Efficacy and Safety of Warfarin for the Treatment of Venous Thromboembolism - A Multicenter Prospective Observational Cohort Study in Japan (AKAFUJI Study)

BACKGROUND

A large-scale prospective study of the efficacy and safety of warfarin for the treatment of venous thromboembolism (VTE) has not been conducted in Japan. Therefore, we conducted a real-world prospective multicenter observational cohort study (AKAFUJI Study; UMIN000014132) to investigate the efficacy and safety of warfarin for VTE.Methods and Results: Between May 2014 and March 2017, 352 patients (mean [±SD] age 67.7±14.8 years; 57% female) with acute symptomatic/asymptomatic VTE were enrolled; 284 were treated with warfarin. The cumulative incidence of recurrent symptomatic VTE was higher in patients without warfarin than in those treated with warfarin (8.7 vs. 2.2 per 100 person-years, respectively; P=0.018). The cumulative incidence of bleeding complications was not significantly different between the 2 groups. The mean prothrombin time-international normalized ratio (PT-INR) during warfarin on-treatment was <1.5 in 180 patients, 1.5-2.5 in 97 patients, and >2.5 in 6 patients. The incidence of bleeding complications was significantly higher in patients with PT-INR >2.5, whereas the incidence of recurrent VTE was not significantly different between the 3 PT-INR groups. The cumulative incidence of recurrent VTE and bleeding complications did not differ significantly among those in whom VTE was provoked by a transient risk factor, was unprovoked, or was associated with cancer.

CONCLUSIONS

Warfarin therapy with an appropriate PT-INR according to Japanese guidelines is effective without increasing bleeding complications, regardless of patient characteristics.

Water Distribution Changes in Complex Decongestive Treatment for Leg Lymphedema: Quantitative Evaluation by Direct Segmental Multi-Frequency Bioimpedance Analysis

Background: There is a need for a simple method for the quantitative evaluation of lymphedema swelling. In this study, we performed a direct segmental multi-frequency impedance analysis in patients with leg lymphedema.

Methods: The subjects were 36 patients (6 men and 30 women) with 46 lymphedema legs. The average age was 61 years. All patients had International Society of Lymphology stage II lymphedema. Swelling ratio and ultrasound subcutaneous tissue echo-free space (FS) were examined. InBody 770 was used to measure the extracellular water (ECW), intracellular water (ICW), and total body water (TBW) volumes. Changes before and after complex decongestive treatment (CDT) were examined.

Results: In 26 unilateral cases, the ECW, ICW, and TBW volumes of the affected legs were higher than those of the contralateral unaffected legs, and the ECW/TBW ratio was significantly higher in the affected legs (0.41) than in the contralateral unaffected legs (0.391). There was a significant correlation between the leg swelling ratio and the ECW/TBW ratio between the affected and contralateral unaffected legs (correlation coefficient=0.882). Ultrasound findings of the 46 affected legs were classified into no FS (group 0), minimal or only horizontal FS (group 1), and cobblestone-like FS (group 2). The ECW/TBW ratio of the affected legs in each group was 0.393 (14 legs), 0.407 (10 legs), and 0.426 (22 legs) respectively, demonstrating significant differences among the 3 groups. After CDT, the amount of water decreased in the affected legs and increased in the trunks and both upper limbs. The ECW/TBW ratio decreased significantly, from 0.432 to 0.414 in the affected legs, from 0.401 to 0.392 in the unaffected legs, and from 0.413 to 0.402 in the trunks. The ECW/TBW ratio had not changed and remained below 0.4 in the upper limbs.

Conclusion: The segmental water contents measured by direct segmental multi-frequency impedance analysis correlates well with the degree of lymphedema swelling, and subcutaneous echo findings and can demonstrate water distribution change before and after CDT, which is considered to be a useful quantitative evaluation method for lymphedema. (This is secondary publication from Jpn J Phlebol 2020; 31(1): 1–7.)

