Comparison of Intravenous and Topical Tranexamic Acid in Total Joint Arthroplasty.

PURPOSE OF THE STUDY To compare topical and intravenous (IV) administration of tranexamic acid (TXA) 2 g in patients undergoing total hip arthroplasty (THA), or total knee arthroplasty (TKA). MATERIAL AND METHODS In total, 452 patients undergoing THA or TKA were randomised to 3 groups: 1) the IV TXA group received 2 doses of TXA 1 g intravenously 3 hours apart; 2) the topical TXA group received TXA 2 g topically, and 3) the NO TXA - control group. Furthermore, each group was divided in two subgroups by performed surgery (THA versus TKA). The following endpoints were used for final analysis: postoperative blood loss, transfusion requirement, haemoglobin drop and postoperative complications (haematoma, surgical site infection, thromboembolism, early surgical revision). RESULTS Both topical and IV administration of TXA significantly reduced postoperative bleeding (mean ± standard deviation) after THA and TKA (topical 504.4±281.0 ml, IV 497.3±251.7 ml, NO 863.1±326.4 ml, p<0.001). Topical use was superior to IV in reducing postoperative drainage output in THA (topical 377±213.3 ml, IV 518.1±259.0 ml, p<0.01). On the opposite, IV use was superior to topical in drainage output in TKA (topical 646.1±281.3 ml, IV 457.8±235.8 ml, p<0.01). The differences in transfusion requirement and Hb drop between these administration methods were not statistically significant (p≥0.05), but any TXA administration was significantly better than no TXA in all endpoints of efficacy (p<0.001). The lowest complication rate was observed in the topical group (NO 24%, IV 19%, topical 7.5%). DISCUSSION Consensus on optimal TXA dosing regime in primary hip and knee arthroplasties is still missing. Use of TXA therapy in routine clinical practice is highly individualized in accordance with the current approach of personalized medicine. Topical application seems to be the safest route of TXA administration. However, precise application technique is essential. IV TXA is beneficial especially in patients with some bleeding coagulopathies undergoing TKA with a tourniquet. Repeat doses of TXA are not usually necessary after completed primary arthroplasties. CONCLUSIONS IV and topical TXA 2 g have similar effect on reduction of transfusion requirements and haemoglobin drop in THA and TKA. The IV route is superior to topical in TKA while topical TXA reduces complications in both THA and TKA. Key words: tranexamic acid, total hip arthroplasty, total knee arthroplasty, topical administration, intravenous administration.

Quality of life and ability to work in ovarian cancer patients in Slovakia.

The aim of this paper was to find out the association of relevant factors on health-related quality of life (HRQOL) among ovarian cancer patients and their ability to work. Analyzed data were prospectively collected on 123 ovarian cancer patients enrolled across multiple oncology practices in Slovakia. We examined knowledge about the disease, negative perceptions related to health care, ability to work and social and economic ranking. HRQOL measurements included quality of life based on a numeric scale (1-worst, 10-best) and selected aspects from QoL-Ov28 questionnaire. We have used non-parametric Friedman and Dunne pairwise comparison tests to detect differences in HRQOL and the ability to work. Spearman correlation was used to measure the strength of association between variables. With hindsight, patients identified first signs of disease 3.6 months prior to diagnosis, with median duration of disease being 3.1 years. HRQOL was significantly different at various points during cancer journey; between current state and at diagnosis (4.19), between current state and at time without cancer or at time in full health (8.94, 9.52 respectively). Similarly, significant differences were noted in patients' current work ability (WA) compared to WA at diagnosis, or at time without cancer or in full health (4.2, 9.07, 9.58). The highest correlation of HRQOL was found in relation to current ability to work (r = 0.87) and in impact of cancer treatment (r = 0.66). Medium correlation was noted with visits to oncology clinics, knowledge about cancer, salary, future expectations or perceived quality of life of relatives (r < 0.51). Low correlation (r < 0.3) was found with other aspects related to healthcare (nursing care, general practitioner appointments) or demographics (age, number of children) and others. Patients were willing to pay monthly for curative treatment €191.84 from an average monthly salary €470.84 (41%). Ovarian cancer diagnosis has a significant impact on HRQOL and WA and both are positively highly correlated. Ovarian cancer patients are willing to give significant share of their monthly salary for treatment leading to cure.

Antioxidant potential of essential oil from Lavandula angustifolia in in vitro and ex vivo cultured liver cells.

