Most Effective Regimen of Tranexamic Acid for Reducing Bleeding and Transfusions in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

The use of tranexamic acid (TXA) during primary total knee arthroplasty (TKA) is well documented. However, considering the potential side effects, including deep vein thrombosis (DVT) and pulmonary embolism (PE), the ideal route of administration remains controversial. Therefore, we performed a meta-analysis to compare the efficacy of topical versus intravenous TXA and explore the most effective regimen in patients undergoing primary TKA. We conducted a systematic literature search in PubMed, Embase, and the Cochrane database through July 2016 to identify randomized controlled trials (RCTs) evaluating the efficacy and safety of topical and intravenous TXA in primary TKA. We assessed the risk of bias using the Cochrane Collaboration's tool. We assessed the quality of evidence using the GRADE profiler software. A total of 15 RCTs including 1,240 participants met the inclusion criteria. We found no statistically significant difference between topical and intravenous TXA in terms of transfusion rate (p = 0.75), total blood loss (p = 0.51), total drain output (p = 0.60), maximum hemoglobin drop (p = 0.24), length of stay (p = 0.08), and thromboembolic complications (p = 0.73). Subgroup analyses showed that compared with 1 g topical TXA, 2 g topical TXA was more effective to reduce blood transfusion rate and total blood loss, and did not increase thromboembolic complications. We also found three times intravenous TXA was more effective than one time of intravenous TXA to reduce blood transfusion rate and total blood loss without increasing of thromboembolic complications. Topical TXA had a similar efficacy to intravenous TXA in reducing blood transfusion and blood loss, and did not increase the risk of thromboembolic complications in primary TKA. Besides, the current meta-analysis suggested that three times of intravenous TXA is efficient and safe. We also recommended 2 g topical TXA instead of 1 g topical TXA because it was more efficient to reduce blood transfusion rate and total blood loss and did not increase thromboembolic complications.

Discoid Lateral Meniscus

Partial and total meniscectomies are the most common treatments for patients with discoid lateral meniscus (DLM). We conducted this study to quantitatively assess and compare the outcomes of partial and total meniscectomies for DLM. We also assessed whether the outcomes differed by the type of DLM, duration of follow-up, and age of patients. We searched PubMed, Embase, and the Cochrane database to identify relevant studies that reported outcomes, including Ikeuchi grade, the International Knee Documentation Committee (IKDC) Subjective Knee score, Lysholm score, or failure rate, in patients who underwent partial and total meniscectomies. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for dichotomous outcomes, whereas mean difference and 95% CIs were calculated for continuous outcomes. Fifteen studies met the inclusion criteria. The overall rate of excellent (E) or good (G) postoperatively was 85.5% (95% CI: 79.5-91.5%). The E or G rate of partial meniscectomy was significantly higher than that of total meniscectomy (OR= 1.97, 95% CI: 1.03-3.75, p = 0.038). Besides, patients younger than 20 years had a significantly higher E or G rate than those older than 20 years. (OR = 3.12, 95% CI: 1.18-8.23, p = 0.022). We also found the E or G rate tended to decrease from short- to long-term follow-up. Our systematic review and meta-analysis showed that that partial meniscectomy could achieve better outcomes compared with total meniscectomy for DLM patients.

Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To use meta-analysis techniques to evaluate the efficacy and safety of platelet-rich plasma (PRP) injections for the treatment knee of osteoarthritis (OA).

METHODS

We performed a systematic literature search in PubMed, Embase, Scopus, and the Cochrane database through April 2016 to identify Level I randomized controlled trials that evaluated the clinical efficacy of PRP versus control treatments for knee OA. The primary outcomes were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores. The primary outcomes were compared with their minimum clinically important differences (MCID)-defined as the smallest difference perceived as important by the average patient.

