Systematic review with meta-analysis: the risk of major gastrointestinal bleeding with non-vitamin K antagonist oral anticoagulants

BACKGROUND

Gastrointestinal (GI) bleeding is a common complication among anticoagulated patients. Non-vitamin K antagonist oral anticoagulants (NOACs) are associated with increased risk of GI (major and clinically relevant non-major) bleeding. However, more information is needed regarding severe events.

AIM

To evaluate the risk of NOACs major GI bleeding.

METHODS

We searched for phase III randomised clinical trials (RCT) evaluating NOACs (apixaban, dabigatran, edoxaban and rivaroxaban) and reporting major GI bleeding events, in MEDLINE, Cochrane Library, SciELO collection and Web of Science databases (July 2015). Meta-analysis was performed to estimate risk ratio (RR) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with the I(2) test.

RESULTS

A total of 23 studies were included. Among patients with atrial fibrillation, the risk of major GI bleeding was not different between NOACs and vitamin K antagonists (VKA) (RR 1.08, 95% CI 0.85-1.36, I(2)  = 78%; 5 RCTs) or acetylsalicylic acid (RR 0.78, 95% CI 0.36-1.72; 1 RCT). Similar results were found for patients undergoing orthopaedic surgery and those with venous thromboembolism. NOACs were not found to increase the risk compared to low-molecular-weight heparin (LWMH) alone (RR 1.42, 95% CI 0.55-3.71, I(2)  = 7%; 8 RCTs), the sequential treatment with LMWH-VKA (RR 0.77, 95% CI 0.49-1.21, I(2)  = 43%; 7 RCTs) or placebo (RR 1.48, 95% CI 0.15-14.84, I(2)  = 21%; 2 RCTs).

CONCLUSION

Despite previous evidence supporting the association of non-vitamin K antagonist oral anticoagulants and overall GI bleeding, non-vitamin K antagonist oral anticoagulants are not associated with increased risk of major GI bleeding compared to other anticoagulant drugs (with known increased risk of these events).

Evaluation of genetic divergence among clones of conilon coffee after scheduled cycle pruning

Coffea canephora genotypes from the breeding program of Instituto Capixaba de Pesquisa e Extensão Rural were evaluated, and genetic diversity was estimated with the aim of future improvement strategies. From an initial group of 55 genotypes, 18 from the region of Castelo, ES, were selected, and three clones of the cultivars "Vitória" and "robusta tropical." Upon completion of the scheduled cycle pruning, 17 morphoagronomic traits were measured in the 22 genotypes selected. The principal components method was used to evaluate the contributions relative to the traits. The genetic dissimilarity matrix was obtained through Mahalanobis generalized distance, and genotypes were grouped using the hierarchical method based on the mean of the distances. The most promising clones of Avaliação Castelo were AC02, AC03, AC12, AC13, AC22, AC24, AC26, AC27, AC28, AC29, AC30, AC35, AC36, AC37, AC39, AC40, AC43, and AC46. These methods detected high genetic variability, grouping, by similarity, the genotypes in five groups. The trait that contributed the least to genetic divergence was the number of leaves in plagiotropic branches; however, this was not eliminated, because discarding it altered the groups. There are superior genotypes with potential for use in the next stages of the breeding program, aimed at both the composition of clonal variety and hybridizations.

Reduced Incidence of Cytomegalovirus Infection in Kidney Transplant Recipients Receiving Everolimus and Reduced Tacrolimus Doses

