Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Accelerated Fibrinolysis: A Tendency to Bleed?

Hyperfibrinolysis is rarely investigated as an underlying mechanism in patients with mild-to-moderate bleeding disorders (MBDs) and bleeding disorders of unknown cause (BDUC). Hereditary hyperfibrinolytic disorders, including α2-antiplasmin (α2-AP) deficiency, plasminogen activator inhibitor type 1 (PAI-1) deficiency, Quebec platelet disorder, and tissue plasminogen activator (tPA) excess, present with mild-to-moderate bleeding symptoms that are common in patients with MBD or BDUC, but may also manifest as life-threatening bleeding. This review summarizes the available data on hyperfibrinolysis in MBD and BDUC patients, and its assessment by various methods such as measurement of fibrinolytic factors, global hemostatic assays (e.g., viscoelastic testing, turbidity-based plasma clot lysis), and fluorogenic plasmin generation (PG). However, evidence on the relationship between hyperfibrinolytic profiles and bleeding severity is inconsistent, and, although found in some coagulation factor deficiencies, has not been universally observed. In BDUC, increased tPA activity and paradoxical increases in thrombin-activatable fibrinolysis inhibitor and α2-AP have been reported. Some studies reported no change in PAI-1 levels, while others observed reduced PAI-1 levels in a significant subset of patients. The tPA-ROTEM (tPA-rotational thromboelastometry) assay identified a hyperfibrinolytic profile in up to 20% of BDUC patients. PG analysis revealed a paradoxically reduced peak plasmin, but showed strong predictive power in differentiating BDUC patients from healthy controls. Although global fibrinolytic assays may help identify hyperfibrinolytic profiles as a potential cause of increased bleeding in some MBD or BDUC patients, the utility of measuring fibrinolytic factors requires further investigation. Tranexamic acid is commonly used to treat hereditary hyperfibrinolysis and is also recommended in MBD/BDUC patients prior to hemostatic challenges.

Discovery of BT-114143, a Novel and Potent Phosphoric Acid-Containing Small-Molecule Plasminogen Activation Inhibitor for Hyperfibrinolysis

Fibrinolysis, the natural process of blood clot dissolution regulated by plasmin, plays a crucial role in preserving vascular health. Nevertheless, if this process becomes hyperactive, it can lead to severe bleeding episodes, particularly in instances of traumatic injuries. Conventional antifibrinolytics such as ε-aminocaproic acid (EACA) and tranexamic acid (TXA) exhibit limited impact attributed to their modest potency. The substantial dosage volume necessary for effectiveness, along with safety concerns, especially when administered in high doses, further constrains their usage. In response to these challenges, we have engineered BT-114143, an innovative plasminogen activation inhibitor featuring a phosphoric acid functional group. Crafted through structure-based drug design and nonclassical bioisosteres, BT-114143 has demonstrated significant antifibrinolytic activity and target selectivity in extensive preclinical studies. Presently, BT-114143 is in Phase Ib clinical trials in China (CTR20222910), representing a noteworthy progression in antifibrinolytic therapy.

Palliative oncodermatology: Management of malignancy-related cutaneous symptoms in the palliative care setting

Dermatologists play a critical role in interdisciplinary cancer care, and as the field of supportive oncodermatology has evolved, a new subdivision has emerged: palliative oncodermatology. In cancer patients awaiting definitive treatment, those unable to undergo surgery or other invasive interventions, and those in the terminal stages of their illness, there is a need for symptom-based, noncurative strategies that address symptoms of cutaneous malignancies as well as cutaneous complications of systemic malignancies. The integration of palliative care principles in the management of such cutaneous complications strives to alleviate suffering and enhance quality of life. Here, we review the complications associated with cutaneous malignancies and metastases, along with skin symptoms of systemic malignancies. We also explore treatment options that emphasize symptom relief and comfort, highlighting the role of dermatologists in managing these challenges and coordinating supportive care in palliative settings.

Development of an assay to quantify tranexamic acid levels in plasma

Dysregulations of blood clot breakdown (fibrinolysis) during vascular trauma can lead to excessive blood loss. Tranexamic acid (TXA) is an inhibitor of fibrinolysis that works by blocking the interaction between plasminogen and fibrin degradation products (FDPs) - a key step in fibrinolysis. Despite the widespread usage, there are no tests available in a clinical setting to monitor TXA levels. We developed a fluorescence resonance energy transfer (FRET)-based assay to quantify TXA concentrations in plasma by using 1) fluorescently labeled plasminogen, and 2) FDPs labeled with a fluorescence quencher. Once plasminogen binds the FDPs, the fluorescent signal is quenched. TXA causes plasminogen to dissociate from the FDPs, thus increasing fluorescence signal in a dose-dependent manner. The dose response was sensitive between 1 and 100 μM (0.16 and 15.7 mg/L). The intraassay and interassay variabilities were determined to be 5.7 % and 3.0 %, respectively. Limit of detection was estimated to be 0.28 μM (0.044 mg/L). When tested for measuring known levels of TXA added to plasma samples, the ratio between measured and expected TXA concentration was 1.0151. Our study demonstrates a novel assay that can rapidly quantify TXA concentrations in plasma samples, thus demonstrating its potential as an in-hospital tool.

The Effects of Systemic Tranexamic Acid Administration on Drainage Volume, Length of Hospital Stay, and Postoperative Complications in Reduction Mammaplasty

Background: Reduction mammaplasty is a common, elective, and safe operation, usually executed in healthy patients. Nonetheless, postoperative complications like bleeding and seroma formation can occur and significantly complicate the postoperative course. Tranexamic acid (TXA), a commonly used antifibrinolytic drug, offers a novel approach to reduce these complications. This study aims to evaluate its effect on the rate of postoperative bleeding, drainage volume, length of hospital stay, and other postoperative complications in patients undergoing reduction mammaplasty. Method: A retrospective study on all patients undergoing reduction mammaplasty at the Department of Plastic, Reconstructive, and Aesthetic Surgery EOC between 2015 and 2022 was conducted. Patients were divided into the TXA group receiving systemic TXA for 48 h and the control group not receiving any TXA. All data were analyzed using nonparametric formulas. Results: A total of 209 breasts were included in the study, with 138 cases in the control group and 71 in the TXA group. Three cases requiring revision surgery due to bleeding were observed in the control group, whereas none were observed in the TXA group. Total drainage volume was significantly reduced in the TXA group compared to the control group (TXA: 41.6 mL vs. control: 53.8 mL; p = 0.012), resulting in a significant reduction in length of hospital stay (TXA: 1.6 days vs. control: 2.2 days; p = 0.0001). Conclusions: TXA is a well-tolerated drug that significantly reduces postoperative bleeding and drainage volume, resulting in earlier drain removal and reduced length of hospital stay. TXA should, therefore, be widely used in plastic surgery, especially as trends in healthcare systems necessitate more outpatient procedures and quicker postoperative recovery.

