PATAL DA,LAVIE CJ,GILLILAND YE,et al.Prediction of all-cause mortality by the left atrial volume index in patients with normal left ventricular filling pressure and preserved ejection fraction[J].,2015,90(11):1499-1505.
To describe the prevalence of left atrial (LA) enlargement (LAE) and its association with all-cause mortality in 10,719 patients with an early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (e′) ratio–determined normal left ventricular (LV) filling pressure and preserved LV ejection fraction (LVEF). We evaluated 10,719 patients (deceased patients: n=479; mean [SD] age, 65 [14] years; 60% male; surviving patients: n=10,240; mean (SD) age, 54 (16) years; 48% male) with estimated normal LV filling pressure (E/e′ ratio ≤8) and preserved LVEF (≥50%) to determine the impact of LA volume index (LAVi) on all-cause mortality during a mean (SD) follow-up of 2.2 (1.0) years. In the univariate analysis, with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04;P<.001). After adjusting for covariates, LAVi (as a continuous variable) was an independent predictor of all-cause mortality (HR, 1.015; 95% CI, 1.005-1.026;P=.01). When LAVi was assessed as a categorical variable with normal LAVi (≤28 mL/m2) as the reference group, moderate LAVi (34-39 mL/m2) and severe LAVi (≥40 mL/m2) were independent predictors of all-cause mortality (HR, 1.34; 95% CI, 1.01-1.79;P=.04; and HR, 1.65; 95% CI, 1.18-2.29;P=.003, respectively). LAE was independently associated with an increased risk of all-cause mortality in our large cohort of 10,719 patients with normal LV filling pressure and preserved LVEF.
IZUMIM,MIGITAK,NAKAMURAM,et al.Risk of venous thromboembolism after total knee arthroplasty in patients with rheumatoid arthritis[J].,2015,42(6):928-934.
To compare the incidence of venous thromboembolism (VTE) following total knee arthroplasty (TKA) between patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA).The subjects were composed of 1084 Japanese patients with OA and 204 with RA. Primary effectiveness outcomes were any deep vein thrombosis (DVT) as detected by bilateral ultrasonography up to postoperative Day 10 (POD10) and pulmonary embolism (PE) up to POD28. The main safety outcomes were bleeding and death from any cause up to POD28. Plasma D-dimer levels were measured before and at POD10 after TKA.The study cohort was composed of 1288 patients from 34 hospitals. There was no death up to POD28. PE occurred in 2 patients with OA and in no patients with RA. The incidence of primary effectiveness outcome was 24.3% and 24.0% in patients with OA and RA, respectively. The incidence of major bleeding up to POD28 was 1.3% and 0.5% in patients with OA and RA, respectively. No differences in the incidence of VTE (symptomatic/asymptomatic DVT plus PE) or bleeding were noted between patients with RA and OA. D-dimer levels on POD10 were significantly higher in patients with OA compared with those with RA. Also, D-dimer levels on POD10 were significantly lower in patients receiving fondaparinux than in patients without pharmacological prophylaxis.Despite some differences in demographic data, patients with RA and OA have equivalent risks of VTE and bleeding following TKA.
BJORNARA BT,GUDMUNDSEN TE,DAHL OE.Fre-quency and timing of clinical venous thromboembolism after major joint surgery[J].,2006,88(3):386-391.
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WASSILEW GI,PERKAC,JANZV,et al.Tranexamic acid reduces the blood loss and blood transfusion requirements following peri-acetabular osteotomy[J].,2015,97(12):1604-1607.
72 Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.72 A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.72 Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.72 Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.72 The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.
NAJAFZADEHM,KIM SC,PATTERSONC,et al.Patients' perception about risks and benefits of antithrombotic treatment for theprevention of venous thromboembolism (VTE) after orthopedic surgery[J].,2015,26(16):319-321.
