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Vandenheuvel M, Vandewiele K, De Somer F, Wouters PF. Protamine dosing in cardiac surgery. Perfusion 2024; 39:645-646. [PMID: 36696481 DOI: 10.1177/02676591231154116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - Filip De Somer
- Department of Perfusion, University Hospital Ghent, Ghent, Belgium
| | - Patrick F Wouters
- Department of Anaesthesia, University Hospital Ghent, Ghent, Belgium
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Dehghani M, Sadeghi M, Barzkar F, Maghsoomi Z, Janani L, Motevalian SA, Loke YK, Ismail-Beigi F, Baradaran HR, Khamseh ME. Efficacy and safety of basal insulins in people with type 2 diabetes mellitus: a systematic review and network meta-analysis of randomized clinical trials. Front Endocrinol (Lausanne) 2024; 15:1286827. [PMID: 38586456 PMCID: PMC10997219 DOI: 10.3389/fendo.2024.1286827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/22/2024] [Indexed: 04/09/2024] Open
Abstract
Aim The comparative effectiveness of basal insulins has been examined in several studies. However, current treatment algorithms provide a list of options with no clear differentiation between different basal insulins as the optimal choice for initiation. Methods A comprehensive search of MEDLINE, Embase, Cochrane Library, ISI, and Scopus, and a reference list of retrieved studies and reviews were performed up to November 2023. We identified phase III randomized controlled trials (RCTs) comparing the efficacy and safety of basal insulin regimens. The primary outcomes evaluated were HbA1c reduction, weight change, and hypoglycemic events. The revised Cochrane ROB-2 tool was used to assess the methodological quality of the included studies. A random-effects frequentist network meta-analysis was used to estimate the pooled weighted mean difference (WMD) and odds ratio (OR) with 95% confidence intervals considering the critical assumptions in the networks. The certainty of the evidence and confidence in the rankings was assessed using the GRADE minimally contextualized approach. Results Of 20,817 retrieved studies, 44 RCTs (23,699 participants) were eligible for inclusion in our network meta-analysis. We found no significant difference among various basal insulins (including Neutral Protamine Hagedorn (NPH), ILPS, insulin glargine, detemir, and degludec) in reducing HbA1c. Insulin glargine, 300 U/mL (IGlar-300) was significantly associated with less weight gain (mean difference ranged from 2.9 kg to 4.1 kg) compared to other basal insulins, namely thrice-weekly insulin degludec (IDeg-3TW), insulin degludec, 100 U/mL (IDeg-100), insulin degludec, 200 U/mL (IDeg-200), NPH, and insulin detemir (IDet), but with low to very low certainty regarding most comparisons. IDeg-100, IDeg-200, IDet, and IGlar-300 were associated with significantly lower odds of overall, nocturnal, and severe hypoglycemic events than NPH and insulin lispro protamine (ILPS) (moderate to high certainty evidence). NPH was associated with the highest odds of overall and nocturnal hypoglycemia compared to others. Network meta-analysis models were robust, and findings were consistent in sensitivity analyses. Conclusion The efficacy of various basal insulin regimens is comparable. However, they have different safety profiles. IGlar-300 may be the best choice when weight gain is a concern. In contrast, IDeg-100, IDeg-200, IDet, and IGlar-300 may be preferred when hypoglycemia is the primary concern.
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Affiliation(s)
- Mohsen Dehghani
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Sadeghi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzaneh Barzkar
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Maghsoomi
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Seyed Abbas Motevalian
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Yoon K. Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Faramarz Ismail-Beigi
- Department of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Hamid Reza Baradaran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Mohammad E. Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
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Mondal S, Abuelkasem E, Vesselinov R, Henderson R, Choi S, Mousa A, Zaza KJ, Tanaka KA. Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis. Transfusion 2024; 64:467-474. [PMID: 38264767 DOI: 10.1111/trf.17730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. STUDY DESIGN Retrospective cohort study. METHODS We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8). RESULTS We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. CONCLUSION High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Biostatistics Division; Department of Anesthesiology, National Study Center, University of Maryland, Baltimore, Maryland, USA
| | - Reney Henderson
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Seung Choi
- Department of Anesthesiology, WakeMed Health System, Raleigh, North Carolina, USA
| | - Ahmad Mousa
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Khaled J Zaza
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Zhou FN, Gellatly RM. Management of an unintentional enoxaparin overdose: A case report and literature review. Am J Health Syst Pharm 2023; 80:1550-1556. [PMID: 37522871 DOI: 10.1093/ajhp/zxad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE The aim of this article is to describe a case in which protamine was used for a low-molecular-weight heparin (LMWH) overdose and present an up-to-date review of the literature on the management of LMWH overdose in adults. SUMMARY An unintentional administration of enoxaparin 900 mg occurred in a 73-year-old man with coronavirus disease 2019-related pulmonary embolism. Management of the overdose included a protamine bolus followed by an infusion. Anti-factor Xa levels and activated partial thromboplastin time were monitored. Anti-factor Xa levels declined in a linear fashion irrespective of protamine administration. No bleeding or further thrombotic complications occurred in the patient. A review of the literature revealed that the optimal strategy to treat an LMWH overdose is unknown, with treatment of overdoses ranging from clinical observation to aggressive protamine dosing in reported cases. Although protamine effectively neutralizes unfractionated heparin, it is unable to completely reverse LMWH activity and has variable effects on laboratory measures of LMWH anticoagulant activity. CONCLUSION The current case report provides additional data to previous literature suggesting that protamine may have a limited effect in decreasing anti-factor Xa levels in LMWH overdose. Continued reporting on the management of LMWH overdoses is warranted to clarify the optimal treatment strategy.
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Affiliation(s)
- Florian N Zhou
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Rochelle M Gellatly
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Shirani-Bidabadi S, Mirian M, Varshosaz J, Tavazohi N, Sadeghi HMM, Shariati L. Gene network analysis of oxaliplatin-resistant colorectal cancer to target a crucial gene using chitosan/hyaluronic acid/protamine polyplexes containing CRISPR-Cas9. Biochim Biophys Acta Gen Subj 2023; 1867:130385. [PMID: 37230419 DOI: 10.1016/j.bbagen.2023.130385] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/27/2023]
Abstract
Colorectal cancer (CRC) treatment is dramatically hampered by resistance to oxaliplatin alone or in the combination of irinotecan or 5-fluorouracil and leucovorin. This study aims to design and assess Chitosan/Hyaluronic Acid/Protamine sulfate (CS/HA/PS) polyplexes loaded with CRISPR plasmid for targeting a key gene in cancer drug resistance. Here, recent findings were considered to validate oxaliplatin-resistant CRC-related genes and systems biology approaches employed to detect the critical gene. The polyplexes were characterized according to particle size, zeta potential, and stability. Moreover, carrier toxicity and transfection efficiency were assessed on oxaliplatin-resistant HT-29 cells. The post-transfection evaluations were performed to confirm gene disruption-mediated CRISPR. Eventually, excision cross complementation group 1(ERCC1), a crucial member of the nucleotide excision repair pathway, was selected to be targeted using CRISPR/Cas9 to reverse oxaliplatin resistance in HT-29 cells. CS/HA/PS polyplexes containing CRISPR/Cas9 plasmid exhibited negligible toxicity and comparable transfection efficiency with Lipofectamine™. Following the efficient gene delivery, sequences in CRISPR/Cas9 target sites were altered, ERCC1 was downregulated, and drug sensitivity was successfully restored in oxaliplatin-resistant cells. Findings indicate that CS/HA/PS/CRISPR polyplexes provide a potential strategy for delivering cargo and targeting oxaliplatin resistance-related gene to manipulate drug resistance as a rising concern in cancer therapeutic approaches.
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Affiliation(s)
- Shiva Shirani-Bidabadi
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran
| | - Mina Mirian
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran.
| | - Jaleh Varshosaz
- Department of Pharmaceutics, Faculty of Pharmacy and Novel Drug Delivery Systems Research Centre, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran.
| | - Nazita Tavazohi
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran
| | - Hamid Mir Mohammad Sadeghi
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran.
| | - Laleh Shariati
- Department of Biomaterials, Nanotechnology and Tissue Engineering, School of Advanced Technologies in Medicine, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran.
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Facchetti N, Hinrichs JB, Becker LS, Schneider MA, Brüning R, Rademacher J, Lenz J, Kudrass K, Vogel A, Wacker FK, Dewald CLA. Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more? Cancer Imaging 2023; 23:68. [PMID: 37452405 PMCID: PMC10349410 DOI: 10.1186/s40644-023-00590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP. MATERIALS AND METHODS All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0). RESULTS Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine. CONCLUSION Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.
