Early in-hospital discontinuation of aspirin following coronary stent implantation in patients with indication for direct oral anticoagulation

Background and purpose

5–10% of patients undergoing percutaneous coronary intervention (PCI) have an indication for oral anticoagulation (OAC). Triple therapy, i.e. anticoagulation plus dual antiplatelet therapy, is associated with a high bleeding rate. Discontinuation of aspirin while continuing direct OAC (DOAC) and a P2Y12 inhibitor (so-called dual therapy) after PCI, was investigated in four randomized trials demonstrating a reduction in bleeding without significant differences in ischemic events. Since randomization was performed several days after the index PCI, these trials allowed for a short period of triple therapy. Whether exclusive procedural application of aspirin and early discontinuation of aspirin at the first postprocedural day is safe, is unknown and was the scope of this work.

Methods and results

We retrospectively analysed 3613 patients (4564 PCIs) treated from 2017 to 2020 at our centre. 871 (24.1%) patients (1059 PCIs, 23.2%) had an indication for OAC. In 284 PCIs with stenting, patients received DOAC (71.8% Rivaroxaban, 25.7% Apixaban, 1.8% Dabigatran, 0.7% Edoxaban) + P2Y12 inhibitor (100% clopidogrel) + aspirin only at the day of procedure (group 1). In 52 PCIs with stenting, patients received DOAC (59.6% Rivaroxaban, 34.6% Apixaban, 1.9% Dabigatran, 3.9% Edoxaban) + P2Y12 inhibitor (100% clopidogrel) + 100 mg aspirin/d at ≥1 postprocedural day (group 2). Based on our local patient database, we analysed the rate of ischemic events (myocardial infarction, stent thrombosis, stroke/transient ischemic attack (TIA), pulmonary/systemic embolism (PE/SE), deep vein thrombosis) as well as major and minor bleeding according to the Thrombolysis in Myocardial Infarction (TIMI) criteria during hospitalisation. Data are presented as mean±standard deviation or median (range).

Baseline characteristics were similar (group 1 vs. group 2: 74.3% vs. 73.1% male, age 75.9±8.5 vs. 74.3±9.3 years, atrial fibrillation 91.2% vs. 88.5%), except previous PE (3.5% vs. 11.5%; p=0.024), type of preprocedural DOAC (Rivaroxaban 52.5% vs. 34.6%; p=0.023) and creatinine clearance (62.4±19.7 vs. 68.9±20.3 ml/min; p=0.029). Median duration of postprocedural hospitalisation was 1 day for both groups (0–20 days vs. 1–21 days). In both groups, one TIA occurred (p=0.292), there were no other ischemic events. 36 (12.7%) bleeding events occurred in group 1 and 11 (21.2%) in group 2 (p=0.126). A subgroup analysis of cases being hospitalised for ≥2 postprocedural days (group 1: 87 cases, median 4 (2–20) days; group 2: 20 cases, median 2 (2–21) days) found no ischemic events and no difference regarding bleeding events (34.5% vs. 45.0%; p=0.443).

Conclusions

Exclusive procedural application of aspirin and start of dual therapy at the first postprocedural day appears safe regarding ischemic events in a real-world population. Nearly ¼ of patients undergoing PCI had an indication for OAC, which is much more frequent than previously reported.

Funding Acknowledgement

Type of funding sources: None.