Tranexamic Acid as a Preventive Strategy Against Periprosthetic Joint Infection in Aseptic Revision Arthroplasty: A Comprehensive Review

Periprosthetic joint infection (PJI) is a severe complication following joint replacement surgeries, particularly in aseptic revision arthroplasty, where infection rates are higher compared to primary procedures. The extended surgical time, increased blood loss, and the presence of scar tissue contribute to the higher susceptibility to PJI in revision surgeries. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is widely used in orthopaedic surgery to reduce intraoperative and postoperative bleeding. By stabilising blood clots and reducing the need for blood transfusions, TXA improves patient outcomes and reduces complications related to excessive bleeding. Emerging evidence suggests that TXA may also play a role in reducing PJI, as minimising bleeding and haematoma formation can reduce bacterial colonisation and blood transfusions are associated with increased infection risks due to immunomodulation. This review explores the potential of TXA as a preventive strategy against PJI in aseptic revision arthroplasty, evaluating its mechanisms, clinical applications, and current evidence. While TXA's efficacy in reducing blood loss is well-established, its role in infection prevention, particularly through indirect mechanisms such as limiting haematoma formation, warrants further investigation. By incorporating TXA into multimodal strategies aimed at reducing PJI, surgeons can potentially improve patient outcomes and reduce the financial burden on healthcare systems. This review provides a comprehensive examination of the available data on TXA's role in preventing PJI in revision arthroplasty, with an emphasis on understanding its mechanisms and identifying gaps in current knowledge that require further research.

Integrating Heat-Stable Carbetocin and Tranexamic Acid for Prevention and Management of Postpartum Hemorrhage in Sub-Saharan Africa: A Five-Country Pilot Implementation Study

Background and Objective

Globally, postpartum hemorrhage (PPH) remains the most common direct cause of maternal mortality. This study evaluated the feasibility and acceptability of introducing heat-stable carbetocin (HSC) for PPH prevention and tranexamic acid (TXA) for PPH treatment in five Sub-Saharan African countries following recent World Health Organization (WHO) recommendations. This study also assessed healthcare providers' (HCPs') favorability toward using these medicines.

Methods

We conducted a mixed methods pilot implementation study in selected facilities across Burkina Faso, Ethiopia, Ghana, Sierra Leone, and Uganda between May and December 2022. We compared baseline data obtained from patient registers with data collected during implementation on the safe and appropriate use of HSC and TXA using descriptive statistics. HCP responses were analyzed qualitatively using a thematic analysis.

Results

Following training, HSC was administered prophylactically in 11,329 (92.4%) of 12,262 deliveries in all study facilities which received a uteorotonic for PPH prevention during implementation and was used safely and appropriately. TXA administration for PPH treatment was done safely, appropriately, and within the WHO-recommended time. No adverse events were reported throughout the study. HCPs overall showed high confidence in, and favorability toward, using both medicines.

Conclusion and Global Health Implications

Our study demonstrated that HSC and TXA can be safely and appropriately implemented in primary and tertiary facilities, and their introduction is feasible and acceptable from the perspective of HCPs. A holistic approach to training and regular supportive supervision is needed to ensure the continued safe use of these new and lesser-utilized PPH medicines. Dedicated training is required to improve the documentation of patient charts on PPH care. Introducing these medicines holds promise for improving PPH care in low- and middle-income countries, including by addressing suboptimal efficacy due to cold chain system challenges.

Usage of Tranexamic Acid for Total Hip Arthroplasty: A Matched Cohort Analysis of 144,344 Patients

Background: The literature is inconclusive regarding the potential complications of tranexamic acid (TXA), an antifibrinolytic drug, for total hip arthroplasty (THA). The purpose of this study is to compare complication rates and patient outcomes between THA patients administered TXA vs. THA patients not administered TXA. Methods: The TriNetX Research network was utilized to generate a cohort of adult patients who underwent THA between 2003 and 2024. These patients were categorized into two subgroups for the retrospective analysis: (1) patients who received TXA 24 h prior to THA (TXA), and (2) patients who did not receive TXA 24 h prior to total hip arthroplasty (no-TXA). The follow-up period was 30 and 90 days. Results: At 30 days following THA, the TXA patients had a reduced risk of transfusion (risk ratio (RR): 0.412; 95% confidence intervals (CI): 0.374, 0.453), reduced risk of DVT (RR: 0.856; CI: 0.768, 0.953), reduced risk of joint infection (RR: 0.808; CI: 0.710, 0.920), but a higher rate of periprosthetic fracture (RR: 1.234; CI: 1.065, 1.429) compared to patients who did not receive TXA. At 90 days following THA, TXA patients had a reduced risk of transfusion (RR: 0.446; CI: 0.408, 0.487), DVT (RR: 0.847; CI: 0.776, 0.924), and periprosthetic joint infection (RR: 0.894; CI: 0.815, 0.982) compared to patients who did not receive TXA. Patients who received TXA had higher rates of periprosthetic fracture (RR: 1.219; CI: 1.088, 1.365), acute postoperative anemia (RR: 1.222; CI: 1.171, 1.276), deep surgical site infection (SSI) (RR: 1.706; CI: 1.117, 2.605), and superficial SSI (RR: 1.950; CI: 1.567, 2.428) compared to patients who did not receive TXA. Conclusions: Patients receiving TXA prior to THA exhibited significantly reduced the prevalence of blood transfusions, DVT, and periprosthetic joint infection following THA. However, superficial SSI and periprosthetic fracture were seen with higher rates in the TXA cohort than in the no-TXA cohort.

Spatiotemporally Controlled Release of Etamsylate from Bioinspired Peptide-Functionalized Nanoparticles Arrests Bleeding Rapidly and Improves Clot Stability in a Rabbit Internal Hemorrhage Model

Achieving rapid clotting and clot stability are important unmet goals of clinical management of noncompressible hemorrhage. This study reports the development of a spatiotemporally controlled release system of an antihemorrhagic drug, etamsylate, in the management of internal hemorrhage. Gly-Arg-Gly-Asp-Ser (GRGDS) peptide-functionalized chitosan nanoparticles, with high affinity to bind with the GPIIa/IIIb receptor of activated platelets, were loaded with the drug etamsylate (etamsylate-loaded GRGDS peptide-functionalized chitosan nanoparticles; EGCSNP). Peptide conjugation was confirmed by LCMS, and the delivery system was characterized by DLS, SEM, XRD, and FTIR. In vitro study exhibited 90% drug release till 48 h fitting into the Weibull model. Plasma recalcification time and prothrombin time tests of GRGDS-functionalized nanoparticles proved that clot formation was 1.5 times faster than nonfunctionalized chitosan nanoparticles. The whole blood clotting time was increased by 2.5 times over clot formed under nonfunctionalized chitosan nanoparticles. Furthermore, the application of rheometric analysis revealed a 1.2 times stiffer clot over chitosan nanoparticles. In an in vivo liver laceration rabbit model, EGCSNP spatially localized at the internal injury site within 5 min of intravenous administration, and no rebleeding was recorded up to 3 h. The animals survived for 3 weeks after the injury, indicating the strong potential of the system for the management of noncompressible hemorrhage.

Bleeding Disorder of Unknown Cause: A Diagnosis of Exclusion

Patients with an unexplained mild to moderate bleeding tendency are diagnosed with bleeding disorder of unknown cause (BDUC), a classification reached after ruling out other mild to moderate bleeding disorders (MBD) including von Willebrand disease (VWD), platelet function defects (PFDs), coagulation factor deficiencies (CFDs), and non-hemostatic causes for bleeding. This review outlines our diagnostic approach to BDUC, a diagnosis of exclusion, drawing on current guidelines and insights from the Vienna Bleeding Biobank (VIBB). According to guidelines, we diagnose VWD based on VWF antigen and/or activity levels ≤50 IU/dL, with repeated VWF testing if VWF levels are <80 IU/dL. This has been introduced in our clinical routine after our findings of diagnostically relevant fluctuations of VWF levels in a high proportion of MBD patients. PFDs are identified through repeated abnormalities in light transmission aggregometry (LTA), flow cytometric mepacrine fluorescence, and glycoprotein expression analysis. Nevertheless, we experience diagnostic challenges with regard to reproducibility and unspecific alterations of LTA. For factor (F) VIII and FIX deficiency, a cutoff of 50% is utilized to ensure detection of mild hemophilia A or B. We apply established cutoffs for other rare CFD being aware that these do not clearly reflect the causal role of the bleeding tendency. Investigations into very rare bleeding disorders due to hyperfibrinolysis or increase in natural anticoagulants are limited to cases with a notable family history or distinct bleeding phenotypes considering cost-effectiveness. While the pathogenesis of BDUC remains unknown, further explorations of this intriguing area may reveal new mechanisms and therapeutic targets.

