Paroxysmal Nocturnal Haemoglobinuria Type III Presenting as Portal and Mesenteric Vein Thrombosis in a Young Girl

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare, acquired, life-threatening haematological disorder. It is characterised by complement induced haemolytic anaemia, thrombosis and impaired bone marrow function. Thrombosis most commonly occurs in the hepatic, portal, superior mesenteric and cerebral veins. A22-year female, previously diagnosed with severe aplastic anaemia treated with anti-lymphocyte globulin (ALG) and cyclosporine, had become transfusion independent for more than 10 years. She presented with abdominal pain and vomiting, initially diagnosed with portal and superior mesenteric vein thrombosis. Immunophenotyping by flow cytometry revealed a diagnosis of paroxysmal nocturnal haemoglobinuria type III. She was treated with vitmamin K anatagonist and platelet transfusion.

Why do parents decline newborn intramuscular vitamin K prophylaxis?

OBJECTIVE

To explore the influencing factors and reasoning of parents who opt out of intramuscular vitamin K prophylaxis for their newborn.

DESIGN

We conducted a qualitative study with 15 families from the Otago/Southland region of New Zealand. Semistructured interviews explored their choice to opt out of intramuscular vitamin K prophylaxis and thematic analysis was used to elucidate themes that captured important aspects of this parental decision-making process.

RESULTS

Parents opt out of intramuscular vitamin K for a variety of reasons. These were clustered into three main themes: parents' beliefs and values (philosophy and spirituality), concerns about their child's welfare (pain and potential side effects) and external influencing factors (family, friends, media and health professionals). As part of a wider family hesitancy towards medical intervention, the majority of parents also raised concerns regarding other perinatal or childhood interventions.

CONCLUSION

Many factors influence parental decision making and lead to a decision to opt out of newborn intramuscular vitamin K prophylaxis. Due to strong parallels with other common childhood interventions, these findings have relevance for vitamin K prophylaxis and for other healthcare interventions in childhood.

Tissue Concentrations of Vitamin K and Expression of Key Enzymes of Vitamin K Metabolism Are Influenced by Sex and Diet but Not Housing in C57Bl6 Mice

BACKGROUND

There has been limited characterization of biological variables that impact vitamin K metabolism. This gap in knowledge can limit the translation of data obtained from preclinical animal studies to future human studies.

OBJECTIVE

The purpose of this study was to determine the effects of diet, sex, and housing on serum, tissue, and fecal vitamin K concentrations and gene expression in C57BL6 mice during dietary vitamin K manipulation.

METHODS

C57BL6 4-mo-old male and female mice were randomly assigned to conventional or suspended-wire cages and fed control [1400 ± 80 μg phylloquinone (PK)/kg] or deficient (31 ± 0.45 μg PK/kg) diets for 28 d in a factorial design. PK and menaquinone (MK) 4 plasma and tissue concentrations were measured by HPLC. Long-chain MKs were measured in all matrices by LC-atmospheric pressure chemical ionization-mass spectrometry. Gene expression was quantified by reverse transcriptase-polymerase chain reaction in the liver, brain, kidney, pancreas, and adipose tissue.

RESULTS

Male and female mice responded differently to dietary manipulation in a tissue-dependent manner. In mice fed the control diet, females had ∼3-fold more MK4 in the brain and mesenteric adipose tissue than did males and 100% greater PK concentrations in the liver, kidney, and mesenteric adipose tissue than did males. In mice fed the deficient diet, kidney MK4 concentrations were ∼4-fold greater in females than in males, and there were no differences in other tissues. Males and females differed in the expression of vitamin K expoxide reductase complex 1 (Vkorc1) in mesenteric adipose tissue and the pancreas and ubiA domain-containing protein 1 (Ubiad1) in the kidney and brain. There was no effect of housing on serum, tissue, or fecal concentrations of any vitamin K form.

CONCLUSIONS

Vitamin K concentrations and expression of key metabolic enzymes differ between male and female mice and in response to the dietary PK concentration. Identifying factors that may impact study design and outcomes of interest is critical to optimize study parameters examining vitamin K metabolism in animal models.