Coupling Methylammonium and Formamidinium Cations with Halide Anions: Hybrid Orbitals, Hydrogen Bonding, and the Role of Dynamics

The electronic structures of four precursors for organic-inorganic hybrid perovskites, namely, methylammonium chloride and iodide, as well as formamidinium bromide and iodide, are investigated by X-ray emission (XE) spectroscopy at the carbon and nitrogen K-edges. The XE spectra are analyzed based on density functional theory calculations. We simulate the XE spectra at the Kohn-Sham level for ground-state geometries and carry out detailed analyses of the molecular orbitals and the electronic density of states to give a thorough understanding of the spectra. Major parts of the spectra can be described by the model of the corresponding isolated organic cation, whereas high-emission energy peaks in the nitrogen K-edge XE spectra arise from electronic transitions involving hybrids of the molecular and atomic orbitals of the cations and halides, respectively. We find that the interaction of the methylammonium cation is stronger with the chlorine than with the iodine anion. Furthermore, our detailed theoretical analysis highlights the strong influence of ultrafast proton dynamics in the core-excited states, which is an intrinsic effect of the XE process. The inclusion of this effect is necessary for an accurate description of the experimental nitrogen K-edge X-ray emission spectra and gives information on the hydrogen-bonding strengths in the different precursor materials.

Impact of n-Butylammonium Bromide on the Chemical and Electronic Structure of Double-Cation Perovskite Thin Films

2D/3D perovskite heterostructures have emerged as a promising material composition to reduce nonradiative recombination in perovskite-based LEDs and solar cells. Such heterostructures can be created by a surface treatment with large organic cations, for example, n-butylammonium bromide (BABr). To understand the impact of the BABr surface treatment on the double-cation (Cs0.17FA0.83Pb(I0.6Br0.4)3) (FA = formamidinium) perovskite thin film and further optimize the corresponding structures, an in-depth understanding of the chemical and electronic properties of the involved surfaces, interfaces, and bulk is required. Hence, we study the impact of the BABr treatment with a combination of surface-sensitive X-ray photoelectron spectroscopy and bulk-sensitive resonant inelastic soft X-ray scattering (RIXS). A quantitative analysis of the BABr-treated perovskite thin film shows a modified chemical perovskite surface environment of carbon, nitrogen, bromine, iodine, and lead, indicating that the treatment leads to a perovskite surface with a modified composition and bonding structure. With K-edge RIXS, the local environment at the nitrogen and carbon atoms is probed, allowing us to identify the presence of BABr in the perovskite bulk albeit with a modified bonding environment. This, in turn, identifies a "hidden parameter" for the optimization of the BABr treatment and overall performance of 2D/3D perovskite solar cell absorbers.

OP0061 A PROOF-OF-CONCEPT STUDY TO ASSESS THE EFFICACY OF TOCILIZUMAB MONOTHERAPY AFTER ULTRA-SHORT GLUCOCORTICOID ADMINISTRATION TO TREAT GIANT CELL ARTERITIS - THE GUSTO TRIAL

Background:

Two randomised controlled trials [1, 2] demonstrated a glucocorticoid (GC)-sparing effect of tocilizumab (TCZ) of at least 50%. Long-term GC treatment leads invariably to numerous side effects, particularly in elderly giant cell arteritis (GCA) patients.

Objectives:

The GUSTO (GCA treatment with ultra-short GC and TCZ) trial was set up to evaluate the efficacy and safety of TCZ-monotherapy after ultra-short GC treatment in new-onset GCA.

Methods:

Eighteen patients with newly diagnosed GCA were enrolled in this investigator-initiated, single-arm, single-center, open-label clinical trial with Simon’s two stage design (NCT03745586). Patients received 500 mg methylprednisolone intravenously for 3 consecutive days. Thereafter, GC treatment was discontinued and TCZ (8 mg/kg body-weight) was administered intravenously, followed by weekly subcutaneous TCZ injections (162 mg) from day 10 until week 52. The primary endpoint was defined as the proportion of patients who achieved remission within 31 days and showed no relapse at week 24; the secondary endpoint included the proportion of patients with complete relapse-free remission of disease at week 52. Remission was defined as disappearance of GCA symptoms, whereas partial remission included the presence of mild symptoms (defined as non-ischemic with NRS<5/10, reported as mild, not occurring on most days of the week). An interim analysis of the primary endpoint was performed after the first 12 patients reached the primary endpoint.

