Synthesis and evaluation of L-quebrachitol derivatives against platelet aggregation

Thrombosis plays an important role in the occurrence and development of cardiovascular and cerebrovascular diseases that contribute to high mortality and morbidity in patients. L-(-)-Quebrachitol (QCT), a natural product, was first isolated from quebracho bark. It can inhibit PAF receptor and decrease gastric damage induced by indomethacin, as a drug against platelet aggregation. Here, five QCT derivatives were synthesized and investigated for their inhibitory effects on platelet aggregation. Among them, compound 3a showed anticoagulant effects comparable to aspirin, while compound 4b showed dose-independent inhibitory activities in rats that were stronger than aspirin.

[Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate).

CONCLUSION

The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery

BACKGROUND

We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL).

METHODS

Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months.

RESULTS

From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes.

CONCLUSION

It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.

Fluoxetine for reducing postoperative cognitive dysfunction in elderly patients after total knee replacement: study protocol for a single-centre, double-blind, randomised, parallel-group, superiority, placebo-controlled trial

INTRODUCTION

Postoperative cognitive dysfunction (POCD) is a common complication following major surgical procedures. The underlying pathophysiology is poorly understood, but the role of neuroinflammation is strongly implicated. Given the antineuroinflammatory and neuroprotective effects of fluoxetine, we hypothesise that fluoxetine may reduce the cumulative incidence of POCD in elderly patients undergoing total knee arthroplasty (TKA).

METHODS AND ANALYSIS

This is a prospective, randomised, double-blind, parallel-group, placebo-controlled, superiority trial. Five hundred elderly patients undergoing unilateral TKA will be randomly assigned to the fluoxetine and placebo groups. The fluoxetine group will receive fluoxetine 20 mg daily 8 weeks preoperatively, and the placebo group will receive placebo capsules daily 8 weeks preoperatively. The primary outcome is the cumulative incidence of POCD at 1 month postoperatively. The secondary outcomes include the occurrence of delirium, the area under the curve of the Numeric Rating Scale pain scores over time, and sleep disturbance. Data on all the results, risk factors and adverse events will also be collected and analysed.

ETHICS AND DISSEMINATION

The Fujian Provincial Hospital Ethics Board has approved the protocol for this trial (identifier number: K2021-01-009). All participants will be required to provide written informed consent before any protocol-specific procedures.

TRIAL REGISTRATION NUMBER

ChiCTR2100050424.

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines

BACKGROUND

Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia.

DESIGN

A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline.

RESULTS

Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%.

DISCUSSION

Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply.

CONCLUSION

In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

Clinical Applications of Aspirin as a Multi-potent Drug Beyond Cardiovascular Implications: A Proof of Concept for Anesthesiologists- A Narrative Review

To the best of our knowledge, aspirin (ASA) is known as a commonly used medication worldwide. Although the cardiovascular aspects of ASA are well-established, recently, it has been identified that ASA can yield multiple extra-cardiovascular therapeutic potencies in facing neurodegenerative disorders, various cancers, inflammatory responses, and the COVID-19 pandemic. In this review, we aimed to highlight the proven role of ASA administration in the variety of non-cardiovascular diseases, particularly in the field of anesthesiology.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Retrospective evaluation of lumbar puncture and intrathecal chemotherapy in thrombocytopenic patients

INTRODUCTION

Lumbar puncture (LP) and intrathecal chemotherapy (IT CT) are common procedures and treatment options for hematologic patients. Although they can also be used in thrombocytopenic patients, there is no consensus on the safe cutoff value of platelet counts for LP and IT CT practices.

AIM

This research aimed to determine the safety of LP and IT CT administration in thrombocytopenic patients using different cutoff platelet values.

METHODS

One hundred and fifty-two adult patients who had LP indications were evaluated. Among them, 42 patients received IT CT. The cerebrospinal fluid results from 100 procedures were available.

RESULTS

The preprocedural platelet count was <100.000/mm³ and <50.000/mm³ in 41 (41 %) and 18 (18 %) patients, respectively. Ten of these patients received platelet transfusion prior to LP. In the untransfused group, the platelet count was <50.000/mm³ in 12 (12 %) patients, among whom seven patients had a platelet count of <30.000/mm³. The traumatic tap was comparable among the transfused and untransfused groups (p = 0.632). No correlation was observed between the thrombocyte value and the traumatic tap (p = 0.891). The ratio of the traumatic tap was not significant between the patient groups with a platelet count of ≥50.000/mm³ or <50.000/mm³ (p = 0.418). After adding the transfused patients, the traumatic tap ratio remained nonsignificant between the two groups (p = 0.851).

