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Kirengo TO, Dossajee H, Onyango EM, Rachakonda RH, Schneider B, Sela DP, Hosseinzadeh Z, Nadeem Z, Obonyo NG. Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa. Syst Rev 2024; 13:89. [PMID: 38500200 PMCID: PMC10946148 DOI: 10.1186/s13643-024-02474-8] [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: 09/10/2023] [Accepted: 01/28/2024] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals. AIM To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa. METHODOLOGY A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search. RESULTS Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge. CONCLUSION Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2022 CRD42022352115 .
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Affiliation(s)
- Thomas O Kirengo
- Imara Hospital, Embu, Kenya.
- Kenya Medical Association, Nairobi, Kenya.
| | - Hussein Dossajee
- MP Shah Hospital, Nairobi, Kenya
- Kenya Medical Association, Nairobi, Kenya
| | - Evans M Onyango
- Ministry of Health, Kajiado County, Kenya
- Kenya Medical Association, Nairobi, Kenya
| | - Reema H Rachakonda
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
| | - Bailey Schneider
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
| | - Declan P Sela
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
| | - Zahra Hosseinzadeh
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
| | - Zohaib Nadeem
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
| | - Nchafatso G Obonyo
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Critical Care Research Group, Brisbane, Australia
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kenya Medical Association, Nairobi, Kenya
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Bai Z, Wang L, Yu B, Xing D, Su J, Qin H. Efficacy and safety of tranexamic acid in the treatment of gastric cancer complicated with upper gastrointestinal bleeding. Am J Transl Res 2024; 16:925-932. [PMID: 38586096 PMCID: PMC10994787 DOI: 10.62347/koli5819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To investigate the efficacy and safety of tranexamic acid (TXA) in preventing upper gastrointestinal (GI) bleeding in patients with gastric cancer. METHODS The clinical data of patients with gastric cancer complicated with acute non-operative GI bleeding treated in the Fourth Hospital of Hebei Medical University from 2020 to 2022 were collected and retrospectively analyzed. The survival status of the patients was followed up by telephone. The dataset of 168 patients was divided into a control group (n=85) and a TXA group (n=83), at a 1:1 ratio. The patients in the control group were treated with esomeprazole, and the patients in the TXA group received additional TXA. The hemostatic effect, rebleeding rate, and mortality of patients were compared between the two groups. The Cox proportional hazard model was used to evaluate the overall survival of patients as well as the related risk factors. RESULTS The success rate of hemostasis and the normal blood coagulation rate in the TXA group were significantly higher than those in the control group (P=0.003 and P=0.016). The secondary bleeding rate, thrombus formation rate and digestive tract perforation rate in the TXA group were significantly lower than those in the control group (P=0.002, P=0.003 and P=0.035). The improvement of all indicators in the TXA group was better than that in the control group (all P<0.05). For patients with gastric cancer complicated with acute GI bleeding treated with TXA, the Cox proportional hazard model identified III~IV stage, time of TXA treatment, surgical treatment after hemorrhage, and an increase of D-dimer as independent risk factors for upper GI bleeding (all P<0.05). CONCLUSION TXA can be an effective treatment for patients with gastric cancer complicated by GI bleeding.
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Affiliation(s)
- Zongjiang Bai
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
| | - Lantao Wang
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
| | - Bin Yu
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
| | - Dong Xing
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
| | - Jie Su
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
| | - Hao Qin
- Emergency Department, The Fourth Hospital of Hebei Medical University Shijiazhuang 050000, Hebei, China
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Hutchcraft ML, Miller RW. Bleeding from Gynecologic Malignancies. Obstet Gynecol Clin North Am 2022; 49:607-622. [PMID: 36122988 DOI: 10.1016/j.ogc.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Initial assessment of vaginal bleeding in gynecologic malignancies includes a thorough history and physical examination, identification of site and extent of disease, and patient goals of care. Patients who are initially hemodynamically unstable may require critical care services. Choice of treatment is disease site specific. Cervical cancer frequently is treated with chemoradiation. Uterine cancer may be treated surgically, with radiation, or pharmacologically. Gestational trophoblastic disease is treated surgically. Alternative treatment modalities include vascular embolization and topical hemostatic agents. Patients with bleeding gynecologic malignancies should be managed as inpatients in facilities with gynecologic oncology, radiation oncology, and critical care services.
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Affiliation(s)
- Megan L Hutchcraft
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, 800 Rose Street, Lexington, KY 40536, USA.
| | - Rachel W Miller
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, 800 Rose Street, Lexington, KY 40536, USA
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Haigh SM. Managing a patient presenting to the emergency department with upper gastrointestinal bleeding. Emerg Nurse 2022; 30:17-23. [PMID: 35076189 DOI: 10.7748/en.2022.e2120] [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: 10/14/2021] [Indexed: 11/09/2022]
Abstract
Upper gastrointestinal (GI) bleeding is a common presentation in emergency departments (EDs). This medical emergency has a mortality rate of up to 14%, particularly in men and older people. The most frequent cause of upper GI bleeding is peptic ulcer disease. Management has not changed significantly in the past 50 years and there is ongoing debate in the literature about the most effective treatment protocols. This article uses a case study of a patient who presented to an ED with upper GI bleeding caused by peptic ulcer disease to examine the evidence on treatment and management. The article also discusses a care bundle that has been developed for rapid assessment and management of patients with acute upper GI bleeding.
