Utilization of international normalized ratio-derived formula to predict plasma rivaroxaban level-Validation study and real-world experience.

INTRODUCTION: Specific assays of plasma rivaroxaban level are not always readily available with short turnaround time, which hamper the management of urgent clinical situations. In this study, we aimed to build a predictive formula of plasma rivaroxaban levels from international normalized ratio (INR) value and validated in real world clinical situations. METHODS: Ninety-four patients who were taking rivaroxaban participated in the study. Patients were randomized into testing cohort and validation cohorts. The prediction formula was built from the testing cohort and then validated in validation cohort. The predictive performance was further validated on real-world clinical requests. RESULTS: The root mean square error (RMSE) of the predictive formula for the testing and validation cohorts were 61.81 and 69.32 ng/mL, respectively. The sensitivity and specificity for the formula to predict the threshold plasma rivaroxaban level of 75 ng/mL were 95% (95% CI: 85.4%-100%) and 87.5% (95% CI: 71.3%-100%), respectively, in real-world clinical situations. CONCLUSION: Plasma rivaroxaban level of threshold level of 75 ng/mL can be calculated from prediction formula by INR value with satisfactory accuracy and it can be used to guide the decision for reversal.

Plasma Rivaroxaban Level in Patients With Early Stages of Chronic Kidney Disease-Relationships With Renal Function and Clinical Events.

Introduction Drug accumulation of rivaroxaban is a concern in patients with chronic kidney disease (CKD). Data regarding the plasma rivaroxaban levels in early CKD patients and its relationship with clinical events is lacking. Methods Early CKD patients (Stage 1-3) with atrial fibrillation who received rivaroxaban (15 or 20 mg daily) were recruited. Plasma rivaroxaban levels were measured at 2 hours (peak) and 24 hours (trough) after drug administration, and correlated with eGFR and clinically significant events during the follow-up period (1 January 2018 to 31 October 2021). Results Ninety-two patients were included (CKD stage 1 n=10, stage 2 n=53, stage 3 n=29). Plasma trough levels in patients with stage 3 CKD were significantly higher than those with stage 2 and 1 CKD (66.0±34.9 ng/ml vs. 35.7 ± 24.7 ng/ml vs. 34.7 ± 26.2 ng/ml, respectively, p=0.005), and showed inverse relationship with eGFR (r=0.391, p=0.001) in patients receiving 20 mg daily. The plasma trough rivaroxaban level correlated with PT and APTT (r = 0.650 and 0.44, respectively, p<0.001 for both). Plasma trough rivaroxaban level in those with bleeding were higher than those who did not (59.9 ± 35.6 ng/ml vs. 41.1 ± 29.2 ng/ml, p=0.011), and multivariate analysis suggested that plasma trough rivaroxaban level was associated with the rate of bleeding complications (OR: 1.020, 95% CI 1.002-1.038, p=0.028). Conclusion Plasma trough rivaroxaban levels correlated with renal function in early CKD patients, and its measurement may help dosage optimization in patients with renal impairment. Moreover, our data suggests that there may be an association between plasma trough rivaroxaban level and the rate of bleeding complication.

Functionalized Polymeric Membrane with Enhanced Mechanical and Biological Properties to Control the Degradation of Magnesium Alloy.

To achieve enhanced biological response and controlled degradation of magnesium alloy, a modified biodegradable polymer coating called polycaprolactone (PCL) is fabricated by a thermal approach in which the heat treatment neither alters the chemical composition of the PCL membrane nor the rate of magnesium ion release, pH value, or weight loss, compared with the untreated sample. The changes in the crystallinity, hydrophilicity, and oxygen content of heat-treated PCL coating not only improve the mechanical adhesion strength between the coating and magnesium substrate but also enhance the biological properties. Moreover, the thermally modified sample can lead to higher spreading and elongation of osteoblasts, due to the enhanced hydrophilicity and CO to CO functional group ratio. In the analyses of microcomputed tomography from one to four weeks postoperation, the total volume of new bone formation on the heat-treated sample is 10%-35% and 70%-90% higher than that of the untreated and uncoated controls, respectively. Surprisingly, the indentation modulus of the newly formed bone adjacent to the heat-treated sample is ≈20% higher than that of both controls. These promising results reveal the clinical potential of the modified PCL coating on magnesium alloy in orthopedic applications.

Development of novel implants with self-antibacterial performance through in-situ growth of 1D ZnO nanowire.

