Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.

Cervical Spine Fractures: Who Really Needs CT Angiography?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria. SUMMARY OF BACKGROUND DATA: As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria. METHODS: A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed. RESULTS: A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P < 0.0002 for each). CONCLUSION: A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption. LEVEL OF EVIDENCE: 4.

Unique pharmacological properties of serotoninergic G-protein coupled receptors from cestodes.

BACKGROUND: Cestodes are a diverse group of parasites, some of them being agents of neglected diseases. In cestodes, little is known about the functional properties of G protein coupled receptors (GPCRs) which have proved to be highly druggable targets in other organisms. Notably, serotoninergic G-protein coupled receptors (5-HT GPCRs) play major roles in key functions like movement, development and reproduction in parasites. METHODOLOGY/PRINCIPAL FINDINGS: Three 5-HT GPCRs from Echinococcus granulosus and Mesocestoides corti were cloned, sequenced, bioinformatically analyzed and functionally characterized. Multiple sequence alignment with other GPCRs showed the presence of seven transmembrane segments and conserved motifs but interesting differences were also observed. Phylogenetic analysis grouped these new sequences within the 5-HT7 clade of GPCRs. Molecular modeling showed a striking resemblance in the spatial localization of key residues with their mammalian counterparts. Expression analysis using available RNAseq data showed that both E. granulosus sequences are expressed in larval and adult stages. Localization studies performed in E. granulosus larvae with a fluorescent probe produced a punctiform pattern concentrated in suckers. E. granulosus and M. corti larvae showed an increase in motility in response to serotonin. Heterologous expression revealed elevated levels of cAMP production in response to 5-HT and two of the GPCRs showed extremely high sensitivity to 5-HT (picomolar range). While each of these GPCRs was activated by 5-HT, they exhibit distinct pharmacological properties (5-HT sensitivity, differential responsiveness to ligands). CONCLUSIONS/SIGNIFICANCE: These data provide the first functional report of GPCRs in parasitic cestodes. The serotoninergic GPCRs characterized here may represent novel druggable targets for antiparasitic intervention.

Caribbean guidelines for the management and prevention of asthma

Findings have highlighted the need to improve asthma management in the Caribbean. The Caribbean Guidelines for the Management and Treatment of Asthma were developed at a meeting in Trinidad in July 1997, organised by the Commonwealth Caribbean Medical Research Council (CCMRC) and the Global Initiative for Asthma (GINA). The guidelines recommend that the best way to control asthma is the use of anti-inflammatory agents, particularly inhaled corticosteroid, since these are currently the most effective long-term control medication. Haahtela et al in their seminal study demonstrated that controlling airway inflammation with inhaled corticosteroids is beneficial in asthma. Compared with trebutaline, regular treatment with the inhaled corticosteroid, budesonide, resulted in improved control of lung function, fewer symptoms and fewer asthmatic exacerbations (AU)

The cost of treating acute asthma at the Queen Elizabeth Hospital, Barbados

OBJECTIVES: To determine the cost of treating acute asthma at the Queen Elizabeth Hospital (QEH) and to identify ways of reducing these costs. DESIGN AND METHODS: Case notes of all patients presenting to the Asthma Bay of the QEH during a two-week period in March 1999, were reviewed. Data, extracted included gender, arrival time, number of nebulizations, dosage of oral prednisolone and inhalers prescribed. A questionnaire was completed by a sample of these patients regarding use of inhalers, follow-up care and time lost from work and school. RESULTS: A total of 303 cases were reviewed and 75 patients completed questionnaires. The majority of asthmatics received oral prednisolone (74 percent) and/or three nebulizations (42 percent). The cost of treating each patient was determined to be approximately US $22.00, including medical and nursing salary costs. The annual cost to the QEH was estimated to be US $214,000 including the costs of admitting patients. Indirect costs included the time lost from work or school in 86 percent of patients and in 56 percent of parents taking time off to look after their sick children. The questionnaire survey revealed that 63 percent of patients with "preventer" medications were not using them and only 38 percent received follow-up care. Seventy-four percent of these patients had repeated asthmatic attacks during the preceding 3 months with 11 percent having more than six attacks. CONCLUSIONS: A significant amount of money is spent on asthma care at the QEH. However, improper understanding and use of medication coupled with lack of continuity of care lead to poor control and frequent attacks. These findings justify the need for an asthma clinic for these patients.(Au)

