An Evaluation of the Modified Diagnostic Criteria for DIC Established by the Japanese Society of Thrombosis and Hemostasis.

OBJECTIVE: We evaluated the modified diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH) in 108 patients with suspected infectious DIC. MATERIAL AND METHODS: The diagnoses of the patients were as follows: DIC (n = 63), pre-DIC (n = 22), and non-DIC (n = 45). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver-operating characteristic analysis. RESULTS: Although the area under the curve for global coagulation test (GCT) scores in the diagnosis of "DIC" was high that for the diagnosis of "DIC and pre-DIC" was low, suggesting that the addition of antithrombin (AT), soluble fibrin (SF)/thrombin-AT complex (TAT), and reduced platelet count (PLT) values was required to diagnose "DIC and pre-DIC." Using GCT score with the AT, SF/TAT, and reduced PLT values, the cutoff value of the DIC score for the diagnosis of "DIC and pre-DIC" was 5 points. DISCUSSION AND CONCLUSION: The modified JSTH's diagnostic criteria for DIC, which used the GCT score and the reduced PLT, AT, and TAT/SF values, were useful for diagnosing "DIC and pre-DIC."

Evaluation of the Diagnostic Criteria for the Basic Type of DIC Established by the Japanese Society of Thrombosis and Hemostasis.

We evaluated the diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH), in 232 patients with suspected DIC without hematopoietic injury or infection. The diagnoses of the patients were as follows: DIC (n = 116), pre-DIC (n = 54), and non-DIC (n = 63). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver operating characteristic analysis. The area under the curve and odds ratio for the global coagulation test (GCT) scores in the diagnosis of "DIC" were high, whereas those for the diagnosis of "DIC and pre-DIC" were low, suggesting that the addition of a reduced platelet count (RPC), antithrombin (AT), and soluble fibrin (SF)/thrombin AT (TAT) complex was required to diagnose DIC and pre-DIC. When the GCT score with the RPC, AT, and TAT/SF values was used, the cutoff DIC score for the diagnosis of DIC or DIC and pre-DIC was 6 points. For predicting the outcome, a scoring system that used the GCT result was useful, but the addition of RPC, AT, or SF/TAT was not. The modified diagnostic criteria of JSTH, which included the GCT score and the RPC, AT, and TAT/SF values, were useful for diagnosing both DIC and pre-DIC.

The valuable diagnosis of DIC and pre-DIC and prediction of a poor outcome by the evaluation of diagnostic criteria for DIC in patients with hematopoietic injury established by the Japanese Society of Thrombosis and Hemostasis.

OBJECTIVE: We evaluated the modified diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH), in 274 suspected DIC patients with hematopoietic injury. MATERIALS AND METHODS: The diagnoses of the patients were as follows: DIC (n=125); pre-DIC (n=42) and non-DIC (n=107). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver operating characteristic (ROC) analysis. RESULTS: The area under the curve (ARC) and odd's ratio for the global coagulation test (GCT) scores in the diagnosis of "DIC" were high, while those for the diagnosis of "DIC and pre-DIC" were low, suggesting that the addition of antithrombin (AT) and soluble fibrin (SF)/thrombin antithrobin complex (TAT) was required to diagnose "DIC and pre-DIC". Although the addition of the AT and SF/TAT values to the GCT did not increase its ability to predict a poor outcome, the JSTH's modified diagnostic criteria scores were correlated with the odds ratio for death. DISCUSSION AND CONCLUSION: The JSTH's modified diagnostic criteria for DIC, which included the GCT score, and the AT, and TAT/SF values, were useful for diagnosing DIC and pre-DIC, and predicting a poor outcome.

The efficacy of the administration of recombinant human soluble thrombomodulin in patients with DIC.

Efficacy of recombinant human soluble thrombomodulin (rhTM), which is frequently used to treat patients with disseminated intravascular coagulation (DIC), was compared with that of gabexate mesilate (GM), which was previously used routinely in the treatment of DIC patients in Japan. Although there was no significant difference in the resolution rates of the patients who were treated with rhTM and GM, the results of our analysis revealed that the mortality rate was significantly higher among infectious disease patients treated with GM than in those treated with rhTM. Levels of fibrinogen and fibrin degradation products (FDP), antithrombin (AT) activity, and thrombin AT complex (TAT) were significantly lower in the DIC patients with infectious diseases, while fibrinogen levels were high. FDP level, D-dimer, platelet count, PT ratio, and DIC score all showed significant improvement following rhTM treatment. There were no significant difference between survivors and non-survivors in terms of DIC score, FDP level, platelet count, AT activity, or in TAT, SF and PPIC levels before rhTM treatment. However, fibrinogen levels were significantly lower in non-survivors than in survivors. These results indicate that rhTM may be superior to GM for the treatment of DIC.

[Progress in diagnosis and treatment for disseminated intravascular coagulation].

As the development of a hypercoagulable state in the setting of disseminated intravascular coagulation (DIC) induces localized infection, therapy for DIC should be evaluated according to the findings of examinations for both severe sepsis and DIC. DIC is classified into the following types: "bleeding type," "organ failure type," "asymptomatic type," and "complication type." The "bleeding type" and "organ failure type" are considered to reflect the "plasmin inhibitor (PI) deficiency type" and "antithrombin (AT) deficiency type," respectively. In order to improve the diagnosis of DIC, in particular limitations in global coagulation tests, the Japanese Society of Thrombosis and Hemostasis recently proposed tentative diagnostic criteria for DIC using hemostatic molecular markers and AT. The recommendations for treatment of DIC, especially the use of AT concentrates, recombinant activated protein C and thrombomodulin, vary among several guidelines for the management of DIC. These agents inhibit the effects of key proteases in activating coagulation and consequently exert an anti-inflammatory effect on DIC. Hence, it is necessary to extensively evaluate these agents in well-conducted clinical trials.

