Junichi Kitazawa

Human small Maf proteins form heterodimers with CNC family transcription factors and recognize the NF-E2 motif

The transcription factor NF-E2, a heterodimeric protein complex composed of p45 and small Maf family proteins, is considered crucial for the regulation of erythroid gene expression and platelet formation. To facilitate the characterization of NF-E2 functions in human cells, we isolated cDNAs encoding two members of the small Maf family, MafK and MafG. The human mafK and mafG genes encode proteins of 156 and 162 amino acid residues, respectively, whose deduced amino acid sequences show approximately 95% identity to their respective chicken counterparts. Expression of mafK mRNA is high in heart, skeletal muscle and placenta, whereas mafG mRNA is abundant in skeletal muscle and is moderately expressed in heart and brain. Both are expressed in all hematopoietic cell lines, including those of erythroid and megakaryocytic lineages. In electrophoretic gel mobility shift assays binding to NF-E2 sites was found to depend on formation of homodimers or heterodimers with p45 and p45-related CNC family proteins. The results suggest that the small Maf family proteins function in human cells through interaction with various basic-leucine zipper-type transcription factors.

Risk of Etoposide-Related Acute Myeloid Leukemia in the Treatment of Epstein-Barr Virus—Associated Hemophagocytic Lymphohistiocytosis

We studied the impact of etoposide on the prognosis of 81 patients (77 of whom were children <15 years old) with Epstein-Barr virus—associated hemophagocytic lymphohistiocytosis (EBV-HLH).The study group received a median cumulative dose of 1500 mg/m2 etoposide (range, 0–14,550 mg/m2), with a median follow-up period of 44 months (range, 20–88 months) from the diagnosis. Only 1 patient, who received 3150 mg/m2 etoposide, developed therapy-related acute myeloid leukemia (t-AML), at 31 months after diagnosis. Excluding 9 patients who underwent hemopoietic stem cell transplantation during the course of treatment, the prognosis was poorer for those patients who received less than a 1000 mg/m2 cumulative dose of etoposide. Our results indicate that the risk of etoposide-related t-AML is low. An appropriate dosage of etoposide for the treatment of EBV-HLH would be in the range of 1000 to 3000 mg/m2. However, even at these doses, care must be taken to prevent the rare risk of t-AML.

A Nationwide Survey of Newly Diagnosed Childhood Idiopathic Thrombocytopenic Purpura in Japan

Background We evaluated the clinical pictures, outcome for childhood idiopathic thrombocytopenic purpura (ITP) and the trends of the choice of management for childhood ITP in Japan. Method Every year, questionnaires were sent to all institutions that employ the active members of the Japanese Society of Pediatric Hematology. The questionnaires included age, sex, date of diagnosis, platelet count at diagnosis, the presence or absence of antecedent infection, hemorrhagic symptoms, initial management, and the outcome of all patients newly diagnosed with ITP. Results A total of 986 newly diagnosed as ITP patients were reported between January 2000 and December 2005. The occurrence of ITP peaked in boys less than 1 year of age, and at 1 year of age in girls. The male-to-female ratio was 1.24:1. Wet purpura was observed in more than half of the patients with platelet counts of <10,000/μL. The initial treatment varied among the patients with different platelet counts at diagnosis; most of the patients with platelet counts <20,000/μL received intravenous immunoglobulin or oral corticosteroids. Conversely, cases without any aggressive treatment increased to a larger degree in patients with ≥20,000/μL of platelet. Conclusions These findings indicate that overall compliance to the Japanese guideline is considered to be relatively good in Japan.

Online reporting system for transfusion-related adverse events to enhance recipient haemovigilance in Japan: A pilot study

BACKGROUND A surveillance system for transfusion-related adverse reactions and infectious diseases in Japan was started at a national level in 1993, but current reporting of events in recipients is performed on a voluntary basis. A reporting system which can collect information on all transfusion-related events in recipients is required in Japan. METHODS We have developed an online reporting system for transfusion-related events and performed a pilot study in 12 hospitals from 2007 to 2010. RESULTS The overall incidence of adverse events per transfusion bag was 1.47%. Platelet concentrates gave rise to statistically more adverse events (4.16%) than red blood cells (0.66%) and fresh-frozen plasma (0.93%). In addition, we found that the incidence of adverse events varied between hospitals according to their size and patient characteristics. CONCLUSION This online reporting system is useful for collection and analysis of actual adverse events in recipients of blood transfusions and may contribute to enhancement of the existing surveillance system for recipients in Japan.

