Comparison of 12-hour with 72-hour terlipressin therapy for bleeding esophageal varices
Salim A, Malik K, Haq IU, Butt AK, Alam A
Journal of the College of Physicians and Surgeons--Pakistan : Jcpsp. 2017;27((6)):334-337.
OBJECTIVE To determine the efficacy of 12-hour of Terlipressin therapy as compared to 72-hour therapy in preventing rebleeding after endoscopic therapy. STUDY DESIGN Interventional study. PLACE AND DURATION OF STUDY Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from January to March 2016. METHODOLOGY Cirrhotic patients presenting to our hospital with GI (gastrointestinal) bleeding received Terlipressin 2 mg intravenous bolus, followed by 1mg 6-hourly until undergoing endoscopy. Those with esophageal varices as the source of bleeding underwent band ligation and were recruited. Of the 93 enrolled patients, 90 remained and were randomized into 25 (27.8%) in control Group-Aand 65 (72.2%) in test Group-B. Group-Areceived 72-hour of Terlipressin while Group-B received it for 12-hour. Both groups were monitored for rebleeding for 5 days. RESULTS Rebleeding occurred in 1 (4%) patient in Group-Aand 3 (4.6%) in Group-B during the 5-day period. All 4 (4.4%) underwent repeat endoscopy. The Group-Apatient and 2 (3%) of 3 Group-B patients showed ulcers over band ligation sites as source of bleed. The third Group-B patient showed varices requiring repeat banding. One (4%) patient (Group-A) died due to persistent encephalopathy. No drug related adverse effects were seen. CONCLUSION A12-hour duration of Terlipressin as an adjunct to endoscopic band ligation shows similar results to 72-hour therapy.
Fibrinogen in the initial resuscitation of severe trauma (FiiRST): a randomized feasibility trial
Nascimento B, Callum J, Tien H, Peng H, Rizoli S, Karanicolas P, Alam A, Xiong W, Selby R, Garzon AM, et al
British Journal of Anaesthesia. 2016;117((6)):775-782.
BACKGROUND Decreased plasma fibrinogen concentration shortly after injury is associated with higher blood transfusion needs and mortality. In North America and the UK, cryoprecipitate transfusion is the standard-of-care for fibrinogen supplementation during acute haemorrhage, which often occurs late during trauma resuscitation. Alternatively, fibrinogen concentrate (FC) can be beneficial in trauma resuscitation. However, the feasibility of its early infusion, efficacy and safety remain undetermined. The objective of this trial was to evaluate the feasibility, effect on clinical and laboratory outcomes and complications of early infusion of FC in trauma. METHODS Fifty hypotensive (systolic arterial pressure ≤100 mm Hg) adult patients requiring blood transfusion were randomly assigned to either 6 g of FC or placebo, between Oct 2014 and Nov 2015 at a tertiary trauma centre. The primary outcome, feasibility, was assessed by the proportion of patients receiving the intervention (FC or placebo) within one h of hospital arrival. Plasma fibrinogen concentration was measured, and 28-day mortality and incidence of thromboembolic events were assessed. RESULTS Overall, 96% (43/45) [95% CI 86-99%] of patients received the intervention within one h; 95% and 96% in the FC and placebo groups, respectively (P=1.00). Plasma fibrinogen concentrations remained higher in the FC group up to 12 h after admission with the largest difference at three h (2.9 mg dL - 1 vs. 1.8 mg dL - 1; P<0.01). The 28-day mortality and thromboembolic complications were similar between groups. CONCLUSIONS Early infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation. Larger trials are justified.
Prophylactic use of tranexamic acid for postpartum bleeding outcomes: a systematic review and meta-analysis of randomized controlled trials
Alam A, Choi S
Transfusion Medicine Reviews. 2015;29((4)):231-41.
Despite multimodal approaches to treatment, postpartum hemorrhage (PPH) is a life-threatening condition whose incidence continues to rise. In developing areas, such as sub-Saharan Africa, PPH is the leading cause of maternal mortality. Tranexamic acid (TXA) is a possible prophylactic treatment for the prevention of PPH. We performed a systematic review and meta-analysis of randomized trials comparing prophylactic TXA vs placebo or no treatment in term parturients to quantify the effects of prophylactic TXA administration on peripartum bleeding outcomes. The meta-analysis was performed using a random-effects model. The outcomes assessed were (i) incidence of PPH, (ii) mean blood loss (in milliliters) within 24hours, (iii) incidence of red blood cell transfusion within 24hours, (iv) use of additional uterotonics, (v) minor side effects (ie, nausea, vomiting, headache, etc), (vi) major venous thromboembolism, (vii) length of hospital stay, and (viii) mortality. Eighteen trials (3846 subjects) were included in the quantitative analysis, with 1935 patients receiving TXA. The studies were of poor to moderate quality. Prophylactic TXA administration was associated with a decreased incidence of PPH after delivery (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.17-0.59; P = .0006), a reduction in mean blood loss by 149.1mL (95% CI, 112.9-185.2; P < .00001), and a reduction in red blood cell transfusions (OR, 0.28; 95% CI, 0.15-0.49; P < .00001) while also being associated with a reduction in the use of additional uterotonics (OR, 0.45; 95% CI, 0.30-0.66; P < .00001). Minor side effects were more common in those who received TXA (OR, 2.51; 95% CI, 1.69-3.74; P < .00001). There appeared to be no increased risk of venous thromboembolism and no difference in length of hospital stay associated with TXA use. Although prophylactic TXA administration may be associated with improved peripartum bleeding, existing evidence is insufficient for any definitive recommendations secondary to the poor to moderate quality of the literature. A large well-designed, methodologically sound, randomized controlled trial is needed to better delineate the true effect size and address potential safety concerns. Copyright © 2015 Elsevier Inc. All rights reserved.