Efficacy of cranial electrotherapy stimulation for neuropathic pain following spinal cord injury: a multi-site randomized controlled trial with a secondary 6-month open-label phase

Background

Chronic pain is a significant problem for many individuals following spinal cord injury (SCI). Unfortunately, SCI-related neuropathic pain has proven to be largely refractory to analgesic medications and other available treatments. Cranial electrotherapy stimulation (CES) has been effective in managing some types of pain. It involves the application of a small amount of current through the head via ear clip electrodes.

Objective

Explore the effectiveness of CES for neuropathic pain in persons with SCI and chronic pain.

Study design

Multi-site, double-blind, sham-controlled study.

Participants

Adults with SCI and chronic neuropathic pain at or below the level of injury were randomized to receive active or sham CES.

Intervention

Application of active CES or sham CES 1 hour daily for 21 days. Six-month open-label phase to assess ‘as-needed’ CES use.

Outcome measures

Change in pre- to post-session pain ratings as well as change in pain intensity, pain interference, pain quality, pain beliefs and coping strategies, general physical and mental health status, depressive symptomatology, perceived stress, and anxiety pre- to post-treatment.

Results

The active group reported a significantly greater average decrease in pain during daily treatments than the sham group (Kruskal–Wallis chi-square = 4.70, P < 0.05). During the 21-day trial, there was a significant group × time interaction for only one outcome variable; the active group showed larger pre- to post-treatment decreases in pain interference than the sham group did (F = 8.50, P < 0.01, d = 0.59).

Conclusions

On average, CES appears to have provided a small but statistically significant improvement in pain intensity and pain interference with few troublesome side effects. Individual results varied from no pain relief to a great deal of relief.     

Body composition modifications in people with chronic spinal cord injury after supervised physical activity

Background

Quantification of body composition variables is important for planning of better activities in relation to individuals with spinal cord injury (SCI).

Objectives

(1) To evaluate changes in body composition in patients with SCI after a supervised physical activity process; (2) To correlate total body fat with time since injury.

Design

Pre-post intervention.

Setting

Sarah Rehabilitation Hospital Network, Brazil.

Participants

Fifty-three men with SCI aged 18–52 years with duration of injury >3 years.

Interventions

The subjects were divided into three groups: tetraplegia (TT) (C5–C8), high paraplegia (HP) (T1–T6), and low paraplegia (LP) (T7–L2). Body composition was estimated in the first and last weeks of hospitalization.

Outcome measures

Body weight (kg), skinfolds sum (mm), absolute (kg), and relative (%) fat and lean body mass.

Results

Body weight increased in TT and decreased in HP (0.8 kg, 95%CI 0.1–1.5; and −1.0 kg, 95%CI −2.0 to 0.0, respectively; P < 0.05). Skinfolds sum decreased only in HP (−13.1 mm, 95%CI −20.7 to −5.5; P < 0.05). Absolute and relative body fat decreased significantly in the paraplegia groups. Lean body mass (LBM) percentage increased significantly in the paraplegia groups. Absolute LBM increased in TT and LP (0.8 kg, 95%CI 0.3–1.3; and 1.3 kg, 95%CI 0.8 to 1.8, respectively; P < 0.05). There was no correlation between time since injury and skinfolds sum for the three groups (P < 0.05).

Conclusion

TT, HP, and LP demonstrated favorable changes in body composition after 29 days of supervised physical activity. However, these changes were different in direction and magnitude.     

Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury

Objective

To determine the association between peripheral blood flow and spasticity in individuals with spinal cord injury (SCI).

Design

A cross-sectional study with measurements of muscle spasticity and whole-limb blood flow in individuals with SCI.

Setting

University of Texas at Austin and Brain & Spine Recovery Center, Austin, TX, USA.

Participants

Eighteen individuals (14 males and 4 females) with SCI were classified into high (N = 7), low (N = 6), and no (N = 5) spasticity groups according to the spasticity levels determined by the modified Ashworth scale scores.

Interventions

Whole-limb blood flow was measured in the femoral and brachial arteries using Doppler ultrasound and was normalized to lean limb mass obtained with dual-energy X-ray absorptiometry.

Outcome measures

Limb blood flow and muscle spasticity.