RESULTS

We included 10 randomized controlled trials with a total of 1069 patients. Our analysis showed that at 6 months postinjection, PRP and hyaluronic acid (HA) had similar effects with respect to pain relief (WOMAC pain score) and functional improvement (WOMAC function score, WOMAC total score, International Knee Documentation Committee score, Lequesne score). At 12 months postinjection, however, PRP was associated with significantly better pain relief (WOMAC pain score, mean difference -2.83, 95% confidence interval [CI] -4.26 to -1.39, P = .0001) and functional improvement (WOMAC function score, mean difference -12.53, 95% CI -14.58 to -10.47, P  < .00001; WOMAC total score, International Knee Documentation Committee score, Lequesne score, standardized mean difference 1.05, 95% CI 0.21-1.89, P = .01) than HA, and the effect sizes of WOMAC pain and function scores at 12 months exceeded the MCID (-0.79 for WOMAC pain and -2.85 for WOMAC function score). Compared with saline, PRP was more effective for pain relief (WOMAC pain score) and functional improvement (WOMAC function score) at 6 months and 12 months postinjection, and the effect sizes of WOMAC pain and function scores at 6 months and 12 months exceeded the MCID. We also found that PRP did not increase the risk of adverse events compared with HA and saline.

CONCLUSIONS

Current evidence indicates that, compared with HA and saline, intra-articular PRP injection may have more benefit in pain relief and functional improvement in patients with symptomatic knee OA at 1 year postinjection.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I studies.

Polycyclic aromatic hydrocarbons (PAHs) in multimedia environment of Heshan coal district, Guangxi: distribution, source diagnosis and health risk assessment

Mining activities are among the major culprits of the wide occurrences of soil and water pollution by PAHs in coal district, which have resulted in ecological fragilities and health risk for local residents. Sixteen PAHs in multimedia environment from the Heshan coal district of Guangxi, South China, were measured, aiming to investigate the contamination level, distribution and possible sources and to estimate the potential health risks of PAHs. The average concentrations of 16 PAHs in the coal, coal gangue, soil, surface water and groundwater were 5114.56, 4551.10, 1280.12 ng g(-1), 426.98 and 381.20 ng L(-1), respectively. Additionally, higher soil and water PAH concentrations were detected in the vicinities of coal or coal gangue dump. Composition analysis, isomeric ratio, Pearson correlation analysis and principal component analysis were performed to diagnose the potential sources of PAHs in different environmental matrices, suggesting the dominant inputs of PAHs from coal/coal combustion and coal gangue in the soil and water. Soil and water guidelines and the incremental lifetime risk (ICLR) were used to assess the health risk, showing that soil and water were heavily contaminated by PAHs, and mean ICLRcoal/coal-gangue and mean ICLRsoil were both significantly higher than the acceptable levels (1 × 10(-4)), posing high potential carcinogenic risk to residents, especially coal workers. This study highlights the environmental pollution problems and public health concerns of coal mining, particularly the potential occupational health hazards of coal miners exposed in Heshan.

Comparison of Postoperative Events between Spinal Anesthesia and General Anesthesia in Laparoscopic Cholecystectomy: A Systemic Review and Meta-Analysis of Randomized Controlled Trials

Background. Laparoscopic cholecystectomy is usually carried out under general anesthesia. There were a few studies which have found spinal anesthesia as a safe alternative. We aimed to evaluate the postoperative events between spinal anesthesia and general anesthesia in patients undergoing laparoscopic cholecystectomy. Methods. We searched PubMed, Embase, and Cochrane Library (from inception to January 2016) for eligible studies. The primary outcome was the visual analogue scale score. Secondary outcomes included postoperative nausea and vomiting and urine retention 24 hours postoperatively. We calculated pooled risk ratios and 95% confidence interval using random- or fixed-effects models. Results. Eight trials involving 723 patients were listed. Meta-analysis showed that patients in spinal anesthesia groups have lower visual analogue scale score 24 hours postoperatively. There were significant decreases in the occurrence of postoperative nausea and vomiting in spinal anesthesia group when compared with general anesthesia group (odds ratios: 0.38, 95% confidence interval: 0.19-0.76; P = 0.006) with heterogeneity accepted (I (2) = 13%; P = 0.33), while urine retention rate was increased in patients with spinal anesthesia (odds ratios: 4.95, 95% confidence interval: 1.24-19.71; P = 0.02) without any heterogeneity (I (2) = 0%; P = 0.98). Conclusions. Spinal anesthesia may be associated with less postoperative pain and postoperative nausea and vomiting compared with general anesthesia.