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Affiliation(s)
- Sandra Michelle Haigh
- emergency department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, England
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Scherdin Y, Halldestam I, Redeen S. Incidence and Mortality Related to Gastrointestinal Bleeding, and the Effect of Tranexamic Acid on Gastrointestinal Bleeding. Gastroenterology Res 2021; 14:165-172. [PMID: 34267831 PMCID: PMC8256901 DOI: 10.14740/gr1383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022] Open
Abstract
Background Gastrointestinal bleeding is a common and potentially life-threatening condition. The incidence of gastrointestinal bleeding has not decreased despite new prophylaxis and treatments. Ulcer is still one of the most common etiologies for upper gastrointestinal bleeding. It is routinely treated with proton pump inhibitors (PPIs) and endoscopic interventions, sometimes endovascular procedures, and rarely today, open surgery with suture to stop the bleeding. The fibrinolytic tranexamic acid (TXA) has a role in bleeding treatment, and is routinely used for example within trauma care, postpartum bleeding and orthopedic surgery. The aim of this study is to assess the incidence of gastrointestinal bleeding. A further aim was to investigate if TXA has any role in medical treatment of gastrointestinal bleeding today. Methods We performed a retrospective cohort study with a review of medical records, involving patients with clinical signs of gastrointestinal bleeding and endoscopically verified ulcers between the years of 2010 and 2016 at the University Hospital of Linkoping, Sweden. The cities of Motala and Linkoping have the primary acute admissions at this Hospital. Results We found in total 1,331 patients with gastrointestinal bleeding. The overall incidence for patients with gastrointestinal bleeding was 98.6 (98.6/100,000 inhabitants and year). For those with endoscopically verified ulcer (386 patients), the incidence for peptic ulcer was 28.6/100,000/year. In the group with endoscopically verified ulcer, 25 patients died, giving the 30-day mortality of 6.4%. TXA is still used for treatment of bleeding ulcers. We had two groups, those with and without TXA treatment. They were equal in age, gender and comorbidity. Clinically we saw no major differences in respect to hemodynamic stability. There were more patients with overt bleeding symptoms in the TXA group. We also saw more patients in need of intensive care in the TXA group. Conclusions The incidence of gastrointestinal bleeding has not significantly decreased during the last years. There was no significant positive effect of TXA in patients with upper gastrointestinal bleeding in this study. The difference between the two groups is probably more a question of whom we treat with TXA (e.g., the patients in worse condition or at higher risk) than a difference in drug effect. It is time to quit with TXA treatment in all patients with gastrointestinal bleeding, even those at intensive care unit (ICU).
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Affiliation(s)
- Ylva Scherdin
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
| | - Ingvar Halldestam
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
| | - Stefan Redeen
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linkoping University, Linkoping, Sweden
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Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials. Intensive Care Med 2020; 47:14-27. [PMID: 33079217 DOI: 10.1007/s00134-020-06279-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). METHODS In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). RESULTS Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. CONCLUSIONS In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.
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Lee PL, Yang KS, Tsai HW, Hou SK, Kang YN, Chang CC. Tranexamic acid for gastrointestinal bleeding: A systematic review with meta-analysis of randomized clinical trials. Am J Emerg Med 2020; 45:269-279. [PMID: 33041136 DOI: 10.1016/j.ajem.2020.08.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding is a common life-threatening emergent condition. Immediate tranexamic acid is useful for reducing hemorrhage following operation and bleeding trauma, but evidence on the effects of tranexamic acid in patients with gastrointestinal bleeding is limited or highly heterogeneous. It is still unclear about using tranexamic acid in the emergent condition of gastrointestinal bleeding. This study, therefore, aimed to determine whether or not tranexamic acid should be used in gastrointestinal bleeding management through systematic review and meta-analysis. METHODS We searched three biomedical databases for relevant randomized controlled trials on this topic. Two authors independently selected studies and extracted data for bias assessment and meta-analysis of bleeding, further intervention, mortality, transfusion, and intensive care unit admission. Available data were pooled using a random-effects model, and the results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity and small study effects were also assessed. RESULTS Thirteen randomized controlled trials (n = 2271) were included in the present synthesis. Our meta-analysis revealed that tranexamic acid significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo. CONCLUSION According to the available evidence, the present synthesis confirms that tranexamic acid is an effective medication for patients with upper gastrointestinal bleeding. Early administration of tranexamic acid may be worth to be recommended for treating upper gastrointestinal bleeding in the emergency department. However, the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification.
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Affiliation(s)
- Po-Lin Lee
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kai-Suan Yang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hong-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-No Kang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, Taipei, Taiwan.
| | - Chun-Chao Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan.
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Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927-1936. [PMID: 32563378 PMCID: PMC7306161 DOI: 10.1016/s0140-6736(20)30848-5] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. METHODS We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. FINDINGS Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). INTERPRETATION We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Godier A, Roquet F, Hamada SR. Tranexamic acid: One more step towards its widespread use. Anaesth Crit Care Pain Med 2019; 39:15-17. [PMID: 31891775 DOI: 10.1016/j.accpm.2019.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anne Godier
- Service d'anesthésie-réanimation, hôpital européen Georges-Pompidou, AP-HP, 25, rue Leblanc, 75015 Paris, France; Inserm UMRS 1140, université Paris Descartes, Paris, France.
| | - Florian Roquet
- Service d'anesthésie-réanimation, hôpital européen Georges-Pompidou, AP-HP, 25, rue Leblanc, 75015 Paris, France; Service de biostatistique et informatique médicale, unité Inserm UMR 1153, université Paris Diderot, Paris, France
| | - Sophie Rym Hamada
- Service d'anesthésie-réanimation, hôpital européen Georges-Pompidou, AP-HP, 25, rue Leblanc, 75015 Paris, France; CESP, Inserm, CESP, Inserm, Maison de Solenn, université paris Sud, université Paris-Saclay, Paris, France
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