Reversal of dabigatran by intraosseous or intravenous idarucizumab in a porcine polytrauma model

BACKGROUND

Idarucizumab is licensed to reverse dabigatran in life-threatening haemorrhage. Establishment of venous access can be challenging, and the intraosseous (IO) route is a potentially life-saving alternative. In this study, we compared the efficacy and safety of IO or intravenous (i.v.) idarucizumab for dabigatran reversal in a porcine polytrauma model.

METHODS

Male pigs (n=21) received oral dabigatran etexilate (30 mg kg^-1 bid) for 3 days. On the 4th day, animals received dabigatran infusion and were randomised 1:1:1 to receive IO saline (control), i.v. idarucizumab (60 mg kg^-1), or IO idarucizumab (60 mg kg^-1), or animals were included in a sham group (n=7). Study treatment was administered after polytrauma and the animals were monitored for 240 min, or until death. Coagulation status was monitored by thromboelastometry, thromboelastography, and thrombin measurements.

RESULTS

Total blood loss was lowest in sham animals [521 (52) ml, P<0.01 vs all other groups], and comparable in the two idarucizumab groups [IO: 1085 (102) ml vs i.v.: 1142 (125) ml], and highest in the control group [4065 (557) ml, P<0.001 vs all other groups]. Survival to 240 min was 100% in the sham group and both idarucizumab groups, and 14% in the control group. IO and i.v. idarucizumab promptly normalised global coagulation assays and thrombin generation. Thromboelastography showed a strong correlation between dabigatran concentrations and R-time (R²=0.90 and 0.89) in idarucizumab-treated animals.

CONCLUSIONS

Intravenous and intraosseous idarucizumab were comparable for reversing dabigatran in a porcine trauma model. Dabigatran reversal could be monitored using fully automated thromboelastography.

[Diabetes and heart failure : Update 2017]

Patients with diabetes mellitus exhibit an increased risk for the development of heart failure. The occurrence of heart failure in patients with diabetes is associated with a poor prognosis. Therapeutic strategies to reduce cardiovascular morbidity and mortality in diabetes have so far mainly focused on the prevention of coronary events but recent data suggest that an early diagnosis of heart failure in diabetes as well as specific therapies could have a major impact on the prognosis for these patients. This article aims to provide a comprehensive overview on the epidemiology, pathophysiology and prognosis of heart failure in diabetes patients and addresses current aspects of heart failure therapy in diabetes as well as diabetes therapy in heart failure patients.

Interaction of the Arabidopsis GTPase RabA4c with its effector PMR4 results in complete penetration resistance to powdery mildew

The (1,3)-β-glucan callose is a major component of cell wall thickenings in response to pathogen attack in plants. GTPases have been suggested to regulate pathogen-induced callose biosynthesis. To elucidate the regulation of callose biosynthesis in Arabidopsis thaliana, we screened microarray data and identified transcriptional upregulation of the GTPase RabA4c after biotic stress. We studied the function of RabA4c in its native and dominant negative (dn) isoform in RabA4c overexpression lines. RabA4c overexpression caused complete penetration resistance to the virulent powdery mildew Golovinomyces cichoracearum due to enhanced callose deposition at early time points of infection, which prevented fungal ingress into epidermal cells. By contrast, RabA4c(dn) overexpression did not increase callose deposition or penetration resistance. A cross of the resistant line with the pmr4 disruption mutant lacking the stress-induced callose synthase PMR4 revealed that enhanced callose deposition and penetration resistance were PMR4-dependent. In live-cell imaging, tagged RabA4c was shown to localize at the plasma membrane prior to infection, which was broken in the pmr4 disruption mutant background, with callose deposits at the site of attempted fungal penetration. Together with our interactions studies including yeast two-hybrid, pull-down, and in planta fluorescence resonance energy transfer assays, we concluded that RabA4c directly interacts with PMR4, which can be seen as an effector of this GTPase.

[Termination of pregnancy for fetal abnormality--a traumatic experience?]