This study compared the incidence of CMV infection/disease in de novo kidney transplant recipients receiving everolimus or mycophenolate and no CMV pharmacological prophylaxis. We randomized 288 patients to receive a single 3 mg/kg dose of antithymocyte globulin, tacrolimus, everolimus, and prednisone (r-ATG/EVR, n = 85); basiliximab, tacrolimus, everolimus, and prednisone (BAS/EVR, n = 102); or basiliximab, tacrolimus, mycophenolate, and prednisone (BAS/MPS, n = 101). The primary end-point was the incidence of first CMV infection/disease in the intention-to-treat population at 12 months. Patients treated with r-ATG/EVR showed a 90% proportional reduction (4.7% vs. 37.6%, HR 0.10, 95% CI 0.037-0.29; p < 0.001), while those treated with BAS/EVR showed a 75% proportional reduction (10.8% vs. 37.6%, HR 0.25, 95% CI 0.13-0.48; p < 0.001) in the incidence of CMV infection/disease compared to BAS/MPS. There were no differences in the incidence of acute rejection (9.4 vs. 18.6 vs. 15.8%, p = 0.403), wound-healing complications, delayed graft function, and proteinuria. Mean estimated glomerular filtration rate was lower in BAS/EVR (65.7 ± 21.8 vs. 60.6 ± 20.9 vs. 69.5 ± 21.5 ml/min, p = 0.021). In de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduced-dose tacrolimus and everolimus was associated with a significant reduction in the incidence of CMV infection/disease compared to standard tacrolimus dose and mycophenolate (ClinicalTrials.gov NCT01354301).

Morphological Variations in the Transverse Venous Sinus Anatomy of Dogs and its Relationship to Skull Landmarks

We characterized the anatomical morphology of the transverse venous sinus (TVS) of 69 canine adult cadavers belonging to three groups: brachycephalic (B), dolichocephalic (D) and mesaticephalic (M). In addition, we outlined its path over the skull using five classic human craniometric points (CPs): the asterion (ast), the bregma (b), the glabella (g), the stephanion (st) and the pterion (pt). The study aimed to establish anatomical differences in the TVS between groups and in the relationship between the TVS and skull. We found that TVS anatomy and its relationships to skull landmarks vary markedly between the groups, with similar anatomical arrangements in B and M. The TVS length can be ranked as M < B < D (with D being the biggest), whereas the width can be ranked as M < D < B (with B being the widest) with the right side being smaller than the left. In the B and M groups, the TVS assumes a craniocaudal trajectory that is closer to the lateral skull wall than in D, where the TVS presents a caudocranial direction. By documenting the morphological characteristics of the TVS, we can create a set of anatomical references allowing construction of a basic framework to greatly decrease the probability of TVS injury during neuronavigation procedures when supported by a good knowledge of the skull, brain anatomies and their relationships.

Longitudinal Cerebral Fissure Anatomy Variations in Brachy-, Dolicho- and Mesaticephalic Dogs and Their Importance to Brain Surgery

The study used a sample of 69 formalin-fixed brains from adult dog cadavers (n = 69) and aimed (1) to characterize the longitudinal cerebral fissure (LCF) anatomy in brachy-(B), dolicho-(D) and mesaticephalic-(M) dogs and their potential differences, and (2) to establish cranioencephalic relationships between the LCF and five classical craniometric points(cp): asterion(ast), bregma(b), stephanion(st), glabella(g), and pterion(pt). Anatomical records were collected using a digital caliper, and for statistical analysis P-values < 0.05 were considered significant. The LCF length can be ranked, in ascending order as B < D < M, and if used as a surgical corridor, the M group had the greatest surgical corridor area, and the D group the smallest. LCF morphology was uniform among the three groups exhibiting dilated anterior(AR) and posterior(PR) regions and narrow middle region, where the most marked differences were registered. The LCF AR is the ideal spot to begin brain surgery if the LCF is to be used as a surgical corridor in B and M, while the LCF PR should be considered in D. The five cp selected were quite useful to understand LCF anatomical morphology, its projections over the external skull surface, and to establish cranioencephalic relationships between the LCF and vault; allowing us to consider the vault anterior area in B, and in M, and the vault posterior area in D for craniotomy initial burr-hole placement. As for the distance from the cp projections in the brain surface to the LCF regions, major differences were registered by comparing the B group with the other two, and for both hemispheres.

