Oral Anticoagulation and Mortality in Cases with Intracranial Bleeding: Analysis of Nationwide Prescription and Hospitalization Data

OBJECTIVES

 To demonstrate the safety of direct oral anticoagulants in relation to intracranial bleeding (ICB), we compared the number of patients taking anticoagulants in all cases of hospitalization and cases of hospitalization for ICB over time in Germany. We analyzed the intrahospital mortality of ICB cases in relation to long-term use of anticoagulants (LUAs).We performed a retrospective registry analysis of nationwide German hospitalizations including all hospital admissions and admission for ICB in patients aged ≥60 years in the period from 2006 to 2020 and separated for LUAs.

RESULTS

 In 2006, the age-standardized rate of hospitalized male patients with LUAs was 7.3% and that of female patients was 5.6%. In 2020, the rates increased to 22.0 and 17.7% for male and female patients, respectively. Among patients hospitalized for ICB in 2006, 7.0 and 5.6% were male and female patients with LUAs, respectively. In 2020, the rate increased to 13.7% for males and 10.8% for females.In 2006, age-standardized mortality rates of male and female patients with ICB without LUAs were 24.1 and 23.9%, respectively. In 2020, the rate slightly decreased to 22.7% in males, but it remained almost unchanged in females at 23.8%. In the cases with LUA, the mortality rate decreased from 30.1 to 24.3% in males and from 28.4 to 24.2% in females in the same period.

CONCLUSION

 LUA seems to be safe because there is a slower increase of the rate of LUAs in ICB cases than in generally hospitalized cases in the period from 2006 to 2020. In addition, mortality in ICB cases with LUA tends to decrease compared to cases without LUA.

Management of Sternal Wound Infection-Determinants of Length of Stay and Recurrence of Infection after Muscle Flap Coverage

AIM

The aim of this study was to define determinants of length of hospital stay (LOS) longer than mean and recurrence of infection (ROI) after complete healing of patients with deep sternal wound infections (DSWI).

PATIENTS AND METHODS

In this observational study, we included 303 patients (155 females and 148 males, with mean age of 68 years) treated from 2016 to 2020 at the Department of Plastic Surgery of the HELIOS Klinik Krefeld, Germany. All patients received extensive necrosectomy, repetitive negative pressure therapy periods, and final transplantation of a pectoral musculocutaneous flap. In the German diagnosis-related group (DRG)-system, the mean inpatient LOS depends on the number of surgical procedures and is longer in those with four or more surgical procedures (DRG IO2B) and shorter in those with fewer procedures (DRGs I02C and I02D). The determinants which have a significant effect on LOS longer than mean and ROI after complete healing were identified by estimating a logistic regression model. The effect of the different calculated determinants was quantified as odds ratio. To measure the discriminant ability of the model between patients, we determined a receiver operating characteristic curve. The fit of the model was quantified by comparing predicted probabilities of the model with empirical probabilities of the data. The goodness of fit was then measured by applying the Hosmer-Lemeshow test.

RESULTS

Among patients in DRG IO2B (n = 246), the variable clopidogrel and therapeutic anticoagulation was the most important determinant for a longer LOS, with an odds ratio of 5.83 (95% CI = 0.83/40.80). Female sex and renal insufficiency also prolonged LOS. Applying this analysis to the patients with group DRG groups I02C and I02D (n = 57), none of these parameters were predictive. The variable immunosuppression was the most important determinant for ROI (n = 49) (OR = 4.67; 95% CI = 1.01/21.52). Body mass index also played a role, but with a much smaller influence.

CONCLUSION

There are specific risk factors for LOS longer than mean and ROI in patients with DSWI that can be identified on admission. Addressing these risk factors, if possible, could reduce the rate of patients with LOS longer than mean and ROI.

