Warfarin Therapy and Percutaneous Left Atrial Appendage Closure for a Patient with Atrial Fibrillation and Antithrombin-III Deficiency.

Some patients develop ischemic stroke despite taking direct oral anticoagulants because of the presence of other risk factors such as coagulopathies. A 65-year-old male patient with non-valvular atrial fibrillation (NVAF) taking rivaroxaban was diagnosed as having embolic stroke and antithrombin-III (AT-III) deficiency. Echocardiography revealed a thrombus in the left atrial appendage (LAA). He was prescribed warfarin, and after resolution of the thrombus, we successfully performed percutaneous LAA closure (LAAC), with no subsequent recurrence or device-related thrombosis. Warfarin and LAAC may be feasible for NVAF patients with AT-III deficiency.

Impact of JSS-PCS on the In-Hospital Workflow and Outcomes of Reperfusion Therapy for Acute Ischemic Stroke: Cases of a Metropolitan Secondary Emergency Facility.

Objective: Protected code stroke has been widely introduced in the emergency medical system for acute stroke in the current coronavirus disease 2019 (COVID-19) pandemic. This study aims to confirm the effects of protected code stroke formulated by the Japan Stroke Society (JSS-PCS) on the quality and outcomes of reperfusion therapy for acute ischemic stroke (AIS), followed by evaluating its validity. Methods: The subjects were 109 consecutive patients with AIS who underwent reperfusion therapy between January 2016 and July 2021, excluding in-hospital onset cases. Patients were classified according to the treatment date into the pre-COVID-19 (n = 82) and the with-COVID-19 (n = 27) groups. JSS-PCS was applied to all patients in the latter group. Statistical comparisons were made between groups on time indicators for initial treatment (onset-to-door time, door-to-imaging time [DTI], door-to-needle time [DTN], door-to-puncture time [DTP], door-to-reperfusion time, and puncture-to-reperfusion time [PTR]). The time indicator transition over the entire period was also evaluated by subgroup analysis. Subsequently, the outcomes at discharge were statistically compared between the two periods, followed by a subgroup comparison. Finally, univariate and multivariate analyses examined whether the application of JSS-PCS affected clinical outcomes. Results: Slight delays were revealed in DTI, DTN, DTP, and PTR in the with-COVID-19 group with no statistical significance. The time indicators were delayed once entering the period of the COVID-19 pandemic and then shortened again. The outcomes at discharge tended to worsen slightly in the with-COVID-19 group with no significance. Subgroup analysis depicted a transient deterioration of outcomes early in the pandemic. Applying JSS-PCS did not significantly affect clinical outcomes in univariate and multivariate analyses. Conclusion: Regarding reperfusion therapy at our facility, the introduction and application of JSS-PCS during the COVID-19 pandemic significantly affected neither time indicators nor outcomes. Infection control should be a top priority in the first medical practice for AIS in today's world, where COVID-19 shows no signs of termination.

[A patient with relapsing-remitting multiple sclerosis who relapsed frequently and developed primary biliary cholangitis after pregnancy and discontinuation of fingolimod].

We present the case of a 37-year-old woman who was diagnosed as having relapsing-remitting multiple sclerosis (MS) when she was 25 years old. She remained relapse-free after she was started on treatment with oral fingolimod. However, at the age of 35, when she became pregnant, fingolimod was discontinued, and she began to suffer from frequent relapses. Following her delivery, she was started on treatment with dimethyl fumarate. Subsequently, with elevation of the serum levels of hepatobiliary enzymes and peripheral blood eosinophil count, possibly caused by dimethyl fumarate, her treatment was switched back to fingolimod. However, the elevation of the serum hepatobiliary enzyme levels and peripheral blood eosinophil count persisted. A serological test for autoantibodies revealed the diagnosis of primary biliary cholangitis (PBC). Pregnancy or discontinuation of fingolimod could have influenced the immune status of the patient and worsened the state of MS. There are some reports of autoimmune hepatic diseases, including PBC, being caused by disease modifying drug (DMD), like interferon-ß or even steroid pulse therapy, although the underlying mechanisms remain unknown. This risk should be borne in mind when treating patients with MS, especially younger women, with DMD.