Recombinant human soluble thrombomodulin (thrombomodulin alfa) to treat disseminated intravascular coagulation in solid tumors: results of a one-arm prospective trial.

BACKGROUND: Disseminated intravascular coagulation (DIC) associated with solid tumors (DIC-ST) is often encountered in clinical practice. Patients with DIC-ST are usually in poor condition and have bleeding diathesis due to advanced or metastatic diseases. Although some affected patients are treated with heparin, this strategy has not been prospectively studied. Recombinant human soluble thrombomodulin (thrombomodulin alfa, TM-α) is a new anticoagulant developed in Japan. We conducted a prospective study that evaluated the efficacy and safety of TM-α in patients with DIC-ST. METHODS: A prospective one-arm study with TM-α was conducted for DIC-ST. TM-α (380 U/kg) was given for 30 min intravenously once daily for 6-14 days. The primary efficacy endpoint was the DIC resolution rate. Change in DIC scores and improvement in bleeding symptoms and outcomes were also evaluated. Safety endpoints included the incidence of bleeding-related adverse events. RESULTS: A total of 101 patients were treated with TM-α. The three main underlying malignant diseases were lung, stomach, and breast cancer, which accounted for 60 % of all patients. The DIC resolution rate was 34.0 % at the end of TM-α treatment. Improvement in DIC scores was seen in 55.2 % of patients, while only 22.9 % of patients had worsening of DIC scores. The overall survival rate was 55.4 % on day 28. The incidence of hemorrhage related to TM-α was 12.9 % until day 28. Cases of severe hemorrhage related to TM-α did not occur. CONCLUSIONS: TM-α is effective and safe for DIC-ST. This agent is the treatment of choice for the management of DIC-ST.

[School-attendance problems, subjective symptoms and lifestyle factors: the Shizuoka health and lifestyle survey of students].

PURPOSE: This cross-sectional study was conducted to examine the prevalence of students with a sense of not wishing to-attend school, and associations with subjective symptoms and lifestyle factors. METHODS: The database of the Shizuoka health and lifestyle survey of students conducted in November 2003 was used. The subjects were 5448 elementary, junior high and high school students and 1051 caregivers of elementary school students. A self-administered questionnaire was administered to obtain infiromation on non-willingness to-attend school, subjective symptoms and lifestyle factors for students and lifestyle factors for caregivers. RESULTS: Valid responses were obtained from 2675 elementary school students, 940 junior high school students, 1377 high school students and 659 caregivers. The prevalence of students who experienced unwillingness to attend school in males was 11.4% in elementary schools, 12.1% in junior high schools and 25.3% in high schools. The prevalences in females were 9.8%, 19.6% and 35.9%, respectively. Multiple logistic regression analysis with such unwillingness as the objective variable and subjective symptoms and lifestyle factors as the explanatory variables, stratified by school and sex, adjusted for school grade in elementary schools, showed significantly high odds ratios (ORs) for reduction of vitality (OR: 3.68-8.22), irritable moods (OR: 3.00-6.30), feelings of fatigue and weariness (OR: 3.63-5.10) and difficulty waking up in the morning (OR: 1.98-2.69) in each school and sex, with an additional strong tendency for weight loss (OR: 1.83-2.97), with insignificantly high OR of boys in junior high schools (OR: 2.09, 95% Confidence interval: 0.95-4.60). No significant association was found between unwillingness to attend school in elementary school students with the lifestyle factors of their caregivers. CONCLUSIONS: There was no gender difference in the prevalence of students with feeleings of unwillingness to attend school in elementary school students, but figures were higher in females than in males for junior high and high school students. This was associated with the same subjective symptoms as those observed for students actually not attending school.

High beta-carotene and beta-cryptoxanthin are associated with low pulse wave velocity.