The prevalence of coagulation abnormalities in hospitalized patients receiving lipid-based parenteral nutrition

BACKGROUND

Vitamin K is not a component of the multivitamin preparation added to parenteral nutrition (PN) solutions, and hospitalized patients receiving parenteral nutrition support are at risk of developing vitamin K deficiency.

METHODS

In this study, 84 consecutive patients receiving PN were followed up prospectively to determine the incidence of a raised international normalized ratio (INR). All patients received lipid in their PN, which contains approximately 30 microg of vitamin K/100 mL.

RESULTS

Patients were followed up for the course of PN or up to 4 weeks if they needed longer total parenteral nutrition. A raised INR compared with baseline developed in 3.6% of patients. All elevations were mild, and no patients developed clinical bleeding.

CONCLUSIONS

It may be unnecessary to routinely supplement patients with vitamin K if they are receiving a lipid emulsion containing significant amounts of vitamin K. For patients receiving warfarin therapy, it will be important for nutrition support services to be aware of the vitamin K content of the lipid emulsion they are using as patients receiving a multivitamin preparation containing vitamin K and lipid emulsion may receive increased amounts of vitamin K, which could lead to warfarin resistance.

A Mixed Micelle Formulation for Oral Delivery of Vitamin K

PURPOSE

To develop a stable micellar formulation of vitamin K for oral delivery, because the commercial and clinically used formulation of vitamin K (Konakion® MM) destabilizes at gastric pH resulting in low bioavailability of this vitamin in neonates with cholestasis.

METHODS

Mixed micelles composed of EPC, DSPE-PEG 2000 and glycocholic acid, with and without vitamin K, were prepared by a film hydration method. The influence of pH on the stability of the micelles was analyzed by dynamic light scattering (DLS). The critical micelle concentration (CMC) was determined by fluorescence spectroscopy using pyrene and the morphology was evaluated by transmission electron microscopy . Caco-2 cells were used to study the cytocompatibilty.

RESULTS

Mixed micelles with mean diameters from 7.1 to 11.0 nm and a narrow size distribution (PDI < 0.2) were obtained after 3 membrane extrusion cycles. Konakion® MM formed aggregated particles at gastric pH, which was avoided through steric stabilization by introducing PEG. TEM showed that mixed micelles had a spherical size (diameter of around 10 nm) with a narrow size distribution in agreement with the DLS results. The loading capacities for vitamin K of mixed micelles with varying molar fractions of DSPE-PEG and EPC (from 0/100 to 50/50 (mol/mol)) were 10.8-5.0 w%, respectively. The mixed micelles showed good cytocompatibility at concentrations of glycocholic acid between 0.12 and 1.20 mM.

CONCLUSIONS

Mixed micelles with superior stability to Konakion® MM at low pH were obtained by introducing DSPE-PEG 2000. These are therefore attractive oral formulations for vitamin K.

PIVKA-II correlates with INR but not protein C or protein S concentrations in cord blood among newborns

BACKGROUND

Protein induced by vitamin K absence (PIVKA)-II, inactive precursor of prothrombin, is elevated in vitamin K (VK) deficiency. Our aims were to find the prevalence of VK deficiency in neonates, assess the utility of international normalized ratio (INR) as a screening tool, and explore the relationship between PIVKA-II, activated partial thromboplastin time (aPTT) and VK dependent anticoagulants.

METHODS

INR, aPTT, PIVKA-II, and proteins C and S activities were measured in neonatal cord blood prior to VK administration.

RESULTS

We found 45% of neonates had subclinical VK deficiency based on PIVKA-II levels and 7% based on INR. Receiver operating characteristic (ROC) analysis assessed the utility of INR in detecting >4 ng/mL of PIVKA-II and ROC of the area under the curve was 0.70 (95% CI 0.46-0.92, p = 0.07). Proteins C and S activities were normal for age and did not correlate with PIVKA-II [(r = 0.40, p = 0.14) and (r = 0.29, p = 0.29), respectively]. There was no association between aPTT and PIVKA-II (p = 0.83).

