INTRODUÇÃO: A fibrilação atrial (FA) é a arritmia cardíaca mais comum e está associada a uma significativa morbidade e mortalidade. A sua prevalência aumenta marcadamente com a idade. A terapia com anticoagulantes orais tem sido a base de tratamento e prevenção de eventos tromboembólicos em pacientes com FA. Entretanto, a anticoagulação oral em idosos pode ser desafiadora devido à vários fatores, como alterações orgânicas funcionais, risco aumentado de sangramento e eventos isquêmicos, presença de comorbidades, polifarmácia e uma menor aderência ao tratamento. OBJETIVOS: Avaliar a frequência de tromboembolismo e complicações hemorrágicas em pacientes muito idosos (idade >= 85 anos) em uso de varfarina; avaliar tempo na faixa terapêutica (TTR), causas do INR fora da faixa, escores de CHADS2 e CHA2DS2 - VASc, comorbidades associadas e causas de mortalidade. METODOS: análise retrospectiva de pacientes que iniciaram o tratamento com varfarina com uma idade >= 85 anos, entre abril de 1999 e setembro de 2013, controlados em uma clínica de anticoagulação oral. RESULTADOS: foram incluídos 164 pacientes; 51% eram do sexo masculino e a idade média de início e fim do tratamento com varfarina foram de 86,8 e 89,7 anos, respectivamente. A indicação mais comum para o uso de ACo foi a fibrilação atrial (86%). O seguimento médio foi de 34,6 ± 23 meses. O CHADS2 e CHA2DS2 - VASc médio dos pacientes foi 2,78 e 4,7, respectivamente. O tempo na faixa terapêutica (TTR) foi de 58,6%. A polifarmácia esteve presente em 78% dos pacientes. De acordo com as estimativas de Kaplan-Meier, a probabilidade livre de TE e sangramento grave foi de 93,5% e 90,5% em três anos, respectivamente. Quando analisados esses dois desfechos combinados, a probabilidade livre de tromboembolismo e sangramento grave foi de 83,4% em três anos. CONCLUSÃO: nesse estudo, o uso de um antagonista da vitamina k (varfarina) em pacientes com idade >= 85 anos esteve associado a um baixo risco de tromboembolismo e sangramento grave durante o período de seguimento. / INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated to a significant morbidity and mortality. Its prevalence strongly increases with aging. Therapy with oral anticoagulants (OAC) has been the basis of treatment and prevention of thromboembolic events in patients with AF. However, oral anticoagulation in the elderly can be challenging due to various factors such as the alteration of organic functions, greater risk of bleeding and ischemic events, presence of comorbidity, polypharmacy and a lower adherence to treatment. OBJECTIVES: Evaluate the frequency of thromboembolism and hemorrhagic complications in very elderly patients (aged >= 85 years) in use of warfarin; evaluate time in therapeutic range (TTR), causes of INR outside the range, scores of CHADS2 and CHA2DS2 - VASc, associated comorbidities and cause of death. METHODS: Retrospective analysis of patients who initiated treatment with warfarin at aged >=85 years, between April of 1999 and September of 2013, controlled in an oral anticoagulation clinic. RESULTS: A total of 164 patients were included in the study; 51% were males and the mean ages at the start and end of the treatment with warfarin were of 86,8 and 89,7 years, respectively. The most common indication for the use of OAC was atrial fibrillation (86%). The mean follow-up was of 34,6 ± 23 months. The mean CHADS2 and CHA2DS2 - VASc of patients was 2,78 and 4,7, respectively. The time in therapeutic range (TTR) was of 58,6%. Polypharmacy was present in 78% of patients. According to the Kaplan-Meier estimates, the survival curve of TE and severe bleeding was of 93,5% and 90,5% in three years, respectively. When these two combined outcomes are analyzed, the survival curve of thromboembolism and severe bleeding was of 83,4% in three years. CONCLUSION: In this study, the use of one vitamin K antagonist (warfarin) in patients aged >= 85 years was associated to a low risk of thromboembolism and severe bleeding during the follow-up period.

