Shigeko Nishimura

A GATA box in the GATA-1 gene hematopoietic enhancer is a critical element in the network of GATA factors and sites that regulate this gene.

ABSTRACT A region located at kbp −3.9 to −2.6 5′ to the first hematopoietic exon of the GATA-1 gene is necessary to recapitulate gene expression in both the primitive and definitive erythroid lineages. In transfection analyses, this region activated reporter gene expression from an artificial promoter in a position- and orientation-independent manner, indicating that the region functions as the GATA-1 gene hematopoietic enhancer (G1HE). However, when analyzed in transgenic embryos in vivo, G1HE activity was orientation dependent and also required the presence of the endogenousGATA-1 gene hematopoietic promoter. To define the boundaries of G1HE, a series of deletion constructs were prepared and tested in transfection and transgenic mice analyses. We show that G1HE contains a 149-bp core region which is critical for GATA-1gene expression in both primitive and definitive erythroid cells but that expression in megakaryocytes requires the core plus additional sequences from G1HE. This core region contains one GATA, one GAT, and two E boxes. Mutational analyses revealed that only the GATA box is critical for gene-regulatory activity. Importantly, G1HE was active in SCL−/− embryos. These results thus demonstrate the presence of a critical network of GATA factors and GATA binding sites that controls the expression of this gene.

A minigene containing four discrete cis elements recapitulates GATA-1 gene expression in vivo

Background:  The GATA‐1haematopoietic enhancer (G1HE), located between 3.9 and 2.6 kb 5′ to the haematopoietic first exon, is essential for GATA‐1 gene transcription in erythroid cells. However, G1HE is not sufficient to confer tissue specificity on the GATA‐1 gene in vivo, indicating that additional regulatory sequences are necessary.

Serum thrombopoietin level is mainly regulated by megakaryocyte mass rather than platelet mass in human subjects.

A patient with idiopathic thrombocytopenic purpura (ITP) developed T‐cell lymphoma while undergoing steroid therapy. We examined the relationship between the patients serum thrombopoietin (Tpo) level, platelet count, megakaryocyte number and CFU‐Meg number during the second 5 d course of chemotherapy for lymphoma in which megakaryopoiesis switched from ITP phase to amegakaryocytic phase. The patients platelet count was temporarily elevated but CFU‐Meg numbers were markedly suppressed, and megakaryocyte numbers were decreased in this period, whereas serum Tpo level was not suppressed despite an increased platelet count, indicating that serum Tpo level is mainly regulated by megakaryocyte mass.

Increased phosphatidylserine exposure on the erythrocyte membrane in patients with polycythaemia vera

Asada, N., Odawara, J., Kimura, S., Aoki, T., Yamakura, M., Takeuchi, M., Seki, R., Tanaka, A. & Matsue, K. (2007) Use of random skin biopsy for diagnosis of intravascular large B-cell lymphoma. Mayo Clinic Proceedings, 82, 1525–1527. Masaki, Y., Dong, L., Nakajima, A., Iwao, H., Miki, M., Kurose, N., Kinoshita, E., Nojima, T., Sawaki, T., Kawanami, T., Tanaka, M., Shimoyama, K., Kim, C., Fukutoku, M., Kawabata, H., Fukushima, T., Hirose, Y., Takiguchi, T., Konda, S., Sugai, S. & Umehara, H. (2009) Intravascular large B cell lymphoma: proposed of the strategy for early diagnosis and treatment of patients with rapid deteriorating condition. International Journal of Hematology, 89, 600–610. Miura, Y. & Tsudo, M. (2010) Fluorodeoxyglucose-PET/CT for diagnosis of intravascular large B-cell lymphoma. Mayo Clinic Proceedings, 85, e56–e57. Murase, T., Yamaguchi, M., Suzuki, R., Okamoto, M., Sato, Y., Tamaru, J., Kojima, M., Miura, I., Mori, N., Yoshino, T. & Nakamura, S. (2007) Intravascular large B-cell lymphoma (IVLBCL): a clinicopathologic study of 96 cases with special reference to the immunophenotypic heterogeneity of CD5. Blood, 109, 478–485. Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E.S., Pileri, S.A., Stein, H., Thiele, J. & Vardiman, J.W. (2008) World Health Organization Classification of Tumours. Tumours of Haematopoietic and Lymphoid Tissues. IARC Press, Lyon.

