Clinical characteristics of acute pulmonary thromboembolism in Japan: results of a multicenter registry in the Japanese Society of Pulmonary Embolism Research

BACKGROUND

Although the incidence of acute pulmonary thromboembolism (APTE) has been increasing in Japan, patient characteristics, management strategies, and outcome have not yet been assessed in large series.

HYPOTHESIS

The present study was designed to investigate the current status of APTE in Japan.

METHODS

Of a total of 533 registry patients with pulmonary thromboembolism, 309 with APTE were analyzed with respect to clinical symptoms and signs, predisposing factors, diagnostic procedures, estimation of deep venous thrombosis, treatment, and clinical course.

RESULTS

Main risk factors were recent major surgery, cancer, prolonged immobilization, and obesity; only a few patients had coagulopathy and 36% were in cardiogenic shock at presentation. The majority of registry patients underwent lung scans or pulmonary angiography; 30% were diagnosed only by lung scanning. Venous ultrasonography was used in only 34 patients, while 188 patients underwent at least one diagnostic procedure for deep venous thrombosis. Thrombolysis was more frequently performed in patients with cardiogenic shock, and only a few patients received thromboembolectomy. In-hospital mortality rate was 14%. In patients with cardiogenic shock, the mortality rate was reduced by thrombolysis. The predictors of in-hospital mortality were male gender, cardiogenic shock, cancer, and prolonged immobilization.

CONCLUSIONS

The patients in this registry had almost the same findings as those in Western patients, except for some points that had the possibility of demonstrating a difference between Westerners and Japanese in the development of APTE. These results can prove especially helpful in planning prospective, randomized trials that will clarify the impact of widely used treatment modalities on the outcome of patients with APTE.

Inhibition of the mevalonate pathway rescues the dexamethasone-induced suppression of the mineralization in osteoblasts via enhancing bone morphogenetic protein-2 signal

We used dexamethasone (DEX)-treated osteoblastic MC3T3-E1 cells, and investigated the effects of an AMP-activated protein kinase activator, 5-aminoimidazole-4-carboxamide-1-beta- D-ribonucleoside (AICAR), a Rho-associated protein kinase inhibitor, fasudil hydrochrolide, as well as HMG-CoA reductase inhibitors, simvastatin and pitavastatin, all of which inhibit the mevalonate pathway. DEX (10(-8) M) significantly enhanced mRNA expression of bone morphogenetic protein (BMP)-2 antagonists, follistatin and Dan, and addition of each of 10 (-4) M AICAR, 10 (-5) M fasudil, 10(-6) M simvastatin, and 10(-6) M pitavastatin significantly reversed the enhancement in mRNA expression of follistatin and Dan and stimulated that of BMP-2 in the cells (p<0.05). DEX (10(-8) M) also significantly suppressed mineralization in the cells, and addition of each of these agents significantly reversed the suppression of mineralization (p<0.05). These findings suggest that the mevalonate pathway was involved in glucocorticoid-induced osteoblast dysfunction, and that its inhibition might promote bone formation through BMP-2 and alleviate glucocorticoid-induced osteoporosis.

Risk factors and predictors for surgical site infection after hepatic resection

Strict control of blood glucose levels with insulin in a surgical intensive care unit reduces postoperative morbidity and mortality. The aim of this study was to identify risk factors and the predictors for the prevention of surgical site infection (SSI) in a consecutive series of hepatectomised cases in a single institution. The association between SSI and various clinical parameters was investigated in 152 patients who underwent hepatic resection at Kochi Medical School from January 2000 through March 2007. The incidence of SSI in these patients was 14.5%. Multivariate analysis identified four independent parameters correlating with the occurrence of SSI: (i) body mass index >23.6 kg/m(2); (ii) estimated blood volume loss >810 mL; (iii) presence of postoperative bile leakage of organ/space SSI; and (iv) use of the sliding scale method for postoperative glucose control. There was no observed SSI after liver resection in the group whose postoperative blood glucose levels were controlled by an artificial pancreas. This study reveals that lack of postoperative glycaemic control is associated with a significantly higher incidence of postoperative infectious complications and longer hospitalisation. Obesity and the level of intraoperative estimated blood loss and bile leakage after hepatic resection are also risk factors with predictive value for SSI. Artificial pancreas is a safe and beneficial device to perform postoperative strict glycaemic control without hypoglycaemia for patients who undergo hepatic resection for liver diseases.