Impact of oral anticoagulation on inhospital mortality of patients with hip fracture - Analysis of nationwide hospitalization data

OBJECTIVES

Oral anticoagulation (OAC) may have an impact on mortality in cases hospitalized for hip fracture (HF). We studied nationwide time trends of OAC prescriptions and compared time trends of inhospital mortality of HF cases with and without OAC in Germany DESIGN: Retrospective cohort study SETTING: Nationwide German hospitalization, Diagnosis-Related Groups Statistic PATIENTS/PARTICIPANTS: All hospital admissions for HF 60 years and older in the years 2006 through 2020.

INTERVENTION

Additional diagnosis with a personal history of long-term use of anticoagulants (ICD code Z92.1).

MAIN OUTCOME MEASUREMENTS

Inhospital mortality RESULTS: Cases hospitalized for HF 60 years and older increased by 29.5%. In 2006, 5.6% had a documented history of long-term use of OACs. This proportion rose to 20.1% in 2020. Age-standardized hospitalization mortality in HF cases without long-term use of OACs in males decreased steadily from 8.6% (95% confidence intervals 8.2 - 8.9) in 2006 to 6.6% (6.3 - 6.9) in 2020 and in females from 5.2% (5.0 - 5.3) to 3.9% (3.7 - 4.0). Mortality of HF cases with long-term use of OACs remained unchanged: males 7.0% (5.7 - 8.2) in 2006 and 7.3% (6.7 - 7.8) in 2020, females 4.8% (4.1 - 5.4) and 5.0% (4.7 - 5.3).

CONCLUSION

Inhospital mortality of HF cases with and without long-term OAC show different trends. In HF cases without OAC, mortality decreased from 2006 to 2020. In cases with OAC such a decrease could not be observed.

An altered heparan sulfate structure in the articular cartilage protects against osteoarthritis

OBJECTIVE

Osteoarthritis (OA) is a progressive degenerative disease of the articular cartilage caused by an unbalanced activity of proteases, cytokines and other secreted proteins. Since heparan sulfate (HS) determines the activity of many extracellular factors, we investigated its role in OA progression.

METHODS

To analyze the role of the HS level, OA was induced by anterior cruciate ligament transection (ACLT) in transgenic mice carrying a loss-of-function allele of Ext1 in clones of chondrocytes (Col2-rtTA-Cre;Ext1e2fl/e2fl). To study the impact of the HS sulfation pattern, OA was surgically induced in mice with a heterozygous (Ndst1+/-) or chondrocyte-specific (Col2-Cre;Ndst1fl/fl) loss-of-function allele of the sulfotransferase Ndst1. OA progression was evaluated using the OARSI scoring system. To investigate expression and activity of cartilage degrading proteases, femoral head explants of Ndst1+/- mutants were analyzed by qRT-PCR, Western Blot and gelatin zymography.

RESULTS

All investigated mouse strains showed reduced OA scores (Col2-rtTA-Cre;Ext1e2fl/e2fl: 0.83; 95% HDI 0.72-0.96; Ndst1+/-: 0.83, 95% HDI 0.74-0.9; Col2-Cre;Ndst1fl/fl: 0.87, 95% HDI 0.76-1). Using cartilage explant cultures of Ndst1 animals, we detected higher amounts of aggrecan degradation products in wildtype samples (NITEGE 4.24-fold, 95% HDI 1.05-18.55; VDIPEN 1.54-fold, 95% HDI 1.54-2.34). Accordingly, gelatin zymography revealed lower Mmp2 activity in mutant samples upon RA-treatment (0.77-fold, 95% HDI: 0.60-0.96). As expression of major proteases and their inhibitors was not altered, HS seems to regulate cartilage degeneration by affecting protease activity.

CONCLUSION

A decreased HS content or a reduced sulfation level protect against OA progression by regulating protease activity rather than expression.