CONCLUSION

PIVKA-II seems to be a sensitive indicator of mild VK deficiency. Further studies are needed to investigate the lack of relationship between PIVKA-II and functional protein C or S levels.

Skin problems and EGFR-tyrosine kinase inhibitor

Epidermal growth factor receptor inhibition is a good target for the treatment of lung, colon, pancreatic and head and neck cancers. Epidermal growth factor receptor-tyrosine kinase inhibitor was first approved for the treatment of advanced lung cancer in 2002. Epidermal growth factor receptor-tyrosine kinase inhibitor plays an essential role in the treatment of cancer, especially for patients harbouring epidermal growth factor receptor activating mutation. Hence, skin toxicity is the most concerning issue for the epidermal growth factor receptor-tyrosine kinase inhibitor treatment. Skin toxicity is bothersome and sometimes affects the quality of life and treatment compliance. Thus, it is important for physicians to understand the background and how to manage epidermal growth factor receptor-tyrosine kinase inhibitor-associated skin toxicity. Here, the author reviewed the mechanism and upfront preventive and reactive treatments for epidermal growth factor receptor inhibitor-associated skin toxicities.

Effect of Vitamin K on Vascular Health and Physical Function in Older People with Vascular Disease--A Randomised Controlled Trial

BACKGROUND AND AIMS

Vitamin K insufficiency is common and linked to an increased risk of cardiovascular disease and osteoporotic fractures. The aim of this study was to examine whether daily supplementation with oral vitamin K could improve vascular health and physical function in older people with established vascular disease.

METHODS AND RESULTS

A double blind, randomised, placebo-controlled trial. Participants aged ≤ 70 years with a history of vascular disease were randomised to receive 6 months of daily oral 100mcg vitamin K2 (MK7 subtype) or matching placebo with outcomes measured at 0, 3 and 6 months. The primary outcome was between-group difference in endothelial function assessed using flow-mediated dilatation of the brachial artery at 6 months. Secondary outcomes included carotid-radial pulse wave velocity, augmentation index, blood pressure, carotid intima-media thickness, C-reactive protein, B-type natriuretic peptide, cholesterol and desphospho-uncarboxylated matrix Gla protein levels. Handgrip strength and the Short Physical Performance Battery assessed physical function, while postural sway was measured using a 3-dimensional force platform.

RESULTS

80 participants were randomised, mean age 77 (SD 5) years; 44/80 were male. Vitamin K levels rose in the intervention arm compared to placebo (+48 pg/ml vs -6 pg/ml, p=0.03) at 6 months. Desphospho-uncarboxylated Matrix Gla protein levels fell in the intervention group compared to placebo at 6 months (-130 [SD 117] pmol/L vs +13 [SD 180] pmol/L, p<0.001). No change was seen in endothelial function (between group difference -0.3% [95%CI -1.3 to 0.8], p=0.62). A modest, non-significant improvement in pulse wave velocity was seen in the vitamin K group (-0.8m/s [95%CI -1.8 to 0.3], p=0.15) while all other vascular and physical function outcomes unchanged.

CONCLUSIONS

Six months of vitamin K2 supplementation did not improve markers of vascular health or physical function in older patients with vascular disease.

Concepts and Controversies in Evaluating Vitamin K Status in Population-Based Studies

A better understanding of vitamin K's role in health and disease requires the assessment of vitamin K nutritional status in population and clinical studies. This is primarily accomplished using dietary questionnaires and/or biomarkers. Because food composition databases in the US are most complete for phylloquinone (vitamin K1, the primary form in Western diets), emphasis has been on phylloquinone intakes and associations with chronic diseases. There is growing interest in menaquinone (vitamin K2) intakes for which the food composition databases need to be expanded. Phylloquinone is commonly measured in circulation, has robust quality control schemes and changes in response to phylloquinone intake. Conversely, menaquinones are generally not detected in circulation unless large quantities are consumed. The undercarboxylated fractions of three vitamin K-dependent proteins are measurable in circulation, change in response to vitamin K supplementation and are modestly correlated. Since different vitamin K dependent proteins are implicated in different diseases the appropriate vitamin K-dependent protein biomarker depends on the outcome under study. In contrast to other nutrients, there is no single biomarker that is considered a gold-standard measure of vitamin K status. Most studies have limited volume of specimens. Strategic decisions, guided by the research question, need to be made when deciding on choice of biomarkers.

