Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT.

BACKGROUND: Tranexamic acid safely reduces mortality in traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury and can cause brain herniation and death. We assessed the effects of tranexamic acid in traumatic brain injury patients. OBJECTIVE: To assess the effects of tranexamic acid on death, disability and vascular occlusive events in traumatic brain injury patients. We also assessed cost-effectiveness. DESIGN: Randomised trial and economic evaluation. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers and those assessing outcomes were masked to allocation. All analyses were by intention to treat. We assessed the cost-effectiveness of tranexamic acid versus no treatment from a UK NHS perspective using the trial results and a Markov model. SETTING: 175 hospitals in 29 countries. PARTICIPANTS: Adults with traumatic brain injury within 3 hours of injury with a Glasgow Coma Scale score of ≤ 12 or any intracranial bleeding on computerised tomography scan, and no major extracranial bleeding, were eligible. INTERVENTION: Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo. MAIN OUTCOME MEASURES: Head injury death in hospital within 28 days of injury in patients treated within 3 hours of injury. Secondary outcomes were early head injury deaths, all-cause and cause-specific mortality, disability, vascular occlusive events, seizures, complications and adverse events. RESULTS: Among patients treated within 3 hours of injury (n = 9127), the risk of head injury death was 18.5% in the tranexamic acid group versus 19.8% in the placebo group (855/4613 vs. 892/4514; risk ratio 0.94, 95% confidence interval 0.86 to 1.02). In a prespecified analysis excluding patients with a Glasgow Coma Scale score of 3 or bilateral unreactive pupils at baseline, the results were 12.5% in the tranexamic acid group versus 14.0% in the placebo group (485/3880 vs. 525/3757; risk ratio 0.89, 95% confidence interval 0.80 to 1.00). There was a reduction in the risk of head injury death with tranexamic acid in those with mild to moderate head injury (166/2846 vs. 207/2769; risk ratio 0.78, 95% confidence interval 0.64 to 0.95), but in those with severe head injury (689/1739 vs. 685/1710; risk ratio 0.99, 95% confidence interval 0.91 to 1.07) there was no apparent reduction (p-value for heterogeneity = 0.030). Early treatment was more effective in mild and moderate head injury (p = 0.005), but there was no obvious impact of time to treatment in cases of severe head injury (p = 0.73). The risk of disability, vascular occlusive events and seizures was similar in both groups. Tranexamic acid is highly cost-effective for mild and moderate traumatic brain injury (base case of £4288 per quality-adjusted life-year gained). CONCLUSION: Early tranexamic acid treatment reduces head injury deaths. Treatment is cost-effective for patients with mild or moderate traumatic brain injury, or those with both pupils reactive. FUTURE WORK: Further trials should examine early tranexamic acid treatment in mild head injury. Research on alternative routes of administration is needed. LIMITATIONS: Time to treatment may have been underestimated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15088122, ClinicalTrials.gov NCT01402882, EudraCT 2011-003669-14, Pan African Clinical Trial Registry PACTR20121000441277. FUNDING: The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 26. See the NIHR Journals Library website for further project information. In addition, funding was provided by JP Moulton Charitable Trust, Joint Global Health Trials (Medical Research Council, Department for International Development and the Wellcome Trust). This project was funded by the NIHR Global Health Trials programme.

Traumatic brain injury is a leading cause of death and disability worldwide, with over 60 million new cases each year. When the head is injured there is often bleeding inside the brain, which can continue for some time and worsen after hospital admission. This bleeding increases pressure inside the skull, causing further damage to the brain, which can be fatal or result in serious disability. Tranexamic acid is a cheap drug that reduces bleeding in other conditions. A large trial of accident victims (other than those with head injury) found that it reduced the chances of bleeding to death. We wanted to find out if tranexamic acid would also reduce deaths among patients with head injuries. We studied just under 13,000 patients with traumatic brain injury who did not have other major injuries to their bodies from 175 hospitals across 29 countries. Patients were assigned at random to receive either tranexamic acid or a dummy medicine called a placebo. Neither the clinical team nor the patient knew which medicine the patient received. All patients received the usual treatments given to head-injured patients. Outcomes from 9127 participants were analysed. Among patients treated early, within 3 hours, the rate of head injury death was 18.5% (855/4613) in the tranexamic acid group and 19.8% (892/4514) in the placebo group. We found no evidence of an effect of tranexamic acid overall. However, in patients with mild or moderate traumatic brain injury, there was a 20% reduction in deaths. There were no side effects and no increase in disability in survivors when the drug was used. The economic analysis shows that tranexamic acid represents value for money for patients with mild or moderate traumatic brain injury.

'Someone batting in my corner': experiences of smoking-cessation support via text message.

