1
|
Kolin DA, Moverman MA, Menendez ME, Pagani NR, Puzzitiello RN, Kavolus JJ. A break-even analysis of tranexamic acid for prevention of periprosthetic joint infection following total hip and knee arthroplasty. J Orthop 2021; 26:54-57. [PMID: 34305348 DOI: 10.1016/j.jor.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/11/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose Despite the commonplace use of tranexamic acid in total joint arthroplasty, much of the current data regarding its cost-effectiveness examines savings directly related to its hemostatic properties, without considering its protective effect against periprosthetic joint infections. Using break-even economic modeling, we calculated the cost-effectiveness of routine tranexamic acid administration for infection prevention in total joint arthroplasty. Materials and methods The cost of intraoperative intravenous tranexamic acid, the cost of revision arthroplasty for periprosthetic joint infections, and the baseline rates of periprosthetic joint infections in patients who did not receive intraoperative tranexamic acid were obtained from the literature and institutional purchasing records. Break-even economic modeling incorporating these variables was performed to determine the absolute risk reduction in infection rate to make routine intraoperative tranexamic acid use economically justified. The number needed to treat was calculated from the absolute risk reduction. Results Routine use of intraoperative tranexamic acid is economically justified if it prevents at least 1 infection out of 3125 total joint arthroplasties (absolute risk reduction = 0.032%). Cost-effectiveness was maintained with varying costs of tranexamic acid, infection rates, and periprosthetic joint infection costs. Conclusion The routine use of intraoperative tranexamic acid is a highly cost-effective practice for infection prevention in primary and revision total joint arthroplasty. The use of tranexamic acid is warranted across a wide range of costs of tranexamic acid, initial infection rates, and costs of periprosthetic joint infection treatment.
Collapse
Affiliation(s)
- David A Kolin
- Hospital for Special Surgery, NY, USA.,Weill Cornell Medicine, NY, USA
| | | | | | | | | | | |
Collapse
|
2
|
García-Pagán JC, Saffo S, Mandorfer M, Garcia-Tsao G. Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep 2020; 2:100122. [PMID: 32671331 PMCID: PMC7347999 DOI: 10.1016/j.jhepr.2020.100122] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.
Collapse
Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ARR, absolute risk reduction
- AVB, acute variceal bleeding
- Ascites
- BNP, brain natriuretic peptide
- BRTO, balloon-occluded retrograde transvenous obliteration
- Bleeding
- CHF, chronic heart failure
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- Cirrhosis
- EVL, endoscopic variceal ligation
- GOV, gastro-oesophageal varices
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HVPG, hepatic venous pressure gradient
- Haemorrhage
- ICA, International Club of Ascites
- IGV, isolated gastric varices
- INR, international normalised ratio
- ISMN, isosorbide mononitrate
- LVP+A, LVP with albumin
- LVP, large-volume paracenteses
- MELD, model for end-stage liver disease
- NNT, number needed to treat
- NSBB, non-selective beta blocker
- OS, overall survival
- PCI, percutaneous coronary intervention
- PFTE, polytetrafluoroethylene
- PLT, platelet count
- PSE, portosystemic encephalopathy
- PV, portal vein
- PVT, portal vein thrombosis
- Portal hypertension
- Portal vein thrombosis
- RA, refractory ascites
- RCTs, randomised controlled trials
- SBP, spontaneous bacterial peritonitis
- SEMS, self-expandable metallic stent
- TFS, transplant-free survival
- TIPS, transjugular intrahepatic portosystemic shunt
- Transjugular intrahepatic portosystemic shunt
Collapse
Affiliation(s)
- Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mattias Mandorfer
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
3
|
Amer T, Osman B, Johnstone A, Mariappan M, Gupta A, Brattis N, Jones G, Somani BK, Keeley FX, Aboumarzouk OM. Medical expulsive therapy for ureteric stones: Analysing the evidence from systematic reviews and meta-analysis of powered double-blinded randomised controlled trials. Arab J Urol 2017; 15:83-93. [PMID: 29071136 PMCID: PMC5653615 DOI: 10.1016/j.aju.2017.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 03/23/2017] [Accepted: 03/27/2017] [Indexed: 11/09/2022] Open
Abstract
Objective To conduct a systematic review and meta-analysis investigating the efficacy and safety of medical expulsive therapy (MET) in low risk of bias (RoB) randomised controlled trials (RCTs). Methods A Cochrane style systematic review was conducted on published literature from 1990 to 2016, to include low RoB and a power calculation. A pooled meta-analysis was conducted. Results The MET group included 1387 vs 1381 patients in the control group. The analysis reveals α-blockers increased stone expulsion rates (78% vs 74%) (P < 0.001), whilst calcium channel blockers (CCBs) had no effect compared to controls (79% vs 75%) (P = 0.38). In the subgroup analysis, α-blockers had a shorter time to stone expulsion vs the control group (P < 0.001). There were no significant differences in expulsion rates between the treatment groups and control group for stones <5 mm in size (P = 0.48), proximal or mid-ureteric stones (P = 0.63 and P = 0.22, respectively). However, α-blockers increased stone expulsion in stones >5 mm (P = 0.02), as well as distal ureteric stones (P < 0.001). The α-blocker group developed more side-effects (6.6% of patients; P < 0.001). The numbers needed to treat for α-blockers was one in 14, for stones >5 mm one in eight, and for distal stones one in 10. Conclusion The primary findings show a small overall benefit for α-blockers as MET for ureteric stones but no benefit with CCBs. α-blockers show a greater benefit for large (>5 mm) ureteric stones and those located in the distal ureter, but no benefit for smaller or more proximal stones. α-blockers are associated with a greater risk of side-effects compared to placebo or CCBs.