Low serum lipids suggest severe bone marrow failure in children with aplastic anemia

Abstract Background : Significantly low serum lipid levels are occasionally seen at the time of diagnosis in children with aplastic anemia (AA). The aim of the present study was to clarify the pathologic and clinical significance of pretreatment serum lipid levels in AA.

SVA retrotransposition in exon 6 of the coagulation factor IX gene causing severe hemophilia B

Abstract Hemophilia B is an X-linked recessive bleeding disorder caused by abnormalities of the coagulation factor IX gene (F9). Insertion mutations in F9 ranging from a few to more than 100 base pairs account for only a few percent of all hemophilia B cases. We investigated F9 to elucidate genetic abnormalities causing severe hemophilia B in a Japanese subject. We performed PCR-mediated analysis of F9 and identified a large insertion in exon 6. Next, we carried out direct sequencing of a PCR clone of the whole insert using nested deletion by exonuclease III and S1 nuclease. We identified an approximately 2.5-kb SINE-VNTR-Alu (SVA)-F element flanked by 15-bp duplications in the antisense orientation in exon 6. Additionally, we carried out exontrap analysis to assess the effect of this retrotransposition on mRNA splicing. We observed that regular splicing at exons 5 and 6 of F9 was disturbed by the SVA retrotransposition, suggesting that abnormal FIX mRNA may be reduced by nonsense-mediated mRNA decay. In conclusion, this is the first report of SVA retrotransposition causing severe hemophilia B; only five cases of LINE-1 or Alu retrotranspositions in F9 have been reported previously.

Hemolytic crisis with fulminant hepatic failure in Wilson disease without consanguinity

Departments of 1 Pediatrics and 2 Ophthalmology, Hirosaki City Hospital, Aomori, Departments of 3 Pediatrics, 4 Second Department of Surgery, 5 Hospital Pathology Center, Hirosaki University School of Medicine, Aomori, 6 Department of Clinical Toxicology and Metabolism, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Hokkaido, 7 Sapporo City Institute of Public Health, Hokkaido, 8 Third Department of Internal Medicine, Sapporo Medical University School of Medicine, Hokkaido and 9 Department of Pathology, Fujita Health University School of Medicine, Aichi, Japan

Successful treatment of acute myelomonocytic leukaemia with NUP98–HOXD11 fusion transcripts and monitoring of minimal residual disease

Summary. Patients with haematological malignancies involving the NUP98 gene have been reported to have an aggressive clinical course and a poor outcome. We report successful treatment of a 15‐year‐old Japanese boy with acute myelomonocytic leukaemia having t(2;11)(q31;p15) and a novel fusion transcript, NUP98–HOXD11. He achieved complete remission by combined chemotherapy, and underwent unrelated cord blood transplantation 4 months after diagnosis. He is in complete remission 24 months after diagnosis. Monitoring of minimal residual disease (MRD) showed the absence of fusion transcript 12 months after transplantation. This is the first report of monitoring MRD in a patient with haematological malignancy involving NUP98 fusion transcripts.

Pharmacist-managed dose adjustment feedback using therapeutic drug monitoring of vancomycin was useful for patients with methicillin-resistant Staphylococcus aureus infections: a single institution experience.

