Edoxaban treatment in atrial fibrillation in routine clinical care: One-year outcomes of the prospective observational ETNA-AF study in South Korean patients

BACKGROUND

The real-world outcomes of edoxaban treatment in patients with atrial fibrillation (AF) were analyzed in the ETNA-AF (Edoxaban Treatment in Routine Clinical Practice) study involving data from multiple regional registries. This report addresses effectiveness and safety of edoxaban in the Korean ETNA-AF population.

METHODS

One-year data from 1887 Korean ETNA-AF participants were analyzed according to edoxaban dose and patient age and compared with results of other ETNA-AF registries.

RESULTS

Approximately 70% of patients received the recommended doses of edoxaban (60 mg/30 mg); non-recommended 60 mg and 30 mg doses were prescribed to 9.6% and 19.8% of the patients, respectively. The proportions of reference age (<65 years), youngest-old (65-74 years) and middle-old/oldest-old (≥75 years) groups were 21.4%, 40.2%, and 38.4%, respectively. Incidence of major or clinically relevant nonmajor bleeding was similar within dose (0.57%-1.71%) and age subgroups (1.26%-1.63%). Incidence of net clinical outcome, a composite of stroke, systemic embolic event, major bleeding, and all-cause mortality, was also comparable among dose subgroups (1.14%-3.10%) and age subgroups (2.28%-2.78%). The percentage of Korean patients receiving non-recommended 30 mg (19.8%) was over twice that of the European population (8.4%). However, the clinical outcomes were generally similar among different populations included in the ETNA-AF study.

CONCLUSIONS

The outcomes in the Korean ETNA-AF population are like those in the global ETNA-AF population, with overall low event rates of stroke, major bleeding and all-cause mortality across age and dose subgroups. Edoxaban can be used effectively and safely in specific populations of Korean AF patients, including the elderly.

Bleeding risk in patients with atrial fibrillation treated with combined anti-platelet and NOAC therapy

Background

The combined use of antiplatelet agents (APT) and non-vitamin K antagonist oral anticoagulants (NOACs) in patient with atrial fibrillation (AF) is commonly encountered in clinical practice. The purpose of this study was to compare the clinical outcomes between combination therapy (NOAC and APT) and monotherapy (NOAC only).

Methods and results

We analyzed patients who were prescribed NOACs between January 2012 and December 2016. The primary outcome was major or any bleeding events and the secondary outcomes were stroke/systemic embolism (SE) and major adverse cardiac events (MACE). Of 1,068 participants, there were 264 (24.7%) patients in the combination group.

The prevalence of diabetes (p=0.017) and history of stroke and transient ischemic attacks (p&lt;0.001) was higher in the combination group than in the monotherapy group. During the mean 14.6±9.8 months of follow-up, the incidence of any bleeding was significantly higher in the combination group than in the monotherapy group (p&lt;0.001). Major bleeding, stroke/SE, and MACE between the two groups were similar. The rate of under-dosage NOACs prescriptions was higher in the combination group than in the monotherapy group (p=0.024).

Conclusions

The combination therapy had higher incidences of any bleeding events compared to the monotherapy. However, there was no difference in stroke/SE and MACE.

The bleeding risk in patients taking the combination of NOACs and APT should be carefully evaluated.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Primary and secondary outcomes

Clinical impact of intravascular ultrasound guidance in patients of ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention with drug eluting stent

Background

There is little data about clinical role of intravascular ultrasound (IVUS)-guided Percutaneous (PCI) in the setting of ST-segment elevation myocardial infarction (STEMI).

Methods

From 2005 to 2018, a total of 8,129 patients who underwent PCI with STEMI were investigated from the Korea Acute Myocardial Infarction Registry-National Institute of Health database. Patients with Non-ST segment elevation myocardial infarction, cardiogenic shock, bare metal stent implantation, thrombolytic treatment, and coronary artery bypass graft surgery were excluded. We categorized patients into two groups based on the treatment strategy: IVUS-guided PCI group (n=1,544), and coronary angiography guidance (CAG)-guided PCI group (n=6,585). The primary endpoint was composite of major adverse cardiovascular (MACE), including, cardiac death, myocardial infarction (MI), repeat target vessel revascularization (TVR) and stent thrombosis (ST).

