The efficacy of tranexamic acid in melasma: A review Authors

Objectives Melasma is a recalcitrant hyperpigmentary disorder requiring innovative treatment options for its management. The objectives of the study are to compare the efficacy of microneedling with platelet-rich plasma (PRP) versus microneedling with tranexamic acid (TXA) in melasma in terms of Modified Melasma Area and Severity Index Score (mMASI), Physician Assessment Score (PAS), and Patient Satisfaction Score (PSS) among them. Material and Methods This was a randomized open-label study in which 50 cases of melasma (18–60 years) were included. Patients were randomly allocated into 2 groups of 25 patients each. Group 1 was treated with microneedling with PRP and group 2 with microneedling with TXA for three sessions every 3 weeks, and were followed up till 15 weeks. Results Mean mMASI decreased significantly from 7.14 to 3.88 and 7.65 to 4.24 in groups 1 and 2, respectively, from baseline to 15 weeks ( P < 0.001) and statistically significantly between the 2 groups ( P = 0.043). However, no significant difference was found between PAS and PSS between them. Conclusion Microneedling was found to be effective with both PRP and TXA in melasma. However, microneedling with PRP demonstrated greater efficacy versus TXA. Hence, it can be considered a promising treatment modality in the future.

Background:Melasma is a common disorder of hyperpigmentation mainly affecting the face. It is difficult to treat and is a cause for great cosmetic concern for the patient. So, we did this research to compare the therapeutic efficacy of tranexamic acid (TXA) through oral route versus its transepidermal administration with a dermaroller in melasma.Materials and Methods:This was a hospital-based, interventional study carried over a span of 1 year on 40 patients with facial melasma. The enrolled patients were randomly divided into 2 groups of 20 patients each. Group A patients received oral tablet TXA in a dose of 250 mg twice daily for 12 weeks and Group B patients were given TXA solution transepidermally into the melasma lesions using a dermaroller at 2 weekly interval for 12 weeks. Thereafter, all patients were followed up for improvement in Melasma Area and Severity Index (MASI) score, adverse effects and relapse at 4 weekly intervals till 24 weeks. All the patients were evaluated for therapeutic outcome both objectively (by MASI) and photographically at 4, 8, 12, 18, and 24 weeks. Grading of improvement was done by assessing percentage reduction in MASI score.Results:Majority of the patients, 24 (60%) in our study had centrofacial pattern of melasma followed by malar pattern seen in 16 (40%) patients. The baseline MASI score was 11.98 (± 5.47) in Group A and 12.13 (± 3.16) in Group B. The mean MASI score in Group A at the end of 4, 8, 12, 18, and 24 weeks was 9.75 (±4.83), 6.09 (±3.64), 4.21 (±2.48), 2.56 (±1.95), and 3.10 (±3.38) while these values were 9.73 (±3.32), 6.06 (±2.75), 4.55 (±1.89), 2.94 (±1.36), and 3.09 (±1.32) for Group B. At the end of 24 weeks follow-up period, good (51%-75% improvement) and very good (>75% improvement) response occurred in 5 (25%) and 14 (70%) patients in Group A and 11 (55%) and 9 (45%) patients in Group B, respectively. However, the final reduction in MASI score was similar in both the groups. Relapse was uncommon and occurred at 24 weeks in 1 patient from Group A.Limitation:The major limitation was small sample size due to time limitation and long follow-up period.Conclusions:Oral and transepidermal TXA appear equally effective suggesting that the efficacy of TXA is perhaps independent of its route of administration. Oral therapy is convenient for the patient. Transepidermal therapy of TXA has the advantage of local action, hence systemic side effects are avoided, but it is slightly painful and the time period between consecutive microneedling sessions is left to the prerogative of the treating doctor, hence a proper quantification is lacking. Moreover, scheduling of maintenance sessions is necessary as melasma is prone for recurrence.

