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Effect of Tranexamic Acid on Blood Management during a High Tibial Osteotomy: A Systematic Review and Meta-analysis
Fang Q, Zhang Z, Wang D, Wang L, Xiong W, Tang Y, Liu W, Wang G
Orthopaedic surgery. 2022
Abstract
This study aimed to evaluate the efficiency and safety of tranexamic acid for blood management during high tibial osteotomy (HTO). A systematic search was conducted in Medline, Embase, and the Cochrane library database. Six studies and 208 patients were included in this meta-analysis using Review Manager V.5.3 and Stata 15.1 software. For primary outcomes, tranexamic acid lowered the total blood loss (WMD = -219.47, 95% CI [-355.61, -83.33], P = 0.002). For secondary outcomes, a significant reduction was found for decreased hemoglobin (POD1: WMD = -9.86, 95% CI [-13.45, -6.28], P < 0.05; POD2: WMD = -8.41, 95% CI [-11.50, -5.32], P < 0.05; POD5: WMD = -11.48, 95% CI [-14.56, -8.39], P < 0.05) and drainage (total: WMD = -105.93, 95% CI [-187.08, -24.78], P < 0.05; POD1: WMD = -122.195, 95% CI [-168.902, -75.488], P < 0.05). The sex difference (male/female ratio) was determined (total blood loss: P = 0.025; total drainage amount: p = 0.018) using meta-regression analysis. Females benefited more from tranexamic acid in terms of total blood loss (M/F > 40%: WMD = -53.11, 95% CI [-100.16, -6.05], P = 0.03; 40% ≥ M/F ≥ 20%: WMD = -362.20, 95% CI [-423.96, -300.45], P < 0.05; M/F < 20%: WMD = -263.00, 95% CI [-277.17, -248.83], P < 0.05) and total drainage (M/F > 40%: WMD = -7.11, 95% CI [-10.75, -3.47], P < 0.05; 40% ≥ M/F ≥ 20%: WMD = -104.72, 95% CI [-155.36, -54.08], P < 0.05; M/F < 20%: WMD = -222.00, 95% CI [-297.42, -146.58], P < 0.05). No significant differences were found for drainage on POD2 and POD3, wound complications, orthromboembolic events. In conclusion, tranexamic acid is effective and safe for blood management during HTO. Females appeared to benefit more from it, and an additional postoperative dose is suggested fora better effect.
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Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis
Chen Y, Zhao X, Wang D, Liu X, Chen J, Song J, Bai T, Hou X
Polymers. 2022;14(12)
Abstract
New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.
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Efficacy and safety of blood purification in the treatment of deep burns: A systematic review and meta-analysis
Zhang G, Liu W, Li J, Wang D, Duan J, Luo H
Medicine. 2021;100(5):e23968
Abstract
INTRODUCTION This meta-analysis aimed to systematically review and evaluate randomized controlled trials (RCTs) and cohort studies examining the efficacy and safety of blood purification in the treatment of patients with deep burns. METHODS The PubMed, Cochrane Library, and Embase databases and relevant references were systematically searched for RCTs and cohort studies published until the end of September 2020 to investigate the potential of blood purification in improving the prognosis of severely burned patients. The primary outcome of this systematic review was overall patient mortality; secondary outcomes included the incidence of sepsis and infection prevention (vital signs and routine blood tests). RESULTS A total of 6 RCTs and 1 cohort study were included, with a total of 538 burn patients (274 patients who received blood purification and 264 control patients). Compared with patients who received conventional treatment, those treated with blood purification displayed significant 2-day reduction in mortality and sepsis with relative risks of 0.62 and 0.41, respectively (95% confidence intervals [CIs], 0.74-0.82 and 0.25-0.67, respectively; P < .05). In terms of vital signs and blood biochemistry, the respiratory rates and blood urea nitrogen levels of patients in the blood purification group 3 days post-treatment were significantly higher than those in the control group (randomized standard deviations (SMDs), 0.78 and 0.77, respectively; 95% CIs, 0.33-1.23 and 1.22-0.31, respectively; P < .05). However, there were no significant differences between groups on day 3 with regard to temperature (P = .32), heart rate (P = .26), white blood cell count (P = .54), or neutrophil count (P = .74), potentially owing to the small sample size or the relatively short intervention time. Heterogeneous differences existed between the groups with respect to blood urea nitrogen (SMD = -1.22; 95% CI, -2.16 to -0.40; P < .00001) and Cr (SMD = -3.13; 95% CI, -4.92 to -1.33; P < .00001) on day 7. No systematic adverse events occurred. CONCLUSIONS Blood purification treatment for deep burn patients can significantly reduce the mortality rate and the incidence of complications.