Results

IVUS-guided PCI was performed in 19% patients (1544/8129). After propensity score matching, there were no statistically difference in the rate of cardiac death (0% in IVUS vs. 0.26% in CAG, p=0.947), MI (2.01% vs. 2.01%, p=0.408), TVR (1.23% vs. 0.91%, p=0.131), ST (0.32% vs. 0.45%, p=0.828) and composite of MACE at 1 year between two groups (2.01% vs. 2.40%, p=0.843). Independent risk factors for MACE were diabetes mellitus and multi-vessel disease, but not IVUS-guided PCI (HR 1.167, 95% CI, 0.896–1.520, p=0.251).

Conclusion

This study suggests that routine usage of IVUS in the setting of STEMI may not be necessary. Large-scaled random study will be needed for further evaluation.

Funding Acknowledgement

Type of funding sources: None.

Adherence to dabigatran and the influence of dabigatran-induced gastrointestinal discomfort in the real-world practice

BACKGROUND

Dabigatran-induced gastrointestinal discomfort (DGID) is an important factor influencing the adherence to dabigatran. We investigated the incidence and risk factors of DGID and its impact on the adherence and persistence to dabigatran.

METHODS

We prospectively enrolled the patients prescribed with dabigatran in 10 tertiary hospitals of the South Korea. The adherence was assessed using the percentage of the prescribed doses of the medication presumably taken by the patient (PDT by pill count). We evaluated the relationship between DGID and the baseline GI symptoms or the previous GI disease history using a questionnaire.

RESULTS

A total of 474 patients (mean age 67.8 ± 9.3 years, male 68.6%, and mean CHA₂DS₂-VASc score 2.2 ± 1.2) were enrolled. The adherence assessed by the PDT was 93.5 ± 5.5% at 1-month and 96.4 ± 8.4% at 6-months among the persistent patients. During the 6-month follow-up, 82 (18.1%) patients discontinued dabigatran, and the most common reason for dabigatran discontinuation was DGID (49, 59.8%). Sixty-eight (14.3%) patients experienced DGID, and there was no difference in the clinical factors between those with or without DGID. Among the patients who experienced DGID, 42 discontinued dabigatran (61.8%). In a multivariate analysis, DGID was the only predictor of dabigatran discontinuation and a low adherence.

CONCLUSION

Overall adherence of dabigatran was excellent, but those with DGID showed low adherence and persistence. Furthermore, it was challenging to predict DGID by clinical parameters. Therefore, it is recommended to follow the patients closely to check for DGID when prescribing dabigatran.

Clinical Impact of Implantable Cardioverter-Defibrillator Therapy and Mortality Prediction Model for Effective Primary Prevention in Korean Patients

BACKGROUND

Studies on the efficacy of implantable cardioverter-defibrillator (ICD) therapy for primary prevention in Asian patients are relatively lacking compared to those for secondary prevention. Also, it is important to stratify which patients will benefit from ICD therapy for primary prevention.

METHODS

Of 483 consecutive patients who received new implantation of ICD in 9 centers in Korea, 305 patients with reduced left ventricular systolic function and/or documented ventricular fibrillation/tachycardia were enrolled and divided into primary (n = 167) and secondary prevention groups (n = 138).

RESULTS

During mean follow-up duration of 2.6 ± 1.6 years, appropriate ICD therapy occurred in 78 patients (25.6%), and appropriate ICD shock and anti-tachycardia pacing occurred in 15.1% and 15.1% of patients, respectively. Appropriate ICD shock rate was not different between the two groups (primary 12% vs. secondary 18.8%, P = 0.118). However, appropriate ICD therapy rate including shock and anti-tachycardia pacing was significantly higher (primary 18% vs. secondary 34.8%, P = 0.001) in the secondary prevention group. Type of prevention and etiology, appropriate and inappropriate ICD shock did not affect all-cause death. High levels of N-terminal pro-B-type natriuretic peptide, New York Heart Association functional class, low levels of estimated glomerular filtration ratio, and body mass index were associated with death before appropriate ICD shock in the primary prevention group. When patients were categorized in 5 risk score groups according to the sum of values defined by each cut-off level, significant differences in death rate before appropriate ICD shock were observed among risk 0 (0%), 1 (3.6%), 2 (3%), 3 (26.5%), and 4 (40%) (P < 0.001).