This issue of TRANSFUSION features two clinical trials on the use of tranexamic acid (TXA) in joint replacement surgery. The first study examines the use of TXA for reducing autologous blood transfusion in total knee or hip replacement surgery.1 The second study reports the effect of TXA on allogeneic blood transfusion for two-staged bilateral total knee replacement surgery.2 The first study is a double-blinded randomized placebo controlled trial in which Oremus and colleagues1 compared TXA with placebo to evaluate the efficacy of TXA to reduce autologous transfusion of shed blood in unilateral primary total knee or hip replacement. Ninety-eight primary hip or primary knee replacement patients were randomly allocated to receive an intraoperative intravenous (IV) dose of 1 g of TXA or placebo 15 minutes before skin incision for total hip replacement or 15 minutes before tourniquet release for total knee replacement. After 3 hours, a second dose of 1 g of TXA or an equivalent volume of placebo (saline) was administered IV. The minimum volume of retransfusion was set at 250 mL and a transfusion trigger of hemoglobin (Hb) level of less than 8 or 8 to 10 g/dL with symptoms of anemia. Only 10.2% in the TXA group versus 85.7% in the placebo group received autologous transfusion. The TXA group had a 75% lower requirement for autologous transfusion than the placebo group. The median total external blood loss during the first 24 hours was 320 mL (80-930 mL) in the TXA group versus 970 mL (100-2600 mL) in the placebo group. This study also examined the safety profile of TXA by measuring hemodynamic changes during administration of TXA and performed postoperative screening for deep vein thrombosis (DVT). Clinical assessment for DVT was performed three times a day and ultrasonography, fibrinogen, and D-dimer measurements were performed in suspected cases. The authors did not find any difference in hemodynamic changes or DVT between both groups. In addition, there was no difference in blood loss between the total knee replacement and total hip replacement surgery. This study provides evidence that using TXA with a restrictive transfusion trigger policy can potentially replace the use of an autologous drain system. This protocol can avoid the autologous blood transfusion related complications such as febrile reactions and possible retrograde infection. The use of closed suction drainage for joint replacement surgery is controversial and there is practice variation in whether surgical drains are used. Although the use of a drain is based on individual or institutional practice, evidence has shown that the use of a closed system suction drainage increases the total blood loss after joint replacement surgery.3 At the same time, a recent meta-analysis has confirmed that autologous shed blood transfusion is an effective method to reduce allogeneic blood transfusion.4 Other techniques used to reduce the blood loss are clamping the drain, retrograde injection of TXA through the drain, and closure without a drain.5 The current study by Oremus and coworkers suggests that TXA could potentially eliminate the need for surgical drains and autologous shed blood transfusion. The cost-effectiveness of using TXA rather than autologous transfusion of shed blood was not analyzed in this study, although the cost of TXA may be lower. Overall this well-designed randomized controlled trial shows the efficacy of TXA on reducing autologous shed blood transfusion. The second study is a retrospective study in which Kelley and coworkers2 determined the effect of TXA on blood transfusion in patients undergoing bilateral total knee replacement staged 3 days apart. Transfusion rates were compared between patients who did not receive TXA (before the routine use of TXA) and after the institution of TXA for bilateral total knee replacement. The TXA group received 1 g of TXA IV 15 minutes before incision and 1 g IV before tourniquet release. The main findings were the TXA group had lower mean blood loss than the non-TXA group (373.8 ± 264.6 mL vs. 871.6 ± 457.7 mL, respectively). The blood transfusion rate was lower (43.1% vs. 71.4%) in the TXA group and the amount of allogeneic blood transfusion was lower (0.64 ± 0.84 units vs. 1.53 ± 1.30 units) in the TXA group. In addition, the TXA group had significantly higher Hb level on Day 1 and Day 2 with each stage of total knee replacement. Otherwise there was no difference in postoperative complications including infection, venous thromboembolism, reoperation, hematoma, or pre- and postoperative Knee Society score and range of movement. Since this study was retrospective, routine screening for venous embolism was not done. The transfusion trigger was 9 g/L for the first surgery and 8 g/L for the second surgery. These two studies add to the growing literature supporting the efficacy of TXA for reducing blood loss6, 7 and blood transfusion in joint replacement surgery. Surgical trauma and the use of a tourniquet have been shown to activate fibrinolysis. TXA is a lysine analog that helps to prevent fibrinolysis in conditions that promote fibrinolysis. TXA is relatively inexpensive, easy to administer, and more cost-effective than transfusion and other blood conservation techniques. Existing studies in the orthopedic surgical literature have not shown an increase in adverse events such as thromboembolic complications with the use of TXA for joint replacement surgery. Although the study designs differ, both current studies used the same total dose of TXA and used closed suction drain systems. The total dose of TXA used in both studies was 2 g, but the timing of administration was different. The timing of administration and dosage of TXA have varied in previous studies. A recent study found a preoperative and intraoperative IV dose of TXA was more effective than a single dose of TXA given intraoperatively or an intraoperative dose followed by a postoperative dose.8 These authors also concluded that a single dose with local application was more effective than a single dose administered IV.8 The optimal dose, timing of administration, mode of administration, and duration of treatment have not been determined. A recent systematic review and meta-analysis concluded that the effect of TXA on blood loss varied with the timing of administration of TXA, but the extent of this variation was small, and the authors questioned the clinical importance of this variation.9 The authors also found a lack of a dose–response relationship of TXA, with a total dose of about 14 mg/kg (approx. 1 g) appearing to be sufficient. However, these authors did not specifically examine joint replacement surgery, but included different types of surgery. Most of the blood loss in total knee replacements occurs during the first few hours after surgery.10 A recent pharmacokinetic study showed that peak fibrinolytic activity occurred at 6 hours from the incision time for both total hip and total knee replacement, and the fibrinolysis activity persisted for 18 hours.11 This finding supports a multiple dose regime or a postoperative infusion as the most effective way to reduce blood loss with use of TXA in joint replacement surgery. However, this protocol must be balanced with the high risk for DVT in this patient population. These studies support the use of TXA to reduce blood loss and transfusion in joint replacement surgery. The optimal timing, dose, duration of treatment, and route of administration of TXA, however, remain uncertain. There is a need for more pharmacokinetics studies to optimize the use of TXA to reduce blood loss and blood transfusion, while minimizing any potential adverse effects in joint replacement surgery. These studies should be encouraged by the transfusion medicine community since TXA appears to be a useful pharmacologic alternative to transfusion in orthopedic surgery. None.