Results

Age, time post-SCI, and the American Spinal Injury Association impairment scale motor and sensory scores were not different among groups with different muscle spasticity. Femoral artery blood flow normalized to lean leg mass was different (P = 0.001) across the three spasticity groups (high 78.9 ± 16.7, low 98.3 ± 39.8, no 142.5 ± 24.3 ml/minute/kg). Total leg muscle spasticity scores were significantly and negatively correlated with femoral artery blood flow (r = −0.59, P < 0.01). There was no significant difference in brachial artery blood flow among the groups.

Conclusions

Whole-leg blood flow was lower in individuals with greater spasticity scores. These results suggest that a reduction in lower-limb perfusion may play a role, at least in part, in the pathogenesis leading to muscle spasticity after SCI.     

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

Purpose

Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery.

Methods

This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions.

Results

In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720).

Conclusions

Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.     

The effect of repetitive transcranial magnetic stimulation on refractory neuropathic pain in spinal cord injury

Objective

To investigate the analgesic effect of repetitive transcranial magnetic stimulation (rTMS) on intractable neuropathic pain in patients with spinal cord injury (SCI).

Design

A single center, prospective, randomized, double-blinded, controlled study.

Setting

SCI rehabilitation unit of university rehabilitation center.

Participants

Seventeen patients with SCI and chronic neuropathic pain who met the inclusion criteria recruited between April 2010 and January 2012.

Interventions

Ten daily treatment sessions of real or sham rTMS (30 trains of 10-Hz stimuli for a duration of 5 seconds; a total of 1500 pulses at intensity equal to 110% of the resting motor threshold) was applied over vertex using a figure-of-8-shaped coil.

Outcome measures

Pain was assessed with visual analog scale (VAS) at baseline and 10 days, 6 weeks and 6 months after the treatment. Patients’ satisfactions obtained using a 5-point Likert scale at 6 months.

Results

Both real and sham rTMS provided a significant reduction in the VAS scores (real rTMS group, P = 0.004; sham rTMS group, P = 0.020). Post hoc analysis revealed the significant difference was at 10 days and 6 weeks compared to baseline in the real rTMS group and only at 10 days compared to baseline in the sham rTMS group. Comparison of VAS scores and patient satisfaction did not show any significant difference at each assessment point (P > 0.05).

Conclusion

Our results demonstrated analgesic effect of rTMS on intractable neuropathic pain in SCI was not superior to placebo. However, middle-term (over 6 weeks) pain relief by rTMS is encouraging and suggests the need for future studies with a larger sample size.     

Etanercept treatment enhances clinical and neuroelectrophysiological recovery in partial spinal cord injury

Purpose

To investigate the effect of an anti-TNF-α agent (etanercept) on recovery processes in a partial spinal cord injury (SCI) model using clinical and electrophysiological tests.

Methods

Twenty-four New Zealand rabbits were divided into three groups: group 1 [SCI + 2 ml saline intramuscular (i.m.), n = 8], group 2 (SCI + 2.5 mg/kg etanercept, i.m., 2–4 h after SCI, n = 8) and group 3 (SCI + 2.5 mg/kg etanercept, i.m., 12–24 h after SCI, n = 8). Rabbits were evaluated before SCI, immediately after SCI, 1 week after, and 2 weeks after SCI, clinically by Tarlov scale and electrophysiologically by SEP.

Results

Tarlov scores of groups 2 and 3 were significantly better than group 1, 2 weeks after SCI. SEP recovery was significantly better in groups 2 and 3 than group 1, 2 weeks after SCI.

Conclusions

These results show that blocking TNF-α mediated inflammation pathway by an anti-TNF-α agent enhances clinical and electrophysiological recovery processes in partial SCI model.     

Effects of compression stockings on sympathetic activity and heart rate variability in individuals with spinal cord injury

Objective

To investigate whether wearing graduated compression stockings (GCS) could affect the sympatho-adrenergic and heart rate variability (HRV) responses at rest and after a strenuous wheelchair exercise in individuals with spinal cord injury (SCI).

Design

Crossover trial.

Setting

Department of Physical Medicine and Rehabilitation, Saint Etienne, France.

Participants

Nine men with SCI (five with low paraplegia: LP, four with high paraplegia: HP).

Interventions

Two maximal wheelchair exercise tests: with and without GCS (21 mmHg).

Main outcome measures

HRV measurements: high frequency (HF), low frequency (LF), and LF/HF ratio. Norepinephrine (NOR) and epinephrine (EPI), at rest and post-exercise. Secondary measures were: blood pressure, heart rate, maximal power output, oxygen uptake, stroke volume, cardiac output, at rest, during and after exercise.