Dexamethasone versus ondansetron in the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Background

Dexamethasone is an antiemetic alternative to ondansetron. We aimed to compare the effects of dexamethasone and ondansetron in preventing postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic surgery.

Methods

We searched PubMed, Embase, Medline and Cochrane Library (from inception to July 2014) for eligible studies. The primary outcome was the incidence of PONV during the first 24 h after surgery. The secondary outcomes included PONV in the early postoperative stage (0–6 h), PONV in the late postoperative stage (6–24 h), and the postoperative anti-emetics used at both stages. We calculated pooled risk ratios (RR) and 95 % CIs using random- and fixed-effects models.

Results

Seven trials involving 608 patients were included in this meta-analysis, which found that dexamethasone had a comparable effectiveness in preventing PONV (RR, 0.91; 95 % CI, 0.73-1.13; P = 0.39) with that of ondansetron within 24 h of laparoscopic surgery, with no evidence of heterogeneity among the studies (I² = 0 %; P = 0.71). In the early postoperative stage (0–6 h), ondansetron was better at decreasing PONV than dexamethasone (RR, 1.71; 95 % CI, 1.05-2.77; P = 0.03), while in the late postoperative stage (6–24 h), dexamethasone was more effective in preventing PONV than ondansetron (RR, 0.51; 95 % CI, 0.27-0.93; P = 0.03). There was no significant difference in the postoperative anti-emetics used (RR, 0.90; 95 % CI, 0.67-1.19; P = 0.45).

Conclusions

Dexamethasone was as effective and as safe as ondansetron in preventing PONV. Dexamethasone should be encouraged as an alternative to ondansetron for preventing PONV in patients undergoing laparoscopic surgery.

Antioxidant status and immune activity of glycyrrhizin in allergic rhinitis mice

Oxidative stress is considered as a major risk factor that contributes to increased lipid peroxidation and declined antioxidants in some degenerative diseases. Glycyrrhizin is widely used to cure allergic diseases due to its medicinal properties. In the present study, we evaluated the role of glycyrrhizin on lipid peroxidation and antioxidant status in the blood and nasal mucosa of allergic rhinitis (AR) mice. Mice were divided into six groups: normal control mice, model control (MC) mice, three glycyrrhizin-treated mice groups and lycopene-treated mice. Sensitization-associated increase in lipid peroxidation was observed in the blood and nasal mucosa of MC mice. Activities of antioxidant enzymes like superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), total antioxidant capacity (TAOC) and levels of glutathione (GSH) were found to be significantly decreased in the blood and nasal mucosa in MC mice when compared to normal control mice. However, normalized lipid peroxidation and antioxidant defenses were reported in the glycyrrhizin-treated and lycopene-treated mice. Moreover, glycyrrhizin treatment still enhanced IFN-γ and reduced IL-4 levels in glycyrrhizin-treated mice. These findings demonstrated that glycyrrhizin treatment enhanced the antioxidant status and decreased the incidence of free radical-induced lipid peroxidation and improved immunity activities in the blood and nasal mucosa of AR mice.

