolerated. Oral TXA took about 1 hour to reach minimum therapeutic concentrations and would not be suitable for emergency treatment. Intramuscular TXA inhibits fibrinolysis within 10 minutes and may be a suitable alternative to IV.
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Affiliation(s)
- Haleema Shakur-Still
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
- Infection et Inflammation, Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, INSERM, Montigny le Bretonneux, France
| | - Rizwana Chaudhri
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Amber Geer
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Monica Arribas
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Elodie Lamy
- Infection et Inflammation, Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, INSERM, Montigny le Bretonneux, France
| | - Raoul Mansukhani
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Mwansa Ketty Lubeya
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynaecology, The University of Zambia School of Medicine, Lusaka, Zambia
| | - Kiran Javaid
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Aasia Kayani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Naila Israr
- Department of Obstetrics and Gynaecology, Federal Government Polyclinic Hospital, Islamabad, Pakistan
| | - Syeda Batool Mazhar
- Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Shaheed Zulfikar Ali Bhutto Medical University, Islamabad, Pakistan
| | - Saïk Urien
- Paediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France
| | - Naïm Bouazza
- Paediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France
| | - Frantz Foissac
- Paediatric and Perinatal Drug Evaluation and Pharmacology, Université Paris Cité, Paris, France
| | - Danielle Prowse
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Collette Barrow
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Julio Gil Onandia
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Eni Balogun
- Clinical Trials Unit - Global Health Clinical Trials Group, London School of Hygiene & Tropical Medicine, London, UK
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Anaposala S, Kalluru PKR, Calderon Martinez E, Bhavanthi S, Gundoji CR. Postpartum Hemorrhage and Tranexamic Acid: A Literature Review. Cureus 2023; 15:e38736. [PMID: 37292548 PMCID: PMC10247241 DOI: 10.7759/cureus.38736] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
This review aims to explore the postpartum hemorrhage (PPH) burden and the efficacy of prophylactic tranexamic acid (TXA) in PPH and recent indications of TXA. A comprehensive review of the literature was conducted using a combination of Medical Subject Headings keywords including "Postpartum haemorrhage," "Tranexamic acid," and "Cesarean section." PPH has been explored for epidemiology, risk factors, and pathophysiology in the first part of the article. Recent indications of TXA, obstetric indications, and the role of TXA as prophylaxis for PPH are discussed in the second part of this article. TXA has many indications apart from obstetric indications and shows a significant effect in controlling bleeding. Furthermore, TXA is more efficient in preventing PPH if administered during the final stage of labor and is a valuable option for managing obstetric bleeding.
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Omori K, Roberts I. Prehospital tranexamic acid for trauma victims. J Intensive Care 2023; 11:12. [PMID: 36949540 PMCID: PMC10035187 DOI: 10.1186/s40560-023-00661-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/15/2023] [Indexed: 03/24/2023] Open
Abstract
The public enquiry into the mass casualty incident at the Manchester Arena in the UK in which 23 people died and over 1000 were injured, identified the need for timely intramuscular administration of tranexamic acid to trauma patients. Since then, a number of studies and trials have been carried out and UK paramedics are now authorized to give intramuscular tranexamic acid in the pre-hospital setting. In Japan, pre-hospital administration by emergency life-saving technicians is not yet authorized, despite the fact that tranexamic acid was invented by Japanese scientists. In Japan, the need for the pre-hospital administration of tranexamic acid has been raised on several occasions, where a patient died from traumatic bleeding prior to hospital admission. This paper summarizes the evidence on the use of tranexamic acid in patients with traumatic bleeding, including new evidence on the intramuscular route.
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Affiliation(s)
- Kazuhiko Omori
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK
| | - Ian Roberts
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
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Ageron F, Shakur‐Still H, Roberts I. Effects of tranexamic acid treatment in severely and non-severely injured trauma patients. Transfusion 2022; 62 Suppl 1:S151-S157. [PMID: 35748686 PMCID: PMC9539885 DOI: 10.1111/trf.16954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urgent treatment with tranexamic acid (TXA) reduces bleeding deaths but there is disagreement about which patients should be treated. We examine the effects of TXA treatment in severely and non-severely injured trauma patients. STUDY DESIGN AND METHODS We did an individual patient data meta-analysis of randomized trials with over 1000 trauma patients that assessed the effects of TXA on survival. We defined the severity of injury according to characteristics at first assessment: systolic blood pressure of less than 90 mm Hg and a heart rate greater than 120 beats per minute or Glasgow Coma Scale score of less than nine or any GCS with one or more fixed dilated pupils. The primary measure was survival on the day of the injury. We examined the effect of TXA on survival in severely and non-severely injured patients and how these effects vary with the time from injury to treatment. RESULTS We obtained data for 32,944 patients from two randomized trials. Tranexamic acid significantly increased survival on the day of the injury (OR = 1.22, 95% CI 1.11-1.34; p < .01). The effect of tranexamic acid on survival in non-severely injured patients (OR = 1.25, 1.03-1.50) was similar to that in severely injured patients (OR = 1.22, 1.09-1.37) with no significant heterogeneity (p = .87). In severely and non-severely injured pateints, treatment within the first hour after injury was the most effective. DISCUSSION Early tranexamic acid treatment improves survival in both severely and non-severely injured trauma patients. Its use should not be restricted to the severely injured.