Three-dimensional architecture of elastin and collagen fiber networks in the human and rat lung

Collagen and elastin fibers are the major components of the lung connective tissue, but their spatial organization has not been well documented. We have demonstrated the three-dimensional architecture of collagen and elastin fiber networks in the human and rat lung using scanning electron microscopy. These networks in their original forms were extracted by an alkali-water maceration technique and a formic acid treatment, respectively. The collagen fibers formed a continuum extending throughout the lung and pleura. They were condensed in the alveolar mouth and subdivided into smaller fibers in the alveolar septa, thus forming basket-like networks. Sizes of the alveolar pores in the collagen fiber network of the alveolar septa became larger with age. In the collapsed lung, collagen fibers in the alveolar mouths and septa took on wavelike configurations, while in the inflated lung they became straight. The elastin fibers also formed a continuum, rich in the alveolar mouths and poor in the alveolar septa, were quite straight without any wavelike configuration. Transmission electron microscopy showed that collagen and elastin fibers were intermingled, suggesting that both fiber systems may act as parallel mechanical elements to stress or strain applied. Our results suggest that at low levels of strain the wavy collagen fibers are easily extended to allow alveolar mouths and alveoli to expand, with most of the stress being borne by adjacent elastin fibers, while at higher levels collagen fibers become straight and limit any further distension of alveolar ducts and alveoli. The elastin fiber continuum appears to permit the lung to effectively recoil or retract. The present study has also shown that alveolar pores enlarge with age, suggesting that collagen remodeling may be related to the pathogenesis of emphysema.

Identification of myelodysplastic syndrome-specific genes by DNA microarray analysis with purified hematopoietic stem cell fraction

Myelodysplastic syndrome (MDS) is a slowly progressing hematologic malignancy associated with a poor outcome. Despite the relatively high incidence of MDS in the elderly, differentiation of MDS from de novo acute myeloid leukemia (AML) still remains problematic. Identification of genes expressed in an MDS-specific manner would allow the molecular diagnosis of MDS. Toward this goal, AC133 surface marker-positive hematopoietic stem cell (HSC)-like fractions have been collected from a variety of leukemias in a large-scale and long-term genomics project, referred to as "Blast Bank," and transcriptome of these purified blasts from the patients with MDS were then compared with those from AML through the use of oligonucleotide microarrays. A number of genes were shown to be expressed in a disease-specific manner either to MDS or AML. Among the former found was the gene encoding the protein Delta-like (Dlk) that is distantly related to the Delta-Notch family of signaling proteins. Because overexpression of Dlk may play a role in the pathogenesis of MDS, the disease specificity of Dlk expression was tested by a quantitative "real-time" polymerase chain reaction analysis. Examination of the Blast Bank samples from 22 patients with MDS, 31 with AML, and 8 with chronic myeloid leukemia confirmed the highly selective expression of the Dlk gene in the individuals with MDS. Dlk could be the first candidate molecule to differentiate MDS from AML. The proposal is made that microarray analysis with the Blast Bank samples is an efficient approach to extract transcriptome data of clinical relevance for a wide range of hematologic disorders.

All-trans-retinoic acid treatment for chemotherapy-resistant acute adult T-cell leukemia

We report a case in which treatment with all-trans-retinoic acid (ATRA) improved the clinical features of a 47-year-old female patient with acute adult T-cell leukemia (ATL). The patient was first treated several times with combination chemotherapy. but the number of ATL cells increased and other clinical manifestations progressed. ATRA 60 mg was then administered daily. ATRA treatment dramatically improved the patient's clinical features. In vitro examination revealed that ATRA inhibited the growth of ATL cells from the patient. These findings suggest that ATRA may be a useful treatment for patients with chemotherapy-resistant acute ATL.