Reasons for Refusal of Newborn Vitamin K Prophylaxis: Implications for Management and Education

OBJECTIVE

The American Academy of Pediatrics recommends intramuscular (IM) vitamin K prophylaxis for all newborns to prevent vitamin K deficiency bleeding. Given the serious implications of late-onset vitamin K deficiency bleeding, our objective was to examine factors influencing parents' decisions to refuse IM vitamin K prophylaxis.

METHODS

Parents intending to refuse IM vitamin K prophylaxis at delivery were recruited from 5 community hospitals, 1 academic medical center, and 2 birthing centers in a single Southeastern state. Participants completed a written survey including demographics, birth and parenting decisions (eg, breastfeeding), and open-ended questions about their vitamin K information sources, concerns, and knowledge of risks.

RESULTS

The incidence of refusal was highest at the birthing centers. Fifty-four parents intending to refuse IM vitamin K completed the survey. Most were white (78%), over age 30 (57%), and college graduates (65%). All reported intention to exclusively breastfeed. Most refused hepatitis B vaccine (90%) and erythromycin eye ointment (77%). The most common source of information was the Internet (70%). Concerns included synthetic or toxic ingredients (37%), excessive dose (28%), and side effects (24%). Eighty-three percent of parents reported awareness of risks associated with vitamin K refusal. However, only 6 parents (11%) decided to accept IM prophylaxis.

CONCLUSIONS

This study provides an understanding of the concerns, mindset, and information sources used by parents refusing IM vitamin K. Educating parents about the importance of IM prophylaxis should begin in the prenatal period and must address concerns parents identify on the Internet.

Vitamins in pancreatic cancer: a review of underlying mechanisms and future applications

Although there is increasing evidence that vitamins influence pancreatic adenocarcinoma biology and carcinogenesis, a comprehensive review is lacking. In this study, we performed a PubMed literature search to review the anticancer mechanisms and the preclinical and clinical studies that support the development of the bioactive vitamins A, C, D, E, and K in pancreatic cancer intervention. Preclinical studies have shown promising results for vitamin A in pancreatic cancer prevention, with clinical trials showing intriguing responses in combination with immunotherapy. For vitamin C, preclinical studies have shown slower tumor growth rates and/or increased survival when used alone or in combination with gemcitabine, with clinical trials with this combination revealing decreased primary tumor sizes and improved performance status. Preclinical studies with vitamin D analogues have shown potent antiproliferative effects and repression of migration and invasion of pancreatic cancer cells, with a clinical trial showing increased time to progression when calciferol was added to docetaxel. For vitamin E, preclinical studies have shown that δ-tocotrienol and γ-tocotrienol inhibited tumor cell growth and survival and augmented gemcitabine activity. Early-phase clinical trials with δ-tocotrienol are ongoing. Vitamin K demonstrates activation of apoptosis and inhibition of cellular growth in pancreatic tumor cells; however, there are no clinical studies available for further evaluation. Although preclinical and clinical studies are encouraging, randomized controlled trials with endpoints based on insights gained from mechanistic and preclinical studies and early-phase clinical trials are required to determine the efficacy of bioactive vitamin interventions in pancreatic cancer.

Routine use of daily oral vitamin K to treat infants with cystic fibrosis

Vitamin K is routinely administered after birth in the UK to prevent haemorrhagic disease of the newborn. Despite this, vitamin K-deficient coagulopathy still occurs in infants with high morbidity and mortality. Up to 50% of late onset bleeding presents with intracranial haemorrhage. The risk of developing vitamin K coagulopathy is higher in infants with cystic fibrosis (CF) and those that are exclusively breast fed due to low vitamin K levels in breast milk and intestinal changes in bacterial flora. Oral vitamin K supplementation is a simple addition to routine CF treatment during infancy to prevent complications from significant coagulopathy.