To prevent the attachment of bacteria to implant surfaces, the 1D zinc oxide nanowire-coating has been successfully developed on material surfaces by using a custom-made hydrothermal approach. The chemical nature, surface topography and wettability of spike-like 1D ZnO nanowire-coating are comprehensively investigated. The anti-adhesive and antimicrobial properties of 1D nanowire-coating are tested against Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli by using in vitro live/dead staining and scanning electron microscopy. We find that the adhesion of bacteria can be reduced via the special spike-like topography and that the release of Zn(2+) ions can help suppress the growth of attached bacteria. Furthermore, the antimicrobial effect is also evaluated under in vivo conditions by using a rat model infected with bioluminescent S. aureus. The amount of live bacteria in the rat implanted with a nanowire-coated sample is less than that of the control at various time points. Hence, it is believed that the nanowire-coated material is promising for application in orthopaedic implantation after the long-term animal studies have been completed.

Plasma Surface Functionalized Polyetheretherketone for Enhanced Osseo-Integration at Bone-Implant Interface.

This study aims at improving osseo-integration at the bone-implant interface of polyetheretherketone (PEEK) by water (H2O) and ammonia (NH3) plasma immersion ion implantation (PIII). The pertinent surface characteristics including surface energy, roughness, morphology, and chemical composition are investigated systematically and the in vitro biological performance is evaluated by cell adhesion and proliferation, alkaline phosphatase (ALP) activity, real-time RT-PCR evaluation, and mineralization tests. In vivo osseo-integration is examined via implanting samples into the distal femur of the rats. The hydrophilicity, surface roughness, cell adhesion, and proliferation, ALP activity, and osteogenic differentiation after H2O PIII or NH3 PIII are improved significantly. Furthermore, substantially enhanced osseo-integration is achieved in vivo. Nonline-of-sight plasma surface functionalization, which is particularly suitable for biomedical implants with an irregular geometry, does not alter the bulk compressive yield strength and elastic modulus of the materials. Consequently, the favorable bulk attributes of PEEK are preserved while the surface biological properties are enhanced thus boding well for wider orthopedic application of the biopolymer.

Maturation of glutamatergic transmission in the vestibulo-olivary pathway impacts on the registration of head rotational signals in the brainstem of rats.

The recognition of head orientation in the adult involves multi-level integration of inputs within the central vestibular circuitry. How the different inputs are recruited during postnatal development remains unclear. We hypothesize that glutamatergic transmission at the vestibular nucleus contributes to developmental registration of head orientations along the vestibulo-olivary pathway. To investigate the maturation profile by which head rotational signals are registered in the brainstem, we used sinusoidal rotations on the orthogonal planes of the three pairs of semicircular canals. Fos expression was used as readout of neurons responsive to the rotational stimulus. Neurons in the vestibular nucleus and prepositus hypoglossal nucleus responded to all rotations as early as P4 and reached adult numbers by P21. In the reticular formation and inferior olive, neurons also responded to horizontal rotations as early as P4 but to vertical rotations not until P21 and P25, respectively. Neuronal subpopulations that distinguish between rotations activating the orthogonally oriented vertical canals were identifiable in the medial and spinal vestibular nuclei by P14 and in the inferior olivary subnuclei IOß and IOK by P25. Neonatal perturbation of glutamate transmission in the vestibular nucleus was sufficient to derange formation of this distribution in the inferior olive. This is the first demonstration that developmental refinement of glutamatergic synapses in the central vestibular circuitry is essential for developmental registration of head rotational signals in the brainstem.

Novel Electrospun Polylactic Acid Nanocomposite Fiber Mats with Hybrid Graphene Oxide and Nanohydroxyapatite Reinforcements Having Enhanced Biocompatibility.

Graphene oxide (GO) and a nanohydroxyapatite rod (nHA) of good biocompatibility were incorporated into polylactic acid (PLA) through electrospinning to form nanocomposite fiber scaffolds for bone tissue engineering applications. The preparation, morphological, mechanical and thermal properties, as well as biocompatibility of electrospun PLA scaffolds reinforced with GO and/or nHA were investigated. Electron microscopic examination and image analysis showed that GO and nHA nanofillers refine the diameter of electrospun PLA fibers. Differential scanning calorimetric tests showed that nHA facilitates the crystallization process of PLA, thereby acting as a nucleating site for the PLA molecules. Tensile test results indicated that the tensile strength and elastic modulus of the electrospun PLA mat can be increased by adding 15 wt % nHA. The hybrid nanocomposite scaffold with 15 wt % nHA and 1 wt % GO fillers exhibited higher tensile strength amongst the specimens investigated. Furthermore, nHA and GO nanofillers enhanced the water uptake of PLA. Cell cultivation, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and alkaline phosphatase tests demonstrated that all of the nanocomposite scaffolds exhibit higher biocompatibility than the pure PLA mat, particularly for the scaffold with 15 wt % nHA and 1 wt % GO. Therefore, the novel electrospun PLA nanocomposite scaffold with 15 wt % nHA and 1 wt % GO possessing a high tensile strength and modulus, as well as excellent cell proliferation is a potential biomaterial for bone tissue engineering applications.