Lavender is a commonly used herb in traditional medicine in Asia and Europe. It has been reported to be an effective medical plant in treating inflammation, depression and stress, thanks to its sedative and anxiolytic action, thrombotic, and antimicrobial properties. In the present study we investigated the protective effects of essential oil from Lavandula angustifolia (LO) against hydrogen peroxide and tert-butyl hydroperoxide -induced DNA damage. Also the effects of LO on the levels of enzymatic and non-enzymatic antioxidants (SOD-superoxide dismutase, GPx-glutathione peroxidase, GSH-glutathione) were evaluated in in vitro (human hepatoma cell line HepG2) and in ex vivo (freshly isolated rat hepatocytes) systems. The results showed that the oxidant-induced DNA lesions were significantly reduced in both systems pre-treated with the Lavandula angustifolia. The observed DNA-protective activity could be explained by both elevation of GPx activity in cells pre-treated with LO and antioxidant activity of LO.

Point prevalence study of antimicrobial usage in acute care hospitals in the Slovak Republic.

BACKGROUND: Antimicrobial use and resultant resistance is still increasing worldwide. Close monitoring and strict implementation of policies are important to tackle this issue. AIM: To assess the use of antimicrobials in acute care hospitals in the Slovak Republic. METHODS: Antimicrobial use was monitored as part of a point prevalence survey (PPS) of healthcare-associated infections. Surveillance was performed in 40 hospitals in the Slovak Republic according to the standardized methodology developed by the European Centre for Disease Prevention and Control. Data were collected according to a standard protocol. FINDINGS: In total, 8397 patients in 40 Slovak hospitals were surveyed. Of these, 30.7% were receiving antibiotics at the time of the survey. In 630 cases, patients were receiving more than one antimicrobial agent. The prevalence of antimicrobial use was highest in intensive care units (54.3%). Antimicrobials were prescribed most frequently for treatment of community-acquired infections (48.1%) and healthcare-associated infections (11.4%). Surgical prophylaxis was the indication for 22.2% of all prescribed antimicrobials, and exceeded 24h in 81.5% of cases. The antimicrobials used most often were fluoroquinolones (20.9%), especially for non-surgical prophylaxis (26.8%) and treatment (21.9%). The antimicrobials prescribed most frequently for surgical prophylaxis were first-generation cephalosporins (23.0%), fluoroquinolones (14.7%) and second-generation cephalosporins (11.4%). The use of antimicrobials was higher in patients with invasive medical devices. CONCLUSION: This study found excessive use of broad-spectrum antibiotics, prolonged surgical prophylaxis, frequent use of parenteral antibiotics and inadequate documentation of the indication for prescription. These findings present opportunities for improving the management of antimicrobials in Slovak hospitals.

[A point prevalence survey of healthcare-associated infections in the Slovak Republic - a part of the EU project]. / Bodové prevalencné sledovanie nozokomiálnych nákaz na Slovensku - súcast projektu Európskej únie.

AIM: The aim of this survey was to estimate the prevalence of healthcare-associated infections (HAI) in the Slovak Republic (SR), distribution of causative pathogens, and risk factors. METHODS: The point prevalence survey (PPS) of HAI in the SR was carried out in 40 acute care hospitals, according to a standardized methodology developed by the European Centre for Disease Prevention and Control (ECDC). Data were collected according to the standard protocol at the country, hospital, and patient levels. RESULTS: Of 8 397 patients included in the survey in the SR, 298 (3.5%) had HAI. The highest prevalence of HAI (12.4%) was found in the intensive care units (ICU) and Anaesthesiology and Intensive Care Medicine Units (AICMU). Nevertheless, intensive care medicine patients only represented 6.5% of all patients. The following six most common types of HAI accounted for 87.3% of all HAI: urinary tract infection (26.2%), pneumonia and other lower respiratory tract infections (22.0%), surgical site infection (15.7%), bloodstream infection (9.9%), infection of the eye, ear, and upper respiratory tract (8.3%), and skin and soft tissue infection (5.2%). The most often isolated pathogens were Escherichia coli (15.0%), Klebsiella spp. (12.5%), and Pseudomonas aeruginosa (10.8%). Of 8 397 surveyed patients, 60.5% had a medical device inserted: central vascular catheter (CVC)(3.4%), peripheral vascular catheter (PVC)(40.8%), urinary catheter (14.1%), or endotracheal tube (2.1%). The prevalence of HAI was higher in patients with than without a medical device inserted. CONCLUSION: By participating in the PPS, the SR has collected the most recent data on HAI and antimicrobial use in acute care hospitals. The adherence to the standard methods, standard definitions of HAI, and PPS protocol allows to repeat the survey, to analyse the HAI prevalence trend, and to take effective interventions.

