Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement

AIM OF THE STUDY: To examine the frequency and adequacy of thromboprophylaxis in acutely ill medical patients hospitalized in eight Swiss medical hospitals. METHODS: A cross-sectional study of 1372 patients from eight Swiss hospitals was carried out. After exclusion of patients (275) given therapeutic anticoagulation, 1097 patients were audited. The adequacy of thromboprophylaxis was assessed by comparison with predefined explicit criteria. RESULTS: Of 1097 patients, 542 (49.4%) received thromboprophylaxis. According to the explicit criteria, 644 (58.7%) should have been on prophylaxis (P < 0.001, when compared with the rate observed). The rate of prevention differed widely between hospitals (from 29.4 to 88.6%) with no difference between teaching and nonteaching hospitals. According to the explicit criteria, a substantial proportion (44.9%) of the patients who should have been treated were not. Conversely, 41.3% of the patients were unnecessarily treated. CONCLUSIONS: Even though the appropriateness of the explicit criteria used could be challenged, our data suggest that the current practice is associated with important uncertainty leading to both overuse and underuse of thromboprophylaxis in patients hospitalized in medical wards. More efforts are urgently needed to develop new or endorse existing explicit, evidence-based criteria and guidelines for thromboprophylaxis in this population of patients.     

Reasons to withhold intra-arterial thrombolysis in clinical practice

Background In selected stroke centers intra-arterial thrombolysis (IAT) is used for the treatment of acute stroke patients presenting within 6 hours of symptom onset. However, data about eligibility of acute stroke patients for IAT in clinical practice are very scarce. Methods We collected prospectively data on indications advising for or against IAT of 230 consecutive stroke patients in a tertiary stroke center. Results 76 patients (33.0%) presented within 3 hours, 69 (30%) between 3 and 6 hours of symptom onset and 85 (37%) later than 6 hours. Arteriography was performed in 71 patients (31%) and IAT in 46 (20%). In 11 patients no or only peripheral branch occlusions were seen on arteriography and therefore IAT was not performed. In 9 patients the ICA was occluded and barred IAT and in five anatomical or technical difficulties made IAT impossible. 72 patients presenting within 6 hours did not undergo arteriography and thrombolysis, mostly because of mild (n = 44) or rapidly improving neurological deficits (n = 13). Other reasons to withhold IAT were CT and/or clinical findings suggesting lacunar stroke due to small vessel occlusion (n = 7), limiting comorbidty (n = 7) and baseline international normalized ratio > 1.7 (n = 1). Conclusions A third of the patients underwent diagnostic arteriography and one fifth received IAT. The most important reasons to withhold thrombolysis were presentation beyond the 6 hours time window and mild or rapidly improving symptoms. Received in revised form: 23 July 2005     

On the role of RNA silencing in the pathogenicity and evolution of viroids and viral satellites

Viroids and most viral satellites have small, noncoding, and highly structured RNA genomes. How they cause disease symptoms without encoding proteins and why they have characteristic secondary structures are two longstanding questions. Recent studies have shown that both viroids and satellites are capable of inducing RNA silencing, suggesting a possible role of this mechanism in the pathology and evolution of these subviral RNAs. Here we show that preventing RNA silencing in tobacco, using a silencing suppressor, greatly reduces the symptoms caused by the Y satellite of cucumber mosaic virus. Furthermore, tomato plants expressing hairpin RNA, derived from potato spindle tuber viroid, developed symptoms similar to those of potato spindle tuber viroid infection. These results provide evidence suggesting that viroids and satellites cause disease symptoms by directing RNA silencing against physiologically important host genes. We also show that viroid and satellite RNAs are significantly resistant to RNA silencing-mediated degradation, suggesting that RNA silencing is an important selection pressure shaping the evolution of the secondary structures of these pathogens.     

Optional inferior vena cava filter use in surgical patients: a Western Australian experience