Polypropylene Biocomposites with Boron Nitride and Nanohydroxyapatite Reinforcements.

In this study, we develop binary polypropylene (PP) composites with hexagonal boron nitride (hBN) nanoplatelets and ternary hybrids reinforced with hBN and nanohydroxyapatite (nHA). Filler hybridization is a sound approach to make novel nanocomposites with useful biological and mechanical properties. Tensile test, osteoblastic cell culture and dimethyl thiazolyl diphenyl tetrazolium (MTT) assay were employed to investigate the mechanical performance, bioactivity and biocompatibility of binary PP/hBN and ternary PP/hBN-nHA composites. The purpose is to prepare biocomposite nanomaterials with good mechanical properties and biocompatibility for replacing conventional polymer composites reinforced with large hydroxyapatite microparticles at a high loading of 40 vol%. Tensile test reveals that the elastic modulus of PP composites increases, while tensile elongation decreases with increasing hBN content. Hybridization of hBN with nHA further enhances elastic modulus of PP. The cell culture and MTT assay show that osteoblastic cells attach and proliferate on binary PP/hBN and ternary PP/hBN-20%nHA nanocomposites.

Osteogenic ability of Cu-bearing stainless steel.

A newly developed copper-bearing stainless steel (Cu-SS) by directly immobilizing proper amount of Cu into a medical stainless steel (317L SS) during the metallurgical process could enable continuous release of trace amount of Cu(2+) ions, which play the key role to offer the multi-biofunctions of the stainless steel, including the osteogenic ability in the present study. The results of in vitro experiments clearly demonstrated that Cu(2+) ions from Cu-SS could promote the osteogenic differentiation by stimulating the Alkaline phosphatase enzyme activity and the osteogenic gene expressions (Col1a1, Opn, and Runx2), and enhancing the adhesion and proliferation of osteoblasts cultured on its surface. The in vivo test further proved that more new bone tissue formed around the Cu-SS implant with more stable bone-to-implant contact in comparison with the 317L SS. In addition, Cu-SS showed satisfied biocompatibility according to the results of in vitro cytotoxicity and in vivo histocompatibility, and its daily released amount of Cu(2+) ions in physiological saline solution was at trace level of ppb order (1.4 ppb/cm(2) ), which is rather safe to human health. Apart from these results, it was also found that Cu-SS could inhibit the happening of inflammation with lower TNF-α expression in the bone tissue post implantation compared with 317L SS. In addition to good biocompatibility, the overall findings demonstrated that the Cu-SS possessed obvious ability of promoting osteogenesis, indicating a unique application advantage in orthopedics.

The development, fabrication, and material characterization of polypropylene composites reinforced with carbon nanofiber and hydroxyapatite nanorod hybrid fillers.

This study focuses on the design, fabrication, microstructural and property characterization, and biocompatibility evaluation of polypropylene (PP) reinforced with carbon nanofiber (CNF) and hydroxyapatite nanorod (HANR) fillers. The purpose is to develop advanced PP/CNF-HANR hybrids with good mechanical behavior, thermal stability, and excellent biocompatibility for use as craniofacial implants in orthopedics. Several material-examination techniques, including X-ray diffraction, Fourier-transform infrared spectroscopy, scanning electron microscopy, thermogravimetric analysis, differential scanning calorimetry, tensile tests, and impact measurement are used to characterize the microstructural, mechanical, and thermal properties of the hybrids. Furthermore, osteoblastic cell cultivation and colorimetric assay are also employed for assessing their viability on the composites. The CNF and HANR filler hybridization yields an improvement in Young's modulus, impact strength, thermal stability, and biocompatibility of PP. The PP/2% CNF-20% HANR hybrid composite is found to exhibit the highest elastic modulus, tensile strength, thermal stability, and biocompatibility.

In vivo stimulation of bone formation by aluminum and oxygen plasma surface-modified magnesium implants.