CONCLUSION

In this multicenter regional registry, the frequency of appropriate ICD therapy is not low in the primary prevention group. In addition, combination of poor prognostic factors of heart failure is useful in risk stratification of patients who are not benefiting from ICD therapy for primary prevention.

Nutrient ileal digestibility evaluation of dried mealworm (Tenebrio molitor) larvae compared to three animal protein by-products in growing pigs

Objective

This study was to investigate the nutrient ileal digestibility of dried mealworm (Tenebrio molitor) larvae and compare with those of three animal protein by-products in growing pigs.

Methods

A total of 12 crossbred ([Landrace×Yorkshire]×Duroc) growing pigs with average body weights of 24.12±0.68 kg were surgically equipped with simple T-cannulas after being deprived of feed for 24 h according to published surgical procedures. These pigs had a recovery period of two weeks. A total of 12 pigs were assigned to individual metabolic crates and allotted to one of four treatments with 3 replicates in a fully randomized design. Dietary treatments included the following: i) Fish meal, corn-vegetable by-product basal diet+9.95% fish meal; ii) Meat meal, corn-vegetable by-product basal diet+9.95% meat meal; iii) Poultry meal, corn-vegetable by-product basal diet+9.95% poultry meal; iv) Tenebrio molitor, corn-vegetable by-product basal diet+9.95% dried Tenebrio molitor larvae.

Results

Results showed that the apparent ileal digestibility (AID) of Lys was higher (p<0.05) in pigs fed Tenebrio molitor diet than that in pigs fed fish meal diet. Pigs fed Tenebrio molitor diet showed increased (p<0.05) AID of His and Arg compared to pigs fed Fish meal or Meat meal diet. The AID of Cys was increased (p<0.05) in pigs fed poultry meal and Tenebrio molitor diets compared to that in pigs fish meal diet. Pigs fed meat meal, poultry meal, and Tenebrio molitor diets showed higher (p<0.05) standardized ileal digestibility (SID) of total energy compared to pigs fed fish meal diet. The SID of Arg was higher (p<0.05) in pigs fed Tenebrio molitor diet than that in pigs fed fish meal or meat meal diet. Furthermore, pigs fed poultry meal or Tenebrio molitor diets showed increased (p<0.05) SID of Cys compared to pigs fed fish meal diet.

Conclusion

In conclusion, providing pigs with diets that contained Tenebrio molitor larvae meal improved AID and SID of nutrients as well as essential and non-essential amino acids. The digestibility of dried mealworm larvae protein and its utilization in vivo are also good. Therefore, dried mealworm larvae protein can be used as protein source at 10% level in growing pigs.

Supraventricular tachyarrhythmias in patients with a persistent left superior vena cava

Aims

A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. This venous anomaly can impact the evaluation and treatment of supraventricular tachyarrhythmia (SVA). The aim of this study was to assess the proportion and characteristics of PLSVC in adult SVA patients.

Methods and results

From July 2002 to July 2012, clinical and procedural data from databases of 10 cardiac electrophysiology laboratories in the Yeungnam region of the Republic of Korea were reviewed. Of 6662 adult SVA patients who underwent an EP study or catheter ablation of SVA during the 10-year study period, 18 patients had PLSVC (mean age 47.6 ± 14.8 years, 10 men). The proportion of PLSVC in adult SVA patients was 0.27% (18/6662). SVA type and procedural outcomes of radiofrequency (RF) catheter ablation in these patients were investigated and the results were as follows: successful slow pathway modification in six of seven patients with atrioventricular nodal reentrant tachycardia (AVNRT), successful ablation of accessory pathway in three of four patients with atrioventricular reentrant tachycardia, and successful ablation of atrial tachycardia (cavotricuspid isthmus-dependent in two, septal macroreentry in one, focal from the PLSVC in one) in three of four patients. In one patient with junctional tachycardia, catheter ablation failed. In two patients with atrial fibrillation, catheter ablation was successful.