Spontaneous Resolution of Chronic Subdural Haematoma in a Patient Receiving Anticoagulant Therapy

Significant chronic subdural hematoma (CSDH) is usually a surgical emergency. Spontaneous resolution of CSDH has rarely been reported in the literature. We are reporting a case of spontaneous resolution of CSDH in a patient receiving anticoagulant therapy who had undergone mitral valve replacement surgery.

[Bone and Nutrition. The association of vitamin K intake and bone health]

The association of vitamin K with bone mineral density has been reported in some previous cohort studies and intervention studies. In cohort studies, higher vitamin K1 intake was associated with lower fracture incidence. Some intervention studies have described that vitamin K1 and vitamin K2 (menaquinone-4 : MK-4) supplementation were modestly efficacious in preventing fracture, but not in preserving bone mass. Although dietary reference intake (adequate intake : AI) for vitamin K was increased from previous value, current AI was determined as the dose sufficient to maintain normal blood coagulation with little mentioning to bone. Vitamin K intake greater than the current AI would be required for the bone health.

[Bone and Nutrition. Nutritional management of osteoporosis]

Calcium intake was negatively associated with bone resorption marker such as DPD, NTX, and P1NP in Japanese postmenopausal osteoporotic patients. Not only to suppress bone resorption but also to keep higher hip bone mineral density were observed in the patients with higher intake of calcium than 800mg/day and higher vitamin D condition (more than 50nmol/L of serum 25 (OH) D). Higher calcium intake than 800mg/day from dairy and Tofu products, higher intake of vitamin D than 10μg/day from fish, and higher intake of vitamin K from vegetables should be recommended in Japanese postmenopausal osteoporotic patients. We should also pay attention to their losing weight and excess intake of these nutrients from supplements.

Association Between Vitamin K and the Metabolic Syndrome: A 10-Year Follow-Up Study in Adults

CONTEXT

The Metabolic Syndrome (MetS) is a cluster of metabolic abnormalities and is associated with increased risk of diabetes and cardiovascular diseases. Phylloquinone, menaquinones, and vitamin K status are associated with several components of MetS, but the association with MetS has hardly been studied to date.

OBJECTIVE

This study aimed to examine whether the intake and/or status of vitamin K is associated with MetS and its components.

DESIGN

This study comprised two cohorts, one of 402 women and one of 400 men (age 40-80 y). At followup 625 participants were still alive and willing to participate. Data were analyzed both cross sectionally and longitudinally with Poisson and linear regression adjusted for multiple confounders. Baseline phylloquinone/menaquinone intakes were measured with a validated food frequency questionnaire and vitamin K status with serum desphospho-uncarborxylated matrix-Gla protein level.

RESULTS

At baseline 270 (34.5%) participants had MetS and 171 (35.7%) at followup. Cross sectionally, high menaquinones intakes were associated (P(trend) = .08) with a lower prevalence of MetS with a prevalence ratio (PR) of 0.74 (95% confidence interval [CI], 0.54-1.03) for the highest vs the lowest tertile. At followup, the highest tertiles of menaquinones intake (PR = 0.62; 95% CI, 0.40-0.95) and vitamin K status (PR = 0.57; 95% CI, 0.38-0.87) were associated (P(trend) = .01) with a lower occurrence of MetS. These associations were mainly driven by relations with lower triacylglycerol concentrations for menaquinones and lower waist circumference for vitamin K status. Phylloquinone intake was not associated with MetS prevalence.

CONCLUSIONS

This study shows that a high intake of menaquinones and high vitamin K status are associated with a lower occurrence of MetS.

[Dental management of hemorrhage-prone patients]

The authors present a proposal of dental treatment and management of anticoagulated patients and of patients on antiplatelet therapy, with the approval by the Hungarian Association of Oral and Maxillofacial Surgeons and by the Dental Implantology Association of Hungarian Dentists. This current guide was based on recent Hungarian and on several foreign national guidelines and considers significant publications from international literature.