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Reporting in clinical studies on platelet-rich plasma therapy among all medical specialties: A systematic review of Level I and II studies
Nazaroff J, Oyadomari S, Brown N, Wang D
PloS one. 2021;16(4):e0250007
Abstract
BACKGROUND The clinical practice of platelet-rich plasma (PRP) therapy has grown significantly in recent years in multiple medical specialties. However, comparisons of PRP studies across medical fields remain challenging because of inconsistent reporting of protocols and characterization of the PRP being administered. The purpose of this systematic review was to determine the quantity of level I/II studies within each medical specialty and compare the level of study reporting across medical fields. METHODS The Cochrane Database, PubMed, and EMBASE databases were queried for level I/II clinical studies on PRP injections across all medical specialties. From these studies, data including condition treated, PRP processing and characterization, delivery, control group, and assessed outcomes were collected. RESULTS A total of 132 studies met the inclusion and exclusion criteria and involved 28 different conditions across 8 specialties (cardiothoracic surgery, cosmetic, dermatology, musculoskeletal (MSK), neurology, oral maxillofacial surgery, ophthalmology, and plastic surgery). Studies on PRP for MSK injuries made up the majority of the studies (74%), with knee osteoarthritis and tendinopathy being most commonly studied. Of the 132 studies, only 44 (33%) characterized the composition of PRP used, and only 23 (17%) reported the leukocyte component. MSK studies were more likely to use patient-reported outcome measures to assess outcomes, while studies from other specialties were more likely to use clinician- or imaging-based objective outcomes. Overall, 61% of the studies found PRP to be favorable over control treatment, with no difference in favorable reporting between MSK and other medical specialties. CONCLUSIONS The majority of level I/II clinical studies investigating PRP therapy across all medical specialties have been conducted for MSK injuries with knee osteoarthritis and tendinopathy being the most commonly studied conditions. Inconsistent reporting of PRP composition exists among all studies in medicine. Rigorous reporting in human clinical studies across all medical specialties is crucial for evaluating the effects of PRP and moving towards disease-specific and individualized treatment.
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The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis
Ma J, Lu H, Chen X, Wang D, Wang Q
Journal of orthopaedic surgery and research. 2021;16(1):373
Abstract
OBJECTIVE The present meta-analysis was conducted to evaluate the efficacy and safety of the application of tranexamic acid (TXA) in patients undergoing high tibial osteotomy (HTO). METHODS PubMed (MEDLINE), EMBASE, and Cochrane Library were systematically searched for relevant literature from inception until 1 February 2021. A combined searching strategy of subject words and random words was adopted. After testing for potential publication bias and/or heterogeneity, we aggregated variables by using the random-effect model. The primary comparison outcome measures were total blood loss, hemoglobin decrease, drain output, wound complications, thrombotic events, and blood transfusion rate of the TXA group versus control. The meta-analysis was performed using the RevMan 5.3 software. RESULTS A total of 5 studies were included involving 532 patients. The results showed that there were significant differences in the two groups concerning total blood loss (95% confidence interval [CI] - 332.74 to - 146.46, P < 0.00001), hemoglobin decrease on postoperative day (POD) 1, 2, and 5 (POD 1 95% CI - 1.34 to - 0.63, P < 0.00001; POD 2 95% CI - 1.07 to - 0.68, P < 0.00001; POD 5 95% CI - 1.46 to - 0.84, P < 0.00001), drain output (POD total 95% CI - 195.86 to - 69.41, P < 0.00001) and wound complications (RR = 0.34, 95% CI 0.12 to 0.97, P = 0.04). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 0.46, 95% CI 0.09 to 2.41, P = 0.36) and blood transfusion rate (RR = 0.25, 95% CI 0.03 to 2.27, P = 0.22). CONCLUSIONS This meta-analysis of the available evidence demonstrated that TXA could reduce total blood loss, hemoglobin decrease, drain output, and wound complications without increasing the incidence of thromboembolic events in patients undergoing HTO. But there is no obvious evidence that TXA could reduce blood transfusion rates. Further studies, including more large-scale and well-designed randomized controlled trials, are warranted to assess the efficacy and safety issues of routine TXA use in HTO patients.