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Affiliation(s)
- Nadia Facchetti
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Lena S. Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martin A. Schneider
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Roland Brüning
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jan Rademacher
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jochen Lenz
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Kirsten Kudrass
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank K. Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Cornelia L. A. Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Brunetti VC, Yu OHY, Platt RW, Filion KB. The association of long-acting insulin analogue use versus neutral protamine Hagedorn insulin use and the risk of major adverse cardiovascular events among individuals with type 2 diabetes: A population-based cohort study. Diabetes Obes Metab 2022; 24:2169-2181. [PMID: 35726454 DOI: 10.1111/dom.14802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
AIMS To compare the risk of cardiovascular outcomes associated with long-acting insulin analogues versus neutral protamine Hagedorn (NPH) insulin among patients with type 2 diabetes. MATERIALS AND METHODS We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink Aurum, linked with hospitalization and vital statistics data. Patients with type 2 diabetes who initiated basal insulin treatment between 2002 and 2018 were included in the study. Exposure was defined as current use of long-acting insulin analogues or NPH insulin, defined using a time-varying approach. The primary outcome was major adverse cardiovascular events (MACE; a composite endpoint of myocardial infarction, ischaemic stroke and cardiovascular death). We used a marginal structural Cox proportional hazards model to estimate the hazard ratio (HR) and 95% confidence interval (CI) for MACE with current use of long-acting insulin analogues versus NPH insulin, and in secondary analyses, by long-acting insulin molecule. RESULTS Our cohort included 57 334 patients. A total of 3494 MACE occurred over a mean follow-up of 1.6 years (incidence rate 37.4, 95% CI 36.2 to 38.7 per 1000 person-years). Long-acting insulin analogues were associated with a decreased risk of MACE compared to NPH insulin (HR 0.89, 95% CI 0.83 to 0.96). CONCLUSIONS Current use of long-acting insulin analogues is associated with a modestly reduced risk of MACE compared to current use of NPH insulin among patients with type 2 diabetes. This study could have important implications for drug plan managers and guideline-writing committees for recommendations of insulin treatment for type 2 diabetes.
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Affiliation(s)
- Vanessa C Brunetti
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Oriana Hoi Yun Yu
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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Khan JH, Barkin MS, Stanton J, Khan A, Stanten RD. Blood and Blood Product Conservation: Results of Strategies to Improve Clinical Outcomes in Open Heart Surgery Patients at a Tertiary Hospital Are Maintained 4 Years after Initiation. J Extra Corpor Technol 2022; 54:35-41. [PMID: 36380821 PMCID: PMC9639683 DOI: 10.1182/ject-35-41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 06/16/2023]
Abstract
Blood product usage is an important outcome for patients undergoing cardiac surgery. In 2015, our center made a concerted effort with multiple departments to focus on reducing transfusion rates in surgical patients requiring cardiopulmonary bypass (CPB). Specific changes included an upgrade of the oxygenator in mid-2015 and, in early 2016, implementation of a hemostasis management system (HMS) that used heparin dose-response titration assays for heparin and protamine management. A retrospective chart review demonstrated significant decreases in the quarterly average of patients receiving packed red blood cells (PRBCs) from a baseline of 26.7% to 22.7% following the oxygenator upgrade (p = .021) and from 22.7% to 8.8% following implementation of the HMS (p = .0017). Platelet usage decreased from an average of 50.5% during the baseline and oxygenator upgrade periods to 22.2% following implementation of the HMS (p < .0001). Usage of fresh frozen plasma (FFP) decreased from an average of 28.2% of cases during the baseline and oxygenator upgrade periods to 10.4% during 2016, and cryoprecipitate usage decreased from 38.5% to 15.4%. Heparin usage averaged 56,903 units before implementation of the HMS, decreasing to an average of 43,796 units following HMS implementation (p < .0001). During the same time periods, protamine usage averaged 340.3 mg and 183.2 mg, respectively. Because improvements achieved during quality initiatives may revert back to their pre-intervention state once the assessment period is over, we performed a second retrospective analysis to determine whether the improvements achieved were maintained during the 48 months following the initial study. During 2017-2020, quarterly average usage of blood products was as follows: PRBCs, 11.9%; platelets, 14.7%; FFP, 6.2%; and cryoprecipitate, 11.5%. Quarterly, average use of heparin and protamine were 31,556 ± 2,757 units and 189 ± 113 mg, respectively. These findings indicate that the improvements achieved were not limited to the duration of the initial quality initiative.
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Affiliation(s)
- Junaid H. Khan
- Sutter Health Alta Bates Summit Medical Center, Oakland, California
| | | | - Jeffrey Stanton
- Sutter Health Alta Bates Summit Medical Center, Oakland, California
| | - Asim Khan
- Sutter Health Alta Bates Summit Medical Center, Oakland, California
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Liang P, Motaganahalli R, Swerdlow NJ, Dansey K, Varkevisser RRB, Li C, Lu J, de Guerre L, Shuja F, Schermerhorn M. Protamine use in transfemoral carotid artery stenting is not associated with an increased risk of thromboembolic events. J Vasc Surg 2020; 73:142-150.e4. [PMID: 32535154 DOI: 10.1016/j.jvs.2020.04.526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Protamine use in carotid endarterectomy has been shown to be associated with fewer perioperative bleeding complications without higher rates of thromboembolic events. However, the effect of protamine use on complications after transfemoral carotid artery stenting (CAS) is unclear, and concerns remain about thromboembolic events. METHODS A retrospective review was performed for patients undergoing transfemoral CAS in the Vascular Quality Initiative from March 2005 to December 2018. We assessed in-hospital outcomes using propensity score-matched cohorts of patients who did and did not receive protamine. The primary outcome was in-hospital stroke or death. Secondary outcomes included bleeding complications, stroke, death, transient ischemic attack, myocardial infarction, and congestive heart failure exacerbation. Bleeding complications were categorized as bleeding resulting in intervention or blood transfusions. RESULTS Of the 17,429 patients undergoing transfemoral CAS, 2697 (15%) patients received protamine. We created 2300 propensity score-matched pairs of patients who did and did not receive protamine. There were no statistically significant differences in stroke or death between the two cohorts (protamine, 2.5%; no protamine, 2.9%; relative risk [RR], 0.85; 95% confidence interval [CI], 0.60-1.21; P = .37). Protamine use was not associated with statistically significant differences in perioperative bleeding complications resulting in interventional treatment (0.9% vs 0.5%; RR, 2.10; 95% CI, 0.99-4.46; P = .05) or blood transfusion (1.2% vs 1.2%; RR, 0.92; 95% CI, 0.53-1.61; P = .78). There were also no statistically significant differences for the individual outcomes of stroke (1.8% vs 2.3%; RR, 0.78; 95% CI, 0.52-1.16; P = .22), death (0.9% vs 0.8%; RR, 1.17; 95% CI, 0.62-2.19; P = .63), transient ischemic attack (1.4% vs 1.3%; RR, 1.10; 95% CI, 0.67-1.82; P = .70), myocardial infarction (0.5% vs 0.4%; RR, 1.20; 95% CI, 0.52-2.78; P = .67), or heart failure exacerbation (1.0% vs 0.9%; RR, 1.05; 95% CI, 0.58-1.90; P = .88). Protamine use in patients presenting with symptomatic carotid stenosis was associated with lower risk of stroke or death (3.0% vs 4.3%; RR, 0.69; 95% CI, 0.47-0.998; P = .048), whereas there were no statistically significant differences in stroke or death with protamine use in asymptomatic patients (1.6% vs 1.0%; RR, 1.63; 95% CI, 0.67-3.92; P = .28). CONCLUSIONS Heparin reversal with protamine after transfemoral CAS is not associated with an increased risk of thromboembolic events, and its use in symptomatic carotid disease is associated with a lower risk of stroke or death.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Raghu Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Jinny Lu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Livia de Guerre
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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11
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Ranasinghe T, Mays T, Quedado J, Adcock A. Thrombolysis Following Heparin Reversal With Protamine Sulfate in Acute Ischemic Stroke: Case Series and Literature Review. J Stroke Cerebrovasc Dis 2019; 28:104283. [PMID: 31324409 PMCID: PMC6800047 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/23/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Administering intravenous IV tissue plasminogen activator (tPA) is the recommended standard of care in acute ischemic stroke (AIS), although it is not recommended to administer intravenous thrombolysis with tPA following heparin reversal with protamine sulfate in patients with AIS. METHODS We describe a case series of three patients and the most comprehensive literature review published to date in this specific subset of AIS patients undergoing thrombolysis following heparin reversal with protamine sulfate. The literature review was based on a scoping review methodology performed on four databases; PubMed, CINAHL, Web of Science, and Cochrane Library. All sources were searched from the inauguration of the database until February 2019. A total of six articles involving eight patients were identified. RESULTS The primary safety outcome of no symptomatic intracranial hemorrhage (sICH) was met in all eleven patients, although only seven cases had a good functional outcome at 3 months. CONCLUSIONS In appropriately selected AIS patients, coagulopathy correction appears to be safe from an sICH standpoint and may be beneficial. However, given the potential for bias with observational databases, case reports and case series, extreme caution is warranted in applying these results to routine clinical practice.