Background: The optional filter is gaining ground, supplementing anticoagulation in the management of venous thromboembolism (VTE) in high‐risk surgical patients, this despite knowledge gaps relating to its efficacy. We studied the literature and audited our experience with inferior vena cava filters to educate ourselves on this mode of VTE prophylaxis, particularly its practical implications, if any, for the surgeon. Methods: A retrospective clinical study on inferior vena cava filter (IVCF)‐related events in a Western Australian tertiary centre in 2008 was performed. Literature on IVCFs was reviewed. Results: The 118 IVCF‐related events at our centre in 2008, involved either Recovery‐G2 75(88%) or Cook‐Celect nine (11%). Of these, 78 were insertions and 36 were retrievals with four failed retrievals (10% of the attempts). Major indications for insertion included multi‐trauma 32 (38%), prothrombotic state 29 (34%), head injury/intracranial bleeding 16 (19%) and others eight (9%). The mean dwelling time was 100 days (12–349 days). The mean age was 43 and the retrieval rate was 58%. Conclusion: Optional filters have presented both versatility and challenge to the management of VTE in high‐risk patients. An underlying concern about the quintessential efficacy of IVCFs lingers on, while the impact of lost follow‐ups in young patients is still at large. Class 1 studies on optional filters would add certainty to the use of this generation of filters, be a step forward in relevance from the seminal work of Decousus and garner the willingness needed to engage teamwork and institutional proactiveness against loopholes such as lost follow‐ups that can undermine the portrayed benefits of a potentially lifesaving device.     

Imaging of translocator protein upregulation is selective for pro-inflammatory polarized astrocytes and microglia

Translocator protein (TSPO) expression is increased in activated glia, and has been used as a marker of neuroinflammation in PET imaging. However, the extent to which TSPO upregulation reflects a pro- or anti-inflammatory phenotype remains unclear. Our aim was to determine whether TSPO upregulation in astrocytes and microglia/macrophages is limited to a specific inflammatory phenotype. TSPO upregulation was assessed by flow cytometry in cultured astrocytes, microglia, and macrophages stimulated with lipopolysaccharide (LPS), tumor necrosis factor (TNF), or interleukin-4 (Il-4). Subsequently, mice were injected intracerebrally with either a TNF-inducing adenovirus (AdTNF) or IL-4. Glial expression of TSPO and pro-/anti-inflammatory markers was assessed by immunohistochemistry/fluorescence and flow cytometry. Finally, AdTNF or IL-4 injected mice underwent PET imaging with injection of the TSPO radioligand ¹⁸F-DPA-713, followed by ex vivo autoradiography. TSPO expression was significantly increased in pro-inflammatory microglia/macrophages and astrocytes both in vitro, and in vivo after AdTNF injection (p < .001 vs. control hemisphere), determined both histologically and by FACS. Both PET imaging and autoradiography revealed a significant (p < .001) increase in ¹⁸F-DPA-713 binding in the ipsilateral hemisphere of AdTNF-injected mice. In contrast, no increase in either TSPO expression assessed histologically and by FACS, or ligand binding by PET/autoradiography was observed after IL-4 injection. Taken together, these results suggest that TSPO imaging specifically reveals the pro-inflammatory population of activated glial cells in the brain in response to inflammatory stimuli. Since the inflammatory phenotype of glial cells is critical to their role in neurological disease, these findings may enhance the utility and application of TSPO imaging.     

[18F]AZD2461, an Insight on Difference in PARP Binding Profiles for DNA Damage Response PET Imaging

Background

Poly (ADP-ribose) polymerase (PARP) inhibitors are extensively studied and used as anti-cancer drugs, as single agents or in combination with other therapies. Most radiotracers developed to date have been chosen on the basis of strong PARP1–3 affinity. Herein, we propose to study AZD2461, a PARP inhibitor with lower affinity towards PARP3, and to investigate its potential for PARP targeting in vivo.

Methods

Using the Cu-mediated ¹⁸F-fluorodeboronation of a carefully designed radiolabelling precursor, we accessed the ¹⁸F-labelled isotopologue of the PARP inhibitor AZD2461. Cell uptake of [¹⁸F]AZD2461 in vitro was assessed in a range of pancreatic cell lines (PSN-1, PANC-1, CFPAC-1 and AsPC-1) to assess PARP expression and in vivo in xenograft-bearing mice. Blocking experiments were performed with both olaparib and AZD2461.

Results

[¹⁸F]AZD2461 was efficiently radiolabelled via both manual and automated procedures (9 %?±?3 % and 3 %?±?1 % activity yields non-decay corrected). [¹⁸F]AZD2461 was taken up in vivo in PARP1-expressing tumours, and the highest uptake was observed for PSN-1 cells (7.34?±?1.16 %ID/g). In vitro blocking experiments showed a lesser ability of olaparib to reduce [¹⁸F]AZD2461 binding, indicating a difference in selectivity between olaparib and AZD2461.

Conclusion

Taken together, we show the importance of screening the PARP selectivity profile of radiolabelled PARP inhibitors for use as PET imaging agents.