Results

When wearing GCS: LFnu_wavelet-post significantly increased and HFnu_wavelet-post significantly decreased (P < 0.05) in SCI subjects, leading to an enhance ratio of LF_wavelet/HF_wavelet and a significantly increased in NOR_rest (P < 0.05).

Conclusions

GCS induces an enhanced sympathetic activity in individuals with paraplegia, regardless of the level of the injury. Enhanced post-exercise sympathetic activity with GCS may help prevent orthostatic hypotension or post-exercise hypotension.     

Neuroprotective therapy using granulocyte colony-stimulating factor for acute spinal cord injury: a phase I/IIa clinical trial

Objective

Granulocyte colony-stimulating factor (G-CSF) is a cytokine that is clinically used to treat neutropenia. G-CSF also has non-hematopoietic functions and could potentially be used to treat neuronal injury. To confirm the safety and feasibility of G-CSF administration for acute spinal cord injury (SCI), we have initiated a phase I/IIa clinical trial of neuroprotective therapy using G-CSF.

Methods

The trial included a total of 16 SCI patients within 48 h of onset. In the first step, G-CSF (5 μg/kg/day) was intravenously administered for 5 consecutive days to 5 patients. In the second step, G-CSF (10 μg/kg/day) was similarly administered to 11 patients. We evaluated motor and sensory functions of patients using the American Spinal Cord Injury Association (ASIA) score and ASIA impairment scale (AIS) grade.

Results

In all 16 patients, neurological improvement was obtained after G-CSF administration. AIS grade increased by one step in 9 of 16 patients. A significant increase in ASIA motor scores was detected 1 day after injection (P < 0.01), and both light touch and pin prick scores improved 2 days after injection (P < 0.05) in the 10 μg group. No severe adverse effects were observed after G-CSF injection.

Conclusion

These results indicate that intravenous administration of G-CSF (10 μg/kg/day) for 5 days is essentially safe, and suggest that some neurological recovery may occur in most patients. We suggest that G-CSF administration could be therapeutic for patients with acute SCI.     

Soleus H-reflex modulation after motor incomplete spinal cord injury: effects of body position and walking speed

Objective:

To examine position-dependent (semireclined to standing) and walking speed–dependent soleus H-reflex modulation after motor incomplete spinal cord injury (SCI).

Participants:

Twenty-six patients with motor incomplete SCI (mean: 45 ± 15 years) and 16 noninjured people (mean: 38 ± 14 years).

Methods:

Soleus H-reflexes were evoked by tibial nerve stimulation. Patients were tested in semireclined and standing positions (experiment 1) and in midstance and midswing positions (experiment 2).

Results:

H-reflexes were significantly greater after SCI in all positions compared with noninjured people (P < 0.05). Position-dependent modulation from semireclined to standing (normally observed in noninjured people) was absent after SCI. In SCI patients, H-reflex modulation was not significantly different at 1.2 m/s compared with 0.6 m/s treadmill walking speed; in noninjured people, H-reflex modulation was significantly greater at 1.2 m/s compared with 0.6 m/s treadmill walking speed. There was a significant positive correlation between modified Ashworth scores, a clinical measure of spasticity and soleus H-reflex amplitudes tested in all positions. A significant negative correlation was also found between H-reflexes in standing and midstance positions and the amount of assistance patients required to walk.

Conclusions:

An improvement in position-dependent and walking speed–dependent reflex modulation after SCI may indicate functional recovery. Future studies will use H-reflex testing to track changes as a result of therapeutic interventions.     

Omega-3 fatty acids’ effect on leptin and adiponectin concentrations in patients with spinal cord injury: A double-blinded randomized clinical trial

Context

Omega-3 fatty acids have been recently proposed to induce neural improvement in patients with spinal cord injury (SCI) while affecting some hormones including leptin and adiponectin.

Objectives

We tried to evaluate the effect of omega-3 fatty acids on circulatory concentrations of leptin and adiponectin among these patients.

Design

This study is a double-blinded randomized clinical trial with intervention duration of 14 months.

Setting

A tertiary rehabilitation center.