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Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, West Virginia University, Morgantown, West Virginia.
| | - Traci Mays
- Health Science Library, West Virginia University, Morgantown, West Virginia
| | - Jeff Quedado
- Department of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Amelia Adcock
- Department of Neurology, West Virginia University, Morgantown, West Virginia
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Papachristofilou A, Hipp MM, Klinkhardt U, Früh M, Sebastian M, Weiss C, Pless M, Cathomas R, Hilbe W, Pall G, Wehler T, Alt J, Bischoff H, Geißler M, Griesinger F, Kallen KJ, Fotin-Mleczek M, Schröder A, Scheel B, Muth A, Seibel T, Stosnach C, Doener F, Hong HS, Koch SD, Gnad-Vogt U, Zippelius A. Phase Ib evaluation of a self-adjuvanted protamine formulated mRNA-based active cancer immunotherapy, BI1361849 (CV9202), combined with local radiation treatment in patients with stage IV non-small cell lung cancer. J Immunother Cancer 2019; 7:38. [PMID: 30736848 PMCID: PMC6368815 DOI: 10.1186/s40425-019-0520-5] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/27/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Preclinical studies demonstrate synergism between cancer immunotherapy and local radiation, enhancing anti-tumor effects and promoting immune responses. BI1361849 (CV9202) is an active cancer immunotherapeutic comprising protamine-formulated, sequence-optimized mRNA encoding six non-small cell lung cancer (NSCLC)-associated antigens (NY-ESO-1, MAGE-C1, MAGE-C2, survivin, 5T4, and MUC-1), intended to induce targeted immune responses. METHODS We describe a phase Ib clinical trial evaluating treatment with BI1361849 combined with local radiation in 26 stage IV NSCLC patients with partial response (PR)/stable disease (SD) after standard first-line therapy. Patients were stratified into three strata (1: non-squamous NSCLC, no epidermal growth factor receptor (EGFR) mutation, PR/SD after ≥4 cycles of platinum- and pemetrexed-based treatment [n = 16]; 2: squamous NSCLC, PR/SD after ≥4 cycles of platinum-based and non-platinum compound treatment [n = 8]; 3: non-squamous NSCLC, EGFR mutation, PR/SD after ≥3 and ≤ 6 months EGFR-tyrosine kinase inhibitor (TKI) treatment [n = 2]). Patients received intradermal BI1361849, local radiation (4 × 5 Gy), then BI1361849 until disease progression. Strata 1 and 3 also had maintenance pemetrexed or continued EGFR-TKI therapy, respectively. The primary endpoint was evaluation of safety; secondary objectives included assessment of clinical efficacy (every 6 weeks during treatment) and of immune response (on Days 1 [baseline], 19 and 61). RESULTS Study treatment was well tolerated; injection site reactions and flu-like symptoms were the most common BI1361849-related adverse events. Three patients had grade 3 BI1361849-related adverse events (fatigue, pyrexia); there was one grade 3 radiation-related event (dysphagia). In comparison to baseline, immunomonitoring revealed increased BI1361849 antigen-specific immune responses in the majority of patients (84%), whereby antigen-specific antibody levels were increased in 80% and functional T cells in 40% of patients, and involvement of multiple antigen specificities was evident in 52% of patients. One patient had a partial response in combination with pemetrexed maintenance, and 46.2% achieved stable disease as best overall response. Best overall response was SD in 57.7% for target lesions. CONCLUSION The results support further investigation of mRNA-based immunotherapy in NSCLC including combinations with immune checkpoint inhibitors. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01915524 .
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Affiliation(s)
| | | | | | - Martin Früh
- Hospital of St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | | | - Miklos Pless
- Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | | | - Wolfgang Hilbe
- Medical Department, Center for Oncology and Hematology, Wilhelminenspital, Wien, Austria
| | - Georg Pall
- University Hospital Innsbruck, Innsbruck, Austria
| | - Thomas Wehler
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | - Jürgen Alt
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | | | - Michael Geißler
- Klinik für Allg Innere Medizin, Onkolologie/ Hämatologie, Gastroenterologie, Infektiologie, Esslingen, Germany
| | - Frank Griesinger
- Department Hematology and Oncology, Pius Hospital University, Oldenburg, Germany
- Department Internal Medicine-Oncology, Medical Campus University of Oldenburg, Oldenburg, Germany
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13
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Erdoes G, Dietrich W, Stucki MP, Merz TM, Angelillo-Scherrer A, Nagler M, Carrel T, Eberle B. Short-term recovery pattern of plasma fibrinogen after cardiac surgery: A prospective observational study. PLoS One 2018; 13:e0201647. [PMID: 30075017 PMCID: PMC6075772 DOI: 10.1371/journal.pone.0201647] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 07/19/2018] [Indexed: 11/18/2022] Open
Abstract
Low plasma fibrinogen level is common after cardiopulmonary bypass (CPB). Current substitution practice with fibrinogen concentrate generally follows a single measurement and cut-off values from the literature, whereas early postoperative endogenous fibrinogen kinetics is incompletely described and widely disregarded. The aim of this study was to determine the short-term recovery pattern of plasma fibrinogen after CPB weaning. Our hypothesis was that in the absence of surgical bleeding, CPB-induced hypofibrinogenemia would resolve spontaneously and predictably within a few hours. In a prospective, observational study of 26 patients undergoing conventional CPB (cCPB) or minimally invasive extracorporeal circulation (MiECC), Clauss fibrinogen level (C-FIB) was determined at 10 closely spaced time points after protamine administration. Primary endpoint was the time to recovery of post-CPB fibrinogen levels to ≥1.5 g/L. C-FIB reached its nadir after protamine administration corresponding to 62 ± 5% (mean ± SD) of the baseline level after cCPB and 68 ± 7% after MiECC (p = 0.027 vs. cCPB). C-FIB recovered spontaneously at a nearly constant rate of approximately 0.08 g/L per hour. In all patients, C-FIB was ≥1.5 g/L at 4 hours and ≥2.0 g/L at 13 hours after CPB weaning. Following cardiac surgery with CPB and in the absence of surgical bleeding, spontaneous recovery of normal endogenous fibrinogen levels can be expected at a rate of 0.08 g/L per hour. Administration of fibrinogen concentrate triggered solely by a single-point measurement of low plasma fibrinogen some time after CPB is not justified.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Wulf Dietrich
- Institute for Research in Cardiac Anesthesia, Munich, Germany
| | - Monika Pia Stucki
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Michael Merz
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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Shore-Lesserson L, Baker RA, Ferraris V, Greilich PE, Fitzgerald D, Roman P, Hammon J. STS/SCA/AmSECT Clinical Practice Guidelines: Anticoagulation during Cardiopulmonary Bypass. J Extra Corpor Technol 2018; 50:5-18. [PMID: 29559750 PMCID: PMC5850589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/02/2017] [Indexed: 06/08/2023]
Abstract
Despite more than a half century of "safe" cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, the Society of Thoracic Surgeons (STS), the Society of Cardiovascular Anesthesiologists (SCA), and the American Society of Extracorporeal Technology (AmSECT) developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered together to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation for CPB using the available evidence. To identify relevant evidence a systematic review was outlined and literature searches were conducted in PubMed® using standardized MeSH terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published prior to 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the AHA/ACCF Task Force on Practice Guidelines. Recommendations were written in the three following areas 1) Heparin dosing and monitoring for initiation and maintenance of CPB, 2) Heparin contraindications and heparin alternatives, 3) Reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and expand upon the evidence base on the topic of anticoagulation for CPB.
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Affiliation(s)
- Linda Shore-Lesserson
- Department of Anesthesiology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Robert A. Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | - Philip E. Greilich
- Department of Anesthesiology & Pain Management, University of Texas-Southwestern Medical Center, Dallas, Texas
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - Philip Roman
- Department of Anesthesiology, Saint Anthony Hospital, Lakewood, Colorado; and
| | - John Hammon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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15
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Kinoda J, Ishihara M, Nakamura S, Fujita M, Fukuda K, Sato Y, Yokoe H. Protective effect of FGF-2 and low-molecular-weight heparin/protamine nanoparticles on radiation-induced healing-impaired wound repair in rats. J Radiat Res 2018; 59:27-34. [PMID: 29121251 PMCID: PMC5778538 DOI: 10.1093/jrr/rrx044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/13/2017] [Indexed: 06/07/2023]
Abstract
We examined the effectiveness of localized administration of fibroblast growth factor-2 containing low-molecular-weight heparin/protamine nanoparticles (FGF-2&LMWH/P NPs) on apoptosis in vivo and on healing of radiation-induced skin injury in a rat model. FGF-2 binds onto LMWH/P NPs, which can significantly enhance and stabilize FGF-2 as a local carrier. X-irradiation at a dose of 25 Gy was administered to the lower part of the back (using a lead sheet with two holes) 1 h before the administration of FGF-2&LMWH/P NPs. Cutaneous full-thickness defect wounds were then formed in X-irradiated areas to examine the time-course of wound healing, and the wound tissues were microscopically and histologically compared and examined. Wound healing was significantly delayed by X-irradiation, but FGF-2&LMWH/P NPs administration prior to irradiation led to a significantly shorter delay compared with FGF-2 alone, LMWH/P NPs alone, and controls. Furthermore, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) staining showed that the proportions of apoptotic dermal fibroblasts in X-irradiated skin were significantly lower in rats administered FGF-2&LMWH/P NPs than in controls. However, 8-hydroxy-2'-deoxyguanosine (8-OHdG) staining showed no differences. Thus, localized administration of FGF-2&LMWH/P NPs prior to irradiation may alleviate X-irradiation-induced healing-impaired wound repair in normal tissue.
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Affiliation(s)
- Jun Kinoda
- Department of Oral and Maxillofacial Surgery, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Masayuki Ishihara
- Division of Biomedical Engineering, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Shingo Nakamura
- Division of Biomedical Engineering, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Masanori Fujita
- Division of Environmental Medicine, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Koichi Fukuda
- Division of Biomedical Engineering, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Yoko Sato
- Division of Biomedical Engineering, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
| | - Hidetaka Yokoe
- Department of Oral and Maxillofacial Surgery, National Defense Medical College Research Institute, 3–2 Namiki, Tokorozawa, Saitama 359–8513, Japan
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Muralidharan-Chari V, Kim J, Mousa SA. Reversal of anticoagulant activity of heparin and low molecular weight heparins by poly-l-lysine: A comparative 'in vitro' study versus protamine sulfate. Thromb Res 2017; 155:128-130. [PMID: 28538195 DOI: 10.1016/j.thromres.2017.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/20/2017] [Accepted: 05/11/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jaehan Kim
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA.