A member of Forkhead family transcription factor, FKHRL1, is one of the downstream molecules of phosphatidylinositol 3-kinase-Akt activation pathway in erythropoietin signal transduction

The phosphatidylinositol 3-kinase (PI3K) signaling pathway is important for the regulation of a number of cellular responses. Serine/threonine kinase Akt (protein kinase B; PKB) is downstream of PI3K and activated by growth factors. This study found that erythropoietin (EPO) induced tyrosine phosphorylation of Akt in a time- and dose-dependent manner in EPO-dependent human leukemia cell line UT-7/EPO. In vitro kinase assay using histone H2B and glucose synthase kinase as substrates demonstrated that Akt was actually activated by EPO. EPO-induced phosphorylation of Akt was completely blocked by a PI3K-specific inhibitor, LY294002, at 10 micromol/L, indicating that activation of Akt by EPO is dependent on PI3K activity. In addition, overexpression of the constitutively active form of Akt on UT-7/EPO cells partially blocked apoptosis induced by withdrawal of EPO from the culture medium. This finding suggested that the PI3K-Akt activation pathway plays some role in the antiapoptotic effect of EPO. EPO induced phosphorylation of a member of the trancription factor Forkhead family, FKHRL1, at threonine 32 and serine 253 in a dose- and time-dependent manner in UT-7/EPO cells. Moreover, results showed that Akt kinase activated by EPO directly phosphorylated FKHRL1 protein and that FKHRL1 phosphorylation was completely dependent on PI3K activity as is the case for Akt. In conjunction with the evidence that FKHRL1 is expressed in normal human erythroid progenitor cells and erythroblasts, the results suggest that FKHRL1 plays an important role in erythropoiesis as one of the downstream target molecules of PI3K-Akt.

A new method for right ventricular endomyocardial biopsy via the femoral veins: a novel approach employing a right ventriculography catheter (Nishiya type)

We have devised a new method for right ventricular endomyocardial biopsy, in which the use of a right ventriculography catheter (Nishiya Type) allows us to ensure the introduction of a guiding sheath (Cordis, right-angled long sheath) to the apical portion of the right ventricle by way of the femoral vein. With this method, we have biopsied the endomyocardium in 52 patients during the last 4 years. In each case, it only took us several minutes to complete the biopsy procedure. Neither failed applications nor significant complications were seen. We believe that this technique provides a clinically beneficial means as it enables us to readily and safely achieve right ventricular endomyocardial biopsy.

Primary duodenal MALT lymphoma

Primary duodenal MALT lymphoma (MALToma) is a very rare neoplasm arising from the mucosa-associated lymphoid tissue of the duodenum. We report a 55-year-old woman with MALToma located in the descending duodenum and accompanying Helicobacter pylori infection of the stomach. We performed operative resection due to involvement of the papilla of Vater and submucosal tumor infiltration. Despite wide mucosal spreading, postoperative examination revealed only a small amount of MALToma cells infiltrating into the submucosa. No invasion into the adjacent structure or metastasis to regional lymph nodes was confirmed, suggesting the disease could have been controlled by eradication of Helicobacter pylori.

[Tricuspid valve replacement in a patient with idiopathic tricuspid regurgitation]

Tricuspid regurgitation is often seen but is rarely categorized as "idiopathic". A 66-year-old man suspected of idiopathic tricuspid regurgitation underwent tricuspid valve replacement. With right heart failure over twenty years, his CTR increased to eighty six (86) per cent. During operation, no abnormal findings were observed except for the dilated tricuspid valve ring. Then a stented porcine xenograft (Carpentier-Edwards 33 mm) was inserted in the tricuspid valve annulus. Seven years after replacement, he died. Autopsy demonstrated myocardial hypertrophy of the right ventricle and dilatation of the right heart, supporting the diagnosis of idiopathic tricuspid regurgitation.

[A case of mediastinal teratoma discovered availing of pneumonia]

A 42-year-old woman was admitted to our hospital with hemosputum and an abnormal shadow on chest X-ray. Although her hemosputum disappeared after the treatment of pneumonia, the abnormal shadow was not improved. Chest CT showed a mediastinal mass. She underwent thoracotomy and the tumor, measuring 6 x 5 x 5 cm in size, was resected. Pathological diagnosis was a mature type teratoma with direct invasion to the lung. We have to take mediastinal teratoma into consideration as one of the causes of pneumonia.