Participants

Total of 104 patients with SCI who did not meet our exclusion criteria entered the study. Those with history of diabetes, cancer, endocrinology disease, acute infection, and use of special medications were excluded. Patients were divided randomly into the treatment and control group by using permuted balanced block randomization.

Intervention

The treatment group received two MorDHA^® capsules per day (each capsule contain 465 mg of docosahexaenoic acid (DHA) and 63 mg of eicosapentaenoic acid (EPA)) for 14 months while the control group received placebo capsules with similar color, shape, and taste.

Main outcomes measures

Leptin and adiponectin concentrations in plasma were measured at the beginning of trial and then after 6 and 14 months.

Results

Fourteen months of treatment with DHA and EPA did not influence concentrations of leptin but adiponectin level was significantly decreased (P: 0.03). Weight was positively correlated with leptin level at stage 0 of trial (P: 0.008, r = 0.41) while this association was attenuated through stages of trial after intervention.

Conclusion

Our data show that omega-3 fatty acids may not affect plasma concentrations of leptin but adiponectin level is decreased in patients with SCI. Moreover, this intervention influences the linear relationship between weight and leptin after 14 months administration of DHA and EPA.     

Weight gain following spinal cord injury: a pilot study

Study design

Retrospective chart review.

Objective

To define the temporal course of weight gain in persons with new spinal cord injury (SCI), and to identify predictors of weight gain in this population.

Setting

A United States Department of Veterans Affairs (VA) SCI Unit.

Methods

A retrospective chart review in a VA SCI Unit was conducted. Participants (n = 85) included all persons with new SCI completing initial rehabilitation at the center between 1998 and 2006. Outcome measures were mean change in body mass index (BMI) between rehabilitation admission and final follow-up, time of greatest BMI change, and distribution of participants by BMI classification. These measures were also examined relative to SCI level, American Spinal Injury Association Impairment Scale (AIS) grade, primary mode of mobility, and age at rehabilitation admission.

Results

Mean BMI increased by 2.3 kg/m² between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants transitioning from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up (P < 0.0005).

Conclusions

These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.     

Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial

Objective/background

People with spinal cord injury (SCI) paraplegia can develop shoulder problems over time, which may also cause pain. Shoulder pain may complicate or interfere with a person''s daily activities, social events, and their overall quality of life (QOL). The purpose of this study was to examine changes in social interaction and QOL after an exercise treatment for shoulder pain in people with SCI paraplegia.

Design

Fifty-eight participants with SCI paraplegia who were also experiencing shoulder pain were selected and randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12-week, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing.

Methods

Participants filled out self-report measures at baseline, 12 weeks later at the end of treatment, and at a 4-week follow-up.

Outcome measures

The Wheelchair User''s Shoulder Pain Index (WUSPI), the Social Interaction Inventory (SII), and the Subjective Quality of Life Scale.

Results

From the baseline to the end of treatment, repeated-measures analysis of variance revealed a significant interaction between WUSPI and SII scores, P < 0.001, and between WUSPI and QOL scores, P < 0.001.

Conclusion

Reductions in shoulder pain were related to significant increases in social participation and improvements in QOL. However, increases in social participation did not significantly affect improvements in QOL.     

Factors associated with early mortality after cervical spinal cord injury

Background

A relatively high early mortality rate (<30 days post-injury) for cervical spinal cord injury (SCI) has been observed.

Objective

To investigate this early mortality rate observed after cervical SCI and analyze the associated influential factors.

Methods

Medical records for 1163 patients with cervical SCI were reviewed, and the number of patients with early mortality was documented. Through logistic regression analysis, the effects of age, gender, occupation, cause of injury, severity of injury, highest involved spinal cord segment, nutritional condition during hospitalization, surgical treatment, tracheotomy, etc., on early mortality were assessed. Implementation of early treatment (i.e. surgery, tracheotomy, and nutritional support) and its effect on patient prognosis were also analyzed.

Results

Early mortality occurred in 109 of 1163 patients (9.4%). Four factors affected the early mortality rate, including level and severity of SCI, whether or not surgery was performed, the time interval between SCI and surgery, malnutrition, and tracheotomy. Patients with an American Spinal Injury Association grade of A, a high cervical SCI (C1–C3), and/or no surgical intervention were statistically more likely to have early mortality (P < 0.001).