Low density lipoprotein-cholesterol levels affect vertebral fracture risk in female patients with primary hyperparathyroidism

Although increased arterial sclerosis and dyslipidemia were observed in primary hyperparathyroidism (pHPT) patients in previous studies, it still remains unclear about the relationships between lipid and bone metabolism in pHPT patients, especially about fracture risk. The present study was performed to examine the relationships between lipid metabolism parameters including body composition and bone metabolism in 116 female patients with pHPT and 116 age-matched control subjects. Bone mineral density (BMD) and body composition were measured by dual-energy x-ray absorptiometry. Serum low density lipoprotein (LDL)-cholesterol (Chol) levels were negatively related to only z-score of BMD at femoral neck and serum creatinine levels. Serum levels of LDL-Chol were significantly lower in the group with vertebral fractures in pHPT patients, although body composition parameters were not significantly different. In univariate logistic regression analyses, age, height, BMD at lumbar spine and radius, serum levels of creatinine, total-Chol and LDL-Chol were significantly selected as a predictor of vertebral fractures. LDL-Chol was related to vertebral fractures independently of the other parameters. In conclusion, the present study demonstrated that lower serum LDL-Chol levels were related to vertebral fracture risk independent of renal function, age, body size, bone metabolism parameters and the severity of the disease in pHPT women.

Effect of retinoic acid on the proliferation and alkaline phosphatase activity of osteoblastic MC3T3-E1 cells by modulating the release of local regulators from monocytes

There has been some evidence suggesting an important role of mononuclear cells at bone remodeling sites in the coupling of bone formation to bone resorption. Since cells of the monocyte-macrophage lineage produce important local regulators of bone remodeling, we examined effects of human monocytes-conditioned medium (CM) treated with retinoic acid on [3H] thymidine incorporation (TdR) and alkaline phosphatase (ALP) activity of osteoblastic MC3T3-E1 cells. Treatment of MC3T3-E1 cells with retinoic acid (10(-8) to 10(-6) M) caused an inhibition of TdR in a dose-dependent manner and an inhibition of ALP activity at 10(-6) M. Conditioned medium from monocytes untreated with retinoic acid caused a stimulation of TdR and an inhibition of ALP activity in these cells. In contrast, treatment of monocytes with retinoic acid (10(-8) or 10(-6) M) abolished both stimulation of DNA synthesis and inhibition of ALP activity induced by CM. The present study suggested that retinoic acid modulated osteoblast proliferation and ALP activity not only directly but also indirectly, presumably through modulating the release of local regulators as to bone remodeling from monocytes.

Congenital adrenal hyperplasia with 47, XXY Klinefelter syndrome

We describe here a unique case of congenital adrenal hyperplasia (CAH) accompanied by Klinefelter syndrome. A Japanese boy was diagnosed as having CAH caused by 21-hydroxylase deficiency at birth, but was untreated thereafter until age 10. In the meantime he showed marked acceleration in somatic growth with sexual precocity by age 9, at which time growth completely stopped. During regular follow-ups at our clinic and steroid treatment after age 10, he was recognized as having bilateral small and firm testes. A chromosomal examination and a testicular biopsy revealed a complication of 47, XXY Klinefelter syndrome with CAH. Association of these two diseases has not been reported so far, and the present case is the first one to our knowledge.

Does the concomitant intra-arterial injection of asialoerythropoietin and edaravone mitigate ischaemic mucosal damage after acute superior mesenteric artery thromboembolism in a rabbit autologous fibrin clot model?