Antioxidants are potentially beneficial in preventing vascular complications in diabetes because oxidative stress would be enhanced in such a condition and play an important role in vascular disorders. This study aimed to investigate whether brachial-ankle pulse wave velocity (baPWV) would be lower in the presence of high serum carotenoid concentrations stratified according to the glycemic state. A total of 297 men and 579 women between 30 and 70 years of age were analyzed cross-sectionally. Multivariate adjusted mean of baPWV in the highest tertile for beta-carotene (1386 cm/s) was lower than that in the lowest tertile (1432 cm/s) and that in the highest tertile for beta-cryptoxanthin (1382 cm/s) was lower than that in the middle tertile (1424 cm/s) in the case of normal fasting glucose. Similar inverse associations were observed in a group that included subjects with both impaired fasting glucose and diabetes, however, without statistical significance. The highest tertile of carotenoids was associated with a low risk for high baPWV (> or =1680 cm/s). Age, sex and glycemic state adjusted odds ratio was 0.35 (95% CI 0.20-0.60) for beta-carotene and 0.45 (0.27-0.77) for beta-cryptoxanthin. Multivariate adjustment did not alter the results. In conclusion, an inverse association of baPWV with beta-carotene and beta-cryptoxanthin was observed independently of the glycemic state.

Temperature-induced cell detachment on immobilized pluronic surface.

The Pluronic F68 and F127, a triblock copolymer of ethylene oxide and propylene oxide, was activated using carbonyldiimidazole (CDI), and CDI-activated Pluronic F68 and F127 was subsequently immobilized on the surface of a poly-L-lysine-coated polystyrene tissue culture flask. Cell culture was performed on the Pluronic-immobilized flask. The morphology of fibroblasts (L929 cells) on the Pluronic F127-immobilized flask was mainly spherical, and showed less spreading behavior than that on the Pluronic F68-immobilized flask and conventional tissue culture flask. This observation indicates that L929 cells on Pluronic F127-immobilized flasks were cultured in a bio-inert environment. L929 cells were successively detached from both Pluronic F127-immobilized flask and Pluronic F68-immobilized flask by cooling the flask to 4-15 degrees C. This detachment is due to the hydration and dehydration properties of Pluronic, depending on the temperature. Umbilical cord blood was cultured in the Pluronic F127-immobilized and conventional polystyrene tissue culture flasks at 37 degrees C. The expression ratio of surface markers on hematopoietic stem cells (CD34 and CD133) cultured in the Pluronic F127-immobilized flask was significantly higher than that of the cells in polystyrene tissue culture flask.

Randomized controlled trial for an effect of green tea consumption on insulin resistance and inflammation markers.

To study the effects of the intake of green tea and polyphenols, which are a component of green tea, on insulin resistance and systemic inflammation, a randomized controlled trial was conducted on 66 patients aged 32-73 y (53 males and 13 females) with borderline diabetes or diabetes. Subjects in the intervention group were asked to take a packet of green tea extracts/powder containing 544 mg polyphenols (456 mg catechins) daily, which was a dose that could be taken without difficulty, and were asked to divide the green tea extracts/powder in a packet into 3 or 4 fractions dissolved in hot water everyday and to take a fraction after every meal or snack for 2 mo, in addition to daily food intake. The subjects in the control group were simply followed. To calculate the level of green tea polyphenol intake that the subject usually drank at home, the subject was asked to taste 3 teas of different strengths (1, 2 and 3%) and the tea that was closest to the one that the subject drank at home, was selected by each subject. After 2 mo, the mean daily polyphenol intake in the intervention group was 747 mg, which was significantly higher than that of 469 mg in the control group. In the intervention group, the body weight, BMI, systolic and diastolic blood pressures, blood glucose level, Hb A1c level, insulin level and HOMA index after taking the supplementation for 2 mo, were lower than the respective value before intervention: however, these parameters in the intervention group at 2 mo did not significantly differ from those in the control group. Within the intervention group, changes in insulin level tended to be associated with changes in polyphenol intake. In addition, changes in BMI were associated with changes in blood glucose level and insulin level. In conclusion, the daily supplementary intake of 500 mg green tea polyphenols did not have clear effects on blood glucose level, Hb A1c level, insulin resistance or inflammation markers. The positive correlation between the level of polyphenol intake and insulin level warrants further studies on the effect of green tea on insulin resistance.

A novel polymorphism, 70Leu/Phe, disrupts a consensus Leu residue within the leucine-rich repeat sequence of platelet glycoprotein Ibalpha.