Melasma is a localized, chronic acquired hypermelanosis of the skin. Despite several treatments available, melasma can often be refractory to treatment. Also recurrences are common. Tranexamic acid is a new addition in treatment of melasma and is effective in dosage of 250 mg BD for atleast 4 to 8 weeks. Tranexamic acid acts mainly via the plasminogen activator-plasmin system to prevent UV radiation induced pigmentation in melasma. This article reviews the mechanism of action of tranexamic acid in melasma and current evidence in literature for use of tranexamic acid in melasma.

Bleeding and the need for allogeneic transfusions are still problems after off-pump coronary artery bypass grafting (OPCAB) surgery. We therefore evaluated the effects of an antifibrinolytic, tranexamic acid, on postoperative bleeding and transfusion requirements in patients undergoing OPCAB surgery. Two hundred thirty-one consecutive patients scheduled for elective OPCAB were enrolled in the study. Using a double-blind method, the patients were randomly assigned to receive either tranexamic acid (bolus 1 g before surgical incision followed by an infusion of 400 mg/h during surgery; n = 116) or a placebo (infusion equivalent volume of saline solution; n = 115). The primary outcome was 24-hour postoperative chest tube drainage. Allogeneic transfusion, mortality, major morbidities, and resource utilization were also recorded. In comparison with the placebo group, the patients receiving tranexamic acid had a significant reduction in chest tube drainage at 6 hours (270 ± 118 mL vs 416 ± 179 mL, P < 0.001) and 24 hours (654 ± 224 mL vs 891 ± 295 mL, P < 0.001). There was also a significant reduction in allogeneic red blood cell transfusions (47 vs 31.9%, P = 0.019) and fresh frozen plasma (29.6% vs 17.2%, P = 0.027) transfusions. There were no differences in mortality, morbidity, and resource utilization between the 2 groups. Tranexamic acid reduces postoperative chest tube drainage and the requirement for allogeneic transfusion in off-pump coronary surgery.

