Venous thromboembolism risk assessment and prophylaxis in hospitalised medical patients in the Cape Town metropole, South Africa

BACKGROUND

Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians' perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident.

OBJECTIVES

To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA).

METHODS

A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated.

RESULTS

Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for <72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients.

CONCLUSIONS

Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Alpha-Glucosylrutin: ein hochwirksames Flavonoid zum Schutz vor oxidativem Stress. Alpha-glucosylrutin, a highly effective flavonoid for protection against oxidative stress

The flavonoid alpha-glucosylrutin (AGR) is a potent antioxidant with a high epidermal bioavailability. This makes this substance particularly suitable for various dermato-cosmetic applications. Flavonoids are phytamines with a common chemical structure and a broad range of activities, the most prominent being their radical scavenging ability. Reactive oxygen species (ROS) damage cells by different mechanisms. Direct cytotoxic effects include destruction of the cell membrane by causing radical chain reactions or induction of mutagenic changes in the nuclear and mitochondrial DNA. Indirect changes involve modification of intracellular signal transduction pathways that regulate inflammatory or proliferative activities. The excellent antioxidant efficacy of AGR has been shown in various experimental studies, both in vitro and in vivo. Subsequent clinical studies have demonstrated that AGR is also effective in the prevention of dermatologic diseases in which oxidative stress is of pathogenetic relevance, e.g. in polymorphous light eruption (PLE). Other promising dermato-cosmetic areas for AGR application are aging of the skin, especially photoaging. All in vivo evaluations indicate that AGR in the applied concentrations is a very well-tolerated ingredient for medical skin care preparations.

Phosducin, beta-arrestin and opioid receptor migration

Internalization of G protein-coupled opioid receptors depends on multiple criteria, including the affinity of drugs to their receptors and the state of the receptor-G protein interaction. Most recent studies reveal that cytosolic components like phosducin and arrestin interfere with receptor internalization, that is phosducin impairs receptor phosphorylation and arrestin enhances endocytosis by uncoupling the receptor from its G protein. This study was designed to examine the mutual effect phosducin and arrestin exert on receptor endocytosis. Neuronal NG 108-15 hybrid cells transiently expressing the mu-opioid receptor, which has been fused to green fluorescence protein, were employed to study internalization of the fluorescent mu-opioid receptor construct in living cells by means of confocal laser scanning microscopy. Fluorescent mu-opioid receptors were detected in drug-naive cells both at the cell membrane and at cell surface protrusions, most likely filopodia, microspikes and retraction fibres. The opioid receptors present in the cell membrane internalize upon etorphine (1 nM) exposure, a process clearly blocked in cells overexpressing phosducin. However, coexpression of both phosducin and beta-arrestin 1 reverses this blockade. In contrast to etorphine, morphine fails to internalize mu-receptors expressed in NG 108-15 cells. When arrestin is overexpressed in these cells, morphine gains the ability to induce endocytosis, and this process is left unaffected by phosducin. The findings suggest that endocytosis of activated mu-opioid receptors primarily depends on arrestin-triggered uncoupling of the receptor from its G protein complex. Drug-induced receptor phosphorylation appears of subordinate significance for receptor internalization.

Mu-opioid receptor expression in High Five insect cells is regulated by 5' untranslated region (5'UTR)

There is increasing evidence that the 5'UTR of mRNAs affects regulation of gene expression in eukaryotic cells. We examined the overexpression of the mu-opioid receptor in High Five insect cells, employing rat mu-receptor cDNA linked to variable lenghts of their native 5'UTR. The sequences employed consist of either 209 nucleotides (termed ,,long") upstream the translation initiation site of the mu-receptor mRNA, or a truncated 5'UTR comprising only 11 nucleotides (,,short"). These constructs served to generate recombinant baculovirus for the expression of mu-receptor protein in High Five insect cells. 48 hours after baculovirus infection cells were harvested for mu-receptor characterization or RNA analysis. Scatchard analysis of radioligand binding consistently revealed three to four fold higher concentrations of the mu-opioid receptors expressed with the ,,long" over the ,,short" UTR containing baculovirus. The distinct expression rates of mu-receptors paralleled the amounts of mRNAs determined by RNase protection assay. Regardless of the distinct 5'UTR regions, the expressed opioid receptors displayed identical high affinity binding characteristics for the opioid antagonist diprenorphine and similar EC50 values to inhibit forskolin (10(-5) M) stimulated cAMP synthesis. Our results demonstrate that the native 5'UTR of the mu-opioid receptor has an enhancing effect on expression in the baculovirus/insect cell system.