Results:

At baseline there were 12/18 female patients, and the median age was 71 (range 64-78) years. Overall, 15/18 had cranial symptoms (10/18 had jaw claudication, 6/18 had visual symptoms), 10/18 suffered from polymyalgia rheumatica (PMR)-symptoms, 16/18 had positive cranial ultrasound, and 13/18 had positive histopathology.

At interim analysis, only 25% (3/12) of patients achieved remission within 31 days and stayed relapse-free up to week 24. Thus, the null hypothesis that the proportion of responders would be smaller than 40% (p=0.92) was not rejected. Of the 18 patients recruited at the time of interim analysis, 14 achieved remission within 24 weeks (mean duration 11.1 (95% CI 8.3-13.9) weeks) and 13 showed no relapses up to 52 weeks (72%, 95% CI 47-90%). Overall, 3/18 patients were non-responders (2/3 with persistent cranial symptoms including one new-onset of an anterior ischemic optic neuropathy (AION); 1/3 with persistent PMR symptoms) and started on rescue GC-treatment, and 2/18 discontinued the study due to an adverse event (hepatopathy and diverticulitis, respectively; 1/2 after induction of remission).

Figure 1 demonstrates remission status over time.

Conclusion:

After a 3-days pulse of methylprednisolone, ensuing TCZ monotherapy induced and maintained remission until week 52 in 13/18 patients. The data add an important piece of evidence regarding the potency of blocking the interleukin-6 pathway in GCA and suggest that a substantial reduction of concomitant GC treatment in TCZ-treated GCA patients is feasible.

References:

[1]Villiger, P.M., et al., Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial. Lancet, 2016. 387(10031): p. 1921-7.

[2]Stone, J.H., et al., Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med, 2017. 377(4): p. 317-328.

Figure 1.

Disease status of patients at each visit (Day 10 - week 52, n=18).

Disclosure of Interests:

Lisa Christ Shareholder of: F. Hoffmann-La Roche, Grant/research support from: Gilead Sciences; F. Hoffmann-La Roche; Pfizer, Luca Seitz: None declared, Godehard Scholz: None declared, Adela-Cristina Sarbu: None declared, Jennifer Amsler: None declared, Lukas Bütikofer: None declared, Christoph Tappeiner: None declared, Florian Kollert Shareholder of: Roche, Consultant of: Yes (Actelion, BMS, Boehringer-Ingelheim, Pfizer), Grant/research support from: Yes (Gilead, Pfizer), Employee of: Yes, I am currently employed by Roche and previously by Novartis, Stephan Reichenbach: None declared, Peter Villiger Speakers bureau: Roche, MSD, Abbvie, Pfizer, Novartis, Grünenthal, Celgene, Sanofi, Chugai, Consultant of: Roche, MSD, Abbvie, Pfizer, Novartis, Celgene, Sanofi, Grant/research support from: Roche, MSD, Abbvie

OP0149 VISUAL LOSS IN PATIENTS WITH GIANT CELL ARTERITIS TREATED WITH TOCILIZUMAB

Background:

Whether Tocilizumab (TCZ) may prevent vision loss in Giant Cell Arteritis (GCA) to the same extent as glucocorticoids remains a key and unanswered question. A patient cohort observed over up to 8 years addresses this issue.

Objectives:

To investigate the frequency of vision loss/visual impariment in a GCA cohort treated with TCZ.

Methods:

In this observational monocentric study, the courses of 192 patients with GCA treated with TCZ between 01.01.2011 and 31.12.2018 were analyzed. Data were extracted from medical records and collected in a Clinical Trial Unit (CTU) - based registry. Demographic, clinical and laboratory data were analyzed.

