Dipyrone

Two hours prior to implantation mice were pre-medicated with 200 μg/g body weight metamizol (WDT, Garbsen, Germany) to control for postoperative pain and inflammation. Mice were anaesthetized with an intraperitoneal injection of 100 μg/g ketamine and 10 μg/g xylazine (both from WDT). Upon reaching surgical tolerance, the mouse head was mounted onto a stereotaxic frame (David Instruments, Tujanga, CA, USA) positioned on a heating plate with 37 °C. The skull was exposed by a 0.5 cm longitudinal skin incision, and a hole was drilled 1.5 mm lateral (right) and 1 mm posterior to the bregma using a pair of 23G and a 21G microlances (BD Biosciences, Heidelberg, Germany). With a stereotactically guided glass syringe (Hamilton, Bonaduz, Switzerland) 90,000 GL261 cells were injected in 1 μl in 3 mm depth from the dura surface into the right striatum. Injection was executed over a time period of 2 min, and the syringe was slowly withdrawn in 3–4 steps. The skin was closed using Ethibond Excel 5–0 suture material (Ethicon, Norderstedt, Germany), and mice were monitored on a heated pad until regaining consciousness.

We conducted a single-center, interventional, quasi-experimental before-after study in the Division of Internal Medicine of the Kantonsspital Olten, a university-affiliated secondary-level teaching hospital with 245 beds in northwestern Switzerland. To detect an effect of 10% of the checklist (decrease in prevalence of inappropriate drug prescription and/or polypharmacy from anticipated 30% at admission to 20% at discharge) with a probability (power) of 90% at a significance level (alpha, 2-tailed) of 0.05, a sample size of 824 patients (412 in each group) is needed. Therefore, we included in the analysis the first 450 consecutive patients aged ≥ 65 years hospitalized in the Division of Internal Medicine during the period September 1^st–December 30^th, 2013, after the introduction of the checklist (intervention group), and compared them to the first 450 consecutive patients aged ≥ 65 years hospitalized in the same division during the same period of the previous year (September 1^st–December 31^th, 2012) (control group) (Fig 1). The consecutive patients were identified through the admission lists generated by the electronic hospital information system. Each patient was included only once (at the first hospitalization). Patients who died during the hospitalization were excluded from further analysis.
We introduced a checklist (Figs 2 and 3) aimed at supporting the therapeutic reasoning of clinicians in order to improve the quality of drug prescriptions. The checklist was based on the conceptual frameworks proposed by Scott et al. [14 (link)] and by Dovjak [15 (link)], and consisted of following 5 sequential steps: 1. ascertain all current medications used; 2. identify patients at high risk of adverse drug reactions; 3. estimate life expectancy; 4. identify medications which are not indicated and/or are potentially dangerous; 5. monitor the patient if drugs were stopped or new drugs were added. For the first 4 steps, a possible tool to be used at the discretion of the physician was proposed: for the assessment of current medications: the “brown paper bag” review [16 (link)]; to identify patients at high risk of adverse drug reactions: the gerontoNet adverse drug reactions risk score [17 (link)]; to estimate life expectancy: the prognostic index for frail elderly people described by Carey et al. [18 (link)]; and for the identification of potentially inappropriate medication: the Medication Appropriateness Index [11 (link)].
The checklist was discussed and presented to all physicians of the Division of Internal Medicine during grand rounds at the beginning of the intervention period. Each physician received the checklist as a pocket-sized leaflet and was asked to systematically apply the five described steps at admission and discharge of each patient and during daily visits. The checklist was also posted on the mobile desk workstations used during ward rounds. A senior physician reiterated weekly the use of the checklist with the medical team on each ward.
The primary outcomes of the study were the proportion of patients prescribed PIMs at discharge, according to STOPP criteria [19 (link)], and the total number of prescribed medications at discharge, before and after the introduction of the checklist. Secondary outcomes (evaluated at discharge), were the prevalence of polypharmacy (concomitant use of ≥ 5 drugs) and hyperpolypharmacy (concomitant use of ≥ 10 drugs), the prevalence of PPOs (according to START criteria [19 (link)]), the prevalence of prescription and the rate of inappropriate prescription of following drugs: non-steroidal anti-inflammatory drugs (NSAID); proton pump inhibitors (PPI); systemic corticosteroids; metamizole (Novalgin^™); potent opiates. In addition we assessed the in-hospital mortality rate and the all-cause re-hospitalization rate at 30 days after discharge.
Basic demographic data and information on diagnoses, medications, duration of hospitalization, admission to the intensive care unit, re-hospitalization within 30 days after discharge, and in-hospital death were collected from the electronic patient records of the hospital. The medication of each patient at admission and discharge was reviewed independently by two of the investigators, who assessed the medication appropriateness by chart review according to STOPP and START criteria [19 (link)]. Discrepancies were resolved by discussion. Data were recorded on a standardized case report form and anonymized before statistical analysis. The group assignment of each patient (intervention vs. control) was not reported on the case report form. However, it was not possible to blind the two investigators assessing medication appropriateness, because charts used for chart review contained hospitalization dates, dates of laboratory examinations etc.
Basic demographic characteristics, co-morbidities, clinical and laboratory parameters as well as the type and number of drugs prescribed at admission and discharge were compared according to the intervention using the chi-squared test or Fisher’s exact test for categorical variables as appropriate, and the non-parametric Wilcoxon-Mann-Whitney U test for continuous variables. As the outcome event was common (> 10%) we estimated relative risks and risk ratios (RR) instead of odds ratios (OR), since there might be an overestimation of the effect of the intervention when using OR [20 (link)–23 (link)]. Because of the failed convergence by the log-binomial logistic method in building multivariate models, we used Poisson regression models with a robust error variance [20 (link)] to estimate the effect of the checklist on prescription of at least 20% less drugs at discharge compared to admission, as well as risk factors of prescribing at least one inappropriate drug or missing to prescribe at least one appropriate drug at discharge. Risk factors of being re-hospitalized after discharge were also assessed using Poisson regression models with a robust error variance. Bivariable Poisson regression analysis was used to preselect independent variables when the Wald statistic was p<0.05. If the Phi correlation coefficient between two variables was ≥0.8, the variable with the lowest Wald statistic was excluded from further analysis. Thereafter, we used a backward stepwise multivariable Poisson regression analysis on the selected variables to form the prediction model (entry criteria = p<0.05; removal criteria = p≥0.10). We retained those variables that are known to be associated with the higher probability of drug prescription in the literature (older age, male sex, comorbidities, i.e. Charlton comorbidity index). Likelihood ratio tests were used to measure goodness of the fit of the regression models. Results are presented as crude and adjusted risk ratios (RR) after adjusting for potential confounders as indicated. Finally, we checked the models for any interactions. Data were analyzed using an intention-to-intervention approach, where all subjects in the intervention group were compared regardless of whether checklist has been used by the physician in charge. All analyses were performed using STATA software version 13 for Windows (Stata Corp, College Station, Texas, USA).
The local research ethics committee (Kantonale Ethikkommission Aargau / Solothurn; N. 2013/039) approved the study and accepted the protocol as a quality improvement project aimed at improving the application of recognized standards of care, waiving the requirement to obtain informed consent.
Trial Registration: ClinicalTrials.gov NCT02712268.