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17
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Bakchoul T, Jouni R, Warkentin TE. Protamine (heparin)-induced thrombocytopenia: a review of the serological and clinical features associated with anti-protamine/heparin antibodies. J Thromb Haemost 2016; 14:1685-95. [PMID: 27378603 DOI: 10.1111/jth.13405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Indexed: 01/04/2023]
Abstract
Protamine is widely used in medicine as a rapidly-acting antidote to heparin, particularly for reversing heparin anticoagulation after cardiac surgery. Protamine is also used as a stabilizing additive to certain preparations of insulin. Recent reports demonstrate that protamine and heparin form multimolecular complexes that result in high rates of immunization in post-cardiac surgery patients, particularly of immunoglobulin G (IgG) class antibodies; a subset of these anti-protamine/heparin IgG antibodies activates platelets through their FcγIIA (IgG) receptors. Although the clinical consequences of anti-protamine/heparin antibodies that are newly generated after cardiac surgery are unknown, there is evidence that platelet-activating anti-protamine/heparin antibodies already present at the time of cardiac surgery might occasionally explain more severe thrombocytopenia with delayed platelet count recovery, as well as thromboembolic complications, in the post-cardiac surgery setting. Triggers for such antibodies remain poorly-defined, but could include preoperative administration of heparin to diabetic patients receiving protamine-insulin as well as recent previous cardiac surgery. Anti-protamine/heparin antibodies have several features in common with anti-platelet factor 4 (PF4) PF4/heparin antibodies implicated in heparin-induced thrombocytopenia (HIT), including immunization by heparin-containing multimolecular complexes, predominant IgG class, pathological platelet-activating properties, relatively rapid IgG formation without IgM precedence, and antibody transience. Despite these similarities, the risk of anti-protamine/heparin antibody-mediated complications seems to affect the early post-cardiac surgery period, whereas HIT usually occurs at least 5 days following cardiac surgery. Clinicians need to become aware of this recently recognized immunohematological disorder, and research is needed to identify triggers of immunization, improve detection of pathological antibodies and identify patients at risk of this complication.
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Affiliation(s)
- T Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany. ,
| | - R Jouni
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Absar S, Gupta N, Nahar K, Ahsan F. Engineering of plasminogen activators for targeting to thrombus and heightening thrombolytic efficacy. J Thromb Haemost 2015; 13:1545-56. [PMID: 26074048 DOI: 10.1111/jth.13033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 05/29/2015] [Indexed: 01/02/2023]
Abstract
Thrombotic occlusion of the coronary artery, which triggers acute myocardial infarction, is one of the major causes of death in the USA. Currently, arterial occlusions are treated with intravenous plasminogen activators (PAs), which dissolve the clot by activating plasminogen. However, PAs indiscriminately generate plasmin, which depletes critical clotting factors (fibrinogen, factor V, and factor VIII), precipitates a lytic state in the blood, and produces bleeding complications in a large patient population. PAs have been extensively investigated to achieve thrombus specificity, to attenuate the bleeding risk, and to widen their clinical applications. In this review, we discuss various strategies that have been pursued since the beginning of thrombolytic therapy. We review the biotechnological approaches that have been used to develop mutant and chimeric PAs for thrombus selectivity, including the use of specific antibodies for targeting thrombi. We discuss particulate carrier-based systems and triggered-release concepts. We propose new hypotheses and strategies to spur future studies in this research arena. Overall, we describe the approaches and accomplishments in the development of patient-friendly and workable delivery systems for thrombolytic drugs.
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Affiliation(s)
- S Absar
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - N Gupta
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - K Nahar
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - F Ahsan
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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Pavlovich KV, Sydorchuk RI. [INJECTING MATERIAL FOR SKIN REGENERATION LACERTA APPLICATION IN TREATMENT OF TROPHIC ULCERS IN PATIENTS WITH DIABETIC FOOT SYNDROME]. Klin Khir 2015:44-46. [PMID: 26591219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Examined 22 patients with diabetes mellitus (DM) type II of neuropathic form of diabetic foot syndrome (DFS). In 12 patients (comparison group) local povidone-iodine was used main in 10 (study group), except povidone-iodine, in the phase of exudation used tyrothricin in gel form, the granulation and epithelization phase, after cleaning the wounds, were injected intradermally 1 ml of injecting material for skin regeneration Lacerta. Trophic defects in 9 (90%) patients of the main group during the observation period healed completely, in the comparison group complete healing of the ulcer reached in 2 (16.7%) patients, the rest-wounds, although purified, however, were lethargic granulation, epithelization occurred very slowly. Consequently, the use of the proposed method allows to achieve more rapid healing of trophic ulcers that do not heal continued in patients of neuropathic forms of DFS.
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Toda M, Ohno J, Shinozaki Y, Ozaki M, Fukushima T. Osteogenic potential for replacing cells in rat cranial defects implanted with a DNA/protamine complex paste. Bone 2014; 67:237-45. [PMID: 25051019 DOI: 10.1016/j.bone.2014.07.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/11/2014] [Accepted: 07/16/2014] [Indexed: 11/21/2022]
Abstract
Osteoinductive scaffolds are required for bone tissue engineering. The aim of the present study was to assess the osteoinductive capacity of deoxyribonucleic acid (DNA)/protamine complexes in a rat model of critical-size calvarial defects. In addition, we investigated whether cultured mesenchymal-like cells (DP-cells) outgrown from DNA/protamine complex engrafted defects could differentiate to become osteogenic cells in vitro. DNA/protamine complexes were prepared by reactions between DNA and protamine sulfate solutions with stirring. Critical-sized (8mm) calvarial defects were created in the central parietal bones of adult rats. Defects were either left empty or treated with DNA/protamine complex scaffolds. Subsequently, micro-computed tomography (micro-CT), histological, and immunohistochemical analyses were performed. Micro-CT and histological assays showed that DNA/protamine complex engrafted defects had enhanced bone regeneration. DP-cells were expanded from explants of DNA/protamine complex engrafted defects using an explant outgrowth culture system. Osteogenesis-related factors were assessed in DP-cells after treatment with an osteoblast-inducing reagent (OIR). After 3months, nearly complete healing was observed for DNA/protamine complex engrafted calvarial defects. Increased alkaline phosphatase (ALP) activity and Alizarin red staining were found for cultured DP-cells. These cells had high expression levels of osteogenic genes, including those for RUNX-2, ALP, osteopontin, and osteocalcin. These results indicated that DNA/protamine complexes could facilitate bone regeneration in calvarial defects. Moreover, in vitro osteogenic induction experiments showed that DP-cells outgrown from DNA/protamine engrafted defects had an osteogenic potential. Based on these results, we suggest that DNA/protamine complexes may recruit osteocompetent cells in these defects, where they differentiate to osteogenic cells.
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Affiliation(s)
- Masako Toda
- Department of Oral Growth and Development, Division of Pediatric Dentistry, Fukuoka Dental College, Fukuoka, Japan
| | - Jun Ohno
- Department of Morphological Biology, Division of Pathology, Fukuoka Dental College, Fukuoka, Japan.
| | - Yosuke Shinozaki
- Department of Oral Rehabilitation, Section of Fixed Prosthodontics, Fukuoka Dental College, Fukuoka, Japan
| | - Masao Ozaki
- Department of Oral Growth and Development, Division of Pediatric Dentistry, Fukuoka Dental College, Fukuoka, Japan
| | - Tadao Fukushima
- Research Center for Regenerative Medicine, Fukuoka Dental College, Fukuoka, Japan
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Fatati G, Grandone I, Palazzi M, Weber P, Mirri E. Use of neutral protamine lispro insulin (NPL) in patients with hyperglycemia receiving parenteral nutrition. Clin Ter 2014; 165:e17-e23. [PMID: 24589955 DOI: 10.7417/ct.2014.1666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIMS Nutritional support with parenteral nutrition (PN), a key component in the care of critically ill patients, usually requires insulin therapy in patients with diabetes or may require insulin treatment in patients not known to be diabetic. We wanted verify whether it is possible to use neutral protamine lispro (NPL) in double administration monotherapy in patients receiving artificial nutrition (AN) and if the same NPL is capable of obtaining and maintaining acceptable glycemic control without inducing hypoglycemia. PATIENTS AND METHODS We studied 18 consecutive patients, who were not taking insulin, they needed to start artificial nutrition, and presenting at least two consecutive blood glucose > 120 mg/dL. Each patient was given at least 1 U of insulin for every 10 grams of glucose infused. RESULTS Eighteen consecutive patients, not stratified in any way, were judged eligible in the last 24 months, with a mean age of 71 years (range 54-85 yrs). All patients were evaluated after 2, 3 and 5 days of treatment; only 1 patient has not been evaluated to 5 days. Mean glycemic values on days 2, 3, 5 were in range between 145 and 180 mg/dL. Any adjustments in NPL dose were carried out by the team of nutrition and there was no hypoglycemia that required medical intervention in emergency. CONCLUSIONS Our impression is that also lispro protamine insulin (NPL) in double subcutaneous administration may contribute to improving the glycemic values in patients receiving parenteral nutrition with hyperglycemia.