Conclusion

Severe cervical SCI, upper-level cervical cord injury, malnutrition, and inappropriate tracheotomy are risk factors for early mortality in patients with cervical SCI. Surgery can reduce early mortality. Early tracheotomy should be performed in patients with complete upper-level cervical SCI, but patients with incomplete cervical SCI or complete low-level cervical SCI should initially be treated surgically to maintain smooth airway flow.     

Mortality in patients with traumatic spinal cord injury: descriptive analysis of 62 deceased subjects

Study design

Retrospective study.

Objective

To investigate the causes of death in patients who were ≤50 years at the time of traumatic spinal cord injury (tSCI).

Setting

Convenience sample of a tertiary rehabilitation center.

Methods

All deceased patients with tSCI who survived a minimum of 10 years post-injury, were included. In addition, causes of death were compared between subjects surviving <10 years and ≥10 years. Neurological assessments were performed according to the American Spinal Injury Association scale. Data on causes of death were analyzed using the ICD-10 classifications. Differences were calculated using the Mann–Whitney and chi-square tests.

Results

A total of 100 patients, with 38 and 62 surviving <10 and ≥10 years, respectively, were included. No significant differences in causes of death were identified between these two groups. In patients surviving ≥10 years, paraplegia was associated with a higher life expectancy compared with tetraplegia, 34 and 25 years (p = 0.008), respectively, and the leading causes of death were septicemia (n = 14), ischemic heart disease (n = 10), neoplasms (n = 9), cerebrovascular diseases (n = 5), and other forms of heart diseases (n = 5). Septicemia, influenza/pneumonia, and suicide were the leading causes of death in tetraplegics, whereas ischemic heart disease, neoplasms, and septicemia were the leading causes of death in paraplegia.

Conclusion

Our monocentric study showed that in 62 deceased patients with SCI, the leading causes of death were septicemia, cardiovascular diseases, neoplasms, and cerebrovascular diseases. In addition, no significant differences were identified between causes of death among patients surviving <10 years and ≥10 years post-injury.     

Comparison of nutritional intake between individuals with acute and chronic spinal cord injury

Objective

To compare the nutritional intake of patients with acute and chronic spinal cord injury (SCI).

Design

Cross-sectional, observational study.

Setting

Spinal cord unit.

Methods

Twelve in-house patients of a spinal cord unit with acute SCI and paralysis duration of 5.3 ± 2.5 months (acute group) were compared with 12 subjects with chronic SCI (chronic group) with lesion duration of 55.5 ± 21.0 months. All subjects recorded their nutritional intake for 7 days, which was analyzed for intake of energy, proteins, fat, carbohydrates, vitamins, mineral nutrients, fluid, and dietary fiber. Resting energy expenditure (REE) and total body fat were also determined.

Results

The chronic group showed a significantly higher total body fat content compared to the acute group (19.4 ± 3.8 vs. 15.7 ± 4.3%). All other parameters were not significantly different between groups. Both groups ingested excessive fat and insufficient amounts of carbohydrates compared with common nutritional recommendations. Low intakes of vitamins C, D, E, biotin, folic acid, as well as potassium and iron were found.

Conclusions

No differences were found in the nutritional intakes of two comparable groups of subjects with acute and chronic SCI. Independent of lesion duration, subjects with SCI showed considerable deviations from the general accepted nutritional recommendations concerning macro- and micronutrients intake. Professional nutritional education for persons with SCI should start as soon as possible after injury to prevent nutrition-related secondary complications like cardiovascular diseases. Periodic determinations of body fat content and REE combined with a physical activity program might be helpful as well.     

Functional outcome of collagenase injections compared with fasciectomy in treatment of Dupuytren’s contracture

Background

This study was designed to provide comparative information on the safety and efficacy of injection with collagenase clostridium histolyticum (CCH) and fasciectomy for patients with Dupuytren’s contracture (DC).

Methods

A single-center, retrospective, observational, longitudinal chart review was conducted of 25 patients treated with CCH injections and 21 patients undergoing fasciectomy. Patients were assessed at 1 week, monthly for 3 months and then yearly for a minimum of 2 years after treatment for changes in contracture and range of motion, time to return to work/normal activities, patient satisfaction, and Disabilities of Arm, Shoulder and Hand (DASH) score.