Results:

192 patients with GCA were treated with TCZ; 121 (63%) were female, 112 (58%) fulfilled 1990 American College of Rheumatology (ACR) criteria, all others had large vessel vasculitis based on magnetic resonance-angiography (MRA). The cumulative duration of TCZ treatment was 3467 months; the median treatment duration was 13.8 (8.5; 22.8) months. At baseline, visual impairment was present in 71 (37%) and vision loss in 21 (7.8%) patients. Visual loss was associated with higher age (74 (70; 82) vs. 70 (63; 76) years; p=0.029), lower C-reactive protein at baseline (14.0 (3.5; 42.0) vs. 54.5 (21.0; 101.0) mg/l; p<0.001), cranial symptoms (p<0.0001), jaw claudication (p=0.030) and negative MRA of the aorta (p=0.020). Over the observed time span only one patient taking part in a clinical trial developed vision loss. In total 4 (2%) patients with vision impairment showed deterioration and 61 (32%) improvement.

Conclusion:

Collectively, our data suggest that TCZ is able to prevent visual loss and may have a favorable effect on visual impairment.

Disclosure of Interests:

Jennifer Amsler: None declared, Iveta Kysela: None declared, Lisa Christ Consultant of: BMS, Christoph Tappeiner: None declared, Luca Seitz: None declared, Godehard Scholz: None declared, Florian Kollert Employee of: Novartis, Stephan Reichenbach: None declared, Peter Villiger Consultant of: MSD, Abbvie, Roche, Pfizer, Sanofi, Speakers bureau: Roche, MSD, Pfizer

Encrypted Storage of Medical Data on a Grid

Objectives: In this article we present grids as an architecture for medical image processing and health-care networks. We argue that confidential patient data should not be stored unprotected on a grid and explain why access control systems alone do not offer sufficient protection. The objective of our work is to propose a method that complements access control systems on a grid architecture and thus makes the storage of confidential data more secure.

Methods: Effective protection can be achieved by storing confidential data in encrypted form. This raises the problem of how authorized users get access to the data, since they need to have the decryption keys.

Results: Our proposal details a key management architecture, that allows encrypted storage and still enables users to access decryption keys for data they are authorized to see. To achieve this functionality we use distributed keyservers storing redundant shares of the keys.

Conclusions: The resulting architecture achieves our primary objective of making the storage of confidential data more secure without loosing the data sharing properties of the grid architecture. Furthermore our architecture is robust against breakdowns and denial of service attacks. It scales well with the number of users and does not introduce a single point of failure into the system.

Health economics analysis of insulin aspart vs. regular human insulin in type 2 diabetes patients, based on observational real life evidence from general practices in Germany

BACKGROUND

A retrospective analysis of German general practice data demonstrated that insulin aspart (IA) was associated with a significantly reduced incidence of macrovascular events (MVE: stroke, myocardial infarction, peripheral vascular disease or coronary heart disease) vs. regular human insulin (RHI) in type 2 diabetes patients. Economic implications, balanced against potential improvements in quality-adjusted life years (QALYs) resulting from lower risks of complications with IA in this setting have not yet been explored.

METHODS

A decision analysis model was developed utilizing 3-year initial MVE rates for each comparator, combined with published German-specific insulin and MVE costs and health utilities to calculate number needed to treat (NNT) to avoid any MVE, incremental costs and QALYs gained/ person for IA vs. RHI. A 3-year time horizon and German 3(rd)-party payer perspective were used. Probabilistic sensitivity analysis was performed, sampling from distributions of key parameters. Additional sensitivity analyses were performed.

RESULTS

NNT over a 3 year period to avoid any MVE was 8 patients for IA vs. RHI. Due to lower MVE rates, IA dominated RHI with 0.020 QALYs gained (95% confidence interval: 0.014-0.025) and cost savings of EUR 1 556 (1 062-2 076)/person for IA vs. RHI over the 3-year time horizon. Sensitivity analysis revealed that IA would still be overall cost saving even if the cost of IA was double the cost/unit of RHI.

CONCLUSIONS

From a health economics perspective, IA was the superior alternative for the insulin treatment of type 2 diabetes, with lower incidence of MVE events translating to improved QALYs and lower costs vs. RHI within a 3-year time horizon.