Clinical application of tranexamic acid in arthroscopic rotator cuff repair surgery: A randomized controlled trial

BACKGROUND

To investigate whether intravenous administration of tranexamic acid (TXA) prior to arthroscopic rotator cuff repair improves operative blood loss, postoperative fibrinolytic index, inflammatory response, and postoperative pain.

METHODS

This was a prospective, double-blind, randomized controlled study. From January 2023 to February 2024, 64 patients who required arthroscopic rotator cuff repair were included and divided into tranexamic acid group (T group) group and control group (C group) according to the random number table method. In T group, 1000 mg TXA was administered intravenously 10 minutes before surgery, and an equivalent dose of normal saline was administered intravenously 10 minutes before surgery in C group. Intraoperative bleeding, postoperative fibrinolytic indexes, inflammatory indexes, pain scores, and occurrence of adverse effects were compared between the 2 groups.

RESULTS

Intraoperative bleeding in T group was lower than that in C group (P < .05); D-D and FDP in T group were significantly lower than those in C group (P < .05); postoperative TNF-α and IL-6 in 2 groups was higher than that before operation and T group was lower than C group (P < .05); The pain scores of the 2 groups after operation were lower than those before operation (P < .05), and there was no difference between the 2 groups (P > .05).

CONCLUSION SUBSECTIONS

TXA is able to reduce blood loss and inflammatory reactions, modulate fibrinolytic function, and promote postoperative recovery in patients undergoing arthroscopic rotator cuff repair, with no elevated risk of complications.

Unravelling the Antifibrinolytic Mechanism of Action of the 1,2,3-Triazole Derivatives

A new family of antifibrinolytic drugs has been recently discovered, combining a triazole moiety, an oxadiazolone, and a terminal amine. Two of the molecules of this family have shown activity that is greater than or similar to that of tranexamic acid (TXA), the current antifibrinolytic gold standard, which has been associated with several side effects and whose use is limited in patients with renal impairment. The aim of this work was to thoroughly examine the mechanism of action of the two ideal candidates of the 1,2,3-triazole family and compare them with TXA, to identify an antifibrinolytic alternative active at lower dosages. Specifically, the antifibrinolytic activity of the two compounds (1 and 5) and TXA was assessed in fibrinolytic isolated systems and in whole blood. Results revealed that despite having an activity pathway comparable to that of TXA, both compounds showed greater activity in blood. These differences could be attributed to a more stable ligand-target binding to the pocket of plasminogen for compounds 1 and 5, as suggested by molecular dynamic simulations. This work presents further evidence of the antifibrinolytic activity of the two best candidates of the 1,2,3-triazole family and paves the way for incorporating these molecules as new antifibrinolytic therapies.

Hemostatic effects of tranexamic acid in cardiac surgical patients with antiplatelet therapy: a systematic review and meta-analysis

BACKGROUND

The purpose of the current study was to assess the efficacy of tranexamic acid (TXA) on reducing bleeding in cardiac surgical patients with preoperative antiplatelet therapy (APT).

METHODS

Five electronic databases were searched systematically for randomized-controlled trials (RCTs) assessing the impact of intravenous TXA on post-operative bleeding on cardiac surgical patients with preoperative APT until May 2024. Primary outcome of interest was post-operative blood loss. Secondary outcomes of interest included the incidence of reoperation due to post-operative bleeding, post-operative transfusion requirements of red blood cells (RBC), fresh-frozen plasma (FFP), and platelet concentrates. Mean difference (MD) with 95% confidence interval (CI) or odds ratios (OR) with 95% CI was employed to analyze the data. Subgroup and meta-regression analyses were performed to assess the possible influence of TXA administration on reducing bleeding and transfusion requirements.

RESULTS

A total of 12 RCTs with 3018 adult cardiac surgical patients (TXA group, 1510 patients; Control group, 1508 patients) were included. The current study demonstrated that TXA significantly reduced post-operative blood loss (MD =  - 0.38 L, 95% CI: - 0.73 to - 0.03, P = 0.03; MD =  - 0.26 L, 95% CI: - 0.28 to - 0.24, P < 0.00001; MD =  - 0.37 L, 95% CI: - 0.63 to - 0.10, P = 0.007) in patients receiving dual antiplatelet therapy (DAPT), aspirin, or clopidogrel, respectively. Patients in TXA group had significantly lower incidence of reoperation for bleeding as compared to those in Control group. The post-operative transfusion of RBC and FFP requirements was significantly lower in TXA group than Control group. Subgroup analyses showed that studies with DAPT discontinued on the day of surgery significantly increased the risk of post-operative blood loss [(MD: - 1.23 L; 95% CI: - 1.42 to - 1.04) vs. (MD: - 0.16 L; 95% CI: - 0.27 to - 0.05); P < 0.00001 for subgroup difference] and RBC transfusion [(MD: - 3.90 units; 95% CI: - 4.75 to - 3.05) vs. (MD: - 1.03 units; 95% CI: - 1.96 to - 0.10); P < 0.00001 for subgroup difference] than those with DAPT discontinued less than 5-7 days preoperatively.

CONCLUSIONS

This meta-analysis demonstrated that TXA significantly reduced post-operative blood loss and transfusion requirements for cardiac surgical patients with preoperative APT. These potential clinical benefits may be greater in patients with aspirin and clopidogrel continued closer to the day of surgery.

TRIAL REGISTRATION NUMBER

CRD42022309427.

Tranexamic acid for the prevention and treatment of postpartum hemorrhage in resource-limited settings: a literature review

Introduction

Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide. Early recognition and appropriate treatment are crucial for managing postpartum haemorrhage.

Objectives

This literature review aimed to evaluate the efficacy of tranexamic acid in the prevention and treatment of postpartum haemorrhage in resource-limited settings.

Search methods

This literature review was conducted based on the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A computerized systematic search of the MEDLINE (PubMed), Google Scholar, and Cochrane databases using a combination of the following Medical Subject Headings (MeSH) terms for PubMed: [(obstetric haemorrhage OR postpartum haemorrhage OR massive obstetric haemorrhage) AND (tranexamic acid OR antifibrinolytic drugs) AND (prophylaxis OR prevention) AND (management OR treatment) AND (resource-limited settings OR resource-limited area OR developing countries)] to find articles published in English since 2010.

Selection criteria

Studies on the obstetric population who underwent vaginal or caesarean delivery, comparing the use of tranexamic acid versus placebo (or no treatment) for treatment (or prevention) of postpartum haemorrhage with the outcome of postpartum haemorrhage rate, blood transfusion requirements, uterotonics requirements, hysterectomy, or mortality were included.

Result

In total, 5315 articles were identified. Following the elimination of duplicates, the methodological quality of 15 studies was evaluated independently, with eligibility determined based on the inclusion and exclusion criteria, as well as outcome variables. Finally, eight articles were included in the review.

Conclusion

This review provides evidence that the administration of tranexamic acid has the potential to decrease the need for blood transfusion, incidence of postpartum haemorrhage, demand for supplementary uterotonics, and maternal morbidity and mortality with marginal adverse effects. Healthcare systems must develop and implement interventions that involve the use of tranexamic acid for the treatment of postpartum haemorrhage in resource-limited settings.