New and Off-Label Uses of Tranexamic Acid.

Major bleeding in noncardiac surgery is common and associated with serious complications. The antifibrinolytic agent tranexamic acid (TXA) reduces bleeding and may reduce the risk of these complications. TXA also may have immunomodulatory effects that could reduce surgical site infection. Clinical trials of TXA in noncardiac surgery have been insufficiently powered to evaluate its efficacy and safety. Therefore, large randomised controlled trials of its use in noncardiac surgery are required. To ensure that future clinical trials are feasible and acceptable, we undertook a survey of Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA). Our aims were to ascertain current patterns of TXA administration and to assess the acceptability of randomising patients to intravenous TXA or placebo. A 12-item survey was electronically mailed to 1001 ANZCA Fellows. Two hundred and eighty nine responses were received and analysed (response rate 29%). Ninety-eight percent of respondents had used intravenous TXA in noncardiac surgery; 67% give TXA routinely for lower limb arthroplasty, with smaller proportions giving TXA for spinal surgery (40%) and other major orthopaedic surgery (28%). Almost half (49%) give TXA routinely for major trauma surgery. Thirty-six percent indicated that they did not give TXA for major vascular, abdominal, pelvic or thoracic surgery. The majority administered TXA as a single, fixed dose. Fifty-seven percent agreed that there is uncertainty about the relative risks and benefits of perioperative TXA in noncardiac surgery and 87% agreed that large definitive trials determining the safety and efficacy of perioperative TXA in noncardiac surgery are required. These results indicate that for ANZCA Fellows the use of TXA in noncardiac surgery is highly variable, that there is uncertainty about the safety and efficacy of TXA, and that a large trial would be acceptable.