To increase the survival rate of patients with acute superior mesenteric artery thromboembolism (ASMAT) treated by catheter thrombolysis, we examined the effects of delivering edaravone and asialoerythropoietin, agents with tissue-protective activities, using a rabbit autologous fibrin clot ASMAT model. Japanese white rabbits (n=32) were randomly separated into four equal groups. 45 min after introducing autologous fibrin clot, Group U received urokinase and heparin; Group E received urokinase and heparin plus edaravone; Group A received urokinase and heparin plus asialoerythropoietin; and Group EA received urokinase, heparin and edaravone plus asialoerythropoietin via a catheter. The intestines were removed 6 h later and intestinal mucosal damage was scored using the Park's injury score. Survival time was assessed. Average mucosal injury was 5.78+/-1.52 (Group U), 2.88+/-0.72 (Group E), 1.90+/-1.23 (Group A) and 1.18+/-1.25 (Group EA). The degree of mucosal injury was significantly lower in Group EA than in Groups U and E (p<0.05). Conversely, there was no significant difference between Group A and Group EA, or between Group A and Group E. The survival times were 31.50+/-13.30 h (Group U), 51.00+/-24.74 h (Group E), 48.00+/-16.97 h (Group A) and 82+/-51.07 h (Group EA); the difference among the four groups was not significant. In conclusion, the concomitant administration of asialoerythropoietin and edaravone reduced mucosal membrane injury significantly compared with edaravone alone. However, to improve the survival of ASMAT rabbit models, the delivery of an appropriate dose of asialoerythropoietin is required, together with the development of methods to assess peripheral recanalisation.

In situ population structure and ex situ representation of the endangered Amur tiger

The Amur tiger (Panthera tigris altaica) is a critically endangered felid that suffered a severe demographic contraction in the 1940s. In this study, we sampled 95 individuals collected throughout their native range to investigate questions relative to population genetic structure and demographic history. Additionally, we sampled targeted individuals from the North American ex situ population to assess the genetic representation found in captivity. Population genetic and Bayesian structure analyses clearly identified two populations separated by a development corridor in Russia. Despite their well-documented 20th century decline, we failed to find evidence of a recent population bottleneck, although genetic signatures of a historical contraction were detected. This disparity in signal may be due to several reasons, including historical paucity in population genetic variation associated with postglacial colonization and potential gene flow from a now extirpated Chinese population. Despite conflicting signatures of a bottleneck, our estimates of effective population size (N(e) = 27-35) and N(e)/N ratio (0.07-0.054) were substantially lower than the only other values reported for a wild tiger population. Lastly, the extent and distribution of genetic variation in captive and wild populations were similar, yet gene variants persisted ex situ that were lost in situ. Overall, our results indicate the need to secure ecological connectivity between the two Russian populations to minimize loss of genetic diversity and overall susceptibility to stochastic events, and support a previous study suggesting that the captive population may be a reservoir of gene variants lost in situ.

[Delayed surgery for traumatic rupture of the aortic arch with an isolated left vertebral artery; report of a case]

Although traumatic rupture of the thoracic aorta has been considered a surgical emergency, we report here an example of successful delayed surgery for acute traumatic rupture of the aortic arch with an isolated left vertebral artery in an 18-year-old woman. The patient was.admitted to the intensive care unit with hemothorax and, rib fractures, and a decision was made to treat the aortic injury conservatively until the patient was stabilized. She underwent surgery after 3 months of observation. After the isolated left vertebral artery had been anastomosed to the left carotid artery, total arch replacement was performed. Delayed surgery for aortic rupture as a treatment choice may be of benefit in selected cases of complex trauma.

RASSF1A hypermethylation in pretreatment serum DNA of neuroblastoma patients: a prognostic marker

The tumour suppressor gene RASSF1A is known to be frequently silenced by promoter hypermethylation in neuroblastoma tumours. Here we explored the possible prognostic significance of aberrant promoter hypermethylation of RASSF1A in serum DNA samples of patients with neuroblastoma as a surrogate marker for circulating tumour cells. We analysed the methylation status of the RASSF1A gene in matched tumour and pretreatment serum DNA obtained from 68 neuroblastoma patients. Hypermethylation of RASSF1A in tumour samples was found in 64 patients (94%). In contrast, serum methylation of RASSF1A was observed in 17 patients (25%). Serum methylation of RASSF1A was found to be statistically associated with age ⩾12 months at diagnosis (P=0.002), stage 4 (P<0.001) and MYCN amplification (P<0.001). The influence of serum RASSF1A methylation on prognosis was found to be comparable with that of the currently most reliable marker, MYCN amplification on univariate analysis (hazard ratio, 9.2; 95% confidence interval (CI), 2.8–30.1; P<0.001). In multivariate analysis of survival, methylation of RASSF1A in serum had a hazard ratio of 2.4 (95% CI, 0.6–9.2), although this association did not reach statistical significance (P=0.194). These findings show that the methylation status of RASSF1A in the serum of patients with neuroblastoma has the potential to become a prognostic predictor of outcome.