Thromboembolic Complications Following Perioperative Tranexamic Acid Administration

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.

Effects of local infiltration of analgesia and tranexamic acid in total knee replacements: safety and efficacy in reducing blood loss and comparability to intra-articular tranexamic acid

INTRODUCTION

The use of periarticular (PA) tranexamic acid (TXA) and its efficacy in comparison with intra-articular (IA) TXA have not been well explored in the literature. This retrospective cohort study aimed to compare the effects of IA and PA TXA with analgesic components in reducing blood loss and improving immediate postoperative pain relief and functional outcomes in patients after unilateral primary total knee arthroplasty (TKA).

METHODS

A total of 63 patients underwent TKA, and they were divided into the IA TXA delivery group ( n = 42) and PA TXA delivery group ( n = 21). All patients were administered 1 g of TXA. They also received pericapsular infiltration consisting of 0.5 mL of adrenaline, 0.4 mL of morphine, 1 g of vancomycin, 1 mL of ketorolac and 15 mL of ropivacaine. Outcomes for blood loss and surrogate markers for immediate functional recovery were measured.

RESULTS

Of the 63 patients, 54% were female and 46% male. The mean drop in postoperative haemoglobin levels in the PA and IA groups was 2.0 g/dL and 1.6 g/dL, respectively, and this was not statistically significant ( P = 0.10). The mean haematocrit drop in the PA and IA groups was 6.1% and 5.3%, respectively, and this was also not statistically significant ( P = 0.58). The postoperative day (POD) 1 and discharge day flexion angles, POD 1 and POD 2 visual analogue scale (VAS) scores, gait distance on discharge and length of hospitalisation stay were largely similar in the two groups.

CONCLUSION

Our study showed that both IA and PA TXA with analgesic components were equally efficient in reducing blood loss and improving immediate postoperative pain relief and functional outcomes.

Effectiveness of tranexamic acid in orthognathic surgery: A systematic review of systematic reviews

PURPOSE

This study aimed to review the currently available evidence on the effectiveness of administering tranexamic acid (TXA) to patients undergoing orthognathic surgery.

METHODS

A study protocol was developed in accordance with the Preferred Reporting Guideline for Overviews of Reviews (PRIOR) and registered on the International Prospective Register of Systematic Reviews (PROSPERO) under Registration No. CRD42021232931. Furthermore, the reporting of the present systematic review was performed based on the PRISMA checklist.

RESULTS

The search strategy yielded a total of 50 articles. After reading the abstracts, 28 articles were excluded, and the English full texts of the remaining 22 studies were separately examined for eligibility by two authors; 15 articles were excluded because they did not meet the inclusion criteria. Finally, seven systematic reviews and meta-analysis satisfied the criteria for inclusion and were processed for critical review evaluation.

CONCLUSIONS

Within the limits of the present study and the reviews of the 7 articles included, it is observed that TXA is able to reduce the amount of intraoperative blood loss and the amount of irrigation fluids required. However, it does not influence postoperative levels of hemoglobin or hematocrit, nor does it affect the requirement for blood transfusions. It was interestingly discovered that TXA could increase the quality of the surgical site. These data imply that TXA may be an effective adjuvant in lowering bleeding during orthognathic surgery. As a result, the potential risk of problems related with considerable blood loss may be minimized.

Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis

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.

Tranexamic acid improves psoriasis-like skin inflammation: Evidence from in vivo and in vitro studies

The chronic disease psoriasis is associated with severe inflammation and abnormal keratinocyte propagation in the skin. Tranexamic acid (TXA), a plasmin inhibitor, is used to cure serious bleeding. We investigated whether TXA ointment mitigated Imiquimod (IMQ)-induced psoriasis-like inflammation. Furthermore, this study investigated the effect of noncytotoxic concentrations of TXA on IL-17-induced human keratinocyte (HaCaT) cells to determine the status of proliferative psoriatic keratinocytes. We found that TXA reduced IMQ-induced psoriasis-like erythema, thickness, scaling, and cumulative scores (erythema plus thickness plus scaling) on the back skin of BALB/c mice. Additionally, TXA decreased ear thickness and suppressed hyperkeratosis, hyperplasia, and inflammation of the ear epidermis in IMQ-induced BALB/c mice. Furthermore, TXA inhibited IMQ-induced splenomegaly in BALB/c mouse models. In IL-17-induced HaCaT cells, TXA inhibited ROS production and IL-8 secretion. Interestingly, TXA suppressed the IL-17-induced NFκB signaling pathway via IKK-mediated IκB degradation. TXA inhibited IL-17-induced activation of the NLRP3 inflammasome through caspase-1 and IL1β expression. TXA inhibited IL-17-induced NLRP3 inflammasome activation by enhancing autophagy, as indicated by LC3-II accumulation, p62/SQSTM1 expression, ATG4B inhibition, and Beclin-1/Bcl-2 dysregulation. Notably, TXA suppressed IL-17-induced Nrf2-mediated keratin 17 expression. N-acetylcysteine pretreatment reversed the effects of TXA on NFκB, NLRP3 inflammasomes, and the Nrf2-mediated keratin 17 pathway in IL-17-induced HaCaT cells. Results further confirmed that in the ear skin of IMQ-induced mice, psoriasis biomarkers such as NLRP3, IL1β, Nrf2, and keratin 17 expression were downregulated by TXA treatment. TXA improves IMQ-induced psoriasis-like inflammation in vivo and psoriatic keratinocytes in vitro. Tranexamic acid is a promising future treatment for psoriasis.

Surgery in rare bleeding disorders: the prospective MARACHI study

Background

Despite the wide use of bleeding scores and the reliability of clotting factor level measurement, bleeding risk stratification before surgery remains challenging in patients with rare inherited bleeding disorders.

Objectives

This multicenter observational prospective study assessed in patients with rare coagulation factor deficiency, the perioperative hemostatic management choices by hemostasis experts and the bleeding outcomes after surgery.

Methods

One hundred seventy-eight patients with low coagulation activity level (factor [F] II, FV, combined FV-FVIII, FVII, FX, or FXI <50%) underwent 207 surgical procedures. The bleeding outcome, Tosetto's bleeding score, and perioperative hemostatic protocols were collected.

Results

Among the 81 procedures performed in patients with severe factor deficiency (level ≤10%), 27 were done without factor replacement (including 6 in patients at high bleeding risk), without any bleeding event. Factor replacement therapy was used mainly for orthopedic procedures. In patients with mild deficiency, 100/126 surgical procedures were carried out without perioperative hemostatic treatment. In patients with FVII or FXI deficiency, factor replacement therapy was in function of the procedure, bleeding risk, and to a lesser extent previous bleeding history. Tranexamic acid was used in almost half of the procedures, particularly in case of surgery in tissues with high fibrinolytic activity (76.8%).

Conclusions

The current perioperative hemostatic management of patients with rare bleeding disorders appears to be adapted. Among the 207 procedures, only 6 were associated with excessive bleeding. Our findings suggest that rather than the bleeding score, factor level and surgery type are the most relevant criteria for perioperative factor replacement therapy.

Primary hemostasis dysfunctions and bleeding risk in newly diagnosed acute myeloid leukemia

BACKGROUND

Acute myeloid leukaemia carries the risk of complications associated with dysfunctions in haemostasis system. The purpose of this study was to investigate the factors associated with the risk of bleeding in patients with newly diagnosed acute myeloid leukaemia (AML).

METHODS

This study involved the methods of immunoenzymatic analysis and classical coagulation studies. The number of biochemical parameters important for establishing coagulative dysfunction in acute myeloid leukaemia was determined, the main ones being the level of von Willebrand factor, the Ristocetin-cofactor activity of von Willebrand factor and factor VIII activity, prothrombin time, platelet count, and fibrinogen concentration.