[Effect of HPA-1a(PLA1) and HLA antibodies on platelet function, measured with the in vitro bleeding test]

The influence of platelet-specific and HLA antibodies on primary hemostasis was investigated by the in vitro bleeding test (IVBT). Seven of 12 plasmas with HPA-1a (PLA1) antibodies and two with antibodies against glycoprotein Ib/IX significantly inhibited the IVBT of normal cross-match-positive donor blood. This correlated with an increase of GMP-140 on the platelets determined by flow cytometry. Therefore the inhibition of the IVBT was interpreted to be due to rapid platelet activation by platelet-specific antibodies followed by an irreversible loss of function. In contrast, with HLA antibodies neither activation nor inhibition of the platelet function could be proven.

Influence of HPA-1a and HLA antibodies on primary hemostasis

The influence of platelet specific and HLA antibodies was investigated on primary hemostasis by the in vitro bleeding test (IVBT) (Thrombostat 4000). Seven of 12 plasmas with HPA-1a (P1A1) antibodies and two with antibodies against glycoprotein Ib/IX significantly inhibited the IVBT of normal, cross-match-positive donor blood. This correlated with a significant increase of GMP-140 (CD 62) on the platelets, determined by flow cytometry. These results agree with the literature showing both activation and inhibition of platelet function by platelet specific antibodies. On the other hand, HLA antibodies showed a similar platelet activation (shortening of occlusion time and decrease in blood volume in the IVBT, increase of CD 62 expression) as plasma samples of polytransfused thrombocytopenic patients without HLA antibodies. It can be concluded that neither an activating nor an inhibitory effect of HLA antibodies on platelet function is significant in vivo. The IVBT seems not to be suited for compatibility testing.

A simple method for the determination of articaine and its metabolite articainic acid in dentistry: application to a comparison of articaine and lidocaine concentrations in alveolus blood

This study was undertaken to develop a time- and cost-effective method for the detection of articaine and articainic acid in alveolus blood by high-performance liquid chromatography with a simple method of sample pretreatment. To overcome the problem of very rapid hydrolysis a method for controlling hydrolysis in vitro after blood sampling was developed. Blood samples were withdrawn from the alveolus of the upper molars 2-14 min after submucous injection of articaine (2.0 ml 4%) or identical injection of lidocaine (2.0 ml 2%). The higher blood levels found for articaine correspond to the higher concentration of the drug in the injection solution. A relationship between the serum concentration of articaine and lidocaine, respectively, and the time between injection and blood sampling could be established.

A new method of blood sampling and determination of the local anesthetic agent lidocaine in dentistry

Blood levels of local anesthetic agents after application in dentistry have been determined only in peripheral venous blood. A method of withdrawing blood from the alveolus after extraction of a tooth was developed. With a new simple gas chromatographic method with a low detection limit, concentration of lidocaine was determined. A correlation between the blood levels of lidocaine and the type of anesthesia and the localization of the extracted teeth was found.

[The pharmacokinetic behavior of AWD 26-06 in humans following single and multiple administration]

The pharmacokinetics of the muscarinolytic drug AWD 26-06 was investigated in two subjects after a single dose of 50 and 100 mg, respectively, and with six subjects after repeated dosage. The half time (t1/2) is 2.4 and 2.6 h, respectively, the height of the concentration maximum (Cmax) 500 and 1400 ng.ml-1, respectively, and the area under the curve (AUC) 2155 and 4334 ng.ml-1.h, respectively. The repeated dosage (25 mg every 8 h for 7 d) showed a small increase of the serum level. The t1/2 and the mean residence time (MRT) at the 1st and the 8th d are 2.6 h (range: 1.8-2.9 h) and 4 h (range: 2.7-5.8 h), respectively. The point (tmax) and the Cmax were not different at the 1st and 8th d: mean tmax (1st d) 1.1 h (range: 1.0-1.5 h), mean tmax (8th d) 0.9 h (range: 0.75-1.0 h); Cmax (1st d) 227 ng.ml-1 (range: 160-320 ng.ml-1), Cmax (8th d) 282 ng.ml-1 (range: 168-320 ng.ml-1). There were also no differences for the AUC0-t at the 1st and 8th d (1st d) 815 ng.ml-1.h (range: 610-1134 ng.ml-1.h). The simulation of the serum level by means of the data from the single dose were established by this investigation. Typical subjective muscarinolytic symptoms (e.g. dryness of the mouth, diminution of accommodation) were observed after the 2nd/3rd dosage. These signs diminished 24-36 h after discontinuation of the dosage. The parameter ALAT, proteins of plasma, and blood cell count were not changed at the end of therapy in comparison to the beginning.