What Parents Need to Know About Vitamin K Administration at Birth

Prophylactic treatment of newborns with intramuscular vitamin K has been the standard of care for many years in the United States. However, instances of parental refusal of routine prophylaxis are currently on the rise. Refusal of routine prophylaxis can have serious long-term neurodevelopmental consequences for some newborns, who may subsequently develop vitamin K deficiency-associated hemorrhagic disease of the newborn (HDN).

Role of prophylactic vitamin K in preventing antibiotic induced hypoprothrombinemia

OBJECTIVE

To determine prophylactic role of single dose of vitamin K in prevention of antibiotic induced hypoprothrombinemia.

METHODS

This prospective comparative study included critically ill children in age group 2 mo to 12 y, admitted to a tertiary care hospital in India, likely to receive prolonged antibiotic therapy. One hundred twenty children, 60 in each group (A & B) were enrolled in the study. Patient allocation was done on alternate basis. Group A children received prophylactic vitamin K while group B did not. Baseline coagulation studies and other investigations were done in all children. Coagulation studies were repeated on day 10 and day 14 of antibiotic therapy and in between if required clinically. Children who developed deranged INR were given therapeutic vitamin K. If deranged INR returns to normal at 12 h of vitamin K administration then it indirectly confirms vitamin K deficiency. Analysis was done by fisher's t test and chi square test.

RESULTS

In children on prolonged antibiotic therapy, vitamin K deficiency was a common problem (15%). It was common in male sex, severe grade of protein energy malnutrition (PEM), N-methylthiotetrazole (NMTT) group containing antibiotics use and duration of antibiotic more than 10 d. It was same in children whether they received or did not receive prophylactic vitamin K on day 1 of antibiotic therapy (95% CI; p value 0.79).

CONCLUSIONS

Vitamin K deficiency is common problem in patients on prolonged antibiotic therapy. There is no role of single dose of prophylactic vitamin K in preventing antibiotic induced hypoprothrombinemia.

Synergistic effect of sorafenib and vitamin K on suppression of hepatocellular carcinoma cell migration and metastasis

Vitamin K plays a role in controlling cell growth. Anti-angiogenic effects of sorafenib lead to impairment of vitamin K uptake and induction of des-γ-carboxyprothrombin release by hepatocellular carcinoma (HCC) cells. We examined sorafenib and vitamin K individually and in combination regarding their ability to suppress migration and metastatic potential of HCC cells. HepG2 cells (HCC cell line) were treated with hepatocyte growth factor (HGF). E-Cadherin expression, phospho-MET (p-MET), and phospho-extracellular signal-regulated kinase (p-ERK) levels and cell migration were evaluated. HGF-stimulated HepG2 cells, which were treated with a combination of sorafenib and vitamin K, showed significantly increased expression of E-cadherin and impairment of migration ability compared to when treated with either agent alone. This combination therapy also induced marked inhibition of epithelial-mesenchymal transition phenotype; inhibition of HGF-stimulated cell proliferation, invasion and migration; and inhibition of HGF/c-MET signaling pathway. Levels of p-MET and p-ERK were also significantly reduced by this combination. Our experimental study demonstrated that sorafenib and vitamin K can function synergistically to inhibit the migration and proliferation of HCC cells. Combination therapy with sorafenib and vitamin K appears to be worthy of clinical trial with expectation of synergistic therapeutic effects.

The effect of preoperative vitamin K on the INR in bridging therapy

We investigated a bridging protocol using oral Vitamin K three days before scheduled surgery. 60 patients in two bridging protocols, 30 cases per protocol. The first cohort (Control group) had its warfarin held on Day-5 (five days before surgery). The intervention cohort (Vitamin K group) routinely received 2.5 mg of oral Vitamin K on Day-3 but was otherwise identically bridged. Primary outcome was INR on Day-1. Secondary outcomes included patients with INRs ≥1.5 on Day-1, bleeding episodes and elevated INR post surgery. Day-1 INR for the Vitamin K group was 1.16, vs. 1.28 for the Control group (p = 0.037). Postoperative INR was similar. Only the Control group had patients with INRs ≥1.5 on Day-1, or patients with significant bleeding. Adding Vitamin K on Day-3 leads to a safe preoperative INR and may limit other complications.