RESULTS

According to the results of the present study, the reduced activity of von Willebrand factor in patients with AML was associated with severe bleeding. The authors observed an increase in the number of platelets count in patients with AML who experienced haemorrhages compared to patients with no bleeding signs. The study also established an increase in the concentration of fibrinogen in cancer patients, compared to the control sample. Symptoms and quantitative indicators for diagnosing the severity of haemorrhagic syndrome were grouped. The authors considered the advantages and disadvantages of many therapeutic preparations and focussed on specific markers of activated haemorrhage-predicting platelets.

CONCLUSION

Further studies concern the search for effective markers and therapeutic approaches to minimize haemorrhagic syndrome. The results were statistically processed using the functions ANOVA, t test, CORREL, determination of the value of reliability, and mean square deviation.

Efficacy and safety of the combination of tranexamic acid injection and electro-optical synergy (ELOS) versus tranexamic acid injection alone in the treatment of melasma

Melasma is a common, relapsing, multifactorial disease for which the treatment decision remains extremely difficult. This study was designed to compare the efficacy and safety of the combination of tranexamic acid (TA) injection and electro-optical synergy (ELOS) versus TA injection alone in treating melasma. A retrospective study was undertaken for patients with facial epidermal or mixed-type melasma to compare clinical data between 15 patients receiving a combination regimen and 15 patients with TA injection only. The study administered TA through intravenous injection to the combination group (twice weekly for 12 weeks) followed by ELOS therapy (once a month for three times). The TA group, on the other hand, received only TA injection (twice weekly for 12 weeks). The evaluation of clinical effectiveness was based on comparing the Melasma Area Severity Index (MASI) scores before and one month after treatment (at 4 months). The Physician Global Assessment (PGA) and Patient satisfaction were documented, and adverse reactions were recorded. All patients were followed up for one year to observe the relapse. After treatment, the MASI scores and melasma severity were significantly reduced in both groups. The combination group showed better efficacy than the TA only group (P < 0.05). The Physician Global Assessment (PGA) and Patient satisfaction showed superior efficacies of the combination group. No significant difference was observed between the two groups in terms of treatment-related side effects. Both groups experienced a certain degree of recurrence during the one-year follow-up, but the TA only group had a significantly higher recurrence rate than the combination group (P < 0.01). Together, the combination of TA injection and ELOS is a safe and effective treatment strategy for melasma and should be promoted.

Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Tranexamic acid is a cost-effective intervention for the prevention of postpartum hemorrhage among women who undergo cesarean delivery, but the evidence to support its use is conflicting. We conducted this meta-analysis to evaluate the efficacy and safety of tranexamic acid in low- and high-risk cesarean deliveries.

DATA SOURCES

We searched MEDLINE (via PubMed), Embase, the Cochrane Library, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform portal from inception to April 2022 (updated October 2022 and February 2023) with no language restrictions. In addition, grey literature sources were also explored.

STUDY ELIGIBILITY CRITERIA

All randomized controlled trials that investigated the prophylactic use of intravenous tranexamic acid in addition to standard uterotonic agents among women who underwent cesarean deliveries in comparison with a placebo, standard treatment, or prostaglandins were included in this meta-analysis.

METHODS

We used the revised Cochrane Risk of Bias tool (RoB 2.0) to assess the quality of the included randomized controlled trials. RevMan 5.4 was used to conduct all statistical analyses using a random-effects model.

RESULTS

We included 50 randomized controlled trials (6 in only high-risk patients and 2 with prostaglandins as the comparator) that evaluated tranexamic acid in our meta-analysis. Tranexamic acid reduced the risk for blood loss >1000 mL, the mean total blood loss, and the need for blood transfusion in both low- and high-risk patients. Tranexamic acid was associated with a beneficial effect in the secondary outcomes, including a decline in hemoglobin levels and the need for additional uterotonic agents. Tranexamic acid increased the risk for nonthromboembolic adverse events but, based on limited data, did not increase the incidence of thromboembolic events. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. The quality of evidence was rated as low to very low for outcomes in the low-risk population and moderate for most outcomes in the high-risk subgroup.

CONCLUSION

Tranexamic acid may reduce the risk for blood loss in cesarean deliveries with a higher benefit observed in high-risk patients, but the lack of high-quality evidence precludes any strong conclusions. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. Additional studies, especially in the high-risk population and focused on evaluating the timing of tranexamic acid administration, are needed to confirm or refute these findings.

Prospective Study of Flap Surgery-Related Complications in Cutaneous Tumors: A Tertiary Care Institutional Experience of 6 Years

Introduction

Flap surgeries are the standard choice for reconstruction of defects post excision of cutaneous tumours. Complications following these surgeries predominantly result as a consequence of bleeding, tension, ischemia, infection.

Study Design

A Prospective study of patients treated for tumor excision and flap reconstruction between the period of 2014 and 2020 were followed up and complications encountered were analysed.

Results

A total of 70 patients with cutaneous malignancies underwent flap surgeries. Complications encountered were bleeding, hematoma, infection, necrosis, pincushioning, keloid, hypertrophic scars.

Conclusion

Successful outcome depends on pre operative evaluation, appropriate technique selection based on site of tumor, intraoperative care, post operative care and timely management of complications if any.

Young apheresis platelet donors show significant and sustained growth over the last decade in the US, 2010-2019: A favorable sign of the resiliency of the platelet supply

BACKGROUND

Platelet demand continues to rise and US hospitals frequently face shortages. The peak median age of apheresis platelet donors (APD) is believed to have increased over the last decade, raising concerns that the APD base is not being adequately replenished with young donors.

STUDY DESIGN/METHODS

American Red Cross (ARC) apheresis platelet collections were evaluated from calendar years 2010 through 2019. APD, products per procedure/split rate (PPP) and donation frequencies were stratified into age groups.

RESULTS/FINDINGS

The number of unique APD from calendar year 2010 through 2019 in the ARC donor pool increased from 87,573 to 115,372 donors, representing a 31.7% overall growth. Donors in the 16-40 year-old (y) age group increased by 78.8% overall, with the largest absolute increases seen in the 26-30 y (4852 donors, 99.9% growth), followed by the 31-35 y (3991, 94.1%) group. Donors aged 56+ increased by 50.4% overall, with the largest increase seen in the 66-70 y (5988 donors, 108.1% growth) group. Middle-aged donors, aged 41-55 y, demonstrated a decrease of 16.5%. Over the last decade, the youngest age groups (16-40 y) comprised 61.3% of first-time donors (FTD). Annual donation frequency increased with increasing age and PPP. The highest donation frequencies were seen in the oldest age groups.

CONCLUSION

Although the peak median age of APD increased over the study period, relative contribution of the 16-40 y APD base also increased. Older donors exhibited the highest donation frequencies and thus contributed the largest volume of apheresis platelet units. Platelet donor activity declined in the middle age (41-55 y) group.

Hypertensive Urgency and Anterior Epistaxis Caused by Antihypertensive Medication Noncompliance: A Case Report

BACKGROUND AND AIMS

A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance.

CASE PRESENTATION

A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os.

DISCUSSION

The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.

Risk factors and clinical outcomes associated with acquired hypofibrinogenemia in patients administered hemocoagulase batroxobin for hemoptysis

Background

Hemocoagulase batroxobin is used to prevent hemostasis or bleeding in surgical and trauma patients; however, the role of batroxobin in patients with hemoptysis is not well understood. We evaluated the risk factors and prognosis of acquired hypofibrinogenemia in hemoptysis patients treated systemically with batroxobin.