The influence of food on the absorption of diclofenac as a pure substance

The interaction of diclofenac as a pure substance was investigated without and with concomitant administration of food in 8 healthy, male volunteers (age: 23-29 years, body weight: 60-87 kg). Diclofenac was given as a pure substance by means of a rapid dissolving capsule in a dose of 50 mg. Paracetamol (1.5 g), a marker of gastric emptying rate, was administered simultaneously with diclofenac in order to elucidate the influence of gastric emptying rate on diclofenac absorption. The bioavailability was determined according to the time (tmax) of the concentration maximum in plasma (Cmax) and the area under the curve (AUC). Food significantly delays tmax of diclofenac (without food: [mean +/- SD] 0.8 +/- 0.5 h, range: 0.5 +/- 2 h; with food: 2.4 +/- 0.9 h, range: 1.5-4 h) and diminishes Cmax (without food: 1,125 +/- 765 ng/ml, range: 95-2,100 ng/ml; with food: 434 +/- 151 ng/ml, range: 250-555 ng/ml). The AUC is not influenced (without food: 1,217 +/- 368 ng/ml x h; with food: 1,037 +/- 267 ng/ml x h). The bioavailability of paracetamol is unchanged. It is concluded that the diminishing of Cmax and the delay of tmax of diclofenac are possibly the consequence of an interaction with food and not of the delayed gastric emptying per se.

The biliary elimination of the selective beta-receptor blocking drug talinolol in man

The biliary elimination of the beta-1-receptor blocking agent talinolol was investigated after intravenous administration of 30 mg in 6 patients with a T-tube drain after cholecystectomy. Serum concentration decreased in a biexponential manner with a median terminal half-life time of 4.4 h (range: 3.0-6.2 h). In some patients a second peak of the serum level was found. Concentration-time curves in bile paralleled serum profiles. The bile:serum concentration ratio (b:s-ratio) ranged from 24 to 98. The biliary clearance amounted to 43 ml/h.kg (range: 13-212 ml/h.kg). The median of the amount of talinolol eliminated by bile was 2.8 mg (range: 1.1-7.4 mg). It is concluded that talinolol undergoes an enterohepatic circulation. However, the amount eliminated cannot provide a sufficient explanation for the second peak, observed in some patients.

Further investigations of race:cultivar-specific induction of enzymes related to phytoalexin biosynthesis in soybean roots following infection with Phytophthora megasperma f.sp. glycinea

The activities of the following enzymes in soybean roots were determined at early times after infection of the roots with zoospores of an incompatible or a compatible race of Phytophthora megasperma f.sp. glycinea: dimethylallyl-diphosphate : 3,6a,9-trihydroxypterocarpan dimethylallyltransferase (prenyltransferase), an enzyme specific for glyceollin biosynthesis; NADPH-cytochrome reductase and hydroxymethylglutaryl-CoA reductase, enzymes related to the glyceollin pathway; and isocitrate dehydrogenase. Already at 4 h after infection there was a higher activity of the prenyltransferase in the incompatible interaction than in the compatible interaction, and enzyme activity in the incompatible interaction increased considerably between 4 and 8 h after infection. In the compatible interaction prenyltransferase activity was only slightly higher than in uninfected roots. The activity of the other enzymes in infected roots was not significantly different from that in the uninfected roots. No qualitative differences could be detected between the two-dimensional patterns of unlabelled proteins or proteins labelled with L-[35S]methionine of infected and uninfected roots at early times after infection. We conclude from these and earlier results (A. Bonhoff et al. (1986) Arch. Biochem. Biophys. 246, 149-154) that infection of the soybean roots with an incompatible race of the fungus leads to selective induction of the phytoalexin pathway and presumably to induction of other as yet unknown defense mechanisms.