Laboratory testing of hereditary thrombophilia: previous data in the face of verification.

OBJECTIVE: Mutations in hemocoagulation factors genes are nowadays routinely examined parameters, important in hereditary trombophilia determination. We have complexly evaluated laboratory data from the 211 unselected patients with venous thrombosis, and compared with the former studies in the same Slovakian population. RESULTS: The Factor V Leiden mutation (FVL) was found in 43 of 211 patients (20.38%), with the mutant allele frequency=10.2%, while the prothrombine G20210A mutation was revealed in 11/205 individuals (5.37%), with the mutant PT 20210A allele frequency=2.68%. In both mutations, all carriers of mutant allele were heterozygotes. In 81 individuals was examined the PCAT-NR with the ProC Global assay. Of them, 24 was heterozygotes for FVL mutation with considerably lower PCAT-NR levels (median=0.67; range: 0.53-0.83) compared with homozygotes without FVL mutation (n=57; median=0.84; range: 0.54-1.67; p<0.001). The sensitivity of the assay was 0.88 (95% CI: 0.68-0.97) and the specifity =0.67 (95% CI: 0.53-0.79). CONCLUSIONS: Our examination revealed considerably lower frequency of the FVL mutation in the target population, by contrast to the neighbouring Caucasian populations. As for the PT 20210 mutation, the differences are milder. Even though the PCAT-NR was validly sensitive (sensitivity=0.88, 95% CI: 0.68-0.97) to the FVL mutation, only DNA-testing is the definitive assay for FVL-carriership (Ref. 19). Full Text (Free, PDF) www.bmj.sk.

[Factor V Leiden and the Slovak population]. / Faktor V Leiden a slovenská populace.

The resistance to activated protein C (APC-resistance) based on the presence of factor V Leiden (F V Leiden) is the most frequent thrombophilic condition in the white race population. It contributes to the origin of thrombosis especially in the venous part of blood vessels. Significant geographic differences have been detected within Europe. The aim of this retrospective study was to determine the frequency in the occurrence of F V Leiden: 1. in healthy (asymptomatic) Slovak population, 2. in their consanguineously unrelated members with thrombosis and 3. in patients with myocardial infarction (IM) without or with other known risk factors of this disease (nicotinism, obesity, hypertension, dyslipoproteinemia, diabetes mellitus), respectively. The detection of FV Leiden was made by molecular biology methods. The occurrence in a group of 152 healthy individuals was four % (6 persons) and this frequency corresponds to the geographic localization of the Slovak Republic in Europe. In a group of 349 patients with thrombosis in anamnesis, FV Leiden was detected in 103 persons (29.5%). The occurrence was higher than the usually reported incidence in these patients (20%). Likewise, in a group of 35 patients with IM without risk factors in anamnesis, the occurrence of FV Leiden (8.6%) was significantly higher in comparison with healthy population and the incidence further increased significantly in a group of 41 patients with IM and the presence of at least one risk factor (14.6%). The authors therefore suppose an active role of the Leiden mutation of FV gene in the pathogenesis of this disease.

Cytotoxic T lymphocyte antigen 4 (CTLA-4) dimorphism in patients with systemic lupus erythematosus.

OBJECTIVE: Genetic susceptibility to systemic lupus erythematosus (SLE) is conferred not only by various genes within the major histocompatibility complex (MHC) region, but also by several other non-MHC linked genes. The negatively signalling molecule CTLA-4 is involved in establishing and maintaining of peripheral T cell tolerance, which controls T cell activation and reactivity. Its attenuating action helps to prevent an inappropriate initiation of T cell responses to self antigens and to terminate ongoing T cell responses. We tested if there was an association between CTLA-4 and SLE, a disease with B and T cell hyperreactivity and impaired peripheral T cell tolerance. METHODS: Using the polymerase chain reaction--restriction fragment length polymorphism method with Bbv I digestion, we assessed an exon 1 transition dimorphism (49 A/G) of the CTLA-4 gene in 102 SLE patients and in 76 healthy controls. RESULTS: The distribution of CTLA-4 exon 1 genotypes in the SLE group was significantly different from that in the controls (chi 2 = 6.178, p < 0.05). 17.6% of the SLE patients were G/G homozygotes compared to 5.3% of the controls; 36.3% were A/G heterozygotes vs 40.8% of controls; and 46.1% were A/A homozygotes vs 53.9% of the controls. The frequency of the G allele was significantly higher in SLE patients (35.8%) than in controls (25.7%; chi 2 = 4.142, p = 0.042). CONCLUSION: Our results indicate that the non-MHC linked CTLA-4 gene could confer susceptibility in SLE, as it does in various other autoimmune diseases (Hashimoto thyroiditis, Graves' disease, IDDM).