CONCLUSION

Hemorrhagic complications were rare in the thrombocytopenic patients who received IT CT after the LP procedure applied by experienced specialists. However, further prospective large studies evaluating the safety of procedures in thrombocytopenic patients are needed to make clear conclusion.

Proximal femur fractures in patients taking anticoagulants

Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs.

Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed.

Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios.

Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days.

Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended.

There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.

Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

Spinal Epidural Hematoma Following Epidural Catheter Removal in a Patient with Postoperative Urgent Coronary Intervention and Intra-Aortic Balloon Pumping (IABP): A Case Report

Patient: Male, 72

Final Diagnosis: Spinal epidural hematoma

Symptoms: Paralysis

Medication: Heparin

Clinical Procedure: Laminectomy

Specialty: Anesthesiology

[Cardiac papillary fibroelastoma and stroke during pregnancy: Case report]

Stroke occurring during pregnancy is linked to high mortality. Stroke may be directly related to pregnancy (e.g. eclampsia, cerebral venous thrombosis), but all the other causes of stroke are possible. Brain magnetic resonance imaging that is not contraindicated during pregnancy remains the reference in this context. We report the case of a woman with severe headache associated with visual disturbances, without hypertension or proteinuria at 32 weeks of pregnancy. MRI revealed multiple recent cerebral vascular accidents. An echocardiogram detected a papillary fibroelastoma of 5mm. Maternal fetal experts determined it safe to continue the pregnancy. Childbirth at 39 weeks was normal uneventful for the newborn and mother. In the postpartum, despite the theoretical operative indication to resect the small residual papillary fibroelastoma, the patient was followed expectantly because of the stable neuro-cardiologic state. A fibroelastoma can be revealed by a stroke during pregnancy. In the postpartum period, an expectant attitude can be reasonably chosen in case of small size of the fibroelastoma.

Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR)

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery.

Hypertensive disorders in pregnancy

Hypertensive disorders of pregnancy (HDP) remain among the most significant and intriguing unsolved problems in obstetrics. In India, the prevalence of HDP was 7.8% with pre-eclampsia in 5.4% of the study population. The anaesthetic problems in HDP may be due to the effects on the cardiovascular, respiratory, neurologic, renal, haematologic, hepatic and uteroplacental systems. The basic management objectives should be facilitating the birth of an infant who subsequently thrives and completes restoration of health to the mother, or the termination of pregnancy with the least possible trauma to mother and foetus in severe pre-eclampsia. This comprises obstetric management, adequate foetal surveillance, antihypertensive management, anticonvulsant therapy, safe analgesia for labour and management of anaesthesia for delivery.

Management of anticoagulation in hip fractures: A pragmatic approach

Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.

The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.

We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.

Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.

The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.

The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.

Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients.

Cite this article: EFORT Open Rev 2017;2:394–402. DOI: 10.1302/2058-5241.2.160083

Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia

Labor causes severe pain for many women. There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician's care. Many women desire pain management during labor and delivery, and there are many medical indications for analgesia and anesthesia during labor and delivery. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. A woman who requests epidural analgesia during labor should not be deprived of this service based on the status of her health insurance. Third-party payers that provide reimbursement for obstetric services should not deny reimbursement for labor analgesia because of an absence of "other medical indications." Anesthesia services should be available to provide labor analgesia and surgical anesthesia in all hospitals that offer maternal care (levels I-IV) (). Although the availability of different methods of labor analgesia will vary from hospital to hospital, the methods available within an institution should not be based on a patient's ability to pay.The American College of Obstetricians and Gynecologists believes that in order to allow the maximum number of patients to benefit from neuraxial analgesia, labor nurses should not be restricted from participating in the management of pain relief during labor. Under appropriate physician supervision, labor and delivery nursing personnel who have been educated properly and have demonstrated current competence should be able to participate in the management of epidural infusions.The purpose of this document is to review medical options for analgesia during labor and anesthesia for surgical procedures that are common at the time of delivery. Nonpharmacologic options such as massage, immersion in water during the first stage of labor, acupuncture, relaxation, and hypnotherapy are not covered in this document, though they may be useful as adjuncts or alternatives in many cases.