Letter: We have read the recent article published by Zhang et al titled "The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Percutaneous Endoscopic Interlaminar Diskectomy: A Retrospective Study". In this retrospective study, authors performed interlaminar endoscopic lumbar discectomy (IELD) for L5-S1 disc herniations, categorizing patients into two groups. One group underwent IELD with saline irrigation fluid containing 0.33 gm of tranexamic acid (TXA) per 1L of saline, while the other group received only saline irrigation fluid. We appreciate the authors' efforts in shedding light on the use of TXA in irrigation fluid, which currently has limited literature available. However, we wish to highlight several points of concern that, in our view, warrant further discussion. Upon reviewing the manuscript, our initial concern centers on the reported amount of blood loss, a crucial outcome in this study. The blood loss figures presented in this study appear significantly higher compared to the existing literature. In both study groups, the authors indicate total blood loss (TBL) exceeding 300 ml and intraoperative blood loss (IBL) surpassing 40 ml. In contrast, a systematic review and meta-analysis by Jitpakdee et al. (1) reported a range of blood loss from 10.9 ml to 23.35 ml for interlaminar endoscopic discectomy without any systemic or local use of tranexamic acid. Accurately assessing blood loss in endoscopic spine surgery poses a challenge, and the accuracy of indirect calculation methods is questionable, particularly when bleeding is minimal. Endoscopic discectomy has been proven benefits by minimal tissue damage and negligible blood loss. Another significant concern we would like to address is related to the safety and efficacy of topical tranexamic acid (TXA) use in endoscopic spine surgery. The existing literature generally accepts the safety profile and efficacy of use of intravenous TXA in open spine surgery where the blood loss incurred is substantial (2, 3). However, when it comes to the safety of topical TXA, it is important to note that TXA is known to have neurotoxic and epileptogenic properties when applied to central nervous system (CNS) tissue (5, 6). This is due to its interference with central GABAA receptors and glycine receptors (7). In endoscopic spine surgeries, small dural tears can sometimes go unnoticed due to continuous irrigation fluid pressure. In such cases, the potential CNS side effects associated with topical TXA could pose a real danger. Furthermore, even when dural tears are identified during surgery, it can be challenging to completely washout all the irrigation fluid containing TXA from the surgical field. The accumulation of excessive epidural or intrathecal TXA, especially after a dural tear, can lead to life-threatening conditions such as seizures or arrhythmias, significantly increasing morbidity and mortality in what is often intended as a day-care procedure. Moreover, the authors have not mentioned any exclusion criteria for patients with conditions that are suspected to elevate risk of developing TXA-related side effects, such as a history of thromboembolic events and/or coagulopathy, convulsive disorders and dural disruption. Lastly, in terms of the efficacy of TXA, there are limited studies demonstrating the use of local TXA in spine surgeries to reduce blood loss. For example, Krohn et al(4) used topical TXA irrigation in open instrumented spinal fusion surgery before wound closure. Their study showed a reduction in postoperative blood loss, with drain output decreasing from 525 ml in the non-TXA group to 252 ml in the TXA group. However, it had no significant effect on intraoperative blood loss. We would like to raise a pertinent question regarding endoscopic discectomy procedures, which are characterized by minimal blood loss and are often conducted as day-care surgeries. It becomes a matter of concern whether the potential advantages of using topical TXA in reducing blood loss outweigh the associated risks of neurological damage to the central nervous system (CNS) and other potentially life-threatening complications.

Tranexamic Acid Administration to Pediatric Trauma Patients in a Combat Setting: The Pediatric Trauma and Tranexamic Acid Atudy (PED-TRAX): Eckert MJ, Wertin TM, Tyner SD, et al. J Trauma Acute Care Surg 2014;77:852–8.

PurposePrevious studies have established the safety and efficacy of tranexamic acid (TXA) in reducing blood loss after total joint arthroplasty and spinal fusion surgery; however, literature regarding the effectiveness of intraoperative TXA in children with cerebral palsy (CP) is limited. The aim of this study was to investigate the safety and efficacy of intraoperative TXA in reducing blood loss and transfusion requirements for children with CP undergoing a proximal femoral varus derotational osteotomy (VDRO).MethodsThis is a retrospective review of 258 children with CP who underwent VDRO performed at the author’s institution between 2004 and 2017. In all, 36 subjects underwent VDRO surgery with administration of intravenous TXA and 222 subjects underwent VDRO without administration of TXA. Outcome measures including blood loss, transfusion requirements and venous thromboembolic events were compared between groups using t-tests and chi-squared tests.ResultsNo significant differences were seen in the rates of transfusion between groups for the entire hospitalization (TXA group: 11.1% versus No TXA group: 19.8%), intraoperatively (TXA: 2.8% versus No TXA: 9.0%) or postoperatively (TXA: 8.3% versus No TXA: 14.4%). Intraoperative estimated blood loss (TXA: 144.4 mL versus No TXA: 159.0 mL) and percentage blood loss (TXA: 8.9% versus No TXA: 9.2%) were similar between groups. No major thromboembolic complications events occurred in either group.ConclusionThe use of TXA was not associated with thromboembolic complications in this series of children with CP undergoing VDRO surgery. Though there was a trend toward lower rates of intraoperative and postoperative blood transfusion with TXA use in these patients, the differences were not significant, possibly due to low estimated blood loss in both groups and sample size.Level of evidenceIII- retrospective comparative study