Supplemental phytases of microbial and cereal sources improve dietary phytate phosphorus utilization by pigs from weaning through finishing

This experiment was conducted to measure the nutritional and metabolic responses of pigs fed diets with continuous supplementation of microbial and cereal phytase from weaning to finishing, and to determine the feasibility of complete replacement of inorganic P addition by supplemental phytase in swine diets. Forty-eight Landrace x Hampshire x Meishan pigs were divided into four groups. In phase 1 (10 to 50 kg BW), pigs in Groups 1, 2, 3, and 4 were fed a low-P, corn-soybean meal basal diet (BD), the BD plus microbial phytase (A. ficuum) at 1,200 units/kg, the BD plus 10% wheat bran (230 units of cereal phytase/kg), and the BD + .24% inorganic P (calcium phosphate), respectively. In phase 2 (51 to 90 kg BW), these pigs were fed a similar BD or the BD plus 1,000 microbial phytase units/kg, 20% wheat bran, or .20% inorganic P, respectively. Repeated measures included growth performance, P, Ca, and N balance, metatarsal and metacarpal bone strength, serum concentration of inorganic P, Ca, and 1,25-dihydroxycholecalciferol, and serum alkaline phosphatase activity. Pigs fed the BD supplemented with microbial phytase and pigs fed the BD supplemented with inorganic P showed almost identical responses for all variables. Pigs fed the BD supplemented with cereal phytase also had responses for various measures that were similar to those of pigs fed microbial phytase or inorganic P, except for some differences in serum inorganic P concentrations and bone strength in phase 1. Because of improvements in apparent digestibility of dietary P and N, fecal excretion of these two nutrients was reduced by 31 to 62% (P < .05) in pigs fed the BD supplemented with phytase compared with pigs fed inorganic P. It is physiologically feasible and environmentally advantageous to replace inorganic P with microbial or cereal phytase in corn-soybean meal diets for this type of pig through the entire growing-finishing period.

[Clinical and experimental studies on treatment postoperative gastric cancer with combined therapy of fuzhen huoxue anticancer prescription and chemotherapy]

Fuzheng Huoxue Anticancer prescription (FZHXAC) showed better clinical effect in treating 35 cases of postoperative patients with gastric cancer in middle or late stage as compared with 35 cases of controls. After treatment, the immune function of T-lymphocytes enhanced significantly, the hypercoagulability improved, the criteria such as OKT4/OKT8 ratio, antithrombase III (AT-III), fibrinolytic activity, etc were all normalized, the one year, 3 year and 5 year suvival rate of patient were elevated. FZHXAC showed obvious inhibitory action on tumor growth in nude mice with transplanted human gastric cancer, as compared with control, the difference was significant, P < 0.001. In comparing with chemotherapeutic drug 5-fluorouracil, FZHXAC showed no significant toxicity, it didn't influence the normal growth of body weight. These results suggested that FZHXAC could not only replenish the Zheng-Qi, improve blood circulation, improve immune function and extend the survival period of patient, but also might have direct inhibiting, killing action on gastric tumor cells, this problem is expecting for further research.

[Pre-, post-operation and before death of blood stasis syndrome in patients with gastric malignant tumor]

In the past three years, the authors observed substance of tongue and 5 indexes of blood coagulation (AT-III, Fn, Fa, VIII R:Ag and beta TG) for a long time in 140 patients of gastric malignant tumor pre-operation, one month post-operation and 3 months before death. All patients were verified as gastric carcinoma by pathological section. The results showed that the positive rate of substance of tongue in patients pre-operation was as high as 58% (51/88), 5 indexes of blood coagulation in patients had obvious difference (P less than 0.001) comparing to that of healthy persons. This implied it existed relationship between gastric malignant tumor and blood stasis in TCM and accorded with diagnosis of blood stasis syndrome. With the resection of tumor focus, the states of blood stasis in patients had been improved to a certain extent. But the positive rate of substance of tongue post-operation was still as high as 51.1% (45/88) comparing to that pre-operation (P greater than 0.05), 5 indexes of blood coagulation in patients post-operation had no obvious improvement comparing to those pre-operation. This showed that the simple resection did not basically improve blood stasis in patients. The another important result was that the substance of tongue and 5 indexes of blood coagulation of 23 patients in last 3 months before death had more obvious blood stasis comparing to those post-operation even those pre-operation. This explained that blood stasis is one of the main characters of gastric malignant tumor before death. In conclusion, the extent of blood stasis syndrome can be used as an objective index to judge seriousness and prognosis of gastric malignant tumor patients' condition.