Male mice ranging from 9 to 12 weeks of age (8 WT and 5 Cxcl4^−/−) were anesthetized by intraperitoneal injection (i.p.) with ketamine/xylazine (90 μg/g bodyweight (BW) ketamine, 9 μg/g BW xylazine). Analgesia was carried out by subcutaneous (s.c.) injection of metamizol (200 μg/g BW). For IRI procedure kidneys were exposed and mobilized by dorsolateral incision and perfusion was interrupted by clamping the renal artery using a non-traumatic microaneurysm clamp. Mice were kept at 37°C. After 28 minutes (min) ischemia, clamps were removed, and reperfusion was observed. The abdominal cavity was closed by peritoneal suture with prolene (6–0) and the skin clipped. For the sham procedure, skin and peritoneum were incised on the contralateral side, the kidney mobilized but not clamped, and the peritoneum and skin closed as described before. To minimize pain, metamizole (1.25 mg/mL) and 1% sucrose were added for three days to the drinking water. 28 days after IRI, mice were killed by cardiac puncture under ketamine/xylazine narcosis. The right ventricle was incised, the mouse was perfused with 30 mL PBS via the left ventricle and organs were taken for further analysis.³ (link)

11 to 17-week-old sex- and age-matched WT (MI: 5x female, 3x male; sham: 5x female, 3x male) and Cxcl4^−/− (MI: 4x female, 3x male; sham: 4x female, 2x male) mice were subjected to myocardial infarction, as previously described.⁷² (link) In brief, mice were anesthetized using isoflurane (2–2.5%), intubated and ventilated with oxygen using a mouse respirator (Harvard Apparatus, March, Germany). For analgesia, metamizole was injected subcutaneously (200 μg/g BW) in addition to local analgesia with subcutaneous and intercostal injection of Bupivacaine (2.5 μg/g BW). Left thoracotomy was performed and mice were subjected to sham surgery or myocardial infarction via ligation of the left anterior descending coronary artery (LAD) with a silk (0–7) suture. The ribs, muscle layer, and skin incision were closed using prolene (0–6), and metamizole was administered for three days via drinking water (1.25 mg/mL 1% sucrose) post-surgery.