RESUMEN
BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.
Asunto(s)
Antifibrinolíticos , Artroplastia de Reemplazo de Rodilla , Ácido Tranexámico , Administración Intravenosa , Antifibrinolíticos/uso terapéutico , Artroplastia de Reemplazo de Rodilla/efectos adversos , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Estudios de Cohortes , HumanosRESUMEN
Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487-2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068-1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936-991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.
Les taux d'accouchements par césarienne au Mexique sont parmi les plus élevés au monde. Au vu de la sensibilisation accrue de la population et des professionnels à ce problème et de la mise à jour des directives nationales de 2014 visant à diminuer la fréquence des accouchements par césarienne, nous avons analysé l'évolution des accouchements par césarienne selon le type d'établissement entre 2008 et 2017 au Mexique. Nous avons obtenu des données issues d'actes de naissance auprès de la Direction générale mexicaine des informations sur la santé et regroupé le nombre total d'accouchements par voie basse et par césarienne en cinq catégories d'établissement: hôpitaux relevant du ministère de la Santé, hôpitaux publics, hôpitaux relevant de l'assurance liée à l'emploi public, hôpitaux militaires et autres établissements. Les taux d'accouchements ont été calculés pour chaque catégorie à l'échelle nationale et pour chaque État. En moyenne, 2 114 630 (intervalle de confiance, IC, à 95%: 2 061 487-2 167 773) naissances vivantes ont eu lieu chaque année entre 2008 et 2017 à l'échelle nationale. Parmi ces naissances, 53,5% (1 130 570; IC à 95%: 1 108 068-1 153 072) étaient des accouchements par voie basse, et 45,3% (957 105; IC à 95%: 922 936-991 274) étaient des accouchements par césarienne, avec peu de variations dans le temps. Au cours de la période étudiée, le nombre de naissances vivantes a augmenté de 4,4% (de 1 978 380 à 2 064 507). Le taux d'accouchements par voie basse est passé de 54,8% (1 083 331/1 978 380) à 52,9% (1 091 958/2 064 507), ce qui correspond à une diminution relative du taux de 3,5%. Le taux d'accouchements par césarienne est passé de 43,9% (869 018/1 978 380) à 45,5% (940 206/2 064 507), ce qui correspond à une augmentation relative du taux de 3,7%. Le changement le plus important concernant les taux d'accouchements a été constaté dans les hôpitaux du secteur privé. Depuis 2014, les taux d'accouchements par césarienne ont légèrement diminué dans tous les secteurs, mais demeurent élevés (45,5%). Des politiques et des interventions appropriées sont nécessaires pour réduire le taux d'accouchements par césarienne aux Mexique, en particulier dans les hôpitaux de secteur privé.
Las tasas de parto por cesárea en México están entre las más altas del mundo. Dada la creciente concienciación pública y profesional sobre este problema y las directrices nacionales actualizadas de 2014 para reducir la frecuencia de los partos por cesárea, se analizaron las tendencias de los partos por cesárea según el tipo de establecimiento en México entre 2008 y 2017. Se obtuvieron datos de los certificados de nacimiento de la Dirección General de Información Sanitaria de México y se agrupó el número total de partos vaginales y por cesárea en cinco categorías de establecimientos: hospitales del ministerio de salud pública, hospitales privados, hospitales gubernamentales para asegurados por empleo, hospitales militares y otras instalaciones. Se calcularon los índices de partos para cada categoría a nivel nacional y según cada estado. De media, 2 114 630 (intervalo de confianza, IC, del 95 %: 2 061 4872 167 773) nacimientos vivos se produjeron a nivel nacional al año entre 2008 y 2017. De estos nacimientos, el 53,5 % (1 130 570; IC del 95 %: 1 108 0681 153 072) fueron partos vaginales y el 45,3 % (957 105; IC del 95 %: 922 936991 274) fueron partos por cesárea, con poca variación a lo largo del tiempo. Durante el periodo de estudio, el número de nacidos vivos aumentó un 4,4 % (de 1 978 380 a 2 064 507). La tasa de partos vaginales disminuyó del 54,8 % (1 083 331/1 978 380) al 52,9 % (1 091 958/2 064 507), lo que supone una disminución porcentual relativa de la tasa del 3,5 %. La tasa de partos por cesárea aumentó del 43,9 % (869 018/1 978 380) al 45,5 % (940 206/2 064 507), lo que representa un aumento porcentual relativo de la tasa del 3,7 %. El mayor cambio en las tasas de partos se produjo en los hospitales del sector privado. Desde 2014, las tasas de parto por cesárea se han reducido ligeramente en todos los sectores, pero siguen siendo elevadas (45,5 %). Se necesitan políticas con intervenciones apropiadas para reducir la tasa de partos por cesárea en México, especialmente en los hospitales del sector privado.
Asunto(s)
Cesárea/tendencias , Adulto , Certificado de Nacimiento , Femenino , Humanos , México , Embarazo , Resultado del EmbarazoRESUMEN
BACKGROUND: Diagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure. METHODS: A multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D. RESULTS: Two hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65). CONCLUSION: Many cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.