P5593The association of recurrence and bleeding events with mortality after venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has a long-term risk for recurrence, which can be prevented by anticoagulation therapy. The duration of anticoagulation therapy after VTE should be based on the balance between risks of recurrent VTE and bleeding. However, there is uncertainty about the impact of these events on subsequent mortality.

Purpose

We sought to evaluate the impact of recurrent VTE events and bleeding events on subsequent mortality in patients with VTE in a large retrospective observational database in Japan.

Methods

We evaluated the association of recurrent VTE and major bleeding with mortality among 3026 patients in the COMMAND VTE Registry. We estimated the risks of recurrent VTE events and major bleeding events for subsequent all-cause death with the multivariable Cox proportional hazard model. We incorporated the recurrent VTE events and major bleeding events during follow-up into the multivariable Cox model as time-updated covariates together with the clinically-relevant 16 risk-adjusting factors. We expressed the adjusted risks of each covariate as hazard ratios (HR) and their 95%confidence intervals (CI). Furthermore, to assess the risks of recurrent PE and recurrent DVT events for subsequent all-cause death respectively, we divided recurrent VTE events into recurrent PE (PE with or without DVT) and recurrent DVT (DVT only), and incorporated these events as well as major bleeding events into the multivariable Cox model as time-updated covariates.

Results

In the current study population, the mean age was 67 years, 61% were women, and mean body weight and body mass index were 57.9 kg and 23.2 kg/m2, respectively. During the median follow-up period of 1,218 days, 763 patients died, 225 patients developed recurrent VTE events, and 274 patients developed major bleeding events. The time-updated multivariable Cox proportional hazard model revealed that both the recurrent VTE events and the major bleeding events were strongly associated with subsequent mortality risk (recurrent VTE events: HR 3.24, 95% CI 2.57–4.08, P<0.001; major bleeding events: HR 3.53, 95% CI 2.88–4.31, P<0.001). Both the recurrent PE events and the recurrent DVT events were associated with subsequent mortality risk with the numerically greater magnitude of effect with the recurrent PE events than with the recurrent DVT events (recurrent PE events: HR 4.42, 95% CI 3.28–5.95, P<0.001; recurrent DVT events: HR 2.42, 95% CI 1.75–3.36, P<0.001).

Conclusions

In the real-world patients with VTE, both recurrent VTE events and major bleeding events were strongly associated with subsequent mortality risk with the comparable effect size. Recurrent PE and recurrent DVT events were also associated with increased risks for mortality, although the magnitude of the effect on mortality was numerically greater with the recurrent PE events than with the recurrent DVT events.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P3847Deep vein thrombosis in upper extremities: clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE Registry

Background/Introduction

Pulmonary embolism (PE) is caused by blockage of pulmonary arteries by thrombus. The sources of thrombus are thought to be mostly veins in lower extremities, whereas deep vein thrombosis (DVT) in upper extremities rarely occurs spontaneously. Recent studies reported that DVT in upper extremities might have significant complications, and DVT in upper extremities could be increasing. However, there is a paucity of data on patients with DVT in upper extremities, leading to uncertainty in optimal treatment strategies including anticoagulation therapy.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with DVT in upper extremities in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE) objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 2498 patients with DVT in upper or lower extremities, after excluding 381 patients with PE only, 144 patients who had thrombus in locations other than upper or lower extremities, and 4 patients with DVT in both upper and lower extremities. The study patients were divided into 2 groups: patients with DVT in upper extremities and patients with DVT in lower extremities. We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

There were 74 patients (3.0%) with upper extremities DVT and 2498 patients (97%) with lower extremities DVT. Patients with upper extremities DVT more often had active cancer at diagnosis (58%) and central venous catheter use (22%). The proportion of concomitant PE at diagnosis was lower in patients with upper extremities DVT than in those with lower extremities DVT (14% and 51%, P<0.001). Discontinuation of anticoagulation therapy was more frequent in patients with upper extremities DVT (63.8% and 29.8% at 1-year, P<0.001). The cumulative 3-year incidence of recurrent VTE was not different between the 2 groups (9.8% and 7.4%, P=0.43) (Figure). After adjusting confounders, the risks of upper extremities DVT relative to lower extremities DVT for recurrent VTE remained insignificant (HR 0.94, 95% CI 0.36–2.01, P=0.89).