Postthrombotic syndrome (PTS) is a frequent complication of venous thromboembolism (VTE). Using MarketScan claims data from January 2012 to June 2015, we identified adults with a primary diagnosis code for VTE during a hospitalization/emergency department visit, ≥6 months of insurance coverage prior to the index event and newly started on rivaroxaban or warfarin within 30 days of the index VTE. Patients with <4-month follow-up postindex event or a claim for any anticoagulant during 6-month baseline period were excluded. Differences in baseline characteristics between rivaroxaban and warfarin users were adjusted for using inverse probability of treatment weights based on propensity scores. Patients were followed for the development of PTS starting 3 months after the index VTE. Cox regression was performed and reported as hazard ratios with 95% confidence intervals (CIs). In total, 10 463 rivaroxaban and 26 494 warfarin users were followed for a mean of 16 ± 9 (range, 4-39) months. Duration of anticoagulation was similar between cohorts (median = 6 months). Rivaroxaban was associated with a 23% (95% CI: 16-30) reduced hazard of PTS versus warfarin. Rivaroxaban was associated with a significant risk reduction in symptoms of PTS compared to warfarin in patients with VTE treated in routine practice.

The relative risk of major gastrointestinal bleeding (GIB) among different direct oral anticoagulants (DOACs) is debatable. Randomized controlled trials (RCTs) comparing DOACs with each other are lacking. We performed network meta-analysis to assess whether the risk of major GIB differs based on type and dose of DOAC. Literature search of PubMed, EMBASE and Cochrane databases from inception to August 2019, limited to English publications, was conducted to identify RCTs comparing DOACs with warfarin or enoxaparin for any indication. Primary outcome of interest was major GIB risk. We used frequentist network meta-analysis through the random-effects model to compare DOACs with each other and DOACs by dose to isolate the impact on major GIB. Twenty-eight RCTs, including 139 587 patients receiving six anticoagulants, were selected. The risk of major GIB for DOACs was equal to warfarin. Comparison of DOACs with each other did not show risk differences. After accounting for dose, rivaroxaban 20 mg, dabigatran 300 mg and edoxaban 60 mg daily had 47, 40 and 22% higher rates of major GIB versus warfarin, respectively. Apixaban 5 mg twice daily had lower major GIB compared to dabigatran 300 mg (OR, 0.63; 95% CI, 0.44-0.88) and rivaroxaban 20 mg (OR, 0.60; 95% CI, 0.43-0.83) daily. Heterogeneity was low, and the model was consistent without publication bias (Egger's test: P = 0.079). All RCTs were high-quality with low risk of bias. DOACs at standard dose, except apixaban, had a higher risk of major GIB compared to warfarin. Apixaban had a lower rate of major GIB compared to dabigatran and rivaroxaban.

La fibrillation auriculaire (FA), l’arythmie cardiaque la plus courante est un facteur de risque majeur pour le développement de l’accident vasculaire cérébral ischémique (AVC). Les anticoagulants oraux directs (AOD) ont largement remplacé la warfarine en usage clinique pour la prévention des AVC dans la FA. Cette recherche a examiné deux défis méthodologiques importants qui peuvent survenir dans les études observationnelles sur l’efficacité et l’innocuité comparatives des AOD et de la warfarine. Premièrement : un biais d’information résultant d’une classification erronée de l’exposition au traitement à la warfarine suite aux ajustements de doses fréquentes qui ne sont pas adéquatement consignés dans les données de dispensations pharmacologiques. Deuxièmement : un biais de sélection, en raison de la censure informative, généré par des mécanismes de censure différentiels, chez les patients exposés aux AOD, ou à la warfarine. À l’aide des données administratives du Québec, j’ai mené trois études de cohortes rétrospectives qui ont portées sur toutes les personnes ayant initié un anticoagulant oral de 2010 à 2016. Ces études étaient restreintes aux résidents du Québec couverts par le régime public d'assurance médicaments (environ 40% de la population au Québec), c’est-à-dire : des personnes âgées de 65 ans et plus; des bénéficiaires de l’aide sociale; des personnes qui n’ont pas accès à une assurance-maladie privée; et les personnes à leur charge. Dans la première étude, nous avons émis l'hypothèse que les données sur les réclamations en pharmacie ne reflètent pas correctement la durée de la dispensation de la warfarine. Les écarts entre les renouvellements consécutifs étaient plus grands pour la warfarine que les AOD. Dans cette étude, on a