Visceral obesity is associated with the metabolic syndrome and elevated plasma retinol binding protein-4 level in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is related to the increased prevalence of cardiovascular disease and metabolic syndrome (MS). A novel adipokine, retinol binding protein-4 (RBP4), was reported to be associated with insulin resistance and the prevalence of type 2 diabetes. To examine whether plasma RBP4 is associated with insulin resistance and MS development in OSAS, we measured plasma RBP4 levels in 181 Japanese men (24 healthy controls and 40 mild, 64 moderate, and 53 severe OSAS) of whom 26 had mild glucose intolerance with HbA1c < or = 6.0%. After a full polysomnography, blood was collected between 06:00 and 07:00 AM. Plasma RBP4 levels in moderate/severe OSAS patients were higher than in control subjects. Plasma RBP4 was not correlated with apnea variables, HOMA-IR, or blood pressure. However, it was positively correlated with visceral fat areas and plasma triglyceride levels. The prevalence of MS was higher in severe OSAS patients than in mild/moderate OSAS and control subjects. Plasma RBP4 was higher in OSAS patients with MS than in those without MS. This study indicates that plasma RBP4 is associated with dyslipidemia, but not with insulin resistance, glucose intolerance, or hypertension in patients with OSAS. Visceral obesity may play key roles in increasing the plasma RBP4 level and MS development in OSAS.

[Assessment of proximal aortic anastomosis device in coronary artery bypass grafting]

The aim of this study was to assess the feasibility and safety of a new proximal anastomotic device (PAD) "Enclose II" in coronary artery bypass grafting (CABG). PAD enables the construction of a proximal aortic anastomosis without the use of partial clamp of the ascending aorta, thus reduces the incidence of adverse perioperative neurologic injury related to atheroembolic events. This device was used in 41 off-pump CABG and 11 on-pump beating heart CABG patients for performing 46 radial artery (RA) and 9 vein anastomoses to the aorta. The subjects were 43 males and 9 females, with a mean age of 63.6 years. Thirteen (25%) patients had severe atherosclerotic cerebrovascular lesions preoperatively. The mean flow in the RA graft was 52.4 +/- 26.9 ml/min and that of saphenous vein graft (SVG) was 61.1 +/- 31.9 ml/min. Angiography showed all grafts patent. There was no procedure-related adverse events or cerebrovascular complication. Enclose II device can be a valuable tool to perform RA and vein anastomoses in CABG.

Two-year longitudinal changes in forearm cortical bone geometry in postmenopausal women with mild primary hyperparathyroidism without parathyroidectomy

Several studies suggest that mild PTH excess does not have any deteriorative effects on bone mineral density (BMD) in several-year-longitudinal studies of patients with mild primary hyperparathyroidism (pHPT) without parathyroidectomy (PTX). However, it remains unknown about the change in bone geometry in pHPT patients without PTX. We examined the longitudinal effects of mild PTH excess on cortical bone geometry in postmenopausal patients with mild pHPT without PTX by using peripheral quantitative computed tomography (pQCT), and we compared them with normal and hypoparathyroidism women. Nine postmenopausal female patients who were diagnosed as pHPT, six postmenopausal female patients with hypoparathyroidism (3 idiopathic and 3 postoperative), and thirty postmenopausal control subjects participated in this study. Radial volumetric (v) BMD and several bone geometry parameters were measured by pQCT at basal line and after 2 years. Cortical vBMD was significantly lower in pHPT group. Moreover, total area and periosteal circumferences were significantly higher in pHPT group. Total and cortical vBMD were significantly decreased after 2 years in control group. However, they were stable in pHPT group after 2-year follow-up. As for bone geometry, cortical thickness and area were also stable in pHPT group during 2-year follow-up, although they were significantly reduced in control group and hypoparathyroidism group. In conclusion, the present longitudinal study revealed that there were no significant changes in radial vBMD and cortical bone geometry in postmenopausal women with mild pHPT, whereas age-related thinning of cortical bone as well as decrease of vBMD were observed in the control and patients with hypoparathyroidism.