A newly developed magnesium implant is used to stimulate bone formation in vivo. The magnesium implant after undergoing dual aluminum and oxygen plasma implantation is able to suppress rapid corrosion, leaching of magnesium ions, as well as hydrogen gas release from the biodegradable alloy in simulated body fluid (SBF). No released aluminum is detected from the SBF extract and enhanced corrosion resistance properties are confirmed by electrochemical tests. In vitro studies reveal enhanced growth of GFP mouse osteoblasts on the aluminum oxide coated sample, but not on the untreated sample. In addition to that a small amount (50 ppm) of magnesium ions can enhance osteogenic differentiation as reported previously, our present data show a low concentration of hydrogen can give rise to the same effect. To compare the bone volume change between the plasma-treated magnesium implant and untreated control, micro-computed tomography is performed and the plasma-treated implant is found to induce significant new bone formation adjacent to the implant from day 1 until the end of the animal study. On the contrary, bone loss is observed during the first week post-operation from the untreated magnesium sample. Owing to the protection offered by the Al2O3 layer, the plasma-treated implant degrades more slowly and the small amount of released magnesium ions stimulate new bone formation locally as revealed by histological analyses. Scanning electron microscopy discloses that the Al2O3 layer at the bone-implant interface is still present two months after implantation. In addition, no inflammation or tissue necrosis is observed from both treated and untreated implants. These promising results suggest that the plasma-treated magnesium implant can stimulate bone formation in vivo in a minimal invasive way and without causing post-operative complications.

Cytocompatibility, osseointegration, and bioactivity of three-dimensional porous and nanostructured network on polyetheretherketone.

Porous biomaterials with the proper three-dimensional (3D) surface network can enhance biological functionalities especially in tissue engineering, but it has been difficult to accomplish this on an important biopolymer, polyetheretherketone (PEEK), due to its inherent chemical inertness. In this study, a 3D porous and nanostructured network with bio-functional groups is produced on PEEK by sulfonation and subsequent water immersion. Two kinds of sulfonation-treated PEEK (SPEEK) samples, SPEEK-W (water immersion and rinsing after sulfonation) and SPEEK-WA (SPEEK-W with further acetone rinsing) are prepared. The surface characteristics, in vitro cellular behavior, in vivo osseointegration, and apatite-forming ability are systematically investigated by X-ray photoelectron spectroscopy, Fourier-transform infrared spectroscopy, scanning electron microscopy, cell adhesion and cell proliferation assay, real-time RT-PCR analysis, micro-CT evaluation, push-out tests, and immersion tests. SPEEK-WA induces pre-osteoblast functions including initial cell adhesion, proliferation, and osteogenic differentiation in vitro as well as substantially enhanced osseointegration and bone-implant bonding strength in vivo and apatite-forming ability. Although SPEEK-W has a similar surface morphology and chemical composition as SPEEK-WA, its cytocompatibility is inferior due to residual sulfuric acid. Our results reveal that the pre-osteoblast functions, bone growth, and apatite formation on the SPEEK surfaces are affected by many factors, including positive effects introduced by the 3D porous structure and SO3H groups as well as negative ones due to the low pH environment. Surface functionalization broadens the use of PEEK in orthopedic implants.

Novel polypropylene biocomposites reinforced with carbon nanotubes and hydroxyapatite nanorods for bone replacements.

Multi-walled carbon nanotubes (MWNTs) of 0.1 and 0.3 wt.% and hydoxyapatite nanorods (nHAs) of 8-20 wt.% were incorporated into polypropylene (PP) to form biocomposites using melt-compounding and injection molding techniques. The structural, mechanical, thermal and in vitro cell responses of the PP/MWNT-nHA hybrids were investigated. Tensile and impact tests demonstrated that the MWNT additions are beneficial in enhancing the stiffness, tensile strength and impact toughness of the PP/nHA nanocomposites. According to thermal analysis, the nHA and MWNT fillers were found to be very effective to improve dimensional and thermal stability of PP. The results of osteoblast cell cultivation and dimethyl thiazolyl diphenyl tetrazolium (MTT) tests showed that the PP/MWNT-nHA nanocomposites are biocompatible. Such novel PP/MWNT-nHA hybrids are considered to be potential biomaterials for making orthopedic bone implants.

Low-modulus Mg/PCL hybrid bone substitute for osteoporotic fracture fixation.