The economics of asthma treatment in Barbados: a review of the drug cost

OBJECTIVE: To determine the annual cost of treating asthma in Barbados over a ten-year period. METHODS: The Barbados Drug Service is the central procurement agent for drugs on the Barbados National Formulary. Information on the costs of the various asthma medications, and the number of prescriptions written for these drugs, were obtained from the Barbados Drug Service records. The prescriptions written for asthma medications between 1986 and 1997 were analysed and the annual cost of the various categories of asthma calculated. RESULTS: The annual drug cost of treating asthma in Barbados increased from $293,111 in 1987 to $1,268,348 in 1996, a four-fold increase over ten years. There was a rapid rise in the cost of anti-inflammatory drugs during the study period, from $48,628 or 16.5 percent of total drug cost in 1986 to $503,092 or 39.6 percent of total drug cost in 1997. The cost of inhaled beta-2-agonists over the same period increased from $131,154 or 44.7 percent of the total drug cost in 1997. However, the cost of oral beta-2-agonists decreased over the ten-year period, reflecting the increased use of the inhaled form of the medication. With the increasing number of acute asthmatics seen in the Accident and Emergency Department at the Queen Elizabeth Hospital, the cost of nebulization solutions increased eight-fold, from $8,361 in 1986 to $69,172 in 1997. CONCLUSIONS: Asthma has been an increasing burden on the medical resources of Barbados over the past decade. The drug costs of treating asthma have increased significantly over the 10-year period 1986 to 1997 and accounted for 5.8 percent of the annual budget of the Barbados Drug Service in 1997.(Au)

Prevalence of asthma and wheezing illnesses in Barbadian school children: the Barbados national asthma and allergy study

In Barbados, there has been a fourfold increase in the number of asthmatic visits to the Accident and Emergency department of the Queen Elizabeth Hospital between 1980 and 1994. However, there are no data on the prevalence of asthma in Barbados. This study was done to determine the prevalence of childhood asthma using the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaires. Questionnaires were distributed to parents of 3,894 pupils (age group 6-7 years) in all 91 primary schools in Barbados, and 3,500 questionnaires were completed by pupils (age 13-14 years) in all 46 secondary schools. The data analysis was carried out by Systems Caribbean Limited utilising SPSS. In the 6-7 years olds, the prevalence of self-reported asthma was 16.8 percent with doctor diagnosed asthma of 16.5 percent wheeze had occurred at some time in 30.7 percent and in the previous 12 months in 18.3 percent. In the 13-14 year-olds, self reported asthma was 17 percent, doctor diagnosed asthma 15.9 percent, wheeze occurring at some time was 30.1 percent and wheeze in the previous 12 months was 17.7 percent. Of the 6-7 year-olds, of those who wheezed in the previous 12 months, 78 percent had 1-3 attacks, 18.5 percent had 4-12 attacks and 3.5 percent had more than 12 attacks. In the 13-14 year-olds, 76.5 percent had 1-3 attacks in the previous 12 months, 18.2 percent had 4-12 attacks, 5.3 percent had more than 12 attacks. There was no difference in frequency of smokers in the household between those who wheezed in the previous 12 months and those who never wheezed. Overall, wheezing was more frequent in boys than in girls. The prevalence of asthma in Barbados is high for a tropical island with relatively little atmospheric pollution. The increase has coincided with increasing affluence and trend toward urbanisation and modernisation of the domestic environment.(AU)

A drug utilization review on asthma in three OECS Countries: St Lucia, Grenada and St Kitts/Nevis - abstract

The Drug Utilization Review (DUR) of asthma treatment comprises simultaneous cross-sectional studies conducted in the OECS countries of St. Lucia, St. Kitts/Nevis and Grenada. The review sought to assess prescribing behaviour in order to devise intervention strategies for enhanced prescribing practice. 1412 prescriptions written for asthmatic patients were drawn for public and private pharmacies on a quota basis. Despite certain inherent constraints in a prescription audit, some meaningful observations and conclusions can be made and drawn. The study revealed that the pattern of prescribing was similar among the countries under review. The top ranking drug was the beta agonist, salbutamol, in tablet form, which was prescribed for 92 percent of patients. Inhaled salbutamol was sparingly used. Experts agree that oral inhalation is the preferred delivery system and is best given on an as-needed basis. Inhaled glucocorticoids, the most effective available drug for controlling asthma, were used in only 6 percent of patients, a gross underutilization of the inhaled steriod. Oral prednisolone emerged as the second most popular drug but was given in multiple daily doses and unecessarily tapered for short one-week courses. The survey showed that the following drugs were frequently prescribed for asthmatic patients despite their dubious efficacy: antibiotics, cough mixtures, decongestants and antihistamines. NSAIDs which are contraindicated in asthma, were prescribed in 3 percent of patients. The DUR pointed to areas of inappropriate prescribing with respect to low use of an inhaled beta agonist and glucocorticoids and concurrent use of supplementary agents of doubtful efficacy(AU)