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Affiliation(s)
- G Fatati
- Units of Diabetology, Dietology and Clinical Nutrition, "S. Maria" Hospital, Terni, Italy
| | - I Grandone
- Units of Diabetology, Dietology and Clinical Nutrition, "S. Maria" Hospital, Terni, Italy
| | - M Palazzi
- Units of Diabetology, Dietology and Clinical Nutrition, "S. Maria" Hospital, Terni, Italy
| | - P Weber
- Units of Health Management, "S. Maria" Hospital, Terni, Italy
| | - E Mirri
- Units of Diabetology, Dietology and Clinical Nutrition, "S. Maria" Hospital, Terni, Italy
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Cao M, Deng X, Su S, Zhang F, Xiao X, Hu Q, Fu Y, Yang BB, Wu Y, Sheng W, Zeng Y. Protamine sulfate-nanodiamond hybrid nanoparticles as a vector for MiR-203 restoration in esophageal carcinoma cells. Nanoscale 2013; 5:12120-12125. [PMID: 24154605 DOI: 10.1039/c3nr04056a] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
We report an innovative approach for miRNA-203 delivery in esophageal cancer cells using protamine sulphate (PS)-nanodiamond (ND) nanoparticles. The efficient delivery of miR-203 significantly suppressed the proliferation and migration of cancer cells through targeting Ran and ΔNp63, exhibiting a great potential for PS@ND nanoparticles in miRNA-based cancer therapy.
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Affiliation(s)
- Minjun Cao
- College of Life Science and Bioengineering, Beijing University of Technology, No. 100 Pingleyuan, Beijing, 100124, P.R. China.
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Tong HP, Wang LF, Guo YL, Li L, Fan XZ, Ding J, Huang HY. Preparation of protamine cationic nanobubbles and experimental study of their physical properties and in vivo contrast enhancement. Ultrasound Med Biol 2013; 39:2147-2157. [PMID: 23932278 DOI: 10.1016/j.ultrasmedbio.2013.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 05/17/2013] [Accepted: 05/24/2013] [Indexed: 06/02/2023]
Abstract
In this study, we aimed to prepare a novel type of microbubble (MB), protamine cationic nanobubble (NB), to provide a new vector for tumor gene therapy. We prepared cationic NBs with protamine and other lipid components using mechanical oscillation. The protamine cationic NBs had a mean diameter of 521.2 ± 37.57 nm, a zeta potential of +18.5 mV, and a gene-carrying capacity of 15.69 μg androgen receptor (AR) siRNA per 10(8) NBs. The cationic NBs exhibited superior contrast enhancement for in vivo imaging compared with SonoVue (Bracco, Geneva, Switzerland), and their physical properties did not change significantly after 1 wk; meanwhile, the transfection efficiency of the cationic NBs in androgen-independent prostate cancer cells mediated by ultrasound irradiation was better than that of liposomes (82.17 ± 7.4% vs. 55.04 ± 5.4%, p < 0.01). Therefore, the protamine cationic NB can be considered for use as a novel type of gene-loading MB for ultrasound imaging and MB-mediated gene therapy of tumors.
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Affiliation(s)
- Hai-Peng Tong
- Department of Ultrasound, Southwest Hospital, Third Military Medical University, Chongqing, China
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Pittalis A, Tuccillo ML, Savron F, Schember C, Morri D, Dell'Oste C. Pediatric enoxaparin overdose: more attention to thromboelastography monitoring. Minerva Anestesiol 2013; 79:1203-1204. [PMID: 23558766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- A Pittalis
- Anesthesia and Intensive Care Unit. Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste - Italy -
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25
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Liu Q, Chen YX, Ni L, Chen Y, Liu CW. [Clinical observation of neutralizing heparin with protamine in carotid endarterectomy]. Zhonghua Yi Xue Za Zhi 2013; 93:2650-2653. [PMID: 24360046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the effects of administrating protamine to reverse heparin on intraoperative hemostatic time, postoperative drainage and postoperative complications in carotid endarterectomy. METHODS A retrospective cohort study of 125 cases of carotid endarterectomy was undertaken at Department of Vascular Surgery, Peking Union Medical Hospital in 2012. They were divided into 2 groups: heparin (H group) and heparin + intra-operative administration of protamine (H+P group). Their medical history, preoperative clinical findings, intraoperative hemostatic time, postoperative drainage volume and complications were compared between two groups and statistically analyzed. RESULTS Fifty cases received heparin alone and 75 cases had heparin reversal with protamine. Drainage volumes at Day 1 postoperation were less in H+P group than those in H group with statistically significant difference ((14 ± 13) vs (19 ± 12) ml, P = 0.038). And total postoperative drainage volumes were less in H+P group with statistical significant difference ((20 ± 17) vs (26 ± 15) ml, P = 0.035). Intraoperative hemostatic time was less in H+P group than that in H group with statistical significant difference ((30 ± 11) vs (36 ± 11) min, P = 0.030). There was no mortality. Only one case was re-operated for cervical hematoma. Cerebral ischemic symptoms of one patient in the H+P group became worse postoperatively and recovered after conservative medical treatment. CONCLUSIONS During carotid endarterectomy, the application of protamine may significantly decrease intraoperative hemostatic time and postoperative wound drainage. And protamine has no effect of increasing the risks of perioperative stroke.
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Affiliation(s)
- Qi Liu
- Department of Vascular Surgery, Peking Union Medical Hospital, Beijing 100730, China
| | - Yue-xin Chen
- Department of Vascular Surgery, Peking Union Medical Hospital, Beijing 100730, China
| | - Leng Ni
- Department of Vascular Surgery, Peking Union Medical Hospital, Beijing 100730, China
| | - Yu Chen
- Department of Vascular Surgery, Peking Union Medical Hospital, Beijing 100730, China
| | - Chang-wei Liu
- Department of Vascular Surgery, Peking Union Medical Hospital, Beijing 100730, China.
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Chen DY, Chen CC, Hsieh IC. Hemoptysis caused by saphenous vein graft perforation during percutaneous coronary intervention. J Invasive Cardiol 2013; 25:E8-E10. [PMID: 23293186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Percutaneous coronary intervention carries the risk of coronary artery perforation, which may lead to serious adverse effects such as cardiac tamponade, myocardial infarction, and even death. We describe a patient who developed hemoptysis immediately after saphenous vein graft rupture, which is a rare complication during coronary intervention. Stenting using a covered stent, along with simultaneous administration of protamine, helped seal the vein graft perforation and stop the hemoptysis.
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Affiliation(s)
- Dong-Yi Chen
- Second Section of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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27
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Quirke M, O'Donnell JJ. Razor blades, heparin and protamine--a potent mix. Ir Med J 2011; 104:126. [PMID: 21675101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Hompesch M, Ocheltree SM, Wondmagegnehu ET, Morrow LA, Kollmeier AP, Campaigne BN, Jacober SJ. Pharmacokinetics and pharmacodynamics of insulin lispro protamine suspension compared with insulin glargine and insulin detemir in type 2 diabetes. Curr Med Res Opin 2009; 25:2679-87. [PMID: 19761358 DOI: 10.1185/03007990903223739] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The primary aim was to evaluate duration of action of a single 0.8 U/kg dose of insulin lispro protamine suspension (ILPS) in type 2 diabetes (T2DM) patients; secondarily to compare onset and duration of action of ILPS, glargine (G), and detemir (D) (0.8 U/kg) and evaluate pharmacokinetic (PK) and pharmacodynamic (PD) dose responses of ILPS. RESEARCH DESIGN AND METHODS In a single-center, double-blind, five-arm crossover study, 34 patients were randomized to a treatment sequence which included a single subcutaneous 0.8 U/kg dose of G and D and three doses of ILPS (0.4 U/kg, 0.8 U/kg, and 1.2 U/kg) and were studied using 24-hour euglycemic glucose clamps. PRIMARY OUTCOME MEASURE Duration of action was determined as the time to the last measurable glucose infusion rate (tR(last)) during glucose clamps. RESULTS The duration of insulin action (tR(last)) for ILPS at 0.8 U/kg was >23 hours and was similar to G (p = 0.114) and D (p = 0.570). Post-hoc analysis demonstrated the probability of achieving 24 hours of glucose-lowering activity after a 0.8 U/kg dose: 48% (ILPS), 43% (G), and 26% (D). G(tot) and R(max) were significantly greater for ILPS versus G or D. The median ILPS time-dependent values demonstrated a significantly earlier maximum PD response (tR(max) and early 50% tR(max)) versus either G or D. ILPS demonstrated dose-dependent increases in PK and PD measures across the dose range. CONCLUSIONS Following a single 0.8 U/kg dose in T2DM patients, ILPS, G, and D demonstrated similar durations of glucose-lowering activity and ILPS demonstrated significantly greater glucose-lowering activity (R(max) and G(tot)) and earlier maximum PD response. These results potentially support once-daily dosing of ILPS in T2DM. LIMITATIONS The observed number of 24-hour censored observations was higher than expected and the wash-out period for basal insulin treated patients may have been too short to definitively rule out a carry-over effect; however, such an effect, if present, would potentially only affect onset of action and not the primary outcome measure.