Kaplan-Meier event curves for recurrence

Conclusions

The prevalence of patients with DVT in upper extremities was 3.0% in the current large-scale real-world registry. Patients with DVT in upper extremities more often had active cancer at diagnosis and central venous catheter use as a transient risk factor for VTE, and less often had concomitant PE. Patients with DVT in upper extremities had similar long-term risk for recurrent VTE as those with DVT in lower extremities despite shorter duration of anticoagulation.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P6461The long-term clinical comparisons of symptomatic patients of pulmonary embolism with and those without deep vein thrombosis: from the COMMAND VTE Registry

Background

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has significant morbidity and mortality. Acute PE, in particular, is fatal if we miss it, and symptomatic patients of PE sometimes have concomitant DVT.

Purpose

This study compared the risk of mortality in symptomatic patients of PE with and those without DVT in the long term.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. Patients with both PE and DVT (N=1334) were regarded as PE patients, and the current study population consisted of 1715 PE patients and 1312 DVT patients.

Results

There were 1203 symptomatic patients of PE, including 381 without and 822 with DVT. In our cohort, the mean age was 67.9±14.9 years, 63% was female, 44% had hypertension, 12% diabetes mellitus, 5% history of VTE. There were 20% of active cancer. Baseline characteristics were well matched except for dyslipidemia (18% vs. 23%, p=0.021) and atrial fibrillation (8% vs. 5%, p=0.045). Patients without DVT had a more severe clinical presentation compared to those with DVT, including hypoxemia, shock and arrest. Moreover, Initial parenteral anticoagulation therapy in the acute phase was administered less frequently in patients without DVT (89% vs. 96%, P=0.0001). Two groups received thrombolysis (20% vs. 26%, P=0.18) and mechanical supports (Ventilator 14% vs. 5%, p<0.001, PCPS 5% vs. 3%, p<0.001, respectively). During follow-up, 93 (8%) patients experienced recurrent VTE events and 98 (8%) major bleeding events, and 323 (27%) patients died. The most frequent cause of death was cancer (11%). There were a significant differences in the cumulative incidences of all-cause death between the groups (32% vs. 24%, P=0.006), whereas there was significant difference in VTE-related death (13% vs. 4%, p<0.001). Estimated freedom rates from death for patients of PE without and those with DVT were as follows: 88% vs 99% at 10-day, 86% vs 95% at 1-month, 75% vs 83% at 1-year, and 64% vs 71% at 5-year, respectively.

Landmark analysis

Conclusions

In symptomatic patients of PE, there was a difference in mortality between groups, but no difference in recurrent VTE. Patients without DVT had a more severe clinical presentation compared to those with DVT, and many VTE-related deaths in the acute phase. The one-month mortality rate differed statistically between groups, but there was no significant difference in long-term survival beyond one month. Most of deaths were due to underlying diseases, mainly cancer, and less commonly due to VTE in the long term.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Novel OK-432-conjugated tumor vaccines induce tumor-specific immunity against murine tongue cancer

Priming with tumor antigens is one of the most important strategies in cancer immunotherapy. To enhance tumor antigenicity, OK-432, a streptococcal preparation, was coupled to squamous cell carcinoma (KLN-205) by means of a 0.2% glutaraldehyde method. The purpose of this study was to investigate whether OK-432-conjugated tumor vaccines could induce tumor-specific immunity. Our originally developed mouse tongue cancer model was used throughout this work for the analysis of antitumor effects. Prepared OK-432-conjugated KLN-205 vaccines were immunized 3 times to DBA/2 mice. The results showed that the KLN-205 vaccines induced cytolytic activity and strongly suppressed both KLN-205 tumor incidence and growth, and survival of the mice was improved. Moreover, the histological results showed that a greater number of lymphocytes had infiltrated around tumor cells by 24 hours after tumor inoculation in the vaccine group. These results suggest that immunizations with KLN-205 vaccines increase the antitumor effects against tongue cancer.