In this paper, we describe a new biodegradable composite composed of polycaprolactone and magnesium. Incorporation of magnesium micro-particles into the polycaprolactone matrix yields mechanical properties close to those of human cancellous bone, and in vitro studies indicate that the silane-coated Mg/PCL composites have excellent cytocompatibility and osteoblastic differentiation properties. The bioactivity of the composites is manifested by the formation of calcium and phosphate after immersion in simulated body fluids. The bulk mechanical properties can be maintained for 2 months before obvious degradation takes place. The in vivo animal study reveals a larger amount of new bone formation on the silane-coated Mg/PCL composites compared to conventional PMMA and pure polycaprolactone and our results suggest potential clinical applications of the sliane-coated Mg/PCL composites.

Effects of carbon and nitrogen plasma immersion ion implantation on in vitro and in vivo biocompatibility of titanium alloy.

Growth of bony tissues on titanium biomedical implants can be time-consuming, thereby prolonging recovery and hospitalization after surgery and a method to improve and expedite tissue-implant integration and healing is thus of scientific and clinical interests. In this work, nitrogen and carbon plasma immersion ion implantation (N-PIII and C-PIII) is conducted to modify Ti-6Al-4V to produce a graded surface layer composed of TiN and TiC, respectively. Both PIII processes do not significantly alter the surface hydrophilicity but increase the surface roughness and corrosion resistance. In vitro studies disclose improved cell adhesion and proliferation of MC3T3-E1 preosteoblasts and L929 fibroblasts after PIII. Micro-CT evaluation conducted 1 to 12 weeks after surgery reveals larger average bone volumes and less bone resorption on the N-PIII and C-PIII titanium alloy pins than the unimplanted one at every time point. The enhancements observed from both the in vitro and in vivo studies can be attributed to the good cytocompatibility, roughness, and corrosion resistance of the TiN and TiC structures which stimulate the response of preosteoblasts and fibroblasts and induce early bone formation. Comparing the two PIII processes, N-PIII is more effective and our results suggest a simple and practical means to improve the surface biocompatibility of medical-grade titanium alloy implants.

Activation of mitogen-activated protein kinases cellular signal transduction pathway in mammalian cells induced by silicon carbide nanowires.

Because of emerging biomedical applications of nanoscale materials, the behavior of cells in contact with nanoscale materials must be better understood. SiC nanostructures constitute a new class of biomaterials and have potential in many applications. In this study, the cellular signal transduction processes and toxicity mechanisms of silicon carbide nanowires (SiCNWs) are investigated. The Chinese hamster ovary (CHO) cells in contact with SiCNWs have significantly lower reproduction rates and genomic instability which may be the upstream event of cell apoptosis. Expression of the phosphorylated form of the mitogen-activated protein kinases (MAPKs) family including phosphorylated signal-regulated kinases (p-ERKs), phosphorylated c-Jun NH2-terminal kinases (p-JNKs), and phosphorylated p38-mitogen-activated protein kinases (p-p38) are observed at different time points during exposure to SiCNWs. Moreover, activation of the MAPKs family by phosphorylation which is an upstream event giving rise to expression of cyclooxygenase-2 (COX-2) is also observed. The specific inhibitors of the MAPKs family are found to restrain COX-2 high expression at some time points. Our results show that activation of the MAPKs cellular signaling pathway and over-expression of COX-2 are the main toxicity mechanisms in SiCNWs irritation.

A biodegradable polymer-based coating to control the performance of magnesium alloy orthopaedic implants.

Magnesium and its alloys may potentially be applied as degradable metallic materials in orthopaedic implantations due to their degradability and resemblance to human cortical bone. However, the high corrosion rate and accumulation of hydrogen gas upon degradation hinders its clinical application. In this study, we adopt a new approach to control the corrosion rate by coating a controllable polymeric membrane fabricated by polycaprolactone and dichloromethane onto magnesium alloys, in which the pore size was controlled during the manufacturing process. The addition of the polymeric membrane was found to reduce the degradation rate of magnesium, and the bulk mechanical properties were shown to be maintained upon degradation. The in-vitro studies indicated good cytocompatibility of eGFP and SaOS-2 osteoblasts with the polymer-coated samples, which was not observed for the uncoated samples. The in-vivo study indicated that the uncoated sample degraded more rapidly than that of the polymer-coated samples. Although new bone formation was found on both samples, as determined by Micro-CT, higher volumes of new bone were observed on the polymer-coated samples. Histological analysis indicated no inflammation, necrosis or hydrogen gas accumulation on either of the samples during degradation. Collectively, these data suggest that the use of polymeric membrane may be potentially applied for future clinical use.