trouvé que l'écart moyen pour les usagers de la warfarine était de 9.3 jours (avec un intervalle de confiance de 95% [IC]: 8.97-9.59), l'apixaban de 3.08 jours (IC de 95%: 2.96--3.20), et de 3.15 jours pour le rivaroxaban (IC de 95%: 3.03-3.27). Les écarts entre les renouvellements consécutifs présentaient une plus grande variabilité chez les personnes qui prenaient de la warfarine comparativement à celles qui prenaient des AOD. Cette variation peut refléter les changements de posologie de la warfarine lorsque la dose quotidienne est ajustée par le professionnel de la santé en fonction des résultats du rapport normalisé international (INR). L’ajustement de la dose peut prolonger (ou raccourcir) la période couverte par le nombre de comprimés délivrés. Dans la deuxième étude, nous avons émis l'hypothèse que la définition de la durée d'exposition basée sur la variable des « jours fournis », disponible dans la base de données, et le délai de grâce fixe, entraîneront une erreur de classification différentielle de l’exposition à la warfarine par rapport aux AOD. Dans cette étude, on a utilisé deux approches pour définir la durée des dispensations : la variable des « jours fournis » disponible dans la base de données ainsi qu’une approche axée sur les données pour la définition de la durée de dispensation qui tient compte des antécédents de distribution précédents. La deuxième étude a révélé qu'en utilisant la variable des « jours fournis », la durée moyenne (et l'écart type) des durées des dispensations pour le dabigatran, le rivaroxaban, et la warfarine étaient de 19 (15), 19 (14), et de 13 (12) jours, respectivement. En utilisant l’approche fondée sur des données, les durées étaient de 20 (16), 19 (15), et de 15 (16) jours, respectivement. Ainsi, l'approche fondée sur les données s’est rapprochée de la variable des « jours fournis » pour les thérapies à dose standard telles que le dabigatran et le rivaroxaban. Une approche axée sur les données pour la définition de la durée de dispensation, qui tient compte des antécédents de distribution précédents, permet de mieux saisir la variabilité de la durée de dispensation de la warfarine par rapport à la méthode basée sur la variable des « jours fournis ». Toutefois, cela n’a pas eu d’impact sur les estimations du rapport de risque sur la sécurité comparative des AOD par rapport à la warfarine. Dans la troisième étude, nous avons émis l'hypothèse que lors de l'évaluation de l’effet d’un traitement continu avec des anticoagulants oraux (l'analyse per-protocole), la censure élimine les patients les plus malades du groupe des AOD et des patients en meilleure santé du groupe de warfarine. Cela peut baisser l'estimation de l'efficacité et de l'innocuité comparative en faveur des AOD. L’étude a démontré que les mécanismes de censure chez les initiateurs d’AOD et de warfarine étaient différents. Ainsi, certaines covariables pronostiquement significatives, telles que l’insuffisance rénale chronique et l’insuffisance cardiaque congestive, étaient associées avec une augmentation de la probabilité de censure chez les initiateurs d’AOD, et une diminution de la probabilité de censure chez les initiateurs de warfarine. Pour corriger le biais de sélection introduit par la censure, nous avons appliqué la méthode de pondération par la probabilité inverse de censure. Deux stratégies de spécification du modèle pour l’estimation des poids de censure ont été explorées : le modèle non stratifié, et le modèle stratifié en fonction de l’exposition. L’étude a démontré que lorsque les poids de censure sont générés sans tenir compte des dynamiques de censure spécifiques, les estimés ponctuels sont biaisés de 15% en faveur des AOD par rapport à l'ajustement des estimés ponctuels avec des poids de censure stratifiée selon l’exposition (rapport de risque: 1.41; IC de 95%: 1.34, 1.48 et rapport de risque: 1.26; IC de 95%: 1.20, 1.33, respectivement). Dans l’ensemble, les résultats de cette thèse ont d’importantes implications méthodologiques pour les futures études pharmacoépidémiologiques. À la lumière de ceux-ci, les résultats des études observationnelles précédentes peuvent être revus et une certaine hétérogénéité peut être expliquée. Les résultats pourraient également être extrapolés à d’autres questions cliniques. / Atrial fibrillation (AF), the most common cardiac arrhythmia is a major risk factor for the development of ischemic stroke. Direct oral anticoagulants (DOACs) replaced warfarin in clinical use for stroke prevention in AF. This research investigated two important methodological challenges that may arise in observational studies on the comparative effectiveness and safety of DOACs and warfarin. First, an