Association between systemic lupus erythematosus and insertion/deletion polymorphism of the angiotensin converting enzyme (ACE) gene.

OBJECTIVE: ACE takes part in the renin-angiotensin and kallikrein-kininogen systems by creating angiotensin-II and inactivating bradykinin. ACE gene insertion/deletion polymorphism is associated with the level of circulating enzymes--subjects with the DD genotype have higher levels of circulating ACE than subjects with the II genotype and show an increased tendency towards impaired vascular function and structure. Patients with systemic lupus erythematosus (SLE) suffer from differentially expressed vascular pathology. We attempted to determine whether the type of ACE polymorphism could contribute to this pathology. METHODS: 101 SLE patients fulfilling the ACR criteria were investigated. The I/D polymorphism was ascertained by PCR, followed by electrophoresis of the amplified fragments and UV visualization. RESULTS: The frequency of the D allele was higher in the SLE group (0.623) than in the controls (0.520) (chi 2 test, p < 0.025). The distribution of the ACE genotype in SLE group was different from that in the control group (p < 0.05). An association between the DD genotype and visceral damage (p < 0.006) was observed. CONCLUSION: Our results suggest that in the multifactorially determined vascular pathology of SLE, changes associated with I/D polymorphism could influence vessel wall inflammation (monocyte adhesion and activation with cytokine release, T-lymphocyte metabolism), a tendency towards vascular impairment (neointimal proliferation, vasospasm, platelet activation, myocyte proliferation) and lead to the subsequent ischemia. The ACE gene could serve as the visceral damage indicator in SLE.

[Is PLA1/A2 gene polymorphism of platelet membrane glycoprotein IIIa a risk factor for myocardial infarct?]. / Je PLA1/A2 polymorfizmus génu pre trombocytárny membránový glykoproteín IIIa rizikovým faktorom infarktu myokardu?

BACKGROUND: The PlA1/A2 polymorphism of the human platelet membrane glycoprotein IIIa gene cause T-->C transition in the exon ii (position 1565) resulting in the leucine-->proline substitution in amino-acid sequence. This polymorphism was shown to be associated with increased risk of myocardial infarction (MI). AIM: To test genetic parameters of the PlA1/A2 polymorphism in our population and to assess the relation between mutant PlA2 allele and MI. METHODS: DNA was isolated from peripheral blood, collected from 40 patients with MI and with present risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, smoking...), 33 patients with MI without risk factors, 34 controls with equivalent average age to both groups of the MI-patients, 58 control probands without MI in their family history and 33 healthy controls randomly recruited. After PCR amplification the resulting 267 bp fragment was digested with the restriction endonuclease NciI and subfragments were separated electrophoretically in 12% polyacrylamide gel. RESULTS: The frequency of the PlA2 allele was 0.121 in patients with MI without risk factors, 0.205 in patients with present risk factors, 0.162 in controls of the equivalent average age to the MI-patients, 0.172 in controls without MI in their family history and 0.20 in healthy controls randomly recruited. Genotype frequencies were in all groups in genetic equilibrium. Although the groups differed significantly (p < 0.01) in serum concentrations of total cholesterol, HDL-cholesterol, LDL-cholesterol, apolipoprotein A-1, apolipoprotein B and malondialdehyde, no significant differences in the serum concentrations of these metabolites between A1/A1, A1/A2 and A2/A2 genotypes were observed. CONCLUSIONS: PLA1/A2 polymorphism is associated with MI, however not as a dominant risk factor, but as a part of environmentally influencable multigene system. There is no relation between genotypes of the PLA1/A2 polymorphism and the lipoproteins plasma concentrations. (Tab. 4, Ref. 17.)