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The Statistical Fragility of Platelet-Rich Plasma in Rotator Cuff Surgery: A Systematic Review and Meta-analysis
Parisien RL, Ehlers C, Cusano A, Tornetta P 3rd, Li X, Wang D
The American journal of sports medicine. 2021;:363546521989976
Abstract
BACKGROUND The practice of evidence-based medicine relies on objective data to guide clinical decision-making with specific statistical thresholds conveying study significance. PURPOSE To determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating the utilization of platelet-rich plasma (PRP) in rotator cuff repairs (RCRs). STUDY DESIGN Systematic review and meta-analysis. METHODS RCTs pertaining to the utilization of PRP in surgical RCRs published in 13 peer-reviewed journals from 2000 to 2020 were evaluated. The FI was determined by manipulating each reported outcome event until a reversal of significance was appreciated. The associated FQ was determined by dividing the FI by the sample size. RESULTS Of the 9746 studies screened, 19 RCTs were ultimately included for analysis. The overall FI incorporating all 19 RCTs was only 4, suggesting that the reversal of only 4 events is required to change study significance. The associated FQ was determined as 0.092. Of the 43 outcome events reporting lost to follow-up data, 13 (30.2%) represented lost to follow-up >4. CONCLUSION Our analysis suggests that RCTs evaluating PRP for surgical RCRs may lack statistical stability with only a few outcome events required to alter trial significance. Therefore, we recommend the reporting of an FI and an FQ in conjunction with P value analysis to carefully interpret the integrity of statistical stability in future comparative trials. CLINICAL RELEVANCE Clinical decisions are often informed by statistically significant results. Thus, a true understanding of the robustness of the statistical findings informing clinical decision-making is of critical importance.
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Transfusion of recently donated (fresh) red blood cells (RBCs) does not improve survival in comparison with current practice, while safety of the oldest stored units is yet to be established: a meta-analysis
Remy KE, Sun J, Wang D, Welsh J, Solomon SB, Klein HG, Natanson C, Cortes-Puch I
Vox Sanguinis. 2016;111((1):):43-54
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Abstract
BACKGROUND AND OBJECTIVES Preclinical studies generated the hypothesis that older stored red blood cells (RBCs) can increase transfusion risks. To examine the most updated and complete clinical evidence and compare results between two trial designs, we assessed both observational studies and randomized controlled trials (RCTs) studying the effect of RBC storage age on mortality. MATERIALS AND METHODS Five databases were searched through December 2014 for studies comparing mortality using transfused RBCs having longer and shorter storage times. RESULTS Analysis of six RCTs found no significant differences in survival comparing current practice (average storage age of 2 to 3 weeks) to transfusion of 1- to 10-day-old RBCs (OR 0.91, 95% CI 0.77-1.07). RBC storage age was lower in RCTs vs. observational studies (P = 0.01). The 31 observational studies found an increased risk of death (OR 1.13, 95% CI 1.03-1.24) (P = 0.01) with increasing age of RBCs, a different mortality effect than RCTs (P = 0.02). CONCLUSION RCTs established that transfusion of 1- to 10-day-old stored RBCs is not superior to current practice. The apparent discrepancy in mortality between analyses of RCTs and observational studies may in part relate to differences in hypotheses tested and ages of stored RBCs studied. Further trials investigating 1- to 10-day-old stored RBC benefits would seem of lower priority than studies to determine whether 4- to 6-week stored units have safety and efficacy equivalent to the 2- to 3-week-old stored RBCs commonly transfused today.
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Comparison between autologous blood transfusion drainage and no drainage/closed-suction drainage in primary total hip arthroplasty: a meta-analysis
Li N, Li P, Liu M, Wang D, Xia L
Archives of Orthopaedic & Trauma Surgery. 2014;134((11):):1623-31.