information bias resulting from misclassification of exposure to dose-varying warfarin therapy when using days supplied value recorded in pharmacy claims data. Second, a selection bias due to informative censoring with differential censoring mechanisms in the DOACs- and the warfarin exposure groups. Using the Québec administrative databases, I conducted three retrospective cohort studies that included patients initiating an oral anticoagulant between 2010 and 2016. The studies were restricted to Québec residents covered by the public drug insurance plan (about 40% of Québec’s population), including those aged 65 years and older, welfare recipients, those not covered by private medical insurance, and their dependents. In the first study, we hypothesized that pharmacy claims data inadequately captured the duration of the dispensation of warfarin. Gaps between subsequent dispensations (refill gaps) and their variation are larger for warfarin than for DOACs. In this study, we found that the average refill gap for the users of warfarin was 9.3 days (95% confidence interval [CI]:8.97-9.59), apixaban 3.08 days (95%CI: 2.96--3.20), dabigatran 3.70 days (95%CI: 3.56-3.84) and rivaroxaban 3.15 days (95%CI: 3.03-3.27). The variance of refill gaps was greater among warfarin users than among DOAC users. This variation may reflect the changes in warfarin posology when the daily dose is adjusted by a physician or a pharmacist based on previously observed international normalized ratio (INR) results. The dose adjustment may lead to a prolongation of the period covered by the number of dispensed pills. In the second study, we hypothesized that the definition of duration of dispensation based on the days supplied value and a fixed grace period will lead to differential misclassification of exposure to warfarin and DOACs. This may bias the estimate of comparative safety in favor of DOACs. In this study, we used two approaches to define the duration of dispensations: the recorded days supplied value, and the longitudinal coverage approximation (data-driven) that may account for individual variation in drug usage patterns. The second study found that using the days supplied, the mean (and standard deviation) dispensation durations for dabigatran, rivaroxaban, and warfarin were 19 (15), 19 (14), and 13 (12) days, respectively. Using the data-driven approach, the durations were 20 (16), 19 (15), and 15 (16) days, respectively. Thus, the data-driven approach closely approximated the recorded days supplied value for the standard dose therapies such as dabigatran and rivaroxaban. For warfarin, the data-driven approach captured more variability in the duration of dispensations compared to the days supplied value, which may better reflect the true drug-taking behavior of warfarin. However, this did not impact the hazard ratio estimates on the comparative safety of DOACs vs. warfarin. In the third study, we hypothesized that when assessing the effect of continuous treatment with oral anticoagulants (per-protocol effect), censoring removes sicker patients from the DOACs group and healthier patients from the warfarin group. This may bias the estimate of comparative effectiveness and safety in favor of DOACs. The study showed that the mechanisms of censoring in the DOAC and the warfarin exposure groups were different. Thus, prognostically meaningful covariates, such as chronic renal failure and congestive heart failure, had an opposite direction of association with the probability of censoring in the DOACs and warfarin groups. To correct the selection bias introduced by censoring, we applied the inverse probability of censoring weights. Two strategies for the specification of the model for the estimation of censoring weights were explored: exposure-unstratified and exposure-stratified. The study found that exposure-unstratified censoring weights did not account for the differential mechanism of censoring across the treatment group and failed to eliminate the selection bias. The hazard ratio associated with continuous treatment with warfarin versus DOACs adjusted with exposure unstratified censoring weights was 15% biased in favor of DOACs compared to the hazard ratio adjusted with exposure-stratified censoring weights (hazard ratio: 1.41; 95% CI: 1.34, 1.48 and hazard ratio: 1.26; 95%CI: 1.20, 1.33, respectively). Overall, the findings of this thesis have important methodological implications for future pharmacoepidemiologic studies. Moreover, the results of the previous observational studies can be reappraised, and some heterogeneity can be explained. The findings can be extrapolated to other clinical questions.

No description available.