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Affiliation(s)
- Marcus Hompesch
- Profil Institute for Clinical Research, Inc., San Diego, CA, USA
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29
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Gao Y, Pan CY, Zou DJ, Xu ZR, Liu XM, Guo XH. [Postprandial glycemic control using insulin aspart with NPH in inadequately controlled diabetics]. Zhonghua Yi Xue Za Zhi 2009; 89:1960-1963. [PMID: 19950569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of insulin aspart (IAsp) and human insulin (HI) when applied as meal-time insulin with neutral protamine Hagedorn insulin (NPH) at bedtime in diabetics. METHODS A total of 220 Chinese subjects with type 1 or type 2 diabetes from 5 different hospitals were randomized by a ratio of 1:1 into two groups accepting IAsp or HI combined with NPH respectively. The main endpoints were assessed by fasting plasma glucose (FPG), 2 hour postprandial plasma glucose (2 h PPG), HbAlc and hypoglycemia. RESULTS A greater reduction in mean 2 h PPG was achieved in the IAsp group [(14.6 +/- 5.3) mmol/L] as compared with the HI group [(8.4 +/- 4.1) mmol/L] (P < 0.01, adjusted for baseline value, center effect and diabetes type). Significantly more IAsp-treated subjects reached the 2 h PPG target (50.0% vs 25.5%, P < 0.01). HbA1c was reduced more in IAsp/NPH group [(9.3 +/- 1.4)% vs (7.7 +/- 1.3)%] than in HI/NPH group [(9.2 +/- 1.2)% vs (7.7 +/- 1.2)%]. HbA1c target was reached by 24.5% (IAsp) vs 14.5% (HI) of subjects (P < 0.05). No major hypoglycemia or serious adverse events were observed for the IAsp group. Lower incidence of nocturnal hypoglycemia (IAsp/NPH: 3% vs HI/NPH: 4%) was reported in the IAsp group. Average daily insulin doses were 0.60/0.23 (IAsp/NPH) and 0.65/0.24 (HI/NPH) IU/kg respectively. CONCLUSION Treatment of IAsp in basal-bolus therapy in combination with NPH provides a superior postprandial glucose control and allows more subjects to reach the glycemic target without elevating the nocturnal hypoglycemic risk or adverse events.
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Affiliation(s)
- Yan Gao
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, China.
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30
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Gilchrist IC. Seal it to heal it: potential option for distal wire perforation. Catheter Cardiovasc Interv 2009; 73:795-6. [PMID: 19367633 DOI: 10.1002/ccd.22071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Fealy N, Baldwin I, Johnstone M, Egi M, Bellomo R. A pilot randomized controlled crossover study comparing regional heparinization to regional citrate anticoagulation for continuous venovenous hemofiltration. Int J Artif Organs 2007; 30:301-7. [PMID: 17520566 DOI: 10.1177/039139880703000404] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a regional heparinization and a regional citrate method of anticoagulation in CVVH. DESIGN Randomized controlled cross-over study. SUBJECTS Ten critically ill patients with acute renal failure. SETTING ICU of tertiary hospital. INTERVENTION CVVH was performed with pre-filter fluid replacement at 2000 ml/h and a blood flow rate of 150 ml/min. Regional heparinization was by the administration of heparin pre-filter at 1500 IU/h and protamine post-filter at 15 mg/h. Regional citrate anticoagulation was by means of a citrate-based replacement fluid (14 mmol/L) administered pre-dilution. RESULTS We studied nine males and one female. The mean age and APACHE II score were 70.5 and 17 respectively. Median circuit life was 13 hours (IQR 9.28) for the regional heparinization method compared to 17 hours (IQR 12,19.5) for the regional citrate method (p=0.77). There were no episodes of bleeding in either group. CONCLUSION Regional heparinization and regional citrate anticoagulation achieve similar circuit life in critically ill patients receiving CVVH.
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Affiliation(s)
- N Fealy
- Department of Intensive Care, Austin Hospital, Melbourne - Australia
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Torjemane L, Guermazi S, Ladeb S, Ben Romdhane N, Lakhal A, Abdelkefi A, Ben Othman T, Ben Abdelhadhim A. Heparin-like anticoagulant associated with multiple myeloma and neutralized with protamine sulfate. Blood Coagul Fibrinolysis 2007; 18:279-81. [PMID: 17413766 DOI: 10.1097/mbc.0b013e32809cc946] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 55-year-old man with multiple myeloma developed sustained bleeding after bone marrow aspiration and cutaneous bleeding. Routine coagulation studies revealed a prolonged activated partial thromboplastin time and thrombin time (> 60 s) with a normal reptilase time. Further evaluation showed failure of the activated partial thromboplastin time to correct completely in a 1: 1 mixture with normal plasma. Treatment of the patient's plasma in vitro with protamine sulfate normalized the thrombin time. The presence of a heparin-like anticoagulant was suspected. The plasma heparin level was 0.73 IU/ml. Intravenous infusion of protamine sulfate appeared to neutralize the anticoagulant activity and stop the bleeding. The cancer cells themselves or the invasive nature of this type of cancer might result in a massive release of a heparinoid. Such coagulopathy appears to be a rare mechanism of bleeding and it is an important entity to consider since it is potentially reversible with protamine sulfate.
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Affiliation(s)
- Lamia Torjemane
- Centre National de Greffe de Moelle Osseuse de Tunis, Tunis, Tunisia.
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Shirakabe A, Takano H, Nakamura S, Kikuchi A, Sasaki A, Yamamoto E, Kawashima S, Takagi G, Fujita N, Aoki S, Asai K, Yoshikawa M, Kato K, Yamamoto T, Takayama M, Takano T. Coronary perforation during percutaneous coronary intervention. Int Heart J 2007; 48:1-9. [PMID: 17379974 DOI: 10.1536/ihj.48.1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Coronary perforation is an undesirable complication during percutaneous coronary intervention (PCI). We reviewed the cases of overt coronary perforation in our institute and analyzed their clinical backgrounds, the characteristics of the target lesion, management, and clinical outcomes. Between 1991 and 2005, we experienced 12 cases (0.35%) of coronary perforation in a total of 3415 PCI procedures. The perforation occurred during the use of debulking devices in 3 cases, immediately after stenting in 2, immediately after postdilatation of the stent in 2, and during wiring in 3 cases. Restoration was attempted by long inflation of a balloon in 7 cases, implantation of a covered stent graft in 1, and emergency surgical repair in 1 case. Subsequent cardiac tamponade occurred in 3 patients who required pericardiocentesis, and 1 patient died due to congestive heart failure. Administration of protamine was effective in stopping the bleeding in 6 patients, whereas continuation of antiplatelet therapy resulted in no overt rebleeding. Coronary perforation during PCI is a rare complication but is associated with significant morbidity and mortality. Intravenous administration of protamine is effective when it is used in conjunction with nonsurgical devices for initial management of perforation.
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Affiliation(s)
- Akihiro Shirakabe
- First Department of Internal Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
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Patel AA, Clyne CA, Henyan NN, White CM, Zembrowski BF, Migeed M, Yarlagadda R, Kluger J, Coleman CI. The use of protamine after radiofrequency catheter ablation: A pilot study. J Interv Card Electrophysiol 2007; 18:155-8. [PMID: 17318446 DOI: 10.1007/s10840-006-9063-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Accepted: 11/22/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Evaluate the effect of administering intravenous protamine immediately post-radiofrequency catheter ablation (RFCA) on thrombotic and bleeding complications in heparinized patients. METHODS Heparinized patients that had RFCA for atrial or ventricular arrhythmias at our institution between January 2001 and March 2006 and had a complete data set were included in this cohort evaluation. Patients receiving at least one dose of protamine within 15 min of RFCA were deemed the prophylactic group while those not receiving protamine within 15 min were the control group. Thrombotic (cerebrovascular event, transient ischemic attack, pulmonary embolism, deep vein thrombosis, or myocardial infarction) and bleeding events (blood loss requiring transfusion, hematoma requiring intervention, or intracranial hemorrhage) were compared between groups. RESULTS Overall, 158 patients (74% male, 55 +/- 13.5) met inclusion criteria. Of these, 73.4% received prophylactic protamine (average dose = 39 mg +/- 17). Only one patient (0.9%) in the prophylactic protamine group and zero patients in the control group experienced a thrombotic event (p > 0.99). Only two patients (1.7%) in the protamine group (n = 2 blood transfusions) and zero patients in the control group experienced bleeding events (p = 0.839). CONCLUSIONS Administering prophylactic intravenous protamine to allow for quicker catheter removal following RFCA in heparinized patients did not markedly impact thrombotic or bleeding complication rates in our population. The perceived benefit in our institution to protamine administration in this population is a reduction in postoperative patient immobilization and discomfort, reduced PACU nursing care, and earlier time to discharge. Given the low rate of thrombotic and bleeding events, a study of several thousand patients would be needed to fully evaluate the impact on these events.
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Affiliation(s)
- Aarti A Patel
- Division of Cardiology, Hartford Hospital, Hartford, CT 06102, USA
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Jiang L, Yu JF. [Measurement of activated clotting time during cardiopulmonary bypass in infective endocarditis patients]. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2007; 32:167-9. [PMID: 17344611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To investigate the proper dosage of heparin and protamin in treating the patients with infective endocarditis (IE) during the operation. METHODS Activated clotting time (ACT) was measured during and after cardiopulmonary bypass (CPB) in 30 patients with IE and 30 patients with rheumatic heart disease (RHD) respectively. RESULTS The dosage of heparin before bypass in IE group was significantly higher than that of RHD group (P<0.05); the dosage of protamin for neutralization after bypass in IE group was significantly higher than that of RHD group (P<0.05); the ratio of protamin and heparin were 0.76 +/-0.23 in IE group and 0.74 +/-0.12 in RHD group (P>0.05). CONCLUSION The dosage of protamin should be increased to 3 mg/kg as the heparin is over 400 U/kg before CPB in the patient with IE, but the ratio of protamin and heparin will not be obviously changed.