Prevalence of atopic eczema in Barbadian schoolchildren: preliminary findings from the Barbados National Asthma and Allergy Study - abstract

In 1995 and 1996 the Barbados National Asthma and Allergy Study, a questionnaire survey of all schoolchildren 6 - 7 years and aged 13 - 14 year, was conducted. The aim of the survey was to describe the prevalence and severity of asthma, rhinitis and eczema in children living in Barbados, to make meaningful comparisions with other countries (e.g Jamaica) and to obtain baseline measures for asessment of future trends in the prevalence and severity of this disease. The questionnaire sought to discover the presence of an itchy rash, persisting for more than six months, and in the typical anatomical distribution of atopic eczema. In addition, doctor diagnosed eczema was sought. Three thousand, eight hundred and ninety-four (3894) questionnaires were returned in the 6 - 7 years old age group (97 percent) and 3552 in the 13 - 14 year- old age group (88 percent). The prevalence of atopic eczema in the 6 - 7 year-old age group was 10.6 percent and in the 13 - 14 year-old age group was 10.0 percent. Diagnosis by a doctor reduced the prevalence to 6.2 percent in the primary school group and 3.6 percent in the secondary school group. This study has demonstrated for the first time in a Caribbean country the prevalence of this common childhood complaint. (AU)

The management of hypertension in general practice: part 1

Hypertension is associated with high morbidity and mortality in the Caribbean and the role of the general practitioner is central to the proper management of this disease. The recognition that the hypertensive population is heterogenous, that there are ethnic differences in the response to different antihypertensive medication and that hypertension often coexists with other diseases, has led to the individualization of the treatment based on patient profiling. The step care approach to the treatment of hypertension is inappropriate for the population in the Caribbean. (Summary)

The management of hypertension in general practice: part ll

The management of hypertension is a constant challenge to the general practitioner in the Caribbean. It is one of the most common disease in the population and is associated with considerable morbidity and mortallity. There are certain cultural beliefs that make compliance and the treatment difficult and patient education is essential to dispel the cultural misconceptions of cause and treatment. (Summary)

The role of the house dust mite and other household pests in the incidence of allergy among Barbadian asthmatics - abstract

The incidence of allergy to 14 different household pests, including 2 house dust mite species (D. farinae and D. pteronyssinus), was investigated among 156 asthmatic children in Barbados. Independent variables, including urban/rural residence, building material of the home, and presence of carpeting, were found to be significant factors related to the house dust mite allergy. The continuing trend of modernization of the domestic environment, which provides an optimal microhabitat for several household pests, is implicated as a probable contributing factor in the increasing overall prevalence of asthma reported in Barbados. Children between the ages of 5 and 18 years with a diagnosis of bronchial asthma were selected from attendees at six polyclinics distributed throughout the island, an urban private general practice, and the accident and emergency department of the only acute general hospital on the island. Skin tests were done by scratching, and by intradermal injection, if the scratch test proved negative. Allergy to the house dust mite was the most common of the reactions to the household pests tested, and was found in 81 percent of the asthmatic children (AU)

The prevalence of hypercholesterolaemia in a general practice population in Barbados - abstract

This study was undertaken to determine the prevalence of hypercholesterolaemia in a general practice population in Barbados, and to determine whether hypercholesterolaemia is a public health problem for which screening would be worthwhile. A total of 498 patients (96 percent over 35 years) drawn from a general practice population of 15,000 patients, were studied. Two hundred and two (202) non-diabetic, non-hypertensives, 152 hypertensives, 123 diabetics and 21 hypertensive diabetics were selected, comprising every third patient in each diagnostic category to visit the clinic. One hundred and forty-two (28. percent) of all patients had a cholesterol level in the desirable range, 185 (37.1 percent) had a borderline high level, and 171 (34.4 percent) had a high-risk level of serum cholesterol. The prevalence of high-risk serum cholesterol was lowest in non-diabetic/non-hypertensive patients, and highest in diabetic hypertensives. The results suggest that the prevalence of hypercholesterolaemia in the Barbadian population is high and that screening is worthwhile (AU)

The management of asthma in general practice

The mortality and morbidity of asthma are unacceptably high worldwide given that there is an effective treatment for this condition. The recognition that asthma is an inflammatory disease has led to use of anti-inflammatory medication as a first line treatment, with the use of bronchodilators on an as required basis. A stepwise approach to treatment based on the severity of the condition is now accepted as the best way to treat the disease. The general practitioner is usually the first contact the asthmatic makes with the health services. Therefore, if asthma is to be treated effectively it is at the primary care level that improvement in management must take place (Summary)