PhD (Department of Biotechnology, Faculty of Applied and Computer Sciences), Vaal University of Technology. / Tulbaghia violacea Harv. has found extensive uses in traditional medicine for the treatment of numerous ailments among which are tuberculosis, oesophageal cancer, diabetes and cardiovascular diseases. Current reports show that cardiovascular diseases are now the primary cause of mortality worldwide. Thus, the potential of T. violacea plant extracts against cardiovascular diseases should be explored. The objectives of this study were, (i) to conduct qualitative and quantitative preliminary phytochemical screening of T. violacea aqueous leaf extracts, (ii) to conduct Gas chromatography–mass spectrometry (GC-MS) analysis for screening of compounds present in the plant extract, (iii) to evaluate the antioxidant activity of the T. violacea crude extracts using the DPPH:1.1-diphenyl-2-picrylhydrazyl and ABTS: 2,2-azino-bis 3-ethylebenzthiazoline-6-sulfonic acid assays, (iv) to evaluate the antimicrobial activity of the T. violacea crude extracts using disk diffusion and Minimum inhibitory concentration/Minimum bactericidal concentration (MIC/MBC), (v) to evaluate the antithrombogenic properties of T. violacea crude extracts on polystyrene, (vi) to fabricate polycaprolactone (PCL) and PCL-T. violacea incorporated scaffolds, (vii) to evaluate the antithrombogenic properties of T. violacea crude extracts on the fabricated PCL and PCL-T. violacea fabricated scaffolds and, (viii) to evaluate the growth and differentiation of adipose derived stem cells (ADSCs) on the fabricated scaffolds. The qualitative and quantitative phytochemical screening was conducted using standard procedures. Folin-Ciocalteu method was used to evaluate both total phenolic content (TPC) and total tannin content (TTC), the Aluminium chloride method was used for total flavonoid content (TFC) and GC-MS was used to screen for compounds present in the plant extract. The antioxidant activity was evaluated using DPPH and ABTS and the antimicrobial activity was evaluated using disc diffusion and MIC/MBC assays. The antithrombogenic properties of the T. violacea aqueous leaf extracts was then evaluated using platelet activation and whole blood clotting kinetics on polystyrene discs which have been reported to induce platelet activation. The experiment was performed in the absence and presence of 100 and 1000 μg/ml T. violacea plant extracts for both the platelet activation study which used blood plasma and the whole blood clotting kinetics assay which used fresh whole blood. Platelet adhesion was evaluated using fluorescence microscopy and a scanning electron microscope (SEM) was used to evaluate their morphology. Three scaffolds designated as PCL, 10% Tvio and 15% Tvio were fabricated which consisted of a 10% PCL powder and 10% as well as 15% T. violacea aqueous plant extract with respect to the PCL powder weight. The scaffolds were then characterized using Fourier-transform infrared spectroscopy (FTIR) and Energy-dispersive x-ray spectroscopy (EDS). The scaffolds were then evaluated for their antithrombogenic properties in the presence and absence of 100 and 1000 μg/ml T. violacea plant extracts. Platelet adhesion was evaluated using a fluorescent microscope and the morphology was evaluated using SEM. For the cell study, adipose derived stem cells (ADSCs) were cultured on the designed scaffolds and evaluated for their toxicity, viability, adhesion, proliferation, morphology and differentiation into osteoblasts over a period of 3 weeks. Lactate dehydrogenase (LDH) assay was used for toxicity studies, alamar blue assay was used for viability, fluorescence microscopy was used to evaluate cellular adhesion and proliferation while the alkaline phosphate (ALP) assay was used to evaluate differentiation of the cells into osteoblasts. Cell morphology was evaluated using SEM. Phytochemical screening of the prepared T. violacea aqueous extract revealed the presence of terpenoids, flavonoids, cardiac glycosides, saponins, protein, phenols, tannins, carbohydrates and amino acids. This is the first study that has identified the presence of carbohydrates and amino acids in T. violacea aqueous leaf extracts. Different concentrations of 0.1, 1.0 and 10 mg/ml of plant extract were used to conduct the quantitative phytochemical screening assays. There was a concentration dependent increase in the amount of phenols, tannins and flavonoids as the concentration of the plant extracts increased. This was the first study that evaluated the total tannic content of T. violacea plant extracts. The amount of total phenols was higher than that of flavonoids and tannins at every concentration range studied followed by the total flavonoids and lastly total tannins. The GC-MS analysis showed the presence of 33 compounds among which were 2,4 – Dithiapentate - 2,2-dioxide, Cannabidiol, 2,4,5,7 –Tetrathiaoctane and 2,4,5,7 - Tetrathiaoctane 2-dioxide. The presence of sulphur compounds support the characteristic garlic-like smell as well as some of the biological activities of T. violacea plant extracts. The antioxidant activities based on DPPH (0.49 mg/ml) and ABTS (0.24 mg/ml) suggest that T. violacea can be used as potential antioxidant agents. For the antimicrobial activity using disc diffusion, the extracts exhibited appreciable antibacterial activities against Bacillus subtilis, Serratia marcescens, Staphylococcus aureus and S. epidermidis. The highest zone of inhibition was