Background Vancomycin (VCM) requires dose adjustment based on therapeutic drug monitoring. At Aomori Prefectural Central Hospital, physicians carried out VCM therapeutic drug monitoring based on their experience, because pharmacists did not participate in the dose adjustment. We evaluated the impact of an Antimicrobial Stewardship Program (ASP) on attaining target VCM trough concentrations and pharmacokinetics (PK)/pharmacodynamics (PD) parameters in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections. Materials and methods The ASP was introduced in April 2012. We implemented a prospective audit of prescribed VCM dosages and provided feedback based on measured VCM trough concentrations. In a retrospective pre- and postcomparison study from April 2007 to December 2011 (preimplementation) and from April 2012 to December 2014 (postimplementation), 79 patients were treated for MRSA infection with VCM, and trough concentrations were monitored (pre, n=28; post, n=51). In 65 patients (pre, n=15; post, n=50), 24-hour area under the concentration–time curve (AUC 0–24 h)/minimum inhibitory concentration (MIC) ratios were calculated. Results Pharmacist feedback, which included recommendations for changing dose or using alternative anti-MRSA antibiotics, was highly accepted during postimplementation (88%, 29/33). The number of patients with serum VCM concentrations within the therapeutic range (10–20 μg/mL) was significantly higher during postimplementation (84%, 43/51) than during preimplementation (39%, 11/28) (P<0.01). The percentage of patients who attained target PK/PD parameters (AUC 0–24 h/MIC >400) was significantly higher during postimplementation (84%, 42/50) than during preimplementation (53%, 8/15; P=0.013). There were no significant differences in nephrotoxicity or mortality rate. Conclusion Our ASP increased the percentage of patients that attained optimal VCM trough concentrations and PK/PD parameters, which contributed to the appropriate use of VCM in patients with MRSA infections.

Recommendations for the electronic pre-transfusion check at the bedside

The current risk of acquiring viral transmission through blood components is very small1. Thus, serious non-infectious hazards of transfusion have emerged as the most common complications2. The risk of non-infectious complications, including risks related to hospital-based steps in transfusion care, is at least 100 times greater than the risk of acquiring human immunodeficiency virus or hepatitis C virus infection through blood components3. One of the most frequent causes of transfusion-associated morbidity or mortality is mistransfusion, when the wrong blood is transfused to the wrong patient. Mistransfusion is the final outcome of one or more procedural errors or technical failures in the transfusion process, starting with the decision to transfuse a patient and ending with the actual administration of blood components3. In particular, ABO-incompatible transfusions attributable to incorrect identification of the patient or the blood unit are among the most serious transfusion hazards3–5. The Japan Society of Transfusion Medicine and Cell Therapy (JSTMCT) conducted nationwide surveys in Japan regarding ABO-incompatible blood transfusions (1st survey: January 1995–December 1999; 2nd survey: January 2000–December 2004). They found that the main cause of ABO-incompatible transfusion was identification error between the patient and blood unit6. These two surveys reported 9 and 8 “preventable” fatalities, respectively. Mislabelled and wrongly collected patient samples (wrong blood in tube [WBIT]) can also initiate a chain of events leading to mistransfusion3. Thus, correct patient identification at the time of sample collection and administration of blood components is critical. The Serious Hazards of Transfusion (SHOT) scheme in England showed that approximately 70% of incorrect blood component transfused (IBCT) errors take place in clinical areas, with the most frequent error being failure of the final patient identification checking procedure at the bedside; the frequency of IBCT events was calculated as 7 per 100,000 components7. However, the true incidence of mistransfusion seems to be even higher due to a failure to recognise many of the errors, and because complete data on transfusion episodes are not available. Thus, the pre-transfusion checking procedure at the bedside is the most critical step to prevent mistransfusion, and represents the final opportunity to prevent blood component misuse. However, a large observational audit revealed a failure to perform the final bedside checking procedure8, in which the practice compliance of healthcare workers for identification and vital sign monitoring of patients receiving blood transfusions were substandard in many hospitals. Machine-readable identification technology, especially a bar code-based electronic identification system (EIS), is ideally suited for pre-transfusion checking procedures and has been reported to significantly improve transfusion practice9–15. The British Committee for Standards in Haematology (BCSH) Guidelines for the Use of Information Technology (IT) in blood transfusion laboratories were recently up-dated16, providing mainly guidance on the operational use of laboratory information management systems (LIMS). Thus, to our knowledge, there are no available recommendations addressing the issues regarding the pre-transfusion check procedures at the bedside employing an EIS. The JSTMCT Task Force proposed the original draft of recommendations for the electronic pre-transfusion check procedures at the bedside and raised public awareness regarding the draft of recommendations on the home page of the JSTMCT17. The draft of the current recommendations developed by the Task Force adopted the opinions were submitted without major changes to the description. The objective of this study was to establish recommendations for the electronic pre-transfusion checking procedures at the bedside, appropriate for clinical situations, where a bar code-based EIS is used.