Conclusion

Among adult SVA patients who underwent an EP study or RF catheter ablation during the 10-year study period, 0.27% had PLSVC. The most common type of SVA was AVNRT. The success rate of catheter ablation was 82% in SVA patients with PLSVC. There were no procedure-related complications.

Corrigendum: Hemorheologic Alterations in Patients with Type 2 Diabetes Mellitus Presented with an Acute Myocardial Infarction

This corrects the article on p. 155 in vol. 42, PMID: 29676545.

Hemorheologic Alterations in Patients with Type 2 Diabetes Mellitus Presented with an Acute Myocardial Infarction

BACKGROUND

Hemorheologic indices are known to be related to vascular complications in variable clinical settings. However, little is known about the associations between hemorheologic parameters and acute myocardial infarction (AMI) in type 2 diabetes mellitus (T2DM). The purpose of this study was to demonstrate the changes of hemorheologic environment inside of blood using hemorheologic parameters, especially the elongation index (EI) and critical shear stress (CSS) in diabetics with versus without AMI.

METHODS

A total of 195 patients with T2DM were enrolled. Patients were divided into the study group with AMI (AMI+, n=77) and control group (AMI-, n=118) who had no history of coronary artery disease. Hemorheologic parameters such as EI and CSS were measured and compared between the two groups.

RESULTS

The EI was lower (30.44%±1.77% in AMI+ and 31.47%±1.48% in AMI-, P<0.001) but the level of CSS was higher (316.13±108.20 mPa in AMI+ and 286.80±85.34 mPa in AMI-, P=0.040) in the AMI+. The CSS was significantly related to the erythrocyte sedimentation rate (R²=0.497, P<0.001) and use of dipeptidyl peptidase-4 inhibitors (R²=0.574, P=0.048).

CONCLUSION

Diabetics with AMI resulted in adverse hemorheologic changes with lower EI and higher CSS compared to diabetic subjects without AMI. Evaluation of the hemorheologic parameters may provide valuable supplementary information for managing patients with AMI and T2DM.

Genetic Variation of SCN5A in Korean Patients with Sick Sinus Syndrome

Background and Objectives

Due to recent studies that have shown an association between the genetic variation of SCN5A and sick sinus syndrome (SSS), we sought to determine if a similar correlation existed in Korean patients with SSS.

Subjects and Methods

We enrolled 30 patients with SSS who showed a sinus pause (longer than 3.0 s) in Holter monitoring, in addition to 80 controls. All exons including the putative splicing sites of the SCN5A gene were amplified by polymerase chain reaction and sequenced either directly or following subcloning. Wild-type and single nucleotide polymorphisms were expressed in human embryonic kidney cells, and the peak sodium current (I_Na) was analyzed using the whole-cell patch-clamp technique.

Results

A total of 9 genetic variations were identified: 7 variations (G87A-A29A, IVS9-3C>A, A1673G-H558R, G3823A-D1275N, T5457C-D1819D, T5963G-L1988R, and C5129T-S1710L) had been previously reported, and 2 variants (A3075T-E1025D and T4847A-F1616Y) were novel; the potential structural effects of F1616Y were analyzed in a three-dimensional model of the SCN5A domain. Patch-clamp studies at room temperature demonstrated that the peak I_Na was significantly increased by 140% in HEK cells transfected with F1616Y compared with wild-type (-335.13 pA/pF±24.04, n=8 vs. -139.95 pA/pF±23.76, n=7, respectively). Furthermore, the voltage dependency of the activation and steady-state inactivation of F1616Y were leftward-shifted compared with wild-type (V_h activation=-55.36 mv±0.22, n=8 vs. V_h activation=-44.21 mV±0.17, n=7; respectively; V_h inactivation=-104.47 mV±0.21, n=7 vs. V_h inactivation=-84.89 mV±0.09, n=12, respectively).