Abstract
PURPOSE Primary aim of this meta-analysis of randomized controlled trials (RCTs) was to compare blood loss, transfusion rate and postoperative hemoglobin levels at 24-48 h after primary total hip arthroplasty (THA) between autologous blood transfusion (ABT) drainage and no drainage/closed-suction drainage and to obtain a powerful conclusion which way of drainage had the best clinical efficacy. Secondary aim was to compare the postoperative complication rates during the first year to indentify which way of drainage was safest. METHODS We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials and identified 12 RCTs (including a total of 1,574 patients) for the meta-analysis. Methodological quality was assessed by the Physiotherapy Evidence Database scale. Two researchers extracted relevant data including study characteristics, blood loss, transfusion rate, hemoglobin levels, hospital stay and complications. After data extraction, we compared results using fixed-effects or random-effects models depending on the heterogeneity of the included studies. RESULTS Autologous blood transfusion drainage had less total blood loss and lower superficial infection rate than no drainage/closed-suction drainage. While there were no statistical differences in postoperative pain, hematoma, hemoglobin levels, hospital stay and other complications between ABT drainage and no drainage/closed-suction drainage. CONCLUSIONS Autologous blood transfusion drainage and no drainage/closed-suction drainage have similar clinical efficacy and safety in primary THA with regard to clinical outcomes and complication rates.
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Systematic review and meta-analysis of perioperative intravenous tranexamic acid use in spinal surgery
Yang B, Li H, Wang D, He X, Zhang C, Yang P
PLoS ONE. 2013;8((2):):e55436.
Abstract
BACKGROUND Tranexamic acid (TXA) is well-established as a versatile oral, intramuscular, and intravenous (IV) antifibrinolytic agent. However, the efficacy of IV TXA in reducing perioperative blood transfusion in spinal surgery is poorly documented. METHODOLOGY We conducted a meta-analysis of randomized controlled trials (RCTs) and quasi-randomized (qi-RCTs) trials that included patients for various spinal surgeries, such as adolescent scoliosis surgery administered with perioperative IV TXA according to Cochrane Collaboration guidelines using electronic PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. Additional journal articles and conference proceedings were manually located by two independent researchers. RESULTS Totally, nine studies were included, with a total sample size of 581 patients. Mean blood loss was decreased in patients treated with perioperative IV TXA by 128.28 ml intraoperatively (ranging from 33.84 to 222.73 ml), 98.49 ml postoperatively (ranging from 83.22 to 113.77 ml), and 389.21 ml combined (ranging from 177.83 to 600.60 ml). The mean volume of transfused packed cells were reduced by 134.55 ml (ranging 51.64 to 217.46) (95% CI; P=0.0001). Overall, the number of patients treated with TXA who required blood transfusions was lower by 35% than that of patients treated with the comparator and who required blood transfusions (RR 0.65; 95% CI; 0.53 to 0.85; P<0.0001, I(2)=0%). A dose-independent beneficial effect of TXA was observed, and confirmed in subgroup and sensitivity analyses. A total of seven studies reported DVT data. The study containing only a single DVT case was not combined. CONCLUSIONS The blood loss was reduced in spinal surgery patients with perioperative IV TXA treatment. Also the percentage of spinal surgery patients who required blood transfusion was significantly decreased. Further evaluation is required to confirm our findings before TXA can be safely used in patients undergoing spine surgery. Systematic Review
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Transfusion of older stored blood and risk of death: a meta-analysis
Wang D, Sun J, Solomon SB, Klein HG, Natanson C
Transfusion. 2012;52((6):):1184-95.
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BACKGROUND Blood for transfusion is stored for up to 42 days. Older blood develops lesions and accumulates potentially injurious substances. Some studies report increasing toxicity as blood ages. We assessed the safety of transfused older versus newer stored blood. STUDY DESIGN AND METHODS PubMed, Scopus, and Embase were searched using terms new and old and red blood cell and storage through May 6, 2011, for observational and randomized controlled studies comparing outcomes using transfused blood having longer and shorter storage times. Death was the outcome of interest. RESULTS Twenty-one studies were identified, predominantly in cardiac surgery (n=6) and trauma (n=6) patients, including 409,966 patients. A test for heterogeneity of these studies' results was not significant for mortality (I(2) = 3.7%, p=0.41). Older blood was associated with a significantly increased risk of death (odds ratio, 1.16; 95% confidence interval [CI], 1.07-1.24). Using available mortality data, 97 (95% CI, 63-199) patients need to be treated with only new blood to save one life. Subgroup analysis of these trials indicated that the increased risk was not restricted to a particular type of patient, size of trial, or amount of blood transfused. CONCLUSION Based on available data, use of older stored blood is associated with a significantly increased risk of death. Copyright 2011 American Association of Blood Banks.