Complement inhibition in a xenogeneic model of interactions between human whole blood and porcine endothelium

Xenotransplantation (xeno-Tx) is considered as an alternative solution to overcome the shortage of human donor organs. However, the success of xeno-Tx is hindered by immune reactions against xenogeneic cells (e. g. of porcine origin). More specifically, activation of innate immune mechanisms such as complement and triggering of the coagulation cascade occur shortly after xeno-Tx, and adhesion of human leukocytes to porcine endothelium is another early critical step mediating the immune attack. To investigate the therapeutic potential of complement inhibition in the context of xenogeneic interactions, we have employed a whole-blood model in the present study. Incubation of human blood with porcine endothelial cells (PAECs) led to activation of complement and coagulation as well as to increased leukocyte adhesion. The observed responses can be attributed to the pig-to-human xenogeneicity, since the presence of human endothelium induced a minor cellular and plasmatic inflammatory response. Importantly, complement inhibition using a potent complement C3 inhibitor, compstatin analogue Cp40, abrogated the adhesion of leukocytes and, more specifically, the attachment of neutrophils to porcine endothelium. Moreover, Cp40 inhibited the activation of PAECs and leukocytes, since the levels of the adhesion molecules E-selectin, ICAM-1, ICAM-2, and VCAM-1 on PAECs and the surface expression of integrin CD11b on neutrophils were significantly decreased. Along the same line, inhibition of CD11b resulted in decreased leukocyte adhesion. Taken together, our findings provide a better understanding of the mechanisms regulating the acute innate immune complications in the context of xeno-Tx and could pave the way for complement-targeting therapeutic interventions.

Multivariate analysis in a genetic divergence study of Psidium guajava

The family Myrtaceae is widespread in the Atlantic Forest and is well-represented in the Espírito Santo State in Brazil. In the genus Psidium of this family, guava (Psidium guajava L.) is the most economically important species. Guava is widely cultivated in tropical and subtropical countries; however, the widespread cultivation of only a small number of guava tree cultivars may cause the genetic vulnerability of this crop, making the search for promising genotypes in natural populations important for breeding programs and conservation. In this study, the genetic diversity of 66 guava trees sampled in the southern region of Espírito Santo and in Caparaó, MG, Brazil were evaluated. A total of 28 morphological descriptors (11 quantitative and 17 multicategorical) and 18 microsatellite markers were used. Principal component, discriminant and cluster analyses, descriptive analyses, and genetic diversity analyses using simple sequence repeats were performed. Discrimination of accessions using molecular markers resulted in clustering of genotypes of the same origin, which was not observed using morphological data. Genetic diversity was detected between and within the localities evaluated, regardless of the methodology used. Genetic differentiation among the populations using morphological and molecular data indicated the importance of the study area for species conservation, genetic erosion estimation, and exploitation in breeding programs.

Evaluation and selection of indicators for land degradation and desertification monitoring: types of degradation, causes, and implications for management

Indicator-based approaches are often used to monitor land degradation and desertification from the global to the very local scale. However, there is still little agreement on which indicators may best reflect both status and trends of these phenomena. In this study, various processes of land degradation and desertification have been analyzed in 17 study sites around the world using a wide set of biophysical and socioeconomic indicators. The database described earlier in this issue by Kosmas and others (Environ Manage, 2013) for defining desertification risk was further analyzed to define the most important indicators related to the following degradation processes: water erosion in various land uses, tillage erosion, soil salinization, water stress, forest fires, and overgrazing. A correlation analysis was applied to the selected indicators in order to identify the most important variables contributing to each land degradation process. The analysis indicates that the most important indicators are: (i) rain seasonality affecting water erosion, water stress, and forest fires, (ii) slope gradient affecting water erosion, tillage erosion and water stress, and (iii) water scarcity soil salinization, water stress, and forest fires. Implementation of existing regulations or policies concerned with resources development and environmental sustainability was identified as the most important indicator of land protection.