Conclusion

F1616Y may be associated with SSS.

Genetic Analysis of SCN5A in Korean Patients Associated with Atrioventricular Conduction Block

Recent several studies have shown that the genetic variation of SCN5A is related with atrioventricular conduction block (AVB); no study has yet been published in Koreans. Therefore, to determine the AVB-associated genetic variation in Korean patients, we investigated the genetic variation of SCN5A in Korean patients with AVB and compared with normal control subjects. We enrolled 113 patients with AVB and 80 normal controls with no cardiac symptoms. DNA was isolated from the peripheral blood, and all exons (exon 2-exon 28) except the untranslated region and exon-intron boundaries of the SCN5A gene were amplified by multiplex PCR and directly sequenced using an ABI PRISM 3100 Genetic Analyzer. When a variation was discovered in genomic DNA from AVB patients, we confirmed whether the same variation existed in the control genomic DNA. In the present study, a total of 7 genetic variations were detected in 113 AVB patients. Of the 7 variations, 5 (G87A-A29A, intervening sequence 9-3C>A, A1673G-H558R, G3578A-R1193Q, and T5457C-D1819D) have been reported in previous studies, and 2 (C48G-F16L and G3048A-T1016T) were novel variations that have not been reported. The 2 newly discovered variations were not found in the 80 normal controls. In addition, G298S, G514C, P1008S, G1406R, and D1595N, identified in other ethnic populations, were not detected in this study. We found 2 novel genetic variations in the SCN5A gene in Korean patients with AVB. However, further functional study might be needed.

Culprit-Lesion-Only Versus Multivessel Revascularization Using Drug-Eluting Stents in Patients With ST-Segment Elevation Myocardial Infarction: A Korean Acute Myocardial Infarction Registry-Based Analysis

BACKGROUND AND OBJECTIVES

In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, complete revascularization (CR) for non-culprit lesions is not routinely recommended. The aim of this study was to compare the clinical outcomes of multivessel compared with infarct-related artery (IRA)-only revascularization in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI.

SUBJECTS AND METHODS

From the Korean Acute Myocardial Infarction Registry (KAMIR) database, 1,094 STEMI patients with multivessel disease who underwent primary PCI with drug-eluting stents were enrolled in this study. The patients were divided into two groups: culprit-vessel-only revascularization (COR, n=827) group; multivessel revascularization, including non-IRA (MVR, n=267) group. The primary endpoint of this study included major adverse cardiac events (MACEs), such as death, myocardial infarction, or target or nontarget lesion revascularization at one year.

RESULTS

There was no difference in clinical characteristics between the two groups. During the one-year follow-up, 102 (15.2%) patients in the COR group and 32 (14.2%) in the MVR group experienced at least one MACE (p=0.330). There were no differences between the two groups in terms of rates of death, myocardial infarction, or revascularization (2.1% vs. 2.0%, 0.7% vs. 0.8%, and 11.7% vs. 10.1%, respectively; p=0.822, 0.910, and 0.301, respectively). The MACE rate was higher in the incompletely revascularized patients than in the completely revascularized patients (15% vs. 9.5%, p=0.039), and the difference was attributable to a higher rate of nontarget vessel revascularization (8.6% vs. 1.8%, p=0.002).

CONCLUSION

Although multivessel angioplasty during primary PCI for STEMI did not reduce the MACE rate compared with culprit-vessel-only PCI, CR was associated with a lower rate of repeat revascularization after multivessel PCI.

Massive left atrial calcification associated with mitral valve replacement

Calcification of the left atrium can be observed in patients with a long-lasting rheumatic heart disease. However, massive calcification of the atrial wall, so called porcelain or coconut atrium is very rare and has been generally reported only as incidental radiographic findings. We report a case of massive and firm calcifications at the left atrium in patient who underwent mitral valve replacement.