Decreased body temperature dependent appearance of behavioral despair in the forced swimming test in mice

Effects of body temperature on the immobile response and brain glucose metabolism were examined in the forced swimming test in mice. The first experiment was performed to study behavior, after initial periods of vigorous activity, a characteristic immobile posture occurred when the water was 25 and 35 degrees C. However, several minutes after forced swimming at 25 degrees C, significantly decreased spontaneous motility occurred in a time-dependent manner, but no changes was observed at 35 degrees C. Our interpretation was that mechanisms of acquisition and retention of the forced swim-induced immobile response differed. Body temperature was also significantly decreased at 25 degrees C but not at 35 degrees C in the forced swimming test. This lowering of body temperature almost paralleled the immobile response. The second experiment was a biochemical study in which the uptake of [(14)C] 2-deoxy-d-glucose into the brain significantly decreased after forced swimming at 25 degrees C but did not change in the forced swim loaded mice when the water was 35 degrees C. These results suggested two types of immobile mechanisms in the forced swimming test: (1) an early phase acquisition of the immobile response which might be related to adaptive response and (2) a late phase to retain the immobile response which might be related to the decrease in brain glucose metabolism.

Rapid tumor necrosis induced by electrochemotherapy with intratumoral injection of bleomycin in a hamster tongue cancer model

This study evaluated the effects of electrochemotherapy (ECT) with intratumoral injection of bleomycin (BLM) on the chemically induced tongue cancer model in the hamster. Intratumoral injection of BLM followed by high-voltage electrical treatment induced rapid necrosis of the tumor within 48 hours and subsequent rapid tumor volume reduction. Three weeks after the ECT with BLM, 3 of the 6 animals showed no palpable tumor, while no antitumor effects were observed in the control groups. Because of the remarkable antitumor effect with no major observed side effects, we concluded that ECT combined with intratumoral injection of BLM has the potential to enhance treatment results for tongue cancer.

In vivo antitumor effects of electrochemotherapy in a tongue cancer model

PURPOSE

This study investigated the in vivo antitumor effects of electrochemotherapy (ECT) using electroporation and bleomycin in a hamster tongue cancer model to assess its clinical applicability.

MATERIALS AND METHODS

Twenty animals with chemically induced tongue cancer were divided into four experimental groups designated B-E-, B-E+, B+E-, and B+E+. The B+E+ and B+E- groups received an intraperitoneal injection of 100 microg bleomycin. Fifteen minutes after the injection, the B+E+ animals received electric pulses. The B-E+ group received only electric pulses. The B-E- group received neither bleomycin nor electric pulses. Each group received the same treatment twice. The antitumor effects were assessed based on tumor volume reduction and histologic findings.

RESULTS

The B+E+ group showed remarkable tumor volume reduction, decreasing an average to 8.8% of its original volume 14 days after the treatment. Complete loss of the protruding tumor was observed in two of the five animals. Histologically, the tumors of the B+E+ group consisted of severely degenerated tumor cells and desquamative keratinizing cells. No living cancer cells were detected in three animals. The B+E-, B-E+, and B-E- groups showed progressive tumor growth, exceeding 200% of initial tumor volume during the experimental period.

CONCLUSION

The current study showed remarkable antitumor effects of ECT with bleomycin in the hamster tongue cancer model. ECT with bleomycin may be clinically applicable to the treatment of oral cancer.