The 9th edition of the American College of Chest Physicians’ Antithrombotic Therapy and Prevention of Thrombosis guidelines emphasize the importance of considering the risk–benefit ratio of “patient-important” outcomes. However, little is known about patients’ perception and understanding regarding the different outcomes of antithrombotic treatment after orthopedic surgery, and the factors that influence their decision to use these treatments. Using a series of semi-structured interviews, we explored patients’ understanding and perception concerning the benefits and risks of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after joint replacement surgery. A series of semi-structured interviews were conducted with patients who had undergone knee or hip replacement surgery at a tertiary care hospital (Brigham and Women’s Hospital, Boston, MA) in 2014. Discussions were recorded and transcribed. Two investigators independently coded and analyzed the data to identify important themes and concepts using the constant comparative method. Of 64 patients who were invited, 12 patients (1902%) completed the interviews. The majority of patients (9202%) were aware of the benefits of antithrombotic therapy for reducing the risk of blood clots, while less than half of them had a clear understanding of deep vein thrombosis and pulmonary embolism. While all patients were aware of risk of minor bleeding, only 6 patients (5002%) considered the risk of major bleeding as a possible side effect of antithrombotic treatment. Overall, patients perceived bleeding as a less important outcome than a thrombotic event. The lack of awareness about the risk of major bleeding, the assumption that a short-term exposure would not meaningfully affect bleeding risk, and the assumption that bleeding is a controllable event influenced their perception. Most patients (8302%) stated that their decision to use antithrombotic medications was mainly based on the trust in their physician’s expertise. Patients perceived thrombotic events as more important outcomes than bleeding events. Patients’ understanding of thrombotic and bleeding events varies and may play a key role in their preferences. The majority of patients stated that trust in their physician’s expertise had a large influence on their decision to use antithrombotic medications.
GILLESPIER,SHISHANIY,JOSEPHS,et al.Neer award 2015:a randomized,prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty[J].,2015,24(11):1679-1684.
Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty. A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted. The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group. In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.
CARVALHO L HJ,FROIS TEMPONIE,MACHADO SOARES LF,et al.Bleeding reduction after topical application of tranexamic acid together with betadine solution in total knee arthroplasty[J].,2015,101(1):83-87.
Topical application of tranexamic acid to the knee joint before closure in total knee arthroplasty reduces postoperative bleeding without increase in complication. However, it is unknown the effectiveness of topic TXA performed with other topical medications, like povidone-iodine solution.One hundred and twenty-five patients were randomized to receive 100mL of povidone-iodine solution (control: group A) or 1.5 (group B) and 3.0g (group C) of topical TXA in povidone-iodine solution applied into the knee before closure in total knee arthroplasty.The patients in the TXA groups had higher mean postoperative hemoglobin levels (P=0.01 and P=0.03 in groups B and C, respectively) and a reduced postoperative blood loss in the TXA groups (P=0.07 and P=0.09 in groups B and C, respectively). No significant complications were observed.In this study, topical application of tranexamic acid after total knee arthroplasty together with povidone-iodine solution results in higher postoperative hemoglobin levels and lower blood loss compared with those in the control group without other complications.I-I: high-powered prospective randomized trial.
ZHAOHUIL,WANSHOUG,QIDONGZ,et al.Topical hemostatic procedures control blood loss in bilateral cemented single-stage total knee arthroplasty[J].,2014,19(6):948-953.
BackgroundBlood management is critical in total knee arthroplasty (TKA). In bilateral, single stage TKA, blood loss seems more prominent. We believe it is important to control all potential bleeding within the wound tissue. PurposeThe purpose of the study was to evaluate a series of topical procedures used to reduce blood loss and transfusion in single-stage bilateral cemented total knee arthroplasty: antifibrinolysis with tranexamic acid, vasoconstriction with epinephrine, sealing of the bone section intraoperatively, and closure of the drainage tube within the first 402h postoperatively. Materials and methodsPatients with osteoarthritis of the knees were randomly divided into two groups. In group A, 502ml (2502mg/ml) tranexamic acid (TXA) and 502ml analgesic containing epinephrine (302μg/ml) solution were injected at several points into the posterior capsule before installation of the prosthesis. The femoral medullar canal was closed with autograft bone and then sealed compressively with cement. Before the tourniquet was released, 1002ml TXA solution and 1002ml analgesic containing epinephrine were injected at several points into the periosteum, synovium, joint capsule, tendons, and deep fascia tissue (injection of analgesic containing epinephrine into subcutaneous fat and dermis was avoided). The residual nail holes in the bone and the uncovered bone section were covered with bone wax. The tourniquet was then removed, and active bleeding points were stanched. TXA solution (2002ml) was injected into the articular cavity after wound closure. The drainage tube was clamped for 402h, then opened. In group B, injection of analgesic containing epinephrine into soft tissue, control of active bleeding, and clamping of the drainage tube for 4-h, only, were performed. ResultsNinety patients were enrolled in the study. Compared with those in group B, intraoperative blood loss, drainage volume, total postoperative blood loss, and number of patients requiring allogenic blood transfusion were significantly reduced in group A. There was no significant difference between the incidence of complications in the groups. ConclusionsOur topical procedures enable effective and safe reduction of blood loss and the number of patients requiring transfusion in single-stage bilateral osteoarthritic TKA.
Prediction of all-cause mortality by the left atrial volume index in patients with normal left ventricular filling pressure and preserved ejection fraction