BACKGROUND: The txt2stop trial demonstrated that smoking-cessation support delivered by text message doubles biochemically verified abstinence at 6 months. There was no significant heterogeneity in any of the pre-specified subgroups. AIM: To explore participants' experiences of the txt2stop intervention via a qualitative study using telephone interviews. DESIGN AND SETTING: Qualitative telephone interviews in the community. METHOD: Thematic content analysis of 1283 feedback forms was conducted to develop a topic guide for 25 telephone interviews. Key themes were identified and described. Any differences in the experiences of those who did, and did not, successfully quit were specifically explored. RESULTS: Participants liked the fact that smoking-cessation support delivered by text message was convenient, easy to access, and chemical free. They reported that the intervention was a reminder that they were quitting and why, provided emotional support, was a reminder of the physical benefits of stopping smoking, and they saved messages so they could refer back to them. However, the intervention was not helpful for all. Receiving texts about smoking could also stimulate craving, and the timing, frequency, and duration of messages were not optimal for some participants. Those who did not quit reported that additional factors influenced them, such as periods of stress or social events, or reported that they had been unable to cope with the physical effects of withdrawal, and combining text-message support with medication could help with this. CONCLUSION: Although the intervention did stimulate craving in some participants at some times, recipients reported that it also provided emotional support and reinforcement at temporally appropriate moments. It was successful at helping people to quit smoking but could be used together with other forms of smoking-cessation support.

[Influence of propyl-thiouracil-induced hypothyroidism on rat gingival mucosa]. / Influência do hipotireoidismo induzido por propiltiouracil na mucosa gengival do rato.

This work aimed at verifying the influence of propyl-thiouracil (PTU)-induced thyroid hormone deficiency on gingival mucosa of young male rats, measuring total protein concentration, collagen content and DNA concentration as indices of cellular population. Fifty Sprague-Dawley rats were used. The animals were grouped in: PTU-treated (i.p. 10 mg/d) and control rats (C). The experience was maintained for a period of 10 weeks. Total protein content of gingival mucosa tissue was determined by the Lowry method; hydroxyprolin rate, as prototype amino acid of collagen, was determined using the Newman method, and DNA concentration was measured by Burton's methodology. The results showed decreased amounts of PTU-treated rats gingival total protein content (PTU= 41.23 +/- 24.05 vs. C= 63.36 +/- 18.05); no alterations were seen in hydroxyprolin concentration neither in DNA content of PTU treated rats, respectively (PTU= 2.18 +/- 1.48 vs. C= 2.29 +/- 1.51) and (PTU= 0.33 +/- 0.19 vs. C= 0.46 +/- 0.41). Thus, PTU treatment promotes a decrease in total protein content of rat gingival mucosa that may be interpreted as a decrease in protein synthesis induced by the hypothyroid condition, but with no alteration either in collagen or nucleic acid rates.

Influência do hipotireoidismo induzido por propiltiouracil na mucosa gengival do rato / Influence of propilthiouracil-induced hypothyroidism on rat gingival mucosa / Influence of propilthiouracil-induced hypothyroidism on rat gingival mucosa

O objetivo foi verificar a influência da deficiência dos hormônios tireoideanos induzida por propiltiouracil (PTU) na mucosa gengival do rato, analisando bioquimicamente as proteínas totais, colágeno (hidroxiprolina) e população celular (DNA). Foram utilizados 50 ratos machos da cepa Sprague-Dawley, separados em 2 grupos: propiltiouracil (PTU) (10 mg/d i.p.), e controle (C), durante 10 semanas. As proteínas totais foram determinadas pelo método de Lowry, a hidroxiprolina pelo método de Newman e DNA pelo método de Burton. Observou-se diminuição das proteínas totais no grupo PTU (PTU= 41,23 ± 24,05; C= 63,36 ± 18,05); não houve diferença na hidroxiprolina e DNA (PTU= 2,18 ± 1,48; C= 2,29 ± 1,51) e (PTU= 0,33 ± 0,19; C= 0,46 ± 0,31). Conclui-se que o tratamento com PTU diminui o conteúdo de proteínas totais na mucosa gengival do rato, provavelmente pela diminuição da síntese protéica, sem alteração do colágeno e da população celular.

This work aimed at verifying the influence of propilthiouracil (PTU)-induced thyroid hormone deficiency on gingival mucosa of young male rats, measuring total protein concentration, collagen content and DNA concentration as indices of cellular population. Fifty Sprague-Dawley rats were used. The animals were grouped in: PTU-treated (i.p. 10 mg/d) and control rats (C). The experience was maintained for a period of 10 weeks. Total protein content of gingival mucosa tissue was determined by the Lowry method; hydroxyprolin rate, as prototype aminoacid of collagen, was determined using the Newman method, and DNA concentration was measured by Burton's methodology. The results showed decreased amounts of PTU-treated rats gingival total protein content (PTU= 41.23 ± 24.05 vs. C= 63.36 ± 18.05); no alterations were seen in hydroxyprolin concentration neither in DNA content of PTU treated rats, respectively (PTU= 2.18 ± 1.48 vs. C= 2.29 ± 1.51) and (PTU= 0.33 ± 0.19 vs. C= 0.46 ± 0.41). Thus, PTU treatment promotes a decrease in total protein content of rat gingival mucosa that may be interpreted as a decrease in protein synthesis induced by the hypothyroid condition, but with no alteration either in collagen or nucleic acid rates.