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Affiliation(s)
| | | | - Ian Roberts
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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Shakur‐Still H, Grassin‐Delyle S, Muhunthan K, Ahmadzia HK, Faraoni D, Arribas M, Roberts I. Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review. Int J Gynaecol Obstet 2022; 158 Suppl 1:40-45. [PMID: 35762806 PMCID: PMC9327714 DOI: 10.1002/ijgo.14201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To review available data on tranexamic acid (TXA) plasma concentration needed to inhibit fibrinolysis and the time to achieve this concentration when giving TXA by different routes in humans. To identify ongoing trials assessing alternatives to intravenous TXA administration. METHODS We updated two previous systematic reviews by searching MEDLINE, EMBASE, OviSP, and ISI Web of Science from database inception to July 2021. We also searched the WHO International Clinical Trials Registry Platform for ongoing trials to July 2021. Titles and abstracts were screened for relevant trials. Two reviewers independently reviewed and agreed the trials to be included. RESULTS Plasma TXA concentrations over 10 mg/L provide near maximal inhibition of fibrinolysis, with concentrations over 5 mg/L providing partial inhibition. Oral TXA tablets take about 1 h to reach a plasma concentration of 5 mg/L in postpartum women. Studies in healthy volunteers and shocked trauma patients show that intramuscular TXA achieves a plasma level of over 10 mg/L within 15 min. One trial is ongoing to determine the pharmacokinetics of intramuscular and oral solution TXA in pregnant women. CONCLUSION Intramuscular TXA in healthy volunteers and shocked trauma patients reaches therapeutic concentration rapidly. Oral TXA tablets take too long to reach the minimum therapeutic concentration in postpartum women.
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Affiliation(s)
| | - Stanislas Grassin‐Delyle
- Département des maladies des voies respiratoiresHôpital FochSuresnesFrance
- Infection et inflammation, Département de Biotechnologie de la Santé, UVSQ, INSERMUniversité Paris‐SaclayMontigny le BretonneuxFrance
| | | | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Texas Children’s HospitalBaylor College of MedicineHoustonTexasUSA
| | - Monica Arribas
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ian Roberts
- Clinical Trials UnitLondon School of Hygiene and Tropical MedicineLondonUK
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35
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Gilliot S, Ducloy-Bouthors AS, Loingeville F, Hennart B, Allorge D, Lebuffe G, Odou P. Pharmacokinetics of Curative Tranexamic Acid in Parturients Undergoing Cesarean Delivery. Pharmaceutics 2022; 14:pharmaceutics14030578. [PMID: 35335955 PMCID: PMC8952437 DOI: 10.3390/pharmaceutics14030578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this study was to evaluate the population pharmacokinetics of tranexamic acid (TXA) administered intravenously at a single dose of 0.5 or 1 g in parturients undergoing active hemorrhagic cesarean delivery and to evaluate the influence of patient variables on TXA pharmacokinetics. Subjects from three recruiting centers were included in this PK sub-study if randomized in the experimental group (i.v TXA 0.5 g or 1 g over one minute) of the TRACES study. Blood samples and two urinary samples were collected within 6 h after TXA injection. Parametric non-linear mixed-effect modeling (Monolix v2020R1) was computed. The final covariate model building used 315 blood and 117 urinary concentrations from seventy-nine patients. A two-compartment model with a double first-order elimination from the central compartment best described the data. The population estimates of clearance (CL), central volume of distribution (V1), and half-life for a typical 70 kg patient with an estimated renal clearance of 150 mL/min (Cockroft–Gault) were 0.14 L/h, 9.25 L, and 1.8 h. A correlation between estimated creatinine clearance and CL, body weight before pregnancy, and V1 was found and partly explained the PK variability. The final model was internally validated using a 500-run bootstrap. The first population pharmacokinetic model of TXA in active hemorrhagic caesarean section was successfully developed and internally validated.
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Affiliation(s)
- Sixtine Gilliot
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
- Correspondence:
| | - Anne-Sophie Ducloy-Bouthors
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Florence Loingeville
- ULR2694—METRICS—Evaluation des Technologies de Santé et des Pratiques Médicales, Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France;
| | - Benjamin Hennart
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
| | - Delphine Allorge
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
- ULR 4483-IMPECS-IMPact de l’Environnement Chimique sur la Santé, Faculté de Médecine-Pôle Recherche, Université de Lille, 1 Place de Verdun, F-59045 Lille, France
| | - Gilles Lebuffe
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Pascal Odou
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
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