Evaluation and selection of indicators for land degradation and desertification monitoring: methodological approach

An approach to derive relationships for defining land degradation and desertification risk and developing appropriate tools for assessing the effectiveness of the various land management practices using indicators is presented in the present paper. In order to investigate which indicators are most effective in assessing the level of desertification risk, a total of 70 candidate indicators was selected providing information for the biophysical environment, socio-economic conditions, and land management characteristics. The indicators were defined in 1,672 field sites located in 17 study areas in the Mediterranean region, Eastern Europe, Latin America, Africa, and Asia. Based on an existing geo-referenced database, classes were designated for each indicator and a sensitivity score to desertification was assigned to each class based on existing research. The obtained data were analyzed for the various processes of land degradation at farm level. The derived methodology was assessed using independent indicators, such as the measured soil erosion rate, and the organic matter content of the soil. Based on regression analyses, the collected indicator set can be reduced to a number of effective indicators ranging from 8 to 17 in the various processes of land degradation. Among the most important indicators identified as affecting land degradation and desertification risk were rain seasonality, slope gradient, plant cover, rate of land abandonment, land-use intensity, and the level of policy implementation.

Neuronal degeneration, synaptic defects, and behavioral abnormalities in tau₄₅₋₂₃₀ transgenic mice

The complement of mechanisms underlying tau pathology in neurodegenerative disorders has yet to be elucidated. Among these mechanisms, abnormal tau phosphorylation has received the most attention because neurofibrillary tangles present in Alzheimer's disease (AD) and related disorders known as tauopathies are composed of hyperphosphorylated forms of this microtubule-associated protein. More recently, we showed that calpain-mediated cleavage leading to the generation of the 17kDa tau₄₅₋₂₃₀ fragment is a conserved mechanism in these diseases. To obtain insights into the role of this fragment in neurodegeneration, we generated transgenic mice that express tau₄₅₋₂₃₀ and characterized their phenotype. Our results showed a significant increase in cell death in the hippocampal pyramidal cell layer of transgenic tau₄₅₋₂₃₀ mice when compared to wild-type controls. In addition, significant synapse loss was detected as early as six months after birth in transgenic hippocampal neurons. These synaptic changes were accompanied by alterations in the expression of the N-methyl-d-aspartate glutamate (NMDA) receptor subunits. Furthermore, functional abnormalities were detected in the transgenic mice using Morris Water Maze and fear conditioning tests. These results suggest that the accumulation of tau₄₅₋₂₃₀ is responsible, at least in part, for neuronal degeneration and some behavioral changes in AD and other tauopathies. Collectively, these data provide the first direct evidence of the toxic effects of a tau fragment biologically produced in the context of these diseases in vertebrate neurons that develop in situ.

Papel do desbridamento e sinovectomia artroscópica no tratamento da rizartrose-experiência inicial do serviço

Objetivos: Apresentar a experiência inicial do serviço com o uso do desbridamento e sinovectomia artroscópica no tratamento da rizartrose.

Realizou-se um estudo retrospetivo de 10 doentes com rizartrose submetidos a desbridamento e sinovectomia artroscópica. Avaliou-se a dor através da escala visual analógica (EVA), o nível funcional com o questionário de QuickDASH, a força de pinça em relação à mão contralateral, o grau de satisfação subjetiva e as complicações no pós-operatório.

O score médio de QuickDASH no pré-operatório foi de 51,5 e no pós-operatório de 20,5 (p=0,036). Houve melhoria a nível da dor com uma avaliação pré operatória de 7,4 pontos para 2,6 pontos no pós-operatório (p= 0,012). Comparativamente ao lado contralateral, a média da força de pinça no pré operatório foi de 61,7 % melhorando para 81% no pós-operatório (p=0,067). A complicação mais grave no pós-operatório foi o desenvolvimento de um quadro de algodistrofia em um doente.

Como em qualquer nova técnica, as indicações para o seu uso serão motivo de debate e evolução ao longo do tempo, o que se aplica ao trabalho apresentado em que algumas das indicações podem ser controversas.

Além disso, trata-se de uma amostra muito pequena e com um tempo de seguimento médio curto, pelo que as conclusões obtidas devem ser interpretadas com cautela.