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Affiliation(s)
- Ling Jiang
- Department of Cardiothoracic Suergery, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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Patel AA, White CM, Coleman CI. Use of protamine to rapidly reverse anticoagulant effect of unfractionated heparin in patients undergoing percutaneous coronary intervention. Conn Med 2007; 71:93-5. [PMID: 17393902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Aarti A Patel
- Hartford Hospital, 80 Seymour Street, CB309, Harford, USA
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37
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Charnaia MA, Klypa TV, Morozov IA, Shmerko NP, Gladysheva VG, Andriianova AA. [Impact of protamine sulfate on hemostasis system after operations with artificial circulation]. Khirurgiia (Mosk) 2007:17-20. [PMID: 17828120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Effects of different doses and lots of protamine sulfate on hemostasis system after cardiac operations with artificial circulation are analyzed. Overall 982 patients underwent cardiac operations with artificial circulation. Quality and purity of protamine may be the causes of side effects. Negative effect of high doses of protamine on hemostasis system is demonstrated. Thrombocyte dysfunction is the main cause of intensive postoperative bleeding after administration of protamine high doses.
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Wiernikowski JT, Chan A, Lo G. Reversal of anti-thrombin activity using protamine sulfate. Experience in a neonate with a 10-fold overdose of enoxaparin. Thromb Res 2006; 120:303-5. [PMID: 17079003 DOI: 10.1016/j.thromres.2006.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Revised: 07/27/2006] [Accepted: 08/03/2006] [Indexed: 11/22/2022]
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Toomey JR, Abboud MA, Valocik RE, Koster PF, Burns-Kurtis CL, Pillarisetti K, Danoff TM, Erhardt JA. A comparison of the beta-D-xyloside, odiparcil, to warfarin in a rat model of venous thrombosis. J Thromb Haemost 2006; 4:1989-96. [PMID: 16961606 DOI: 10.1111/j.1538-7836.2006.02064.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND A significant need exists for new chronic oral anticoagulation therapies to replace warfarin. Previous studies have shown that beta-D-xylosides, which prime glycosaminoglycan (GAG) synthesis, have antithrombin and antithrombotic activity. In the following report, a new orally active beta-D-xyloside (odiparcil) has been characterized in a rat model of venous thrombosis and its efficacy and bleeding liability compared to warfarin. Additionally, studies were conducted to investigate odiparcil's ex vivo antithrombin and antiplatelet activity, and also to explore the potential utility of protamine sulfate as a neutralizing agent. METHODS AND RESULTS In vivo thrombosis studies were conducted in a rat inferior vena cava model, and bleeding studies in a rat tail transection model. Following oral dosing, warfarin and odiparcil produced dose-related suppression of thrombus formation. A therapeutically relevant dose of warfarin in this model (international normalized ratio; INR 3.0) achieved approximately 65% inhibition of thrombus formation. Warfarin caused dose-related significant increases in bleeding indices. Odiparcil antithrombotic activity was limited by its mechanism to a maximum suppression of thrombus formation of 65-70%, and did not prolong bleeding indices. Additionally, odiparcil-induced heparin cofactor II (HCII)-dependent antithrombin activity was shown to be a function of dermatan sulfate-like GAG production. Other than thrombin-related effects, no odiparcil effects on platelet function were observed. In antidote studies, it was demonstrated that odiparcil-induced antithrombotic activity could be partially neutralized by protamine sulfate. CONCLUSIONS These experiments suggest that an antithrombotic approach based upon xyloside induction of circulating GAGs may have the potential to approximate the efficacy of warfarin and yet with a reduced risk to hemostasis.
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Affiliation(s)
- J R Toomey
- Cardiovascular and Urogenital Diseases Center of Excellence, GlaxoSmithKline, King of Prussia, PA, USA.
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Abutaleb N. The problem of unintended anticoagulation in hemodialyis patients. Saudi J Kidney Dis Transpl 2006; 17:230-1. [PMID: 16903633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
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Dyke CM, Smedira NG, Koster A, Aronson S, McCarthy HL, Kirshner R, Lincoff AM, Spiess BD. A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: The EVOLUTION-ON study. J Thorac Cardiovasc Surg 2006; 131:533-9. [PMID: 16515902 DOI: 10.1016/j.jtcvs.2005.09.057] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 10/06/2005] [Accepted: 10/20/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Unfractionated heparin and its antidote, protamine sulfate, allow for rapid and reversible anticoagulation during cardiac surgery with cardiopulmonary bypass, yet limitations exist, including a variable dose-response, dependence on a cofactor for anticoagulant effect, and antigenic potential. This trial was performed to evaluate the safety and efficacy of bivalirudin as an alternative to heparin with protamine reversal in on-pump cardiac surgery. METHODS We conducted a randomized, open-label, multicenter trial comparing heparin with protamine reversal to bivalirudin in patients undergoing cardiac surgery with cardiopulmonary bypass. The primary objective was to demonstrate comparable rates of in-hospital procedural success defined as freedom from death, Q-wave myocardial infarction, stroke, or repeat revascularization. Twenty-one institutions enrolled 101 patients randomized to bivalirudin and 49 patients to heparin treatment. RESULTS The primary end point of procedural success was not significantly different between the bivalirudin arm and the heparin/protamine arms at 7 days, 30 days, or 12 weeks' follow-up. Adequate anticoagulation was achieved in all patients. Secondary end points including mortality, 24-hour blood loss, overall incidence of transfusions, and duration of surgery were similar between the two arms. CONCLUSIONS Bivalirudin is a safe and effective anticoagulant for patients undergoing a wide range of cardiac surgical procedures with cardiopulmonary bypass. Procedural success rates with bivalirudin were similar to rates in patients receiving heparin anticoagulation, with no difference in mortality. Avoidance of blood stasis and attention to the intraoperative medical management of patients is critical for successful use of bivalirudin during cardiopulmonary bypass.
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Affiliation(s)
- Cornelius M Dyke
- Carolina Cardiovascular and Thoracic Surgery Associates, Gaston Memorial Hospital, Gastonia, NC 28056, USA.
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Kaneda H, Suzuki J, Hosokawa G, Tanaka S, Hiroe Y, Saito S. Impact of heparin neutralization by protamine on restenosis after coronary stent implantation. Int J Cardiol 2006; 105:111-2. [PMID: 16207558 DOI: 10.1016/j.ijcard.2004.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 11/13/2004] [Indexed: 11/28/2022]
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Baufreton C, Corbeau JJ, Pinaud F. [Inflammatory response and haematological disorders in cardiac surgery: toward a more physiological cardiopulmonary bypass]. ACTA ACUST UNITED AC 2006; 25:510-20. [PMID: 16488106 DOI: 10.1016/j.annfar.2005.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 12/23/2005] [Indexed: 10/25/2022]
Abstract
The systemic inflammatory response in cardiac surgery is closely related to the haemostasis disturbances. It is responsible of a significant morbidity and mortality that was previously suspected to be caused by cardiopulmonary bypass alone. However, it is time now to clearly identify the factors that are material-dependent from that material-independent. From this point of view, off-pump surgery allowed for better comprehension of the multiple sources of the inflammatory response. Numerous pathways are activated, involving complement, platelets, neutrophiles and monocytes. The tissue pathway of the coagulation system, through tissue factor, is of major importance and has to be surgically considered in order to reduce the whole body inflammatory response postoperatively. The quality of the extracorporeal perfusion through its consequences on organ perfusion, particularly in the splanchnic area, also participates to this pathophysiological process. Beyond the progress of technology provided by the industry, particularly the minimally extracorporeal circulation derived from off-pump surgery evolution, the surgical approach is of major importance in the control of the systemic inflammatory response and must not be ignored yet.
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Affiliation(s)
- C Baufreton
- Service de Chirurgie Cardiaque et Département d'Anesthésie-Réanimation, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France.
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Smedira NG, Dyke CM, Koster A, Jurmann M, Bhatia DS, Hu T, McCarthy HL, Lincoff AM, Spiess BD, Aronson S. Anticoagulation with bivalirudin for off-pump coronary artery bypass grafting: the results of the EVOLUTION-OFF study. J Thorac Cardiovasc Surg 2006; 131:686-92. [PMID: 16515924 DOI: 10.1016/j.jtcvs.2005.10.049] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Revised: 10/10/2005] [Accepted: 10/20/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Unfractionated heparin has many shortcomings, including indirect and partial inhibition of thrombin, antibody formation, and platelet activation. Bivalirudin, a short-acting direct thrombin inhibitor, avoids these limitations and has superior outcomes during percutaneous revascularization. This trial was performed to evaluate the safety and efficacy of bivalirudin in off-pump coronary artery bypass grafting. METHODS An open-label, multicenter randomized trial compared heparin with protamine reversal to bivalirudin in patients undergoing off-pump coronary artery bypass. The primary objective was safety as demonstrated by similar rates of procedural success defined as freedom from a composite of death, myocardial infarction, stroke, and repeat revascularization. Twenty-one institutions randomized 105 patients to receive bivalirudin and 52 patients to receive heparin. RESULTS The mean age was 65 years for both groups. The bivalirudin group had more grafts: 3.0 +/- 1 versus 2.5 +/- 1. Procedural success rates at 30 days were identical in bivalirudin- and heparin-treated patients (93%). Operative times, total blood loss, reoperations for bleeding, and major adverse events were not significantly different. Strokes were more frequent in the heparin group: 5.5% versus 0; P = .05. Mortality was 2% in each group. Repeat revascularization was required in 3% of bivalirudin- and 2% of the heparin-treated patients. CONCLUSIONS For patients undergoing off-pump coronary artery bypass grafting, bivalirudin was an effective anticoagulant, without excessive bleeding and with a safety profile similar to that of heparin. Further trials are warranted to assess whether anticoagulation with bivalirudin improves clinical outcomes.