Elevated soluble platelet glycoprotein VI is a useful marker for DVT in postoperative patients treated with edoxaban.

Prevention of deep vein thrombosis (DVT) is important in patients undergoing major orthopedic surgery. Although the detection of an elevated D-dimer level is useful for predicting DVT, it is not efficacious in postoperative patients being treated with anti-Xa agents. The soluble platelet glycoprotein VI (sGPVI) level is a marker of activated platelets, but not bleeding. Therefore, sGPVI levels are usually examined as a predictor of DVT in such patients. In the present study, 83 orthopedic patients were treated with 30 mg of edoxaban for prophylaxis of DVT. Fourteen patients developed DVT and 17 patients discontinued the prophylaxis due to decreased hemoglobin levels. Plasma levels of sGPVI in the patients were significantly higher after surgery than before surgery. On day 1, the sGPVI levels increased, while the platelet counts decreased. There were no significant differences in D-dimer, soluble fibrin, or FDP levels in orthopedic patients with and without DVT before surgery and on days 1, 4, and 8. Plasma sGPVI levels were significantly higher in the patients with DVT than in those without DVT on days 1 and 4. Plasma levels of D-dimer were significantly higher in patients with withdrawal than in those without. However, there were no significant differences in sGPVI levels between those with and without withdrawal. As D-dimer levels are known to increase in patients with withdrawal, this parameter is not useful for evaluating the risk of DVT in these patients. In contrast, the sGPVI level is not increased in those with withdrawal and may therefore be useful for evaluating the risk of DVT in postoperative patients treated with an anticoagulant.

[Monitoring of Anticoagulant Therapy after Orthopedic Surgery].

Venous thromboembolism (VTE) is a serious, although decreasingly prevalent, complication following major orthopedic surgery, such as total hip replacement and total knee replacement. In Japan, patients undergoing orthopedic surgery are treated with adjusted-dose warfarin, low-dose unfractionated heparin (UFH), fondaparinux, low-molecular-weight heparin (LMWH), and edoxaban postoperatively for VTE prophylaxis. The American College of Chest Physicians guidelines recommend the administration of various anticoagulants, including warfarin, LMWH, UFH, edoxaban, fondaparinux, dabigatran, apixaban, rivaroxaban, and aspirin. Although the prothrombin time (PT) remains constant under monitoring of warfarin therapy, the PT, activated partial thromboplastin time (APTT), and anti-Xa activity may vary under monitoring of treatment with UFH, LMWH, fondaparinux, and/or novel oral anticoagulants (NOACs). Therefore, the monitoring of selective anti-Xa drugs has not yet been established. A marked prolongation of the APTT and PT values in patients treated with NOACs indicates a risk of bleeding, whereas low levels of D-dimer and soluble fibrin suggest the usefulness of anticoagulants for VTE prophylaxis. An elevation of the anti-Xa activity on day 1 in addition to a marked elevation of the D-dimer level reflect the risk of major bleeding in patients undergoing orthopedic surgery treated with fondaparinux postoperatively. However, there are currently no biomarkers for the efficacy of selective Xa or thrombin inhibitors. Therefore, it is necessary to establish further evidence for monitoring the effects of NOACs.

[A endoscopic treatment of penetration of the colon by an ingested fish bone].

An 81-year-old woman was admitted complaining of left lower abdominal pain. Computed tomography on admission revealed foreign a body penetrating descending colon and free air. We extracted the foreign body endoscopically. The foreign body was a sharp-edged fish bone. She was treated by conservative medication without complication.

Essential roles of tumor-derived helper T cell epitopes for an effective peptide-based tumor vaccine.

In this study, we identified a c-erbB-2/HER2/neu (HER2)-derived Th epitope (HER2 (16-30) ) and examined the role of Th epitopes in HER2-specific CD8+ T cell induction and in vivo tumor eradication, with a particular emphasis on the role of tumor cell-derived Th epitopes. Immunization of BALB/c mice using a mixture of Th epitope HER2 (16-30) and CTL epitope HER2 (63-71) administered subcutaneously with murine GM-CSF (mGM-CSF) induced a much higher level of HER2 (63-71) -specific CD8+ T cells compared with that obtained with the CTL epitope alone. HER2-unrelated OVA-derived Th epitope (OVA (323-339) ) exhibited a similar enhancing effect on HER2 (63-71) -specific CD8+ T cell induction. However, only mice immunized with HER2 (16-30) and HER2 (63-71), but not with a tumor-unrelated OVA (323-339) and HER2 (63-71), showed in vivo eradication of CMS5mHE tumor cells expressing HER2 but not OVA. This distinction was observed in preventative as well as therapeutic experimental settings. Conversely, both HER2 (16-30) and OVA (323-339) Th epitopes were equally effective in inducing the eradication of CMS5mHEOVA tumor cells which express HER2 as well as OVA. Our results clearly indicate that CTL and Th epitopes of target tumor cell origin should be used for effective induction of in vivo antitumor immunity.