Methods

We retrospectively reviewed the medical charts of hospitalized patients who were administered batroxobin for hemoptysis. Acquired hypofibrinogenemia was defined as a plasma fibrinogen level >150 mg/dL at baseline, decreasing to <150 mg/dL after batroxobin administration.

Results

Overall, 183 patients were enrolled, of whom 75 had acquired hypofibrinogenemia after the administration of batroxobin. There was no statistical difference in the median age of the patients in the non-hypofibrinogenemia and hypofibrinogenemia groups (72.0 vs. 74.0 years, respectively). The patients in the hypofibrinogenemia group showed a higher rate of intensive care unit (ICU) admission (11.1% vs. 22.7%; P=0.041) and tended to have more massive hemoptysis than those in the non-hyperfibrinogenemia group (23.1% vs. 36.0%; P=0.068). The patients in the hypofibrinogenemia group further showed a higher requirement for transfusion (10.2% vs. 38.7%; P<0.000) than those in the non-hyperfibrinogenemia group. Low levels of baseline plasma fibrinogen and a prolonged and higher total dose of batroxobin were associated with the development of acquired hypofibrinogenemia. Acquired hypofibrinogenemia was associated with increased 30-day mortality [hazard ratio (HR), 4.164; 95% confidence interval (CI), 1.318-13.157].

Conclusions

The plasma fibrinogen levels in patients who were administered batroxobin for hemoptysis should be monitored, and batroxobin should be discontinued if hypofibrinogenemia occurs.

Hyperfibrinolysis drives mechanical instabilities in a simulated model of trauma induced coagulopathy

INTRODUCTION

Trauma induced coagulopathy (TIC) is common after severe trauma, increasing transfusion requirements and mortality among patients. TIC has several phenotypes, with primary hyperfibrinolysis being among the most lethal. We aimed to investigate the contribution of hypercoagulation, hemodilution, and fibrinolytic activation to the hyperfibrinolytic phenotype of TIC, by examining fibrin formation in a plasma-based model of TIC. We hypothesized that instabilities arising from TIC will be due primarily to increased fibrinolytic activation rather than hemodilution or tissue factor (TF) induced hypercoagulation.

METHODS

The influence of TF, hemodilution, fibrinogen consumption, tissue plasminogen activator (tPA), and the antifibrinolytic tranexamic acid (TXA) on plasma clot formation and structure were examined using rheometry, optical properties, and confocal microscopy. These were then compared to plasma samples from trauma patients at risk of developing TIC.

RESULTS

Combining TF-induced clot formation, 15 % hemodilution, fibrinogen consumption, and tPA-induced fibrinolysis, the clot characteristics and hyperfibrinolysis were consistent with primary hyperfibrinolysis. TF primarily increased fibrin polymerization rates and reduced fiber length. Hemodilution decreased clot optical density but had no significant effect on mechanical clot stiffness. TPA addition induced primary clot lysis as observed mechanically and optically. TXA restored mechanical clot formation but did not restore clot structure to control levels. Patients at risk of TIC showed increased clot formation, and lysis like that of our simulated model.

CONCLUSIONS

This simulated TIC plasma model demonstrated that fibrinolytic activation is a primary driver of instability during TIC and that clot mechanics can be restored, but clot structure remains altered with TXA treatment.

Recurrent Gastrointestinal Bleed Due to Small Bowel Vascular Malformation in a Patient with Turner Syndrome Diagnosed with Surgically Assisted Push Enteroscopy

BACKGROUND Obscure gastrointestinal bleeding accounts for approximately 5% of all cases of gastrointestinal bleeding and the most frequent site is the small bowel. Turner syndrome (TS) is a genetic disorder of the second X chromosome in females. The association between gastrointestinal vascular malformations and Turner syndrome has been described in some case reports. Vascular malformation in Turner's syndrome can vary from asymptomatic to severe recurrent GI bleeds, but data on diagnosis and management of these patients are lacking. CASE REPORT A 14-year-old girl with TS presented with recurrent symptomatic melena. The initial work-up included a negative upper endoscopy, negative bidirectional endoscopies, and a video capsule endoscopy (VCE) that demonstrated large amount of blood and small erythematous lesion in the small bowel without active bleeding, and a negative Meckel scan. CT angiography was remarkable for prominent left lower mesenteric blood vessels, and a single-balloon enteroscopy demonstrated prominent vasculature throughout the small bowel. A a clip was placed at the site of a questionable bleed. The patient underwent a surgically assisted push enteroscopy due to recurrent bleeding; findings were consistent with diffuse vascular malformations. She was started on tranexamic acid and later transitioned to estrogen therapy without further reports of GI bleeding, anemia, or adverse effects from treatment 6 months after initial presentation. CONCLUSIONS Small bowel bleeding can be life-threating, and evidence-based guidelines in children are needed. Turner syndrome is associated with gastrointestinal vascular malformations, and suspicion for this diagnosis should be high for these patients when presenting with gastrointestinal bleeding. Estrogen might be an effective therapy in TS adolescent patients in the setting of diffuse vascular malformations (DVM).

Plasma-based assays distinguish hyperfibrinolysis and shutdown subgroups in trauma-induced coagulopathy

BACKGROUND

Trauma patients with abnormal fibrinolysis have increased morbidity and mortality. Knowledge of mechanisms differentiating fibrinolytic phenotypes is important to optimize treatment. We hypothesized that subjects with abnormal fibrinolysis identified by whole blood viscoelastometry can also be distinguished by plasma thrombin generation, clot structure, fibrin formation, and plasmin generation measurements.

METHODS

Platelet-poor plasma (PPP) from an observational cross-sectional trauma cohort with fibrinolysis shutdown (% lysis at 30 minutes [LY30] < 0.9, n = 11) or hyperfibrinolysis (LY30 > 3%, n = 9) defined by whole blood thromboelastography were studied. Noninjured control subjects provided comparative samples. Thrombin generation, fibrin structure and formation, and plasmin generation were measured by fluorescence, confocal microscopy, turbidity, and a fluorescence-calibrated plasmin assay, respectively, in the absence/presence of tissue factor or tissue plasminogen activator (tPA).

RESULTS

Whereas spontaneous thrombin generation was not detected in PPP from control subjects, PPP from hyperfibrinolysis or shutdown patients demonstrated spontaneous thrombin generation, and the lag time was shorter in hyperfibrinolysis versus shutdown. Addition of tissue factor masked this difference but revealed increased thrombin generation in hyperfibrinolysis samples. Compared with shutdown, hyperfibrinolysis PPP formed denser fibrin networks. In the absence of tPA, the fibrin formation rate was faster in shutdown than hyperfibrinolysis, but hyperfibrinolysis clots lysed spontaneously; these differences were masked by addition of tPA. Tissue plasminogen activator-stimulated plasmin generation was similar in hyperfibrinolysis and shutdown samples. Differences in LY30, fibrin structure, and lysis correlated with pH.

CONCLUSION

This exploratory study using PPP-based assays identified differences in thrombin generation, fibrin formation and structure, and lysis in hyperfibrinolysis and shutdown subgroups. These groups did not differ in their ability to promote tPA-triggered plasmin generation. The ability to characterize these activities in PPP facilitates studies to identify mechanisms that promote adverse outcomes in trauma.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level III.

Estimation of Platelet Count and Bleeding Time of Mice Treated with Musa paradisiaca var. sapientum (L.) Kuntze Extract

Objective

The aim of this study was to estimate the platelet count and bleeding time on peripheral blood smear of mice tail wound using Musa paradisiaca var. sapientum (L.) Kuntze (ambonese banana stem extract).