Effect of phosducin on opioid receptor function

Phosducin (Phd) regulates the function of G proteins by its ability to tightly bind Gbetagamma subunits. Because the internalization of opioid receptors as well as the activity of adenylyl cyclase (AC) activity depends on G proteins, we tested Phd on these parameters. NG 108-15 hybrid cells stably expressing the phosphoprotein were challenged with [D-penicillamine2,D-penicillamine5]enkephalin to inhibit cAMP generation, demonstrating an increased efficacy of the opioid on AC. Studying the binding of [35S]guanosine-5'-O-(gamma-thio)-triphosphate to membranes from Phd overexpressing cells, we found that [D-penicillamine2, D-penicillamine5 ]enkephalin failed, in the presence of Phd (0.1 nM), to elevate incorporation of the nucleotide. Phd also strongly inhibited opioid-stimulated GTPase activity. NG 108-15 cells were also employed to investigate the effect of Phd on opioid receptor internalization. Control cells and cells overexpressing Phd were transiently transfected to express mu-opioid receptors fused to green fluorescence protein. In controls and in Phd overexpressing cells confocal microscopy identified fluorescence associated with the membrane. Time-lapse series microscopy of living control cells challenged with etorphine (1 microM) revealed receptor internalization within 30 min. In contrast, Phd overexpressing cells largely failed to respond to the opioid. Thus, in Phd overexpressing cells, opioids exhibit an increased efficacy despite the inhibitory action of the phosphoprotein on opioid-stimulated incorporation of [35S]guanosine-5'-O-(gamma-thio)-triphosphate. We suggest that inhibition of GTPase stabilizes the opioid-induced G protein Gi-GTP complex, which is believed to enhance AC inhibition. Finally, scavenging of Gbetagamma by Phd attenuates internalization of opioid receptors, which may contribute to the efficacy of opioids.

Translocation of phosducin in living neuroblastoma x glioma hybrid cells (NG 108-15) monitored by red-shifted green fluorescent protein

Activation of G protein-coupled receptors triggers translocation of certain proteins from cytoplasm to cell membrane located targets. One of these cytosolic proteins is phosducin (Phd) which has been described to compete with G protein-coupled receptor kinases for Gbetagamma dimers attached to the cell membrane, thereby attenuating desensitization of activated receptors. These features of protein redistribution prompted us to examine whether stimulation of membrane associated E-prostaglandin receptors coupled to Gs causes Phd to migrate towards the plasma membrane. We made use of enhanced green fluorescence protein (EGFP), a reporter protein, to follow redistribution of Phd both by means of confocal microscopy and biochemical techniques in living neuronal NG 108-15 hybrid cells challenged with prostaglandin E1 (PGE1). The cells were transiently transfected to express Phd fused to the C-terminus of EGFP, or to express EGFP only. Overexpression of the proteins is implied by FACS analysis as well as by western blot technique, and the functional integrity of EGFP-tagged Phd was confirmed by its ability to elevate cAMP accumulation. Time-lapse imaging of single living cells by means of confocal microscopy revealed that exposure to prostaglandin causes EGFP/Phd, which is evenly spread throughout the cell, to relocate towards the membrane within few minutes. Fluorescence associated with the cell nucleus displayed little rearrangement. The principle finding that prostaglandin triggers translocation of Phd from cytosol to the cell periphery was verified with membranes prepared from EGFP/Phd expressing cells. We found maximal concentrations of membrane associated fluorescent material 5 to 7 min upon prostaglandin exposure. The present study reports for living NG 108-15 hybrid cells that PGE1 stimulation causes cytosolic Phd to translocate towards the membrane, where it is believed to bind to G protein subunits such as Gbetagamma and Galphas.

Phosducin expression in NG 108-15 hybrid cells enhances prostaglandin E1 stimulated adenylate cyclase activity

Phosducin (Phd), a cytosolic protein, has been proposed to compete with certain receptor kinases for Gbetagamma of heterotrimeric G proteins, and may inhibit GTPase activity of G alpha s. These suggestions together with the enhancing effect of Phd on odorant-induced cAMP accumulation let us assume a stimulatory action of the protein on intracellular signaling. Therefore, this investigation was designed to examine the excitatory effect of PGE1 on signal transmission in neuroblastoma x glioma hybrid cells (NG 108-15) overexpressing Phd. The neuronal cells stably expressing Phd were found to display a 3 to 4-fold increased sensitivity to PGE1 as compared to wild type cells, using cAMP accumulation as measure. Examination of membranes prepared from Phd-overexpressing cells revealed an elevated GTPase activity as indicated by the formation of 32Pi upon PGE1 challenge. This activity was inhibited by exogenous Phd. In addition, receptor independent stimulation of adenylate cyclase by forskolin reveals an increased formation of cAMP in Phd expressing cells, which is accompanied by an increased binding of [3H]forskolin. The findings let us propose that Phd elevates intracellular levels of functional G alpha s which accounts for the increased response to PGE1.