Platelet glycoprotein (GP) Ib/IX/V complex mediates high-shear dependent platelet activation through an interaction with the von Willebrand factor (vWF). All four subunits of the complex have a structural motif, the leucine-rich repeat (LRR) sequence, with leucines in conserved positions. Here we report a new polymorphism, Leu/Phe at residue 70 of GPIbalpha, which disrupts the consensus sequence of the LRR in the vWF binding domain. Genotype frequencies among 142 healthy Japanese subjects were 92.3%, 7.7%, and 0.0%, for the 70Leu/Leu, 70Leu/Phe, and 75Phe/Phe genotypes, respectively. Ristocetin-induced or shear-induced platelet aggregation was not significantly different between the 70Leu/Leu and 70Leu/Phe genotypes. In in vitro studies, a recombinant GPIbalpha fragment with 70Phe (L70F) as compared to that with 70Leu (WT) had low reactivity to anti-GPIbalpha monoclonal antibodies, GUR20-5 and Hip1, both of which recognize conformation-specific epitopes within the 45-kDa domain. Ristocetin-induced 125I-vWF binding to L70F, however, did not differ from that to WT.

A single thymine nucleotide deletion responsible for congenital deficiency of plasmin inhibitor.

Plasma plasmin inhibitor (PI) is a physiological inhibitor of plasmin-mediated fibrinolysis and constitutes a hemostatic component in blood plasma; hence its deficiency results in a severe hemorrhagic diathesis. We have carried out molecular analysis of American family members with congenital PI deficiency, and detected a single thymine deletion at nucleotide position 332 in exon 5. The deletion was found in both alleles of the homozygotes and in one allele of the heterozygotes, and the patterns of restriction fragment length polymorphism created by the mutation in the family members were compatible with their phenotypes. The deletion caused a frameshift leading to an alteration and shortening of the deduced amino acid sequence. The amino acid sequence consists of the first 83 amino acids of the N-terminal sequence of the normal PI and additional new amino acids, resulting in a mutant composed of 94 amino acids in contrast to 464 amino acids of the normal PI. In transient expression analysis, the mutant PI whose molecular size was compatible with the predicted amino acid sequence was detected in the lysates of the cells transfected with the mutated PI expression vector. The mutant PI was retained and underwent progressive degradation within the cells, and was minimally excreted into the media. These data indicate that this mutation is the cause of PI deficiency in this pedigree.

A comparative double-blind randomized trial of activated protein C and unfractionated heparin in the treatment of disseminated intravascular coagulation.

A randomized prospective double-blind trial was performed to compare the safety and efficacy of human activated protein C (APC) and unfractionated heparin for the treatment of disseminated intravascular coagulation (DIC). One hundred thirty-two patients with DIC were enrolled in this study: 63 patients received APC (12.5 U [2.5 microg]/kg body wt per hour) and 69 patients received heparin (8 U/kg body wt per hour) by intravenous infusion for 6 days. Forty-nine APC-treated patients and 55 heparin-treated patients were evaluated for efficacy, and 52 APC-treated patients and 55 heparin-treated patients were evaluated for safety. The 2 groups were similar with respect to sex, age, body weight, underlying diseases, and coagulation/fibrinolysis parameters before treatment. Aggravation of bleeding was seen after treatment in 8 patients receiving heparin, but in none of the patients receiving APC. The number of patients who showed alleviation of bleeding was significantly higher in the APC group than the heparin group (P = .009). The effects on DIC-related organ dysfunction were not significantly different between the 2 groups. Fibrinogen-fibrin degradation products, D-dimer, thrombin-antithrombin complex (TAT), and plasmin-plasmin inhibitor complex (PIC) were all significantly decreased by treatment in both groups. Fibrinogen, protein C, and antithrombin were significantly increased in the APC group, whereas only protein C was significantly increased in the heparin group. Platelet count in the nonleukemic group was significantly increased in those patients receiving APC but not increased in those patients receiving heparin. Improvement of coagulation/fibrinolysis was assessed by scoring 4 parameters (soluble fibrin monomers, D-dimer, TAT, and PIC), and the results indicated that the APC group showed significantly greater improvement than the heparin group (P = .046). There was, however, no significant difference in the rate of complete recovery from DIC between the 2 groups. The rate of death from any cause within 28 days after treatment was 20.4% in the APC group, significantly lower than the 40% death rate observed in the heparin group (P < .05). There were no severe adverse events in either group. These results suggest that APC in a relatively small dosage can improve DIC more efficiently than can heparin, without increasing bleeding, and may be a better alternative.

Shear-induced platelet aggregation increases in patients with proximal and severe coronary artery stenosis.