The diagnosis of a lethal anomaly of the fetus can affect a pregnant woman in a traumatic way. Almost immediately she has to decide whether she wishes the pregnancy to be terminated or not. Literature shows that such a loss is very difficult to cope with, and can lead to social isolation and depression. Contrary to popular belief the loss felt by the woman is at least the same to that following a stillbirth. Problems arise when the woman has difficulties in expressing her feelings, has a lack of self-esteem or receives very little social support. The prenatal diagnosis evokes an acute grief reaction. Only few studies are available regarding length, course and severity of grief in this case. Although an abortion through a fetal anomaly is a traumatic experience, research is vague on the trauma caused. Present day research of the psychological sequelae after the termination will be summarized. In respect to the current trauma-research lies the question of which psychiatric conditions arise from such a traumatic experience.

Influence of forskolin on the force-frequency behavior in nonfailing and end-stage failing human myocardium

End-stage failing human myocardium is characterized by a negative force-frequency relationship (FFR), possibly as a result of reduced SR Ca2+ uptake capacity. We investigated the effects of the direct adenylate cyclase stimulator, forskolin, on force of contraction and FFR in isolated human myocardium from 7 nonfailing hearts (NF) and end-stage failing hearts (NYHA IV) due to either ischemic (ICM; n = 13) or dilated cardiomyopathy (DCM; n = 16).

METHODS

Isolated left ventricular muscle strips, isometric contraction, electrical stimulation at a basal stimulation rate of 1 Hz (37 degrees C). Inotropic responses: Cumulative concentration-response curves for forskolin (0.01-10 microM) and for Ca2+ (2.5-15 mM). Force-frequency experiments: stepwise increase in stimulation rate from 0.5 to 3.0 Hz without and in the presence of 0.3, 1.0 or 3.0 microM forskolin.

RESULTS

Forskolin concentration-dependently increased force of contraction to 386 +/- 28% (n = 5) in NF, to 256 +/- 48% (n = 7) in ICM, and to 212 +/- 13% (n = 14) in DCM. The effectiveness of forskolin was significantly reduced in failing myocardium. Ca2+ increased force of contraction to maximally 438 +/- 108% in NF, to 267 +/- 15% in ICM, and to 292 +/- 20% in DCM. Again, the effectiveness of Ca2+ was significantly reduced in failing myocardium. Forskolin activated contractile reserve to similar extents in all types of myocardium (90%, 95%, and 82%, respectively). Force of contraction continuously increased with increasing stimulation rates in nonfailing myocardium (positive FFR), but was blunted or inversed in ICM and DCM. Prestimulation with forskolin (0.3 microM) further enhanced frequency-potentiation in nonfailing, and normalized the slope and optimum stimulation frequency in ICM and DCM. However, at higher concentrations of forskolin, FFR was blunted or inversed in non-failing myocardium, and further impaired in failing myocardium.

CONCLUSION

Low concentrations of forskolin with only marginal inotropic effects may partially normalize the inverse force-frequency relation in end-stage failing human myocardium. Reduced cAMP levels in conjunction with reduced expression of SR Ca2+ ATPase may be the underlying cause for altered excitation-contraction coupling in diseased human hearts.

An enzyme-immunoassay for antibodies against hepatitis B core antigen: characteristics and clinical validation

An enzyme-immunoassay (EIA) for antibodies to hepatitis B core antigen (anti-HBc) was developed. The new test uses undiluted samples, incubated directly into an HBcAg coated well. Three alternative test procedures are possible. The stability of reagents was studied and a preclinical evaluation was performed intramurally. An assay correlation study was organised. We report the results of the external evaluation performed at 4 centres. A mean analytical sensitivity of 1.1, 1.2 and 0.36 PEI units/ml anti-HBc was found for procedure I (1 h/1 h/30 min), procedure II (30 min/30 min/30 min) and procedure III (16-20 h/1 h/30 min), respectively. In total, 5288 determinations on serum or plasma from various patients and healthy individuals were performed: 10% with procedure I, 52% with procedure II and 38% with procedure III. The qualitative (positive or negative) results were compared with those found with tests used routinely at the centres--47% with Corzyme (Abbott) and 53% with Corab (Abbott)--in a first screening. A final evaluation was made taking into account the repeatability of the results. Based on all results together, the agreement between the new EIA for anti-HBc and the routine tests was 97.6% at the first screening and increased to 99.0% after further evaluation.