Overexpression of delta-opioid receptors in recombinant baculovirus-infected Trichoplusia ni "High 5" insect cells

"High 5" cells derived from Trichoplusia ni ovaries were infected with baculovirus bearing the cDNA of the mouse delta-opioid receptor. The maximal binding capacity for the narcotic antagonist [3H] naltrindole was 1.4 pmol/mg of membrane protein, and that for the agonist [3H][D-penicillamine2,D-penicillamine5]enkephalin (DPDPE) was 0.3 pmol/mg. DPDPE proved highly potent in competing with its tritiated analogue at delta-receptors of NG108-15 hybrid cells and of High 5 and Sf9 insect cells. However, in insect cells the opioid was more than 100-fold less effective in competing with [3H]naltrindole as compared with the mammalian cells. This decline in potency was counteracted in a dose-dependent manner by exposure of High 5 membranes to the exogenous G protein G(o), which increased the binding capacity for DPDPE. Functional studies revealed a dose-dependent inhibition (up to 30%) by opioids on forskolin-stimulated cyclic AMP synthesis, and this effect was potentiated by G(o). Quantification of G alpha o and G alpha i disclosed striking differences between Sf9 and High 5 insect cells, both of which overexpressed the cloned delta-opioid receptor. Although no inhibitory G proteins were detected in membranes of Sf9 cells, High 5 cells contained 0.5 pmol of G alpha o/mg of membrane protein, and a 20-fold higher concentration for G alpha i. The distinct G-protein expression in insect cells may be considered an advantage for studying functions of G protein-coupled receptors.

Expression of mu-, delta- and kappa-opioid receptors in baculovirus-infected insect cells

The mu-, delta- and kappa-opioid receptors have been expressed in Sf9 and 'High Five' insect cells using the baculovirus expression system. In both cell lines highest receptor levels (pmol/mg membrane protein) were observed 48 h after infection. Concomitant exposure to the narcotic antagonist naloxone (1 microM) enhanced the production of each receptor type. However, "High Five' cells differed from Sf9 cells in a 2-3-fold higher receptor density in the cell membrane and were therefore employed for receptor characterization. In membranes of 'High Five' cells opioid receptor levels ranged from 1.0 +/- 0.2 pmol/mg protein for the kappa-opioid receptor, 1.7 +/- 0.2 pmol/mg for the delta-opioid receptor to 2.1 +/- 0.5 pmol/mg for the mu-opioid receptor. The mu-, delta- and kappa-opioid receptor agonists [D-Ala2,N-methyl-Phe4-Gly-ol5]enkephalin ([3H]DAMGO), [D-Pen2,D-Pen5]enkephalin ([3H]DPDPE) and (5 alpha, 7 alpha, 8 beta)-(+)-N-methyl-N-(7-(1-pyrrolidinyl-1-oxaspiro(4,5)dec-8-yl) benzeneacetamide ([3H]U69,563) bound to the opioid receptors with Kd values of 3.4 +/- 0.3 nM, 4.5 +/- 0.1 nM and 1.2 +/- 0.3 nM, respectively, resembling those reported for opioid receptors expressed in mammalian cells. Testing the functionality of the receptors in 'High Five' cells, we found that high affinity agonist binding was strongly reduced in the presence of GTP gamma S/sodium, indicating their coupling to G proteins. Furthermore, activation of the three receptor types inhibited forskolin-stimulated cAMP formation. The results presented here suggest that the 'High Five' cell/baculovirus system provides a convenient method for high level expression of functionally intact opioid receptors as judged by receptor binding studies, their G-protein coupling and inhibition of adenylyl cyclase.

Sjögren syndrome: comparative studies in local ocular and serum immunoglobulin concentrations with special reference to secretory IgA

The objective of the present study was to examine Secretory IgA in tears and serum of Sjögren patients (34 patients and 23 controls). The test was performed in a parallel study using a polyclonal and a monoclonal method (Inter-Assay variation 9.1/Intra-Assay variation 5.5). No differences in the levels of tear secretory IgA were found between patients and controls. In serum however, secretory IgA, total IgA, IgM and IgG showed a significant increase in the Sjögren patients. The fact that secretory IgA levels remain normal in the ocular mucosa of these patients may explain that, despite the autoimmune destruction of the lacrimal gland, humoral defense factors are normally present on the surface of the eye to combat infections.