observed for S. epidermidis at 19.50 ± 0.87 mm. The MIC results revealed that the plant extract of T. violacea was moderately active against B. subtilis, S. aureus, S. epidermidis, E. coli, and S. marcescens with MIC value of 2.5 mg/ml. However, the antimicrobial effect of the extract on S. epidermidis was bactericidal when compared to the bacteriostatic effect on the other active microorganisms. The antithrombogenic results on the polystyrene discs showed a significant reduction in the number of platelets that adhered on the polystyrene surfaces treated with plasma mixed with 100 μg/ml of plant extract when compared to the untreated control and the 1000 μg/ml treatment. For the 1000 μg/ml treatment, there was a significant increase in the number of platelets that adhered to polystyrene surfaces. These results were confirmed by the fluorescence and SEM results which showed a higher platelet count for the 1000 μg/ml treatment when compared to the other groups. The whole blood clotting kinetics study showed delayed blood clotting with the 100 μg/ml treatment over a period of 60 min when compared to the untreated control and the 1000 μg/ml treatment. These results correspond with the lower platelet adhesion observation and thus confirm the anticlotting properties of T. violacea aqueous leaf extracts at lower concentrations. The mean diameter of the scaffolds was recorded on the SEM as 275.60 ± 60.65 nm, 193 ± 30 nm and 537 ± 138 nm for the PCL, 10% Tvio and 15% Tvio scaffolds, respectively. The FTIR spectrum revealed the presence of amide groups as well hydroxyl O–H stretching groups which were the characteristic groups for the presence of T. violacea plant extracts in the polycaprolactone. The EDS results showed the presence of potassium, chlorine and sulphur compounds which were only present in the T. violacea scaffolds in addition to the carbon, oxygen and silicon observed in the PCL scaffold. The fabricated scaffolds were then used to evaluate platelet adhesion and activation on blood plasma in the absence and presence of 100 and 1000 μg/ml T. violacea aqueous leaf extracts. The results showed that the 10% Tvio scaffold was more effective in inhibiting platelet adhesion and activation at every treatment group especially when plasma was used in the absence of T. violacea plant extracts. A similar observation to the polystyrene study was observed were addition of 1000 μg/ml of plant extract resulted in the highest number of activated platelets. The study suggests the potential of the 10% Tvio scaffold in the prevention of platelet adhesion and aggregation. The in vitro cell adhesion, proliferation and differentiation of adipose derived stem cells (ADSCs) on the fabricated T. violacea loaded PCL nanofibers was then evaluated. The LDH assay illustrated less activity on the 10% Tvio scaffold when compared to PCL and 15% Tvio scaffolds however, none of the scaffolds were considered as toxic. The alamar blue assay was used for viability after 4 and 7 days of culture. The results showed a significant increase in cell viability for all scaffolds from day 4 to day 7 with the 10% Tvio scaffold having the highest overall cell viability for both day 4 and day 7 of cell cultures. Immunofluorescence staining was then used to count the number of cells using DAPI (4′,6-diamidino-2-phenylindole) stained images and illustrated that the T. violacea incorporated scaffolds supported better cell growth compared to the PCL scaffold. Cell morphology on the T. violacea scaffolds was denser and spread out into cellular extensions when compared to the PCL scaffold after 7 days of cell culture, supporting the higher number of adhered cells from the fluorescence results. For the long term cell study after week 1 and 3, the ALP results showed a significant difference in ALP activity between week 1 and week 3 for all scaffolds. The highest ALP activity was observed for the 15% Tvio scaffolds which is a marker for initial phase of bone matrix deposition. The designed T. violacea scaffolds supported better cell growth compared to the PCL scaffold and their morphology was more spread out and covered the entire surface of the scaffolds after week 3. Lastly, the cell count and osteocalcin differentiation was more prominent on 10% Tvio scaffold indicating higher levels of the protein marker for bone formation. Thus, supporting the use of the 10% Tvio scaffold for long-term cell studies. In conclusion, the results of this study indicated that the aqueous extract of T. violacea is rich is phytochemicals and also possess a broad range of pharmaceutically important compounds which may be attributed to the high antioxidant and antimicrobial activities identified. The results from this study suggest that T. violacea aqueous extracts have antithrombogenic properties at lower concentrations. Scaffolds fabricated with the incorporation of T. violacea plant extract also confirm the potential antiplatelet activity of the fabricated 10% Tvio scaffold. The results also suggest the potential of the fabricated 10% Tvio scaffold to enhance cell adhesion, proliferation and differentiation over long-term cell studies. It can thus be recommended that T. violacea may be useful for tissue engineering applications and bone repair with prospects of preventing cardiovascular diseases associated with bone defects. This research study has provided the foundation for clinical evaluation and outlined the potential effects of T. violacea aqueous leaf extracts as a clinical drug.