Design

Randomized post-test-only control group design.

Materials and Methods

Twenty-four male mice (Mus Musculus) were randomly divided into 4 groups. A negative control group was treated with carboxymethyl cellulose (CMC), a positive control group (K+) treated aspirin 100 mg/kg body weight, group P1 treated with aspirin 100 mg/kg body weight and tranexamic acid 50 mg/kg body weight, and group P2 treated with 30% of ambonese banana stem extract (ABSE). The mean and standard deviation data of platelet counts and bleeding time were analyzed by one-way ANOVA statistical software.

Results and Discussion

Tranexamic acid had no significant effect on platelets count compared to CMC group (p = 0.871), but administration of aspirin resulted in low platelets count significantly (p = 0.003). The platelet counts of ABSE and CMC groups were not significant different (p = 0.937). Aspirin has significantly shown prolonged bleeding time than CMC, tranexamic acid, and ABSE groups. However, there was no difference between the tranexamic acid and ABSE groups (p=0.934). The bleeding time of tranexamic acid and ABSE groups was similar, although the platelet count in the ABSE group was lower than in the CMC group.

Conclusion

This study proved that ambonese banana stem extract has a potency to shorten the bleeding time in mice tail wound without interfering to platelet count.

Efficacy and safety of tranexamic acid for patients with intertrochanteric fractures treated with intramedullary fixation: A systematic review and meta-analysis of current evidence in randomized controlled trials

Background: Tranexamic acid (TXA) has been widely applied to reduce perioperative bleeding. Recently, several studies focused on the administration of TXA in the treatment for with intertrochanteric fracture patients treated with intramedullary fixation. However, the efficacy and safety of TXA in these studies remain controversial. Therefore, we performed this systematic review and meta-analysis to investigate the efficacy and safety of TXA in intertrochanteric fracture patients treated with intramedullary fixation.

Methods: We systematically searched electronic databases, including Cochrane, PubMed, and EMBASE, up to 16 May 2022. The efficacy and safety of TXA was evaluated in four aspects, which were bleeding-related outcomes, non-bleeding-related outcomes, thromboembolic events, and other complications. The outcomes of these studies were extracted and analyzed by RevMan Manager 5.4.

Results: Finally, nine randomized controlled trials, involving nine hundred and seventy-two intertrochanteric fracture patients treated with TXA, were enrolled in this study. In the bleeding-related outcomes, TXA group was significantly lower than the control group in terms of total blood loss (MD = −219.42; 95% CI, −299.80 to −139.03; p &lt; 0.001), intraoperative blood loss (MD = −36.81; 95% CI, −54.21 to −19.41; p &lt; 0.001), hidden blood loss (MD = −189.23; 95% CI, −274.92 to −103.54; p &lt; 0.001), and transfusion rate (RR = 0.64; 95% CI, 0.49 to 0.85; p = 0.002). Moreover, the postoperative hemoglobin on day 3 of the TXA group was significantly higher than that of the control group (MD = 5.75; 95% CI, 1.26 to 10.23; p = 0.01). In the non-bleeding-related outcomes, the length of hospital stays was significantly shorter in the TXA group (MD = −0.67; 95% CI, −1.12 to −0.23; p = 0.003). In terms of thromboembolic events, there was no significant differences between the TXA group and control group in deep vein thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke. As for complications and mortality, there was no significant differences between the TXA group and control group in respiratory infection, renal failure, and postoperative mortality within 1 year.

Conclusion: TXA is an effective and safe drug for perioperative bleeding control in intertrochanteric fracture patients treated with intramedullary fixation. However, the long-term efficacy of TXA still needs to be investigated by large-scale multicenter randomized controlled trials.

Level of evidence: II, Systematic review and Meta-analysis.

Systematic Review Registration:https://inplasy.com/, identifier [INPLASY202280027]

Placenta accreta spectrum disorder in a primigravida with angular pregnancy: a case report

Placenta accreta spectrum (PAS) is characterized by abnormal invasion of placental tissue into the underlying uterine muscles and has an incidence of 1/533–1/251. The incidence of complications includes uterine rupture (14–29%), PAS (6–10%), and retained placenta or incomplete placenta removal (4%). Here, we described a rare case of PAS and angular pregnancy, including how to diagnose and manage it preoperatively. A 32-year-old primigravida diagnosed at 24 weeks of gestation with a right angular pregnancy was admitted due to preterm premature rupture of membrane (PPROM) with a singleton fetus. We decided to perform hysterotomy because of the PPROM and intrauterine infection. Intraoperatively, we found PAS in the right angular pregnancy; therefore, we performed uterine conservative management with wedge resection on the right uterine fundus. Intraoperative bleeding was 1,600 cc. Histopathological examination revealed placenta increta. The maternal prognosis was good, while the fetus was poor, with an APGAR score of 1/1/0.

Comparative study of the effect of administering two doses of tranexamic acid in patients undergoing adenotonsillectomy

BACKGROUND

Adenotonsillectomy is a safe and common operation to remove adenoids and tonsils. Here we decided to compare the two dosages of tranexamic acid and their effects on hemodynamic changes and anesthesia-related indexes during surgical interventions.

METHODS

This is a double-blinded clinical trial performed in 2019-2020 on 64 children who were candidates for adenotonsillectomy. The patients were randomly divided into two groups of 32 based on the table of random numbers. Group A received 5 mg/kg slowly tranexamic acid for 10 minutes and group B received 10 mg/kg tranexamic acid slowly for 10 minutes. The study protocol was approved by the Research committee of Isfahan University of Medical Sciences and the Ethics Committee has confirmed it (Ethics code: IR.MUI.MED.REC.1398.639) (Iranian Registry of Clinical Trials (IRCT) code: IRCT20171030037093N33, https://en.irct.ir/trial/46553).

RESULTS

The mean volume of intraoperative bleeding in children in group A is significantly higher than in children in group B (P < 0.05). However, no significant difference was observed between the length of stay in recovery and the duration of extubation and the mean dose of propofol in the two groups (P > 0.05). The mean arterial oxygen saturation of children in both groups increased significantly over time (P < 0.05). However, no significant difference was observed between the two groups (P > 0.05). According to the results, the mean HR in both groups decreased significantly over time (P < 0.05). In addition, the mean HR in children in the group B was significantly lower than children in the group A (P < 0.05).

CONCLUSION

Administration of 10 mg/kg of tranexamic acid during tonsillectomy is associated with lower amounts of bleeding and lower heart rate than 5 mg/kg dosage. These results were in line with most previous studies.

Appraising the use of tranexamic acid in traumatic and non-traumatic intracranial hemorrhage: A narrative review

Recently there has been increasing interest and debate on the use of tranexamic acid (TXA), an antifibrinolytic drug, in both traumatic and non-traumatic intracranial hemorrhage. In this review we aim to discuss recent investigations looking at TXA in traumatic brain injury (TBI) and different categories of spontaneous intracranial hemorrhage. We also discuss differences between setting (hospital vs pre-hospital), dosing and timing strategies, and other logistical challenges surrounding optimal use of TXA for isolated intracranial hemorrhage. Last, we hope to provide guidance for clinicians when considering the use of TXA in a patient with traumatic or non-traumatic intracranial hemorrhage based on appraisal of the available literature as well as some potential ideas for future research in this area.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.

Hyperfibrinolysis secondary to acquired factor XIII deficiency A case report

INTRODUCTION

Hyperfibrinolysis induced by factor XIII deficiency (FXIIID) is extremely rare, and patients with no manifestations of active bleeding can easily and frequently be neglected in clinical practice, leading to a missed diagnosis. Herein, we report a rare case of idiopathic FXIIID with secondary hyperfibrinolysis.