Statin suppresses apoptosis in osteoblastic cells: role of transforming growth factor-beta-Smad3 pathway

Statins possess pleiotropic effects in several tissues. Among them, their bone anabolic actions have been recently noted. We have proposed that Smad3, a TGF-beta-signaling molecule, is a promoter of bone formation. However, whether statins would affect TGF-beta-Smad3 pathway in osteoblasts is still unknown. The present study was performed to examine the effects of statin on Smad3 expression and cell apoptosis by employing mouse osteoblastic MC3T3-E1 and rat osteoblastic UMR-106 cells. Statins (pitavastatin, mevastatin, and simvastatin) as well as alendronate increased the levels of Smad3 in MC3T3-E1 cells. The effects of pitavastatin on Smad3 levels were observed from 3 hours and later. Pitavastatin induced the expression of TGF-beta, and cycloheximide, a protein synthesis inhibitor, antagonized the increased levels of pitavastatin on Smad3. On the other hand, pitavastatin antagonized dexamethasone- or etoposide-induced apoptosis in a dose-dependent manner, and Smad3 inactivation by dominant negative Smad3 or an inhibition of endogenous TGF-beta action by SB431542 antagonized anti-apoptotic effects of pitavastatin, indicating that pitavastatin suppressed osteoblast apoptosis partly through TGF-beta-Smad3 pathway. In conclusion, the present study has demonstrated for the first time that statin suppressed cell apoptosis partly through TGF-beta-Smad3 pathway in osteoblastic cells.

Select Calcium Compounds Reduce the Severity of Phytophthora Stem Rot of Soybean

This study investigated the effects of several calcium compounds on Phytophthora stem rot of soybean (Glycine max) and fungal growth and zoospore release of a Phytophthora sojae isolate in vitro. All concentrations of five formulated calcium products [Ca(COOH)₂-A, Ca(COOH)₂-B, Ca(COOH)₂-C, CaSO₄-A, and CaCl₂-A] and two chemical compounds [CaCl₂ and Ca(NO₃)₂] applied prior to inoculation significantly suppressed disease incidence. Among all the products and chemicals, Ca(COOH)₂-A was the most effective in suppressing the incidence of disease. In most cases, no significant relationship was observed between inhibition of growth rate in vitro and disease reduction in growth chamber tests. Therefore, disease suppression recorded in laboratory experiments using pathogen mycelium was likely due to the responses of plant tissues rather than the direct inhibition of pathogen fungal growth by the calcium compounds. The extent of disease reduction was related to increased calcium uptake by plants, suggesting that calcium was the effective element in reducing Phytophthora stem rot. Seedling tray experiments using zoospores indicated that the application of 10 mM Ca(COOH)₂-A was more effective for reducing incidence of disease under growth chamber conditions, compared to other concentrations. The presence of 4 to 20 mM of all seven calcium solutions decreased the release of zoospores, although 0.4 mM of all compounds significantly increased zoospore release. Therefore, disease reduction in the growth-chamber experiments was due to the multiple effects of direct suppression on zoospore release and fungal growth in combination with the response of the host plant tissue to Ca(COOH)₂-A.

Neonatal pseudo-Bartter syndrome due to maternal eating disorder

A total of 4 of 153 low birth weight infants at our hospital were found to have pseudo-Bartter syndrome in 2005 and 2006. The neonates (two of whom were twins; light for gestational age 2, appropriate for gestational age 1 and small for gestational age 1) showed symptoms of apnea and/or poor feeding or patent ductus arteriosus, which disappeared by day 4. Hypokalemia, hypochloremia and metabolic alkalosis normalized by day 8. The mothers had repeatedly rushed to the restroom after eating while in hospital, and were lighter at delivery than before pregnancy; however, vomiting was not observed. The mothers had several stress factors related to pregnancy, and all recovered from the eating disorder after delivery. Urinary Cl/creatinine (mequiv. mg(-1)) and serum Mg in the infants were <0.1 and 1.6 to 2.3 mg per 100 ml, respectively. Eating disorder during pregnancy may have caused Bartter-like syndrome and weight loss, and led to the same syndrome and intrauterine growth retardation in the offspring. Therefore, a hidden maternal eating disorder may underlie neonatal pseudo-Bartter syndrome.