BACKGROUND: Current guidelines give class I recommendations for uninterrupted use of dabigatran rivaroxaban as an alternative to vitamin K antagonist (VKA) in patients of atrial fibrillation (AF) who are undergoing catheter ablation. The recent randomized controlled trials have shown similar efficacy of novel oral anticoagulants when compared to VKA in these patients. We sought to perform a meta-analysis with a focus on subgroup analysis of novel oral anticoagulants. METHODS: We searched PubMed, Clinical trials registry and the Cochrane Center Register of Controlled Trials were searched through August 2020. Six RCTs studies (n = 2260) comparing the use of NOACs versus VKA in patients with AF undergoing catheter ablation were included. The odds ratio (OR) with 95% confidence interval was computed and P < 0.05 was considered as a level of significance. Major adverse cardiac events (MACE) were considered as a primary endpoint. RESULTS: Our results showed a significant difference in MACE between NOACs and VKA [OR 0.57 (0.37-0.88); P = 0.01] and in major bleeding events [OR 0.55 (0.35-0.86); P = 0.009], which is mainly derived from the use of dabigatran. No significant difference in MACE or major bleeding events was found on the subgroup analysis of rivaroxaban and apixaban over VKA therapy. CONCLUSION: Uninterrupted use of NOACs is safe and effective alternative for the prevention of cerebral thromboembolism and reducing the risk of major bleeding in patients undergoing catheter ablation of AF. However, the individual subgroup analysis showed that only dabigatran is superior to VKA in terms of reducing MACE through a reduction in major bleeding. The rivaroxaban, apixaban and edoxaban are non-inferior to VKA therapy based on these results. Further studies are needed to generalize these recommendations in morbidly obese patients.

Cette thèse met en évidence l'importance des transporteurs lipidiques et leurs implications pharmaceutiques dans la délivrance de principes actifs de nature différente, par voie orale et/ou par voie cutanée. L'introduction générale de cette thèse donne un aperçu des différents types é en mettant l'accent sur les nanoparticules lipidiques solides ( SLN ) et les nanocapsules lipidiques ( LNC ). Dans la première partie, les SLN chargées avec le propionate de clobétasol ( CP ), ont été développées et formulées en un hydrogel pour une long terme corticothérapie topique. Les études du transport ex vivo ont indiqué que le CP maintenu par la peau était plus élevé pour les SLN gel par rapport au produit commercial. La deuxième partie met l'accent sur les nanocapsules lipidiques ( LNC ). Chapitre 1 de cette partie vise à obtenir des LNC chargées d'un principe actif hydrophile le pentasaccharide, fondaparinux ( F ) à partir de deux microémulsions ( ME ) selon un brevet qui a été déposé. Les résultats obtenus par les LNC préparés de la ME1 contenant les tensio-actifs non ioniques ( Imwitor/Span ) ont été les meilleurs ( 59.87 nm, 48.62 % taux d'encapsulation ). Le chapitre 2 vise à encapsuler le F par la stratégie de l'intéraction cationique pour réaliser une association efficace élevée ( 80-100%). L'impact de cette formulation sur la pharmacocinétique du médicament après administration orale chez le rat a montré une amélioration de la biodisponibilité de F d'une mode dépendante de la dose. Les LNC cationiques chargées en F ont démontré une potentialité thérapeutique intéressante pour l'administration d'un pentasaccharide dérivé de l'héparine par voie orale comme une première preuve de concept comme une solution alternative à l'administration de F.