Collapse
Affiliation(s)
| | - Banan Osman
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | | | | | | | - Nikolaos Brattis
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | | | | | - Francis X Keeley
- Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK
| | - Omar M Aboumarzouk
- Glasgow Royal Infirmary, Glasgow, UK.,Bristol Urological Institutes, North Bristol NHS Trust, Bristol, UK.,Queen Elizabeth University Hospitals, Glasgow, UK.,Islamic Universities of Gaza, College of Medicine, Gaza, Palestine
| |
Collapse
|
4
|
Owens RE, Snyder HS, Twilla JD, Satapathy SK. Pharmacologic Treatment of Alcoholic Hepatitis: Examining Outcomes Based on Disease Severity Stratification. J Clin Exp Hepatol 2016; 6:275-281. [PMID: 28003716 PMCID: PMC5157883 DOI: 10.1016/j.jceh.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/12/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Maddrey discriminant function (MDF) score is a measure of disease prognosis in alcoholic hepatitis (AH) used to identify patients at highest risk of mortality and determine the need for initiation of pharmacologic treatment. The purpose of this study was to evaluate the effects of pharmacologic therapy for hospitalized AH patients as stratified by MDF score. METHODS A retrospective review of patients with an AH diagnosis admitted to a Methodist LeBonheur Healthcare adult hospital between 06/2009 and 06/2014 was conducted. Patients ≥18 years of age with an ICD-9 code for AH were evaluated. RESULTS Of the 493 patients screened, 234 met the inclusion criteria, comprised of 62 patients with an MDF ≥ 32 (treatment, n = 42 vs. no treatment, n = 20) and 172 patients with an MDF < 32 (treatment, n = 15 vs. no treatment, n = 157). For the patients with an MDF ≥ 32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (31% vs. 11%, respectively; P = 0.18) and 6-month mortality (45% treatment vs. 38% non-treatment; P = 0.75). For the patients with an MDF <32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (0% vs. 7%, respectively; P > 0.99) and 6-month mortality (11% treatment vs. 13% non-treatment; P > 0.99). There was no difference in incidence of acute kidney injury, hepatorenal syndrome, development of infection or hepatic encephalopathy between the treatment vs. non-treatment groups. CONCLUSIONS Pharmacologic treatment showed no survival benefit, regardless of disease severity. Given the mortality risk seen in mild-moderate AH patients not receiving treatment and concern for a possible treatment ceiling effect in severe AH patients, more data are needed to adequately assess the utility of MDF in selecting appropriate candidates for AH treatment.
Collapse
Key Words
- AASLD, American Association for the Study of Liver Diseases
- AH, alcoholic hepatitis
- AKI, acute kidney injury
- ALD, alcoholic liver disease
- ARR, absolute risk reduction
- GI, gastrointestinal
- HRS, hepatorenal syndrome
- INR, international normalized ratio
- MDF, Maddrey discriminant function
- MELD, Model for End-Stage Liver Disease
- Maddrey discriminant function
- PT, prothrombin time
- SCr, serum creatinine
- SD, standard deviation
- eGFR, estimated glomerular filtration rate
- pentoxifylline
- prednisolone
Collapse
Affiliation(s)
- Ryan E. Owens
- University of Oklahoma College of Pharmacy, Department of Pharmacy, Clinical and Administrative Sciences, 1110 North Stonewall Avenue, Oklahoma City, OK 73117, USA,Address for correspondence: Ryan E. Owens, Department of Pharmacy, Clinical and Administrative Sciences, 1110 North Stonewall Avenue, Oklahoma City, OK 73117, USA.Department of Pharmacy, Clinical and Administrative Sciences1110 North Stonewall AvenueOklahoma CityOK73117USA
| | - Heather S. Snyder
- Methodist University Hospital, Department of Pharmacy, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Jennifer D. Twilla
- Methodist University Hospital, Department of Pharmacy, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Sanjaya K. Satapathy
- Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Division of Surgery, Transplant Hepatology, 1265 Union Avenue, Memphis, TN 38104, USA
| |
Collapse
|