BACKGROUND: Shear stress generated in stenosed arteries promotes platelet thrombi formation at the stenosed sites by accelerating the binding of von Willebrand factor (vWF) to platelets. Shear-induced platelet aggregation (SIPA) has been studied in acute coronary syndromes, but not in chronic coronary disease. HYPOTHESIS: We investigated the effect of both the site and severity of coronary stenosis on SIPA in patients with chronic coronary artery disease. METHODS: Shear-induced platelet aggregation was measured using platelet-rich plasma in 49 patients (41 men and 8 women; mean age 61+/-10 years) with coronary artery disease to evaluate the association between the extent of SIPA and coronary angiographic findings. Stenoses > 75% were considered severe. In all, 62 healthy individuals (54 men and 18 women; mean age 45+/-7 years) served as controls. The correlation between SIPA and the site and severity of the coronary lesion, and parameters of coagulation and fibrinolysis were evaluated. RESULTS: Shear-induced platelet aggregation was increased in the stenosis group (69.0+/-10.6%) compared with the controls (57.7+/-10.3%, p < 0.0001). Patients with severe stenosis in the proximal segments had significantly increased SIPA (p< 0.0001) and vWF larger multimer concentration (p<0.0001) compared with the control group. A significant correlation existed between SIPA and the vWF larger multimer concentration in all subjects studied (r = 0.422, p < 0.0001). CONCLUSIONS: Shear-induced platelet aggregation is increased in patients with severe stenosis of the proximal coronary arteries and correlates with plasma concentrations of vWF larger multimers, suggesting that severe stenosis in the proximal segments is not only associated with an increased risk of significant myocardial ischemia, but may also generate high shear stress in the stenosed artery and increase plasma vWF larger multimers, thereby promoting the formation of platelet thrombi.

[Red blood cell deformability in relation to gender, age, blood pressure, obesity, serum lipids, alcohol consumption and smoking].

OBJECTIVES: To determine the effects of environmental factors on abnormalities in red blood cell deformability (RBCD), which may play an important role in the development of cardiovascular diseases, a cross-sectional epidemiological study was conducted in healthy subjects. METHOD: The subjects were 350 males (mean age 52.7 +/- 10.3 SD) and 364 females (52.6 +/- 10.4) who participated in a health check program in the town of Akabane, Japan, in 1995-1998. Blood and serum were obtained to determine the values of RBCD and TP, TG, TCHOL, and HDLC. The inverse of RBCD (RBCDI, ms-1) was used as an indicator of RBCD. The subjects were also investigated for drinking and smoking habits, BMI, and SBP. Males and females were stratified into tertiles for each variable except drinking and smoking. For those exceptions, male subjects were stratified into three groups according to alcohol consumption (non-drinkers, moderate drinkers (up to 27 ml pure ethanol per day), and habitual drinkers (28 ml or more per day)) and according to tobacco use (non-smokers, mild smokers (equal or fewer than 20 cigarettes per day), and heavy smokers, (more than 20)). Each stratum was further divided into two groups according to age (younger, < 50 years; older, > or = 50 years). RESULTS: The mean value of RBCDI was significantly higher in males (1.041 +/- 0.135 SD) than in females (1.013 +/- 0.113). RBCDI declined with age in both genders. In analyses of variance, the averages of RBCDI decreased as TP increased in all ages and in both genders and as TCHOL increased in older males. With regard to alcohol consumption, the averages of RBCDI were the highest in moderate drinkers in younger males. Multiple linear regression analyses showed negative correlations between RBCDI values and age, TP or TCHOL values, and showed positive correlations between RBCDI values and BMI in males as well as negative correlations between RBCDI values and age and TP in females. When alcohol drinking was entered into the model, the statistical significance between TCHOL and RBCDI disappeared in males. No apparent relations between smoking habit and levels of SBP and TG to RBCDI were found. CONCLUSIONS: RBCDI was higher in males than in females and higher in the younger group than in the older group. This study suggested that TCHOL may lower RBCDI and moderate drinking may improve it. Further epidemiological study is required to clarify these relationships.

Thrombomodulin alfa in the treatment of infectious patients complicated by disseminated intravascular coagulation: subanalysis from the phase 3 trial.