Understanding interactions between manganese oxide and gold that lead to enhanced activity for electrocatalytic water oxidation

To develop active nonprecious metal-based electrocatalysts for the oxygen evolution reaction (OER), a limiting reaction in several emerging renewable energy technologies, a deeper understanding of the activity of the first row transition metal oxides is needed. Previous studies of these catalysts have reported conflicting results on the influence of noble metal supports on the OER activity of the transition metal oxides. Our study aims to clarify the interactions between a transition metal oxide catalyst and its metal support in turning over this reaction. To achieve this goal, we examine a catalytic system comprising nanoparticulate Au, a common electrocatalytic support, and nanoparticulate MnO(x), a promising OER catalyst. We conclusively demonstrate that adding Au to MnO(x) significantly enhances OER activity relative to MnO(x) in the absence of Au, producing an order of magnitude higher turnover frequency (TOF) than the TOF of the best pure MnO(x) catalysts reported to date. We also provide evidence that it is a local rather than bulk interaction between Au and MnO(x) that leads to the observed enhancement in the OER activity. Engineering improvements in nonprecious metal-based catalysts by the addition of Au or other noble metals could still represent a scalable catalyst as even trace amounts of Au are shown to lead a significant enhancement in the OER activity of MnO(x).

[Management of patients with the cardinal symptom dizziness or vertigo]

BACKGROUND

Vertigo and dizziness are common symptoms leading patients to consult a physician. The nationally representative "2003 Health Survey" depicts the epidemiology of the symptoms vertigo and dizziness across all of Germany. A breakdown of the data by region is not available.

METHODS

Routine data of the Bavarian Association of Statutory Health Insurance Physicians accounting centre ("Kassenärztliche Vereinigung Bayerns", KVB) from 2008 were analysed using multilevel models to investigate individual and regional factors and the relevance of nonspecific regional heterogeneity.

RESULTS

Altogether, 866,086 of 9,269,729 (9.34%) inhabitants received an ambulatory diagnosis of vertigo or dizziness, including 1.77 times as many women as men. Visits to the doctor because of vertigo or dizziness increased with age. After adjustments for age and sex, a North-South divide and a higher prevalence in the urban centres were apparent within Bavaria. The majority of patients were seen by their GP and nearby doctors. This held especially true for women. Also older patients were less likely to go to specialists further afield.

CONCLUSION

This analysis of the KVB data of patients with vertigo or dizziness underlines the central role that is played by GPs in diagnosis and treatment. In order to correctly diagnose the underlying causes, treat patients or send them to specialists effectively, all doctors need to be trained about this relevant clinical symptom. The insufficient representation of clinically established vertigo disorders by the ICD-10 was problematic. The most frequently coded diagnosis was N95.1 "postmenopausal dizziness".

Encrypted storage of medical data on a grid

OBJECTIVES

In this article we present grids as an architecture for medical image processing and health-care networks. We argue that confidential patient data should not be stored unprotected on a grid and explain why access control systems alone do not offer sufficient protection. The objective of our work is to propose a method that complements access control systems on a grid architecture and thus makes the storage of confidential data more secure.

METHODS

Effective protection can be achieved by storing confidential data in encrypted form. This raises the problem of how authorized users get access to the data, since they need to have the decryption keys.

RESULTS

Our proposal details a key management architecture, that allows encrypted storage and still enables users to access decryption keys for data they are authorized to see. To achieve this functionality we use distributed keyservers storing redundant shares of the keys.

CONCLUSIONS

The resulting architecture achieves our primary objective of making the storage of confidential data more secure without loosing the data sharing properties of the grid architecture. Furthermore our architecture is robust against breakdowns and denial of service attacks. It scales well with the number of users and does not introduce a single point of failure into the system.