Thrombin is the key protease that regulates hemostasis; the delicate balance between procoagulation and anticoagulation of blood. In clotting disorders, like deep vein thrombosis or pulmonary embolism, procoagulation is up-regulated, but propagation of clotting can be inhibited with drugs targeting the proteases involved, like thrombin. Such drugs however, have serious side effects (e.g., excessive bleeding) and some require monitoring during the course of treatment. The reason for these side effects is the mechanism by which the drugs’ act. The two major mechanisms are direct orthosteric and indirect allosteric inhibition, which will completely abolish the protease’s activity. Herein we sought an alternative mechanism called allosteric, partial inhibition, that has shown promise to truly regulate coagulation. Partial inhibition through allosteric mechanisms are well described for membrane-bound and oligomeric proteins. However proteases, specifically monomeric proteases (i.e., thrombin), have not shown this phenomenon until now. A small library of coumarin-based sulfated allosteric modulators (CSAMs) was synthesized to target a surface region called exosite 2; mainly composed of highly positively charged residues surrounded by hydrophobic patches. Studies revealed a non-competitive mechanism of binding with a range of IC50s between 0.2-58 µM combined with inhibitory efficacies (ΔY) between 22-73%; indicative of allosteric, partial inhibition. The KD was determined for the most potent compound (3g; IC50 = 0.2 µM, ΔY = 47%) at 0.15 µM. 3g was observed to bind at exosite 2 through unfractionated heparin competition and thrombin mutant studies. Additional computational studies were in agreement with the mutant and competition studies, showing the sulfate of 3g binding within a pocket containing R126 and R233. Fluorescence quenching and antithrombin inactivation rate studies described a conformational change to thrombin’s active site in the presence of 3g, supporting reduction of thrombin’s catalytic efficiency, without complete inhibition of thrombin’s proteolytic activities. Coupled enzyme assays and gel electrophoresis showed that in the presence of 3g, hydrolysis of fibrinogen (IC50 = 0.51 µM, ΔY = 94%) and protein C activation (IC50 = 1.7 µM, ΔY = 91%) is fully inhibited. Alternatively, FXIII activation was shown to be only partially inhibited by the presence of 3g, and FXI activation did not show any significant activation or inhibition. 3g was also shown to be active in human plasma and whole blood, but requiring much higher concentrations to induce an anticoagulant effect. Mice studies looking at the effects of 3g in vivo showed that even at high concentrations, showed no abnormal bleeding or any other irregularities. This work highlights a novel occurrence regarding thrombin’s allosteric functionality against multiple endogenous substrates. This library of compounds may be useful in the future development of allosteric inhibitors and probes that pose little to no risk of bleeding events by inducing partial inhibition.

O estudo farmacognóstico comparativo das folhas de duas espécies de capuchinha, T. majus e de T. pentaphyllum, constituiu o escopo deste trabalho Artigos científicos sobre a espécie T. majus reportam a atividade antibacteriana, antifúngica, antiviral e antitumoral, devidas ao benzilisotiocianato, presente nos órgãos aéreos da espécie. Na medicina popular, também é utilizada para \"afinar\" o sangue. O efeito anticoagulante é de grande importância para indivíduos predispostos a distúrbios hemostáticos. No âmbito farmacológico, foram avaliadas, in vitro, as atividades anticoagulante sobre o plasma humano e antileishmania dos extratos e das frações. O benzilisotiocianato não apresentou atividade anticoagulante nem anti-leishmania. Foi observada atividade anticoagulante nos ensaios com os extratos e as frações hidrofílicas de T.majus e de T. pentaphyllum e a ausência de efeito destes sobre a viabilidade da forma promastigota de Leishmania chagasi. Os resultados apontam os flavonóides como os responsáveis pelo prolongamento do tempo de trombina provocado pelos extratos de T.majus e T. pentaphyllum. / The aim of this work was the pharmacognostic comparative study of leaves and flowers of nasturtium: Tropaeolum majus e Tropaeolum pentaphyllum. Scientific articles report the antibacterial, antiviral and antitumoral activity due to benzyl-isothiocianate, wich is present in the aerial organs of both species. Folk medicine uses leaves extract of T. majus to \"thin\" the blood. Anticoagulant effect is of great importance for predisposed individuals to haemostatic disturbances. Hidroalcoholic extracts of leaves and flowers of T. majus and T. pentaphyllum were appraised for the anticoagulant and anti-leishmania activities. The benzyl-isothiocianate neither presented anticoagulant activity nor anti-leishmania. Anticoagulant activity was observed in the essays with the extracts and the hidrofilic fractions of both species. The extracts and benzyl-isothiocianate showed no activity against Leishmania chagasi. The results allowed conclude that flavonoids are responsible for the prolongation of thrombin time (TT), provoked by the extracts of T. majus e T. pentaphyllum.