Results

Post-procedure follow-up averaged 32 months for the injection group compared with 39 months for fasciectomy group. For the CCH group, the mean postinjection contracture was 3.6° for the metacarpophalangeal and 17.5° for the proximal interphalangeal joints compared with 3.7° and 8.1° in the fasciectomy group, respectively. Patients treated with injections returned to normal activities after a mean of 1.9 days compared with 37.4 days for fasciectomy patients (p < 0.0001). DASH scores for 13 CCH and 15 fasciectomy patients were obtained. The mean DASH score was significantly lower in the injection group in the first 3 months (p < 0.01). At the 2-year follow-up visit, patients were satisfied with their outcomes following either treatment (92 % and 96 % of CCH and fasciectomy patients, respectively).

Conclusion

CCH injections are safe and effective and may be a viable alternative to fasciectomy for treating DC. It also allows earlier return to work and daily activities.     

Prevalence of vitamin D insufficiency in Swiss teenagers with appendicular fractures: a prospective study of 100 cases

Background

The significance of subclinical vitamin D deficiency in the pathogenesis of fractures in children and adolescents currently remains unclear.

Objective

We aimed to determine the prevalence of vitamin D insufficiency and its effect on bone mineral density (BMD) and bone mineral content (BMC) values in a collective of Swiss Caucasian children with a first episode of appendicular fracture.

Design and methods

One hundred teenagers with a first episode of appendicular fracture [50 upper limb fractures (group 1) and 50 lower limb fractures (group 2)] and 50 healthy controls (group 3) were recruited into a cross-sectional study. The BMC and BMD values were measured by dual-energy X-ray absorptiometry, and serum 25 hydroxyvitamin D [25(OH)D] was assessed by electrochemiluminescence immunoassays.

Results

From the 100 injured teenagers in the study, 12 % had deficient vitamin D levels (<20 ng/mL; <50 nmol/L) and 36 % had insufficient levels (≥20 <30 ng/mL; ≥50 <78 nmol/L), whereas 6 and 34 % of healthy controls were, respectively, vitamin D deficient and insufficient. There were no significant differences for serum 25(OH)D levels, L2–L4 BMD Z-score, and L2–L4 BMC Z-score variables (p = 0.216) between the three groups nor for the calcaneal BMD Z-score variables (p = 0.278) between healthy controls and lower limb fracture victims. Investigations on the influences of serum 25(OH)D on BMD and BMC showed no correlation between serum 25(OH)D and L2–L4 BMD Z-scores (r = −0.15; p = 0.135), whereas low but significant inverse correlations were, surprisingly, detected between serum 25(OH)D and calcaneal BMD Z-scores (r = −0.21; p = 0.034) and between serum 25(OH)D and L2–L4 BMC Z-scores (r = −0.22; p = 0.029).

Conclusions

A significant proportion of Swiss Caucasian teenagers were vitamin D insufficient, independent of limb fracture status, in our study. However, this study failed to show an influence of low vitamin D status on BMD and/or BMC of the lumbar spine and heel.     

Repeat-dose intravenous tranexamic acid further decreases blood loss in total knee arthroplasty

Purpose

Tranexamic acid (TXA) reduces blood loss in patients undergoing total knee arthroplasty (TKA). However, few studies have reported the optimum timing and dosage for administration of TXA. The purpose of this study was to evaluate the effect of repeat-dose TXA on blood loss during TKA and the necessity of autologous blood donation or postoperative autotransfusion.

Methods

We enrolled 78 patients with primary osteoarthritis undergoing cemented TKAs. Consecutive patients were divided into three groups, as follows: control group (n = 31), single-TXA group (n = 21) in whom TXA (1,000 mg) was intravenously administered 10 min before deflation of the tourniquet, and twice-TXA group (n = 26) in whom TXA (1,000 mg) was intravenously administered 10 min before deflation of the tourniquet and 3 h after the operation. We measured the volume of drained blood after the operation. Haemoglobin (Hb) levels were measured at days 1, 4 and 7 postoperation. Venous thromboembolic events (VTE) were screened using compression ultrasonography at enrollment and 1 and 7 days after operation.

Results

The mean volume of drained blood after the operation was lower in the twice-TXA group than in the single-TXA (p < 0.001) and control (p < 0.0001) groups. No significant differences were observed in the incidence of VTE between these groups.

Conclusion

Administration of TXA twice reduced postoperative blood loss after TKA, and TXA was not associated with the risk of deep-vein thrombosis (DVT) or pulmonary embolism (PE). Further, administration of TXA twice may eliminate the need for blood transfusion during TKA.