Effect of intra articular tranexamic acid at different doses in unilateral total knee arthroplasty

Introduction: Tranexamic acid is routinely used to reduce blood loss in some dental and cardiac surgeries. Several studies have demonstrated similar effect in total knee arthroplasty surgery, but the route of administration, regimen used and dosage have been quite variable, ranging from single intra-articular dose of 1.5 gram to a triple intravenous dose of 3 grams. This study has been designed to compare the effect of intra-articular irrigation of tranexamic acid in reducing blood loss in unilateral total knee arthroplasty surgery at 3 different doses (1, 2 and 3 grams). Methodology: This was a prospective, randomised, single blinded study involving 57 patients, undergoing unilateral total knee replacement surgery in HUSM. Each patient received a randomised intra-articular dose of either 1 , 2 or 3 grams of tranexamic acid before joint closure and tourniquet release. Randomisation was done by a web-based software. Each patient received the same volume inside their knee joint (tranexamic acid + normal saline made up to 30 mL). Group 1 received 1 gram of tranexamic acid, group 2 received 2 grams of tranexamic acid and group 3 received 3 grams of tranexamic acid. An intra-articular drain size 12 was inserted for each patient and connected to the vacuum drain bottle which was opened 4 hours after surgery for tamponade effect. The pre-operative and 48 hours postoperative haemoglobin and haematocrit level, as well as the volume of drain output at 24 and 48 hours were recorded for each patient. The mean difference between pre-operative and post-operative haemoglobin and haematocrit level and the mean volume of drain output at 24 and 48 hours were calculated and analysed by SPSS version 20.0 and compared using one way ANOVA analysis. Results: The mean difference between pre-operative and post-operative haemoglobin for group 1, 2 and 3 grams were 1.36g/dL,1.40g/dL and 1.23g/dL respectively (p value 0.747).The mean difference between preoperative and postoperative haematocrit for group 1,2 and 3 grams were 4.15%.4.26% and 4.27% respectively (p value 0.950). The mean volume of drain output at 48 hours for group 1,2 and 3 grams were 336.84 mL,313.68 mL and 263.68 mL respectively(p value 0.195). Conclusions: There was no significant difference in the amount of blood loss among the 3 doses of tranexamic acid (1, 2 or 3 grams) when it was used as a single intra-articular administration before wound closure in unilateral total knee arthroplasty. This can turn out to be a cost effective finding in the long run for the inpatient management of those undergoing TKR

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.

OBJECTIVE: Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare. DESIGN: Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH). SETTING AND PARTICIPANTS: A range of clinical settings in four English NHS hospitals. RESULTS: The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC. CONCLUSIONS: Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed

The clinical and phenotypical assessment of seronegative villous atrophy; a prospective UK centre experience evaluating 200 adult cases over a 15-year period (2000-2015).

BACKGROUND: Seronegative villous atrophy (SNVA) is commonly attributed to coeliac disease (CD). However, there are other causes of SNVA. More recently angiotensin-2-receptor-blockers (A2RBs) have been reported as an association but data on SNVA have been limited to centres evaluating complex case referrals and not SNVA in general. OBJECTIVES: To provide clinical outcomes and associations in a large prospective study overseeing all newcomers with SNVA. DESIGN: Over a 15-year period (2000-2015) we evaluated 200 adult patients with SNVA at a UK centre. A diagnosis of either seronegative CD (SNCD) or seronegative non-CD (SN-non-CD) was reached. Baseline comparisons were made between the groups, with 343 seropositive CD subjects serving as controls. RESULTS: Of the 200 SNVA cases, SNCD represented 31% (n=62) and SN-non-CD 69% (n=138). The human leucocyte antigen (HLA)-DQ2 and/or DQ8 genotype was present in 61%, with a 51% positive predictive value for SNCD. The breakdown of identifiable causes in the SN-non-CD group comprised infections (27%, n=54), inflammatory/immune-mediated disorders (17.5%, n=35) and drugs (6.5%, n=13; two cases related to A2RBs). However, no cause was found in 18% (n=36) and of these 72% (n=26/36) spontaneously normalised duodenal histology while consuming a gluten-enriched diet. Following multivariable logistic regression analysis an independent factor associated with SN-non-CD was non-white ethnicity (OR 10.8, 95% CI 2.2 to 52.8); in fact, 66% of non-whites had GI infections. On immunohistochemistry all groups stained positive for CD8-T-cytotoxic intraepithelial lymphocytes. However, additional CD4-T helper intraepithelial lymphocytes were occasionally seen in SN-non-CD mimicking the changes associated with refractory CD. CONCLUSIONS: Most patients with SNVA do not have CD, in particular those who are not white. Furthermore, a subgroup with no obvious aetiology will show spontaneous histological resolution while consuming gluten. These findings suggest caution in empirically prescribing a gluten-free diet without investigation