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Charnaia MA, Morozova IA, Gladysheva VG. [Protamin-sulfate in cardiac surgery: between Scilla and Haribda]. Khirurgiia (Mosk) 2006:45-9. [PMID: 17419491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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Cui Z, Huang L. Liposome-polycation-DNA (LPD) particle as a carrier and adjuvant for protein-based vaccines: therapeutic effect against cervical cancer. Cancer Immunol Immunother 2005; 54:1180-90. [PMID: 15846491 PMCID: PMC11032885 DOI: 10.1007/s00262-005-0685-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Accepted: 02/07/2005] [Indexed: 12/12/2022]
Abstract
With the successful identification of many tumor-specific antigens, tumor-associated antigens, and the potential of using unfractioned tumor cell derivatives as tumor antigens, a system and/or adjuvant that can deliver these antigens and help them to induce strong and effective anti-tumor immune responses is greatly needed. Previously, we reported that a MHC class I-restricted peptide epitope derived from human papillomavirus (HPV) 16 E7 protein, when incorporated into a clinically proven safe LPD (liposome-polycation-DNA) particle, was able to effectively eradicate tumors established in mice. Cervical cancer is the second most common cancer among women worldwide. HPV infection is clearly linked to this cancer. Vaccines based on the early (E) gene products of HPV could be effective in controlling it. However, besides the fact that epitope vaccines have many limitations particularly, concerning the diverse HLAs in humans, the use of the epitope as an antigen prevented us from fully characterizing the immune responses induced by the LPD as a vaccine carrier and/or adjuvant in previous studies. In the present study, by using the HPV 16 E7 protein as an antigen, we first showed that LPD, as a vaccine carrier and adjuvant induced strong and robust immune responses, both cellular and antibody. We then showed that immunization with LPD particles incorporated with either the wild type HPV 16 E7 protein or a potentially safer mutant induced strong immune responses that caused complete regressions of a model cervical cancer tumor established in murines. LPD could be a potent vaccine carrier and/or adjuvant for many antigens.
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Affiliation(s)
- Zhengrong Cui
- Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, 633 Salk Hall, Pittsburgh, PA 15213 USA
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, OR 97331 USA
| | - Leaf Huang
- Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, 633 Salk Hall, Pittsburgh, PA 15213 USA
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Rauova L, Zhai L, Kowalska MA, Arepally GM, Cines DB, Poncz M. Role of platelet surface PF4 antigenic complexes in heparin-induced thrombocytopenia pathogenesis: diagnostic and therapeutic implications. Blood 2005; 107:2346-53. [PMID: 16304054 PMCID: PMC1895727 DOI: 10.1182/blood-2005-08-3122] [Citation(s) in RCA: 183] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) antibodies recognize complexes between heparin and platelet factor 4 (PF4). Heparin and PF4 bind HIT antibodies only over a narrow molar ratio. We explored the involvement of platelet surface-bound PF4 as an antigen in the pathogenesis of experimental HIT. We show that cell-surface PF4 complexes are also antigenic only over a restricted concentration range of PF4. Heparin is not required for HIT antibody binding but shifts the concentration of PF4 needed for optimal surface antigenicity to higher levels. These data are supported by in vitro studies involving both human and murine platelets with exogenous recombinant human (h) PF4 and either an anti-PF4-heparin monoclonal antibody (KKO) or HIT immunoglobulin. Injection of KKO into transgenic mice expressing different levels of hPF4 demonstrates a correlation between the severity of the thrombocytopenia and platelet hPF4 expression. Therapeutic interventions in this model using high-dose heparin or protamine sulfate support the pathogenic role of surface PF4 antigenic complexes in the etiology of HIT. We believe that this focus on surface PF4 advances our understanding of the pathogenesis of HIT, suggests ways to identify patients at high risk to develop HIT upon heparin exposure, and offers new therapeutic strategies.
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Affiliation(s)
- Lubica Rauova
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Pretorius M, Scholl FG, McFarlane JA, Murphey LJ, Brown NJ. A pilot study indicating that bradykinin B2 receptor antagonism attenuates protamine-related hypotension after cardiopulmonary bypass. Clin Pharmacol Ther 2005; 78:477-85. [PMID: 16321614 DOI: 10.1016/j.clpt.2005.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Accepted: 08/08/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The administration of protamine to patients who received heparin during cardiopulmonary bypass (CPB) induces hypotension. Protamine inhibits the carboxypeptidase N-mediated degradation of bradykinin, a peptide that causes vasodilation and tissue-type plasminogen activator (t-PA) release. This study tests the primary hypothesis that blocking the bradykinin B(2) receptor would attenuate protamine-related hypotension. METHODS We conducted a prospective, double-blind, randomized study in 16 adult male patients undergoing elective cardiac surgery requiring CPB and taking an angiotensin-converting enzyme (ACE) inhibitor preoperatively, because ACE inhibition increases bradykinin concentrations during CPB. Subjects were randomized to receive either saline solution (N = 8) or the bradykinin B(2) receptor antagonist HOE 140 (100 mug/kg, N = 8) before the administration of protamine. Mean arterial pressure (MAP) and t-PA activity were measured intraoperatively and before and after protamine administration. RESULTS Protamine administration caused a significant increase in bradykinin concentrations in the saline solution group (from 6.0 +/- 1.3 to 10.0 +/- 1.6 fmol/mL, P = .043), as well as the HOE 140 group (from 6.5 +/- 1.8 to 14.3 +/- 4.6 fmol/mL, P = .042). Protamine significantly decreased MAP in the saline solution group (from 69.8 +/- 4.4 mm Hg to a mean individual nadir of 56.1 +/- 2.6 mm Hg, P = .031), but bradykinin receptor antagonism blunted this effect (from 74.3 +/- 3.7 mm Hg to a mean individual nadir of 69.6 +/- 1.2 mm Hg in the HOE 140 group, P = .545). Hence, during protamine infusion, MAP was significantly lower in the saline solution group compared with the HOE 140 group (P = .002). t-PA activity decreased significantly during administration of HOE 140 (from 3.59 +/- 0.31 to 1.67 +/- 0.42 IU/mL, P = .001) but not during saline solution (from 2.12 +/- 0.48 to 1.44 +/- 0.36 IU/mL, P = .214). Similarly, t-PA activity decreased significantly during protamine administration in the HOE 140 group (from 1.67 +/- 0.42 to 0.77 +/- 0.26 IU/mL, P = .038) but not in the saline solution group (from 1.44 +/- 0.36 to 0.99 +/- 0.26 IU/mL, P = .132). CONCLUSION Increased bradykinin contributes to protamine-related hypotension through its B(2) receptor in ACE inhibitor-treated patients.
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Affiliation(s)
- Mias Pretorius
- Veterans Affairs Medical Center and Department of Anesthesiology, Vanderbilt University School of Medicine, 560 Robinson Research Building, Nashville, TN 37232, USA.
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Stafford-Smith M, Lefrak EA, Qazi AG, Welsby IJ, Barber L, Hoeft A, Dorenbaum A, Mathias J, Rochon JJ, Newman MF. Efficacy and safety of heparinase I versus protamine in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass. Anesthesiology 2005; 103:229-40. [PMID: 16052104 DOI: 10.1097/00000542-200508000-00005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemodynamic protamine reactions with heparin reversal during cardiac surgery are common and associated with adverse outcomes. As an alternative to protamine, the authors examined heparinase I reversal of heparin after aortocoronary bypass graft surgery. METHODS In a randomized, double-blind, double-dummy trial, 167 on- and off-pump aortocoronary bypass graft surgery patients received either heparinase I (maximum 35 microg/kg) or protamine (maximum 650 mg) for heparin reversal, monitored by activated clotting time values and clinical assessment. Hemodynamic parameters were recorded electronically; safety evaluation was to 30 days postoperatively. Noninferiority was predefined as 400 ml or less median 12-h chest tube drainage from intensive care unit arrival for heparinase I patients, after risk adjustment. Hemodynamic instability was defined as systemic hypotension (> or = 30 mmHg decrease) and/or pulmonary hypertension (> or = 40 mmHg with an increase > or = 10 mmHg) within 30 min of heparin reversal initiation. RESULTS Patient enrollment was terminated on advisement of the Data Safety Monitoring Board. Although heparinase I was noninferior for 12-h chest tube drainage, protamine had a superior safety profile. Overall, heparinase I subjects had longer hospital stays (P = 0.04), were more likely to experience a serious adverse event (P = 0.01), and were less likely to avoid transfusion (P = 0.006). A composite morbidity score was not different (P = 0.24), and similar rates of hemodynamic instability were observed between groups. Findings were consistent in analyses stratified by on- and off-pump surgery. CONCLUSIONS Heparinase I reverses heparin anticoagulation after aortocoronary bypass graft surgery but is not equivalent to protamine because of its inferior safety profile.
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Affiliation(s)
- Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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De Bels D, Demeere JL, Dugauquier J, Louis P, Van der Vorst E. Continuous infusion of factor VIIIc during heart surgery in a patient with haemophilia A. Eur J Anaesthesiol 2005; 21:984-6. [PMID: 15719864 DOI: 10.1017/s026502150423037x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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