PATIENT CONCERNS

A 69-year-old man presented with ecchymosis of the right arm and chest wall.

DIAGNOSIS

Considering the clinical picture, coagulation function test results, and FXIII activity, the patient was finally diagnosed with hyperfibrinolysis secondary to acquired factor XIII deficiency.

INTERVENTIONS

The patient was treated with fresh frozen plasma, aminomethylbenzoic acid, a prothrombin complex, etamsylate, dexamethasone, and cryoprecipitate.

OUTCOMES

The patient improved and was discharged after factor replacement therapy, and no further bleeding was reported 1 month after discharge.

CONCLUSION

This case report illustrates that the complications of Factor XIII deficiency may include hyperfibrinolysis. Since timely diagnosis of FXIIID is challenging, detailed coagulation factor examinations are needed for definitive diagnosis. It has been suggested that gene testing and antibody testing can help in diagnosis. If ideal treatment is not available, alternative treatment should be provided to reduce bleeding.

Topical use of tranexamic acid: Are there concerns for cytotoxicity?

Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Evaluation of applying topical tranexamic acid to control septorhinoplasy - induced hemorrhage

OBJECTIVES

Hemorrhagic events related to surgical field is a common disturbing complication which could worsen the outcomes of operation. This study aimed to evaluate how applying of topical tranexamic acid (TXA) could affect bleeding related to septorhinoplasty operation.

MATERIAL AND METHODS

This double-blind controlled trial study finally evaluated 198 candidates for septorhinoplasty repair who were randomly allocated to two groups: TXA receivers (5 mg/kg) and control group (received 5 mg/kg of saline 0.9 %). Then cumulative volume of hemorrhage was calculated by adding total volume of suctioned blood and numbers of fully blood-filled surgical gauzes (15 mL in each). Additionally postoperative 24 h volume of hemorrhage was measured by counting number of bloody surgical gauzes.

RESULTS

Of all participants, 90 % were female. The mean age was 26 ± 7 years. Total cumulative volume of hemorrhage during surgery was significantly diminished when topical TXA was applied (p < 0.0001). Additionally drier field of operation was illustrated postoperatively in patients received topical TXA (2 % & 28 % in TXA and saline 0.9 % receivers, respectively) (p < 0.001).

CONCLUSION

Using topical TXA could decrease bleeding volume and make surgical field of septorhinoplasty drier either during surgery or postoperatively.

Iota-carrageenan/xyloglucan/serine powders loaded with tranexamic acid for simultaneously hemostatic, antibacterial, and antioxidant performance

This study sought to prepare powder hemostats based on iota-carrageenan (ιC), xyloglucan (XYL), l-serine (SER), and tranexamic acid (TA). The powder form was chosen because it enables the hemostat to be used in wounds of any shape and depth. The powder hemostats showed irregular shapes and specific surface areas ranging from 34 to 46 m²/g. Increasing TA amount decreases the specific surface area, bulk density, water and blood absorption, and the antibacterial activities of the powder hemostats, but not the water retention ability. Conversely, in vitro biodegradation was positively impacted by increasing the TA content in the powder hemostats. In both the in vitro and in vivo tests, powder hemostats showed reduced bleeding time, significant adhesion of red blood cells, great hemocompatibility, moderate antioxidant activity, and high biocompatibility. These findings shed new light on designing powder hemostats with intrinsic antibacterial and antioxidant activity and excellent hemostatic performance.

Blood Loss and Transfusion in a Pediatric Scoliosis Surgery Cohort in the Antifibrinolytic Era

Children and adolescents undergoing posterior spinal fusion for scoliosis experience high rates of bleeding and blood product transfusion. Antifibrinolytic therapy is one key strategy to decrease blood loss and transfusion in pediatric scoliosis surgery. Here we review 172 pediatric scoliosis patients (birth to 21 y) who underwent posterior spinal fusion at our institution from 2017 to 2018. We reported rates of blood loss and transfusion, compared patients receiving tranexamic acid to a ε-aminocaproic acid, and evaluated antifibrinolytic agent and laboratory parameters as predictors of blood loss and transfusion. Intraoperatively, 62% received tranexamic acid and 38% received ε-aminocaproic acid. Overall, blood loss (mean intraoperative estimated blood loss=14.9±9.7 mL/kg, 22% with clinically significant blood loss [>20 mL/kg], and mean calculated hemoglobin mass loss=175.9±70.1 g) and transfusion rates (15% with intraoperative allogeneic red blood cell transfusion and mean intraoperative allogeneic red blood cell transfusion volume=12.5±7.1 mL/kg) were similar to previous cohorts studying intraoperative antifibrinolytics. There was no difference in intraoperative estimated blood loss, clinically significant blood loss, calculated hemoglobin mass loss, or transfusion rates between the antifibrinolytic groups. Antifibrinolytic choice was not predictive of blood loss or transfusion. Routine hematologic laboratory parameters and antifibrinolytic choice were insufficient to predict blood loss or other outcomes. Future prospective laboratory-based studies may provide a more comprehensive model of surgical-induced coagulopathy in scoliosis surgery and provide a better tool for predicting blood loss and improving outcomes.

Prostate biopsy and prostate cancer management in patients with haemophilia: The experience of French Haemophilia Treatment Centres

BACKGROUND

Data are limited on prostate cancer (PC) management in patients with haemophilia (PWH).

AIM

To describe PC screening and diagnosis, treatment modalities and bleeding complications in a group of unselected PWH followed at French Haemophilia Treatment Centres (HTCs) PATIENTS AND METHODS: PC screening, management and bleeding complications were retrospectively investigated at 14 French HTCs between 2003 and 2018.

RESULTS

Among> 1549 > 50-year-old PWHs, 73 (4.7%) underwent PC screening (median age 71.1 years; 67/6 HA/HB, 17/56 severe-moderate/mild). At diagnosis, haematuria was infrequent. Prophylaxis was administered during 76/86 (88%) prostate biopsies (PB) (n = 67 clotting factor concentrates, CFC; n = 9 desmopressin; n = 17 associated with tranexamic acid, TA). Bleeding (11/86, 12.8%) occurred mainly post-prophylaxis (median delay: 7 days): haematuria (9/11, 81.8%), and rectal bleeding (2/11, 18.2%) including one major (1.2%). PC was confirmed in 50/86 PB and in two prostatectomy specimens (total n = 50 patients, n = 6 with only active surveillance). Surgery (n = 28/44 patients) was managed with CFC. Fifteen patients had radiotherapy/brachytherapy, 10 had hormone therapy; CFC-based prophylaxis was only prescribed for brachytherapy (n = 2). Major bleedings occurred in 3/28 (10.7%) and 2/15 (13.3%) patients who underwent surgery and radio/brachytherapy, respectively. No bleeding risk factor was found.

CONCLUSION

Our data indicate that PB requires prophylaxis for atleast 7 days, using CFC, desmopressin or TA in function of haemophilia severity. PC surgery should be considered at high bleeding risk. Long-term post-procedural CFC or oral TA could be discussed. Radiotherapy/brachytherapy also should be managed with prophylaxis (CFC or TA).

Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness.

METHODS

PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes.

RESULTS

A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I² = 96%, P = .14) and 12 weeks (MD -0.03, I² = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I² = 56%, P < .00001) and weeks 3-6 (MD -0.38, I² = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I² = 74%, P = .002) and weeks 4-6 (MD 6.17, I² = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I² = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I² = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5.

CONCLUSIONS

Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak.

LEVEL OF EVIDENCE

Level II, systematic review of therapeutic Level I-II studies.