IFN-gamma induces coordinate expression of MHC class I-mediated antigen presentation machinery molecules in adult mouse Schwann cells

The expression of major histocompatibility complex (MHC) class I molecules on adult mouse Schwann cells (SCs) was examined using immunofluorescence analysis. MHC class I molecules were not expressed on the surface of untreated SCs. Interferon (IFN)-gamma treatment induced expression of the molecules on the SCs. Expression of genes coding for the molecules involved in MHC class I-mediated antigen presentation was also analysed in SCs by reverse transcription-polymerase chain reaction (RT-PCR). Expression of MHC class I heavy chain genes was faintly detected in untreated SCs. IFN-gamma treatment augmented the expression. In addition, IFN-gamma induced expression of the genes for beta2-microglobulin, the peptide transporter TAP-1 and the proteasomal subunit LMP-2, whose expression was not detected in untreated SCs. The expressions of MHC class II molecules and their genes were not detected even after IFN-gamma treatment. These data suggest that MHC class I-mediated antigen presentation machinery functions in adult mouse SCs and that the SCs themselves work as antigen presenting cells and as targets for cytotoxic T cells in some physiological conditions.

Carbohydrate antigens recognized by anti-horseradish peroxidase antiserum are expressed on mammalian cells

Antiserum raised against horseradish peroxidase (HRP) recognizes neural specific carbohydrate antigens in Drosophila and other insects. The occurrence of the antigens in mammalian cells was investigated. Proteins were extracted from rat pheochromocytoma cells, PC12, and various tissue of rat and bovine origin, and further purified by successive chromatography with Con A-Sepharose and anti-HRP glycopeptide antibody-Sepharose. The proteins were separated by SDS-PAGE and subjected to immunoblot analysis of the antigens. When the Con A- and antibody-Sepharose bound fractions were examined, four glycoproteins with carbohydrate antigens recognized by anti-HRP antiserum were identified in all the tissue. They are low molecular weight glycoproteins that are not membrane-bound. We demonstrated that the carbohydrate antigens recognized by the anti-HRP antibodies are not confined to insects but are expressed on mammalian cells in several tissue.

[An ultrastructural investigation of changes in hypoxia in the subependymal layer of the newborn rabbit]

Fetal and neonatal hypoxia is suggested as a noticeable risk factor related to the occurrence of subependymal hemorrhages. To investigate the cause of newborn subependymal hemorrhages, a 0 day old newborn rabbit was exposed to either 5 or 10 minutes hypoxia by N2 box. After exposure, the brain was observed by optical and electric microscope using horseradish peroxidase (HRP) as the protein tracer to study the change in the capillary permeability. The result obtained were as follows: 1) In the newborn rabbit blood gas analysis, PO2 (mmHg) decreased more in the 5 and 10 min hypoxia groups than the control group which used the N2 box. pH and BE changes were similar to PO2 (mmHg). On the other hand, PCO2 (mmHg) increased proportionately. These results indicated that this hypoxic method changed blood gas and caused acidosis. 2) In the optical microscopic examination, the 0 day old newborn rabbit brain was found to have a thin subependymal layer. We could not find obvious subependymal hemorrhage using optical microscope. 3) In the electric microscopic examination, HRP was found in the cavity of the brain capillary at the subependymal layer and was slightly incorporated into the pinocytic vesicle of the lumen on the control. Since the tight junction filled the roll out, HRP was not found outside the capillary. 4) The 5 min hypoxia group caused astrocyte foot swelling, edema and slight opening of the tight opening of the tight junction. HRP was passed through the tight junction, but not outside the capillary. 5) The 10 min hypoxia group caused destruction of astrocyte and edema around the capillary. The tight junction was more opened than in the 5 min hypoxia group and HRP leaked out of the capillary through the tight junction. From the findings mentioned above, it is suggested that our hypoxic model increased permeability of the capillary in subependymal layers and that this change might be the first ultrastructural change before the onset of subependymal hemorrhages.

Metabolism of tenoxicam in rats

The structures of six metabolites of tenoxicam in rats (2 mg/kg, orally), elucidated by physicochemical analyses or the reverse-isotope dilution method, were 5'-hydroxytenoxicam (5% dose), 3-(methylsulphamoyl)-2-thiophenecarboxylic acid (9% dose), and the C-7 or C-8 O-glucuronide of tenoxicam (30% dose). The mechanism of formation of N-methylthiophenesulphimide, a possible precursor of 3-(methylsulphamoyl)-2-thiophenecarboxylic acid from tenoxicam, is discussed.