The absolute and relative bioavailability of dipyridamole from different preparations and the in vitro-in vivo comparison

The in vitro liberation and the bioavailability (BV) of dipyridamole (D) in three different brands (A, B, C) were determined in a three way cross-over study on 12 healthy subjects. Also, the pharmacokinetics of D given intravenously was investigated. The in vitro liberation of B is only to be achieved by repeated touching. The tmax for the preparations, expressed as mean +/- s mean amounts as follows: A: 0.8 +/- 0.06; B: 1.1 +/- 0.1; C: 0.8 +/- 0.09 hours and is in the case of B significantly different (p less than 0.05) from the others. The cmax values (A: 1.01 +/- 0.25; B: 1.16 +/- 0.15; C: 1.51 +/- 0.3 mumol X l-1) and the AUC values (A: 3.8 +/- 0.9; B: 3.1 +/- 0.5; C: 3.8 +/- 0.7 mumol X h X l-1) are not different. The absolute BV of D is 27 +/- 5.5% (range: 11-44%) independent of the used brand. In 4 subjects a second tmax at the 4th-6th hour is to be observed irrespective of the way of dosing. An enterohepatic circulation is assumed. It is concluded that the determination of the in vitro liberation is a necessary and useful parameter, but cannot be used alone for characterization of the BV in every case, as e.g., for problem drugs.

The in vitro liberation and the bioavailability of different brands of griseofulvin in plasma and urine in man

The bioavailability of griseofulvin in three different brands, two microfine forms (Gricin = G, Likuden = L), and one ultramicrofine form (Gris-PEG = GP), was determined in plasma and urine in six healthy volunteers in a crossover study and compared with in vitro liberation data. GP shows a higher AUCo infinity (140 +/- 24 mumol . h . l-1) and Cmax (4.5 +/- 0.1 mumol . h-1) than the microsize brands of griseofulvin (AUCo infinity:58 +/- 7, and 45 +/- 6 mumol . h . l-1; Cmax:1.7 +/- 0.2, and 1.5 +/- 0.2 mumol . l-1; G and L, resp.), but the same tmax at the third hour. There results correspond with the in vitro liberation data. Contradictory results of the bioavailability are found by determining the amount of 6-Demethylgriseofulvin eliminated in urine. The elimination of this main metabolite after dosing with L is lower (0.18 +/- 0.02 mmol) than those of the other two brands, which do not differ (0.31 +/- 0.04; 0.32 +/- 0.02 mmol, G and GP, resp.). It is concluded that the determination of bioavailability only by means of the eliminated amount of a metabolite in urine may produce false results.

Some aspects of pharmacokinetic and biotransformation differences in humans and mammal animals

The erroneous tendency to set pharmacokinetics and biotransformation of drugs in man against results obtained in animals as a different homogenous group is discussed. Species differences have mainly a quantitative character, such as the body weight to surface ratio, organ weight to body weight ratio, presence of differing fat deposits, etc. Qualitative differences are not so common. The great importance of a better knowledge of these problems for the prediction of drug effects in man from results obtained in animals is emphasized.

On the distribution of drugs in saliva and blood plasma

The equilibration of drug concentrations between blood plasma (unbound part) and saliva was studied for selected drugs with different physicochemical properties: Quinidine, sulfamerazine, paracetamol, diazepam and ethanol. From these and other experimental results it is suggested: 1. The concentration ratio between saliva and blood plasma (unbound) can only equal one for basic drugs with a pK a lower than 5.5 and acid drugs with a pK a higher than 8.5 and for pH indifferent drugs. 2. The drug must have a sufficient permeation ability through lipid membranes, valuable by the lipid water partition coefficient.