To the Editor: The efficacy of tranexamic acid (TXA) in traumatic brain injury (TBI) remains inconsistent. Recently, two meta-analyses1,2 reviewed the available evidence and reported that TXA had no significant effect on mortality compared to placebo. Homogeneity is an essential factor in meta-analysis. However, there is evidence indicating that the effect of TXA may be interacted by many factors, such as the timing of TXA use, neurological severity, or short/long-term outcomes. Therefore, we reanalyzed the current evidence and hope our findings will be helpful. First, in the meta-analysis by Lawati et al,1 they used the longest follow-up timepoint during data extraction and found that the pooled outcome was nonsignificant. However, the efficacy of TXA may vary over time. For instance, in an international, randomized placebo-controlled trial (TICH-2)3 involving 2325 patients with intracerebral hemorrhage, researchers found that compared to placebo, TXA use only reduced the short-term mortality (7 d) but not the 90-d mortality rate. Furthermore, the second analysis4 of this trial also reported that the TXA reduced the risk of early but not late neurological deterioration. Similarly, in a study of subarachnoid hemorrhage, Post et al5 found that compared to placebo, TXA use was significantly associated with lower in-hospital mortality, while the long-term neurological outcome (at 6 mo) was comparable between these two groups. However, in the Lawati et al meta-analysis,1 the timepoint of death varies in all 8 included trials (such as death at 28 d, at hospital discharge, at 6-mo, or others). Therefore, there is a risk that the conclusion may be biased as the efficacy of TXA changes over time. In another review,2 2 critical trials (Rowell-2020 and Mousavinejad-2020) were missing, which may also lead to a biased conclusion. Therefore, we re-extracted the data from 8 trials6-13 to investigate the different impacts of TXA on short/long-term mortality. The pooled outcome showed that TXA significantly reduced the short-term mortality (death at 28 d or hospital discharge, Figure; risk ratio (RR) 0.91, 95% CI 0.84-0.99, P = .026) in TBI patients. However, the impact on long-term mortality remains unclear due to the lack of sufficient data.FIGURE.: Forest plot comparing TXA and placebo for mortality at 28 d or at hospital discharge.Second, the timing of TXA therapy also played an important role. One multicenter trial involving 10 096 trauma patients (CRASH-2)14 reported that TXA should be given as early as possible to bleeding trauma patients, as TXA use at a late stage is less effective and could even be harmful. In most included trials, the enrollment time after trauma was 2 to 8 h except for the Chakroun 2018 study (24 h).9 This may be the reason for the opposite trend of efficacy on mortality in Chakroun-2018’s study (Figure, red arrow). Third, the neurological severity was different within all included studies. The CRASH-3 trial11 showed that TXA leads to a substantial reduction in mortality in patients with mild to moderate TBI, while there is no benefit in severe TBI. Therefore, we excluded data of patients with severe brain injury (detailed description in the Figure legend)6-8,11,12 and found that the efficacy of TXA therapy in the mild to moderate brain injury subgroup was more significant (RR 0.86, 95% CI 0.77-0.95, P = .004). In conclusion, TXA may have a positive impact on short-term outcomes in patients with mild to moderate TBI. However, the benefit in terms of long-term outcome remains unclear, and the late use of TXA in severe TBI should be done with caution. Notes: Short-term mortality subgroup: The 28-d mortality was reported in the Perel-2012, Chakroun-2018, Roberts-2019, and Rowell-2020 trials. Mortality at hospital discharge was reported in the Yutthankasemsunt-2013 and Fakharian-2017 trials. The timepoint was unclear in the Ebrahimi-2019 (most likely at hospital discharge) and Mousavinejad-2020 trials. Enrollment time ≤ 8 hours subgroup: The enrollment time after trauma was 24 h in Chakroun2018’s trial, which was excluded from this subgroup. Mild to moderate brain injury subgroup: Patients with Glasgow Coma Scale (GCS) = 3 or with bilateral unreactive pupils were excluded in Roberts-2019’s trial. No patients were excluded in the Rowell-2020 (at least 1 reactive pupil), Fakharian-2017 (the mean GCS value at hospital arrival was 12.1), Yutthankasemsunt-2013 (GCS 4-12), and Perel-2012(the proportion of patients with severe brain injury was 33.3%) trials. The proportion of patients with severe brain injury was high in the Mousavinejad-2020 (67.5%) and Ebrahimi-2019 (58.5%) trials, and these 2 trials were excluded from this subgroup. Funding Dr Shen received funding from the Medical Health Science and Technology Project of Zhejiang Provincial Health Commission (NO. 2021KY001). Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran's Q test, and I2 test performed with R statistical programming software. A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference -218.44 mL; 95% CI -379.34 to -57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.