A case of huge thrombus in the aortic arch with cerebrovascular embolization

Pedunculated thrombus in the aortic arch that is associated with cerebral infarction is very rare requires prompt diagnosis and treatment to prevent occurrence of another devastating complication. Transesophageal echocardiography is useful for detecting source of embolism including aortic thrombi. The treatment options of aortic thrombi involves anticoagulation, thrombolysis, thromboaspiration, and thrombectomy. Here we report a case of huge thrombus in the aortic arch, resulting in acute multifocal cerebellar embolic infarct in patient without any risk factors for vascular thrombosis. Thrombi in the aortic arch were diagnosed by transesophageal echocardiography and treated with anticoagulants successfully.

Comparison of the efficacy and tolerability of pitavastatin and atorvastatin: an 8-week, multicenter, randomized, open-label, dose-titration study in Korean patients with hypercholesterolemia

BACKGROUND

Although previous studies have examined the efficacy of pitavastatin, its tolerability and effects on lipid concentrations have not been compared with those of atorvastatin in a multicenter, randomized study.

OBJECTIVE

This trial compared the efficacy and tolerability of pitavastatin and atorvastatin in hypercholesterolemic Korean adults.

METHODS

This 8-week, multicenter, randomized, open-label, dose-titration study was conducted at 18 clinical centers in Korea between May 2005 and February 2006. After a 4-week dietary lead-in period, patients with hypercholesterolemia were randomized to receive either pitavastatin 2 mg/d or atorvastatin 10 mg/d. Patients who had not reached the low-density lipoprotein cholesterol (LDL-C) goal by week 4 received a double dose of the assigned medication for an additional 4 weeks. Efficacy was evaluated in terms of achievement of the National Cholesterol Education Program Adult Treatment Panel III LDL-C goals and changes from baseline in other lipids and high-sensitivity C-reactive protein (hs-CRP). The tolerability profile was assessed by physical and electro-cardiographic examinations, laboratory tests, and recording adverse reactions at all visits.

RESULTS

A total of 268 patients were randomized to treatment, and 222 (82.8%) completed the study (149 women, 73 men; mean age, 59 years; mean weight, 63.5 kg). At the end of the study, there was no significant difference between the pitavastatin and atorvastatin groups in the proportion of patients achieving the LDL-C goal (92.7% [102/110] vs 92.0% [103/112], respectively). In addition, there were no significant differences between groups in terms of the percent changes from baseline in LDL-C, total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), or hs-CRP. Twenty-six of 136 patients (19.1%) taking pitavastatin reported 35 treatment-emergent adverse reactions; 33 of 132 patients (25.0%) taking atorvastatin reported 39 treatment-emergent adverse reactions. Elevations in creatine kinase were observed in 6 patients (4.4%) in the pitavastatin group and 7 patients (5.3%) in the atorvastatin group. There were no serious adverse drug reactions in either group.

CONCLUSIONS

In these adult Korean patients with hypercholesterolemia, pitavastatin and atorvastatin did not differ significantly in terms of the proportions of patients achieving the LDL-C goal; reductions in LDL-C, total cholesterol, and triglycerides; or increases in HDL-C. Both drugs were well tolerated.

A case of silent giant cell arteritis involving the entire aorta, carotid artery and brachial artery screened by integrated PET/CT

We report a case of giant cell arteritis involving the aorta and several large arteries identified by integrated positron emission tomography (PET)/computed tomography (CT) obtained in a patient with a high erythrocyte sedimentation rate (ESR). A 63-year-old man with anemia and a high ESR noted on a regular medical examination was transferred to our department. The patient complained of only a low-grade general weakness for several months; there were no specific symptoms or signs. A PET was recommended. The image showed strong (18)F-fluorodeoxyglucose ((18)F-FDG) uptake at the ascending aorta, aortic arch, descending aorta, thoraco-lumbar aorta, brachial artery, and the carotid artery wall, bilaterally. Suspicious for large-vessel vasculitis, a temporal artery biopsy was performed, which confirmed giant cell arteritis. After treatment with prednisolone, the high ESR and anemia resolved, and (18)F-FDG uptake decreased on follow-up integrated PET/CT.