To investigate treatment effects of thrombomodulin alfa (TM-α) in patients with disseminated intravascular coagulation (DIC) having infection as the underlying disease, retrospective subanalysis of a double-blind, randomized controlled phase 3 trial was conducted. In the phase 3 trial, 227 DIC patients (full-analysis set) having infection and/or hematologic malignancy as the underlying disease received either TM-α (0.06 mg·kg for 30 min once daily) or heparin (8 U·kg·h for 24 h) for 6 days using the double-dummy method. Among these patients, 147 patients with noninfectious comorbidity leading to severe thrombocytopenia (e.g., hematologic malignancy, or aplastic anemia) were excluded from the present analysis, and 80 patients with infectious disease and DIC were extracted and subjected to the present retrospective subanalysis. Disseminated intravascular coagulation resolution rates were determined using the DIC diagnostic criteria for critically ill patients at 7 days, and mortality rates were evaluated at 28 days. In the TM-α and heparin groups, DIC resolution rates were 67.5% (27/40) and 55.6% (20/36), and 28-day mortality rates were 21.4% (9/42) and 31.6% (12/38), respectively. Mortality rates of patients who recovered from DIC were 3.7% (1/27) in the TM-α group and 15% (3/20) in the heparin group. These results suggest TM-α may be valuable in the treatment of DIC associated with infection.

Poloxamer 188 enhances apoptosis in a human leukemia cell line.

Poloxamer block copolymers have been studied in multiple applications as drug delivery systems (DDS). These A-B-A amphiphilic block copolymers up-regulate the expression of selected genes in cells and alter genetic responses to antineoplastic agents in cancer. One example is poloxamer 188, also known as pluronic F68, which may be promising as a carrier in DDS. To clarify the possible mechanistic role of pluronic F68 in several leukemia cell lines, we examined whether pluronic F68-inducible factors were capable of causing apoptosis. The influence of pluronic F68 on the cell lines was examined using a comprehensive analysis. It was found that treatment of K562 cells with 6% pluronic F68 resulted in G2/M phase arrest of the cell cycle, followed by caspase activation and the accumulation of apoptotic cells. When used as a carrier in a DDS, pluronic F68 may provide a synergistic effect on the drug of interest. Although the mechanisms behind the function of pluronic F68 are not fully understood, the results suggests that pluronic F68 may act as a useful carrier in DDS for the purpose of leukemia therapy.

Bioinert surface of pluronic-immobilized flask for preservation of hematopoietic stem cells.

The bioinert materials on which cells do not proliferate, differentiate, nor de-differentiate should be useful for the culture and preservation of stem cells. The Pluronic F127, a triblock copolymer of ethylene oxide, and propylene oxide was activated using carbonyldiimidazole (CDI), and CDI-activated Pluronic was subsequently immobilized on the surface of a lysine-coated polystyrene tissue culture flask. The morphology of fibroblasts (L929 cells) on the Pluronic-immobilized flask was spherical, and did not show spreading behavior. This observation indicates that L929 cells on the Pluronic-immobilized flask were cultured in a bioinert environment. The expression ratio of surface markers on hematopoietic stem cells (CD34 and CD133) cultured in the Pluronic-immobilized flask was significantly higher than that in polystyrene tissue culture flask and commercially available bioinert flask (i.e., low cell binding cultureware). This is caused by the existence of hydrophilic segments of Pluronic F127 on the Pluronic-immobilized flask.

Feasibility and effect on blood pressure of 6-week trial of low sodium soy sauce and miso (fermented soybean paste).

A double-blind, randomized placebo-controlled study was conducted to evaluate the feasibility of the long-term use of low-sodium soy sauce and miso in the general Japanese population and its effect on blood pressure (BP). Forty men and 24 women were randomly allocated to a low-sodium group (n=32) or a control group (n=32). Low-sodium soy sauce and miso, which were approximately 25% and 20% lower in salt content than common soy sauce and miso, were used in the study. The change in BP after a 6-week intervention was evaluated. There were no significant differences in age, sex, body mass index, BP or hypertension between the 2 groups before intervention. After the 6-week intervention, no significant change in BP was observed in the entire cohort. However, in those aged 40 years and older, 6.4 mmHg net reduction in diastolic BP with no significant change in systolic BP was noted in the low-sodium group. Taste evaluation for the low-sodium seasoning was considerably good. Replacing soy sauce and miso of the common type with the low-sodium alternative is feasible in the general population and could be the basis for a salt reduction strategy in the Japanese diet.