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BMJ 2011; 342 doi: (Published 28 March 2011) Cite this as: BMJ 2011;342:d1979

Give tranexamic acid early to prevent deaths from haemorrhage

Last year, a landmark trial from 40 different countries reported that tranexamic acid reduced all cause mortality in patients who were bleeding (or very likely to bleed) after major trauma. A new analysis of the same data shows that the drug specifically prevented deaths from bleeding, but only when given early. Among patients treated within an hour of injury, tranexamic acid reduced deaths from bleeding by more than 30%, compared with a placebo (5.3% (198/3747) v 7.7% (286/3704); relative risk 0.68, 95% CI 0.57 to 0.82). It was still effective, but less so, in patients treated between one and three hours after injury. Any further delay, and tranexamic acid seemed to increase mortality from bleeding (4.4% (144/3272) v 3.1% (103/3362); 1.44, 1.12 to 1.84), an unexpected result that the authors can’t explain.

The unlucky play of chance is one possibility, although the authors and a linked comment (doi::10.1016/S0140-6736(11)60396-6) agree that trauma personnel should exercise caution after the first three hours until we find out more.

Tranexamic acid is a cheap, widely available, and easy to use antifibrinolytic agent. It helps reverse the systemic fibrinolysis and coagulopathy that can follow acute tissue injury, and it may be particularly useful where health workers have limited access to blood products, such as fresh frozen plasma and platelets, says the comment. Many of the study sites in the original trial fall into this category. Researchers in well resourced health systems could usefully investigate tranexamic acid in the prehospital setting.

No link between mercury and cardiovascular disease in US adults

During the 1980s, two established cohorts of US adults were asked for toenail clippings alongside their usual questionnaire responses about lifestyles and illnesses. Researchers recently tested the clippings for mercury, to find out if adults with higher intakes might be more susceptible to cardiovascular disease. They weren’t. If anything, higher concentrations of …

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