Incidentally found, growing congenital aneurysm of the left atrium

A left atrial aneurysm is a very rare cardiac anomaly that usually develops in the left atrial appendage. It usually develops congenitally, and has a risk of life-threatening complications. Here, we report a case of a growing aneurysm of the left atrium that was incidentally found in a 42-yr-old woman. Eighteen years prior, an abnormal cardiomegaly was found on a chest radiography for a pre-operative study. The chest radiography at this time demonstrated a more prominent cardiomegaly than the previous radiography findings. The left atrial aneurysm was diagnosed by echocardiography and cardiac catheterization. Although asymptomatic, she underwent a successful surgical excision to allay the possibilities of rupture, arrhythmia, heart failure, or thromboembolism. The surgical findings demonstrated an 8 x 15 cm sized saccular aneurysm at the left atrial appendage, and the pathologic findings showed three myocardial layers. The patient has been asymptomatic during the 15 months of follow-up. In conclusion, a congenital left atrial aneurysm can grow with time, even in asymptomatic cases, and an aneurysmectomy is a curative treatment, which can eliminate the potential complications.

Expression and regulation of endothelial nitric oxide synthase by vascular endothelial growth factor in ECV 304 cells

Nitric oxide (NO) seems to play a pivotal role in the vascular endothelial growth factor (VEGF)-induced endothelial cell proliferation. This study was designed to investigate the role and intracellular signal pathway of endothelial nitric oxide synthase (eNOS) activation induced by VEGF. ECV 304 cells were treated with VEGF(165) and then cell proliferation, eNOS protein and mRNA expression levels were analyzed to elucidate the functional role of eNOS in cell proliferation induced by VEGF. After exposure of cells to VEGF(165), eNOS activity and cell growth were increased by approximately two-fold in the VEGF(165) -treated cells compared to the untreated cells. In addition, VEGF stimulated eNOS expression at both the mRNA and protein levels in a dose-dependent manner. Phosphatidylinositol-3 kinase (PI-3K) inhibitors were used to assess PI-3K involvement in eNOS regulation. LY294002 was found to attenuate VEGF-stimulated eNOS expression. Wortmannin was not as effective as LY294002, but the reduction effect was detectable. Cells activated by VEGF showed increased ERK1/2 levels. Moreover, the VEGF-induced eNOS expression was reduced by the PD98059, MAPK pathway inhibitor. This suggests that eNOS expression might be regulated by PI-3K and the ERK1/2 signaling pathway. In conclusion, VEGF(165) induces ECV 304 cell proliferation via the NO produced by eNOS. In addition, eNOS may be regulated by the PI-3K or mitogen-activated protein kinase pathway.

Response to high-dose intravenous immune globulin as a valuable factor predicting the effect of splenectomy in chronic idiopathic thrombocytopenic purpura patients

This study was conducted to verify whether the response to high-dose intravenous immune globulin (IVIG) was related to the effect of splenectomy in chronic idiopathic thrombocytopenic purpura (ITP) patients. A total of 79 patients over 16 years of age were enrolled in this study. The response to the treatment was classified on the basis of the platelet count as no response (NR, <50 x 10(9)/l), incomplete response (IR, (50-150) x 10(9)/l), and complete response (CR, >150 x 10(9)/l). The response was evaluated after the infusion of high-dose IVIG, within 2 weeks after splenectomy (immediate response), and during a follow-up period of more than 6 months after splenectomy (sustained response), respectively. 58 patients (73.4%) showed responses (CR or IR) to high-dose IVIG. After splenectomy, immediate responses were observed in 73 patients (92%). The response to high-dose IVIG had no relationship with the immediate response to splenectomy (P = 0.333). A follow-up evaluation was possible with 58 patients; 6 patients with NR in immediate responses did not show any response during the follow-up period, and 17 patients relapsed within 6 months after immediate responses, so 35 patients (60.3%) had sustained responses. Responders to IVIG had significantly higher sustained response rates to splenectomy than non-responders (62% vs. 38%, P = 0.001). These results indicate that the response to high-dose IVIG could be a valuable factor predicting the sustained response to splenectomy in chronic ITP patients.