Serum des-gamma-carboxyprothrombin level by a modified enzyme immunoassay method in hepatocellular carcinoma: clinical significance in small hepatocellular carcinoma

BACKGROUND/AIMS

In the diagnosis of hepatocellular carcinoma (HCC), serum des-gamma-carboxyprothrombin (DCP) is a useful tumor marker. The conventional immunoassays for measurement of DCP levels, however, are not sensitive enough to detect small HCC. Therefore, we intended to elevate the minimal detection level of DCP by a modified enzyme linked immunosorbent assay method.

METHODOLOGY

This modified assay method is similar to the conventional enzyme linked immunosorbent assay (ELISA) method, but the first reaction occurs overnight. As a result, the minimal detection levels of DCP varied from 0.06 AU/ml, by the conventional method, to 0.008 AU/ml, by the modified method. Two hundred and twenty five serum samples from 100 patients with HCC, 75 with liver cirrhosis and 50 with chronic hepatitis were subjected to the present study. Simultaneous determinations of serum DCP by the modified assay and a-fetoprotein (AFP) levels were performed.

RESULTS

Eighty five of 100 patients with HCC had increased DCP levels of more than 0.008 AU/ml. This method yielded a sensitivity of 85%, a specificity of 90% and a total accuracy value of 88%. In 27 patients with small HCC (less than 30 mm in diameter), 12 had elevated DCP levels, resulting in a sensitivity of 44%. When the modified DCP assay together with AFP measurement (more than 20 ng/ml) were introduced, the sensitivity was 67% in the 27 patients with small HCC.

CONCLUSIONS

This modified ELISA method increased the sensitivity in patients with small HCC, and the combination assay of serum DCP and AFP levels was more useful for the early diagnosis of HCC.

Oculomotor nerve invasion of acute myelogenous leukemia demonstrated by magnetic resonance imaging

A 53-year-old male was diagnosed as having acute myelogenous leukemia (M2, FAB). He complained of double vision and right blepharoptosis after receiving remission induction chemotherapy. Magnetic resonance imaging (MRI) showed enlargement of the bilateral oculomotor nerves. Intrathecal injections of methotrexate and cytosine arabinoside were partially effective and repeated MRI showed shrinkage of the enlarged oculomotor nerves, after therapy. This case shows the importance of MRI in the early diagnosis of CNS leukemia.

[Retrospective analysis of elderly patients > or = 60 years of age with acute leukemia]

A retrospective analysis was performed on 76 consecutive elderly patients with acute leukemia aged 60 years or more (48 men, 28 women). Forty patients were 60-69 years old, 28 were 70-79 years old and 8 were > or = 80 years old. There were 55 patients with acute myelogenous leukemia (AML), 13 acute lymphoblastic leukemia (ALL) and 8 AML from myelodysplastic syndrome (MDS/AML). Patients were treated with the JALSG protocol, CAG regimen, or low-dose Ara-C regimen for AML, and DVP/M-CHOP protocol for ALL. The complete remission (CR) rates were 52.7% (29 of 55) in AML, 61.5% (8 of 13) in ALL, and 0% in MDS/AML. The median CR durations were 226, 85, 0 days, and the median survivals were 204, 177, 99 days, respectively. CR rates were 65.3% for the JALSG protocol, 62.5% for the CAG regimen and 25.0% for low-dose Ara-C regimen. According to age, CR was obtained 62.5% in patients aged 60-69 years and 33.3% in patients over 70 years old. Our results indicated that patients aged 60-69 years should be treated with intensive chemotherapy.

[A case of anastomotic aneurysm-enteric fistula]

We successfully performed circulation reconstructive surgery and repair of a small intestine resection, primarily at an anatomical position, for perforation of a pseudoaneurysm in the small intestine, which occurred in an anastomosis site of the right leg of a Y graft of an artificial blood vessel and internal iliac artery graft on a patient, at the remote time of 18 years after she had received a Y-type artificial blood vessel. The patient's life was saved. The results suggest that it is important to make a definitive diagnosis quickly after the occurrence of symptoms and to select an appropriate surgical technique according to the findings of infection adjacent to the perforation site.