Differences between serious and nonserious patient safety incidents in the largest hospital district in Finland

OBJECTIVES: To determine if and in what ways serious patient safety incidents differ from nonserious patient safety incidents. METHODS: Statistical analysis was performed on patient safety incident reports that were reported in 2015 in Finland's largest hospital district (Helsinki and Uusimaa, HUS). Reports were divided into two groups: nonserious incidents and serious incidents. Differences between groups were studied from several types of categorically divided information. RESULTS: Of the total number of reports (15,863), 1% were serious incidents (175). Serious and nonserious incidents differed significantly from each other. Serious incidents concerning laboratory, imaging, or medical equipment were more common. On the other hand, incidents concerning medication, infusion, and blood transfusion were less frequent. In serious incidents, the proportion of doctors reporting was greater, and contributing factors were better recognized, the most common being working of procedures. CONCLUSIONS: In the future, special attention should be given to the particular aspects of serious patient safety incidents, such as safe use of medical equipment, training, and handling of procedures. Root cause analysis is an effective way to handle serious incidents and enables the prevention of their reoccurrence. However, a systematic follow-up of the root cause analysis should be developed. © 2018 American Society for Health Care Risk Management of the American Hospital Association.Peer reviewe

Financialising acute kidney injury: From the practices of care to the numbers of improvement

Although sociological studies of quality and safety have identified competing epistemologies in the attempt to measure and improve care, there are gaps in our understanding of how finance and accounting practices are being used to organise this field. This analysis draws on what others have elsewhere called ‘financialisation’ in order to explore the quantification of qualitatively complex care practices. We make our argument using ethnographic data of a quality improvement program for acute kidney injury (AKI) in a publicly funded hospital in England. Our paper is thus concerned with tracing the effects of financialisation in the emergence and assembly of AKI as an object of concern within the hospital. We describe three linked mechanisms through which this occurs: (1) representing and intervening in kidney care; (2) making caring practices count; and, (3) decision-making using kidney numbers. Together these stages transform care practices first into risks and then from risks into costs. We argue that this calculative process reinforces a separation between practice, and organisational decision-making made on the basis of numbers. This elevates the status of numbers while diminishing the work of practitioners and managers. We conclude by signalling possible future avenues of research that can take up these processes

Factors influencing participation in randomised clinical trials among patients with early Barrett's neoplasia: a multicentre interview study

OBJECTIVES: Strong recruitment and retention into randomised controlled trials involving invasive therapies is a matter of priority to ensure better achievement of trial aims. The BRIDE (Barrett's Randomised Intervention for Dysplasia by Endoscopy) Study investigated the feasibility of undertaking a multicentre randomised controlled trial comparing argon plasma coagulation and radiofrequency ablation, following endoscopic resection, for the management of early Barrett's neoplasia. This paper aims to identify factors influencing patients' participation in the BRIDE Study and determine their views regarding acceptability of a potential future trial comparing surgery with endotherapy. DESIGN: A semistructured telephone interview study was performed, including both patients who accepted and declined to participate in the BRIDE trial. Interview data were analysed using the constant comparison approach to identify recurring themes. SETTING: Interview participants were recruited from across six UK tertiary centres where the BRIDE trial was conducted. PARTICIPANTS: We interviewed 18 participants, including 11 participants in the BRIDE trial and 7 who declined. RESULTS: Four themes were identified centred around interviewees' decision to accept or decline participation in the BRIDE trial and a potential future trial comparing endotherapy with surgery: (1) influence of the recruitment process and participant-recruiter relationship; (2) participants' views of the design and aim of the study; (3) conditional altruism as a determining factor and (4) participants' perceptions of surgical risks versus less invasive treatments. CONCLUSION: We identified four main influences to optimising recruitment and retention to a randomised controlled trial comparing endotherapies in patients with early Barrett's-related neoplasia. These findings highlight the importance of qualitative research to inform the design of larger randomised controlled trials

The problem with root cause analysis

Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents, (1-3) is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events, (1) RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science (4,5) that are used to establish how and why an incident occurred in an attempt to identify how it, and similar problems, might be prevented from happening again.(6) In this article, we propose that RCA does have potential value in healthcare, but it has been widely applied without sufficient attention paid to what makes it work in its contexts of origin, and without adequate customisation for the specifics of healthcare. (7,8) As a result, its potential has remained under-realised (7) and the phenomenon of organisational forgetting (9) remains widespread (Box 1). Here, we identify eight challenges facing the utilisation of RCA in healthcare and offer some proposals on how to improve learning from incidents