Studies on (beta,1-->5) and (beta,1-->6) linked octyl Gal(f) disaccharides as substrates for mycobacterial galactosyltransferase activity

The emergence of multi-drug resistant (MDR) strains of Mycobacterium tuberculosis (MTB) and the continuing pandemic of tuberculosis emphasizes the urgent need for the development of new anti-tubercular agents with novel drug targets. The recent structural elucidation of the mycobacterial cell wall highlights a large variety of structurally unique components that may be a basis for new drug development. This publication describes the synthesis, characterization, and screening of several octyl Galf(beta,1-->5)Galf and octyl Galf(beta,1-->6)Galf derivatives. A cell-free assay system has been utilized for galactosyltransferase activity using UDP[14C]Galf as the glycosyl donor, and in vitro inhibitory activity has been determined in a colorimetric broth microdilution assay system against MTB H37Ra and three clinical isolates of Mycobacterium avium complex (MAC). Certain derivatives showed moderate activities against MTB and MAC. The biological evaluation of these disaccharides suggests that more hydrophobic analogues with a blocked reducing end showed better activity as compared to totally deprotected disaccharides that more closely resemble the natural substrates in cell wall biosynthesis.

Altered immunomodulating and toxicological properties of degraded Quillaja saponaria Molina saponins

Quillaja saponins are readily hydrolyzed under physiological conditions, yielding deacylated forms that are significantly less toxic than their precursors. Yet, deacylated saponins are unable to stimulate a strong primary immune response. Although deacylated saponins elicit a strong total IgG response, their capacity to stimulate a Thl type IgG isotype profile (i.e. high levels of IgG2a and IgG2b) has been significantly diminished. Instead, an IgG profile closer to that of a Th2 immune response is stimulated (i.e. high IgG1 levels). Deacylated saponins have also lost their capacity to elicit an effective T cell immunity, as shown by their stimulation of a marginal lymphoproliferative response and their inability to elicit the production of cytotoxic lymphocytes (CTL). Modification of the immune-modulating properties brought by the degradation of quillaja saponins during vaccine storage may change the intended immune response from a Th1 to a Th2 type. This alteration would have negligible effects on vaccines depending on Th2 immunity mediated by neutralizing antibodies. However, the performance of vaccines directed against intracellular pathogens as well as therapeutic cancer vaccines may be seriously affected by the loss of their capacity to stimulate both a Th1 immune response and the production of CTL.

Plasma corticosterone and testosterone levels during the annual reproductive cycle of male brown anoles (Anolis sagrei)

The objective of the present study was to determine the plasma levels of testosterone and corticosterone in male Anolis sagrei during the annual reproductive cycle and to examine the relationships between seasonal change in the levels of these hormones, male reproductive activity, and body condition. Both testosterone and corticosterone levels in adult males captured in the Miami, Florida, area varied significantly with month and with season (i.e., breeding vs. nonbreeding period), although they were not significantly correlated with each other or with body mass. Mean monthly testosterone levels were higher during the breeding season (March-August) than during the nonbreeding season, with the one exception that the highest mean testosterone level occurred in February immediately before the beginning of the breeding season. Testosterone levels in the overall sample of 144 males were significantly correlated with testes mass but not with any of the other measured variables. Corticosterone levels were highest during the nonbreeding season and lowest during the breeding season. Corticosterone levels on a monthly basis were negatively correlated with monthly changes in testes mass and positively correlated with monthly changes in abdominal fat-body mass.

Self-esteem and leisure patterns of persons in a residential chemical dependency treatment program

Occupational therapists who work with persons who are alcohol and drug dependent often provide services to enhance self-esteem and to promote healthy leisure activities. This article describes a study conducted in a residential chemical dependency program with 101 subjects. Each subject was assessed for selfesteem and leisure interest patterns. Although for the entire group self-esteem was not found to be strongly correlated with a variety of and involvement in leisure activities, decreased past involvement in activities was found to be prevalent in those subjects with a low self-esteem. Treatment and evaluation implications for the occupational therapist in a chemical dependency setting are discussed.