Research on the timing and efficacy of tranexamic acid (TXA) use for perioperative bleeding in bariatric surgery is lacking. To evaluate the effects of TXA use on clinical outcomes in laparoscopic sleeve gastrectomy (LSG) by comparing TXA use at the beginning of induction with TXA use at the end of surgery and placebo use. Between February 2022 and August 2022, 177 patients were randomized into three groups: TXA administered at the beginning of induction (TXAI), TXA administered at the end of surgery (TXAP), and placebo groups. Preoperative and postoperative care was standardized, and all patients received LSG. Analyzed using ANOVA, Mann-Whitney U test, and Student's t-test. No significant difference was observed between the groups in terms of operative time and blood loss. There were significantly fewer intraoperative bleeding points in the TXAI group compared to the other groups (P < 0.05). Postoperative bleeding was significantly lower in the TXAI and TXAP groups compared to the placebo group (P < 0.05). Hemoglobin and CRP levels showed significant differences between the groups. TXA administration did not cause a significant decrease in coagulation values, and there were no cases of venous thromboembolism (VTE) during the follow-up period. This study provides evidence that TXA administered during LSG is effective in reducing postoperative bleeding. No data were obtained regarding the superiority of TXA administration at the beginning of induction and at the end of surgery. ClinicalTrials.gov with the registration code NCT05696951, 25 January 2023: https://www. gov/study/NCT05696951 .

This study aims to determine the effectiveness of using oral tranexamic acid in melasma patients, as well as to explain the definition of melasma, melasma epidemiology, melasma etiopathogenesis, and to explain the effectiveness of using oral tranexamic acid in melasma. The method used was to collect and analyze research articles on the effectiveness of the use of oral tranexamic acid topical drugs in Melasma patients. The articles are obtained through a search using Google Scholar, Pubmed. The term melasma comes from the Greek word "melas" which means black. Clinically melasma appears as macules or brown spots. Complaints of melasma usually occur symmetrically. The areas of melasma predilection are most commonly the cheeks, upper lip, chin and forehead, but can also be affected in other areas. (Debabrata, Handel et al., 2014). Research conducted for 6 months by Sufan et al ,. It is known that after therapy using Tranexamic Acid, there was a decrease in hyperpigmentation. After 6 months of treatment, the results were very good (10.8%, 8/74), good (54%, 40/74), moderate (31.1%, 23/74), and bad (4.1%). , 3/74). There were 4 patients (5.4%) who experienced mild gastrointestinal discomfort, 6 patients (8.1%) hypomenorrhea, subjects who rarely reported skin rash due to allergies as well as dizziness, alopecia, drowsiness and hyposexuality. From these results it is concluded that oral Tranexmatic Acid has good effectiveness in melasma therapy. (Sufan et al., 2012). From the results of this study it can be concluded that Tranexamic Acid has good effectiveness in the therapy of melasma. Where there are several risk factors that cause melasma, which can occur due to genetic factors, UV exposure, hormonal factors and inflammatory factors. Tranexamic acid will inhibit the action of tyrosinase activity by blocking the interaction of melanocytes and keratinocytes through inhibition of the plasminogen system.&#x0D; &#x0D; Keywords: Melasma, treatment for melasma, epidemiologi, etiologi, tranexamic acid,.

With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, -0.18 points; 95% CI -0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.