Effects of using potassium adsorption filters on saline-filled and saline-removed methods for the removal of potassium from red blood cell solutions

Abstract Introduction: Red blood cell (RBC) transfusion places preterm infants with non-oliguria at high risk of cardiac arrest due to hyperkalemia. Potassium adsorption filters (PAFs) can remove potassium from RBCs.

Use of potassium adsorption filter for the removal of ammonia and potassium from red blood cell solution for neonates: PAF-N FOR BLOOD FILTRATION

Ammonia in the plasma usually does not pass through the blood–brain barrier (BBB). However, it can affect the brain as a neurotoxin in neonates with anemia of prematurity. Excess intake of ammonia should therefore be restricted in conditions involving BBB breakdown, such as in premature neonates. A potassium adsorption filter (PAF) can remove not only potassium, but also ammonia from red blood cell (RBC) solution. PAF for neonates (PAF‐n) has been recently introduced using small satellite packs. We evaluated the effects of PAF‐n on the removal of ammonia and potassium from RBC solution in small satellite packs.

Chronic Subdural Hematoma in Elderly Patient with EDTA-dependent Pseudothrombocytopenia Recently Treated with Aspirin and Warfarin: Case Report

A 78-year-old man who had a history of myocardial and cerebral infarction and who was treated with aspirin and warfarin, presented with left chronic subdural hematoma. Cerebral computed tomography showed severe brain compression of hematoma with midline shift, indicating the need for emergent surgery. The hematology and clotting tests upon admission revealed severe thrombocytopenia (platelet count, 1.3 × 104/μL) with normal clotting activity. Because platelet aggregation was evident in the smear, we re-examined the patient for hematology using tubes that contained heparin, showing also low platelet count (2.3 × 104/μL). The day on admission, we performed irrigation and drainage of the chronic subdural hematoma through single burr-hole craniostomy. During surgery, we used 10 units of platelet concentrates (PCs) for the reason that the patient was taking aspirin and coagulopathy derived from low platelet count could not be excluded. After surgery, we re-evaluated the hematology of the blood stored in tubes that contained ethylenediaminetetraacetic acid (EDTA) with or without kanamycin (KM). Treatment with KM dissociated EDTA-induced platelet aggregation and revealed platelet counts with highest accuracy (no KM treatment, 1.3 × 104/μL; KM treatment, 15.2 × 104/μL). This phenomenon is called EDTA-Dependent Pseudothrombocytopenia (PTCP) defined as falsely low platelet counts reported by automated hematology analyzers due to platelet aggretgation. Awareness of the phenomenon will enable neurosurgeons to manage patients with PTCP appropriately and clinical laboratory especially in emergency hospital is recommended to prepare for the hematological tubes being added KM in routine analysis, resulting in preventing mistaken diagnosis.

Effects of Co-infusion of Plasma, Whole Blood and Anticogulants on Their Clotting Activities

Aims: Nafamostat mesilate (NM), a protease inhibitor is available for treating acute pancreatitis and disseminated intravascular coagulopathy and it is used as an anticoagulant for hemodialysis in Japan. A

Possible red blood cell damage due to iatrogenic transfusion filter-related mistakes during blood transfusion

Abstract Background: Red cell concentrates are usually transfused through a transfusion filter. Iatrogenic accidents can occur in which the red blood cell concentrate is transfused through the infusion filter by

Coagulopathy and transfusion product usage in relation to ruptured abdominal aortic aneurysm scoring systems in a tertiary care centre in Japan.

Dear Sir, Ruptured abdominal aortic aneurysm (rAAA) is a frequently fatal condition, with a mortality of approximately 67% in Japan1. Recently, two studies on the outcome of rAAA were reported from the viewpoint of blood transfusion for haemostasis. Johansson et al. reported on the application of platelet concentrates in rAAA patients undergoing surgery2. In the intervention group, platelet concentrates were transfused at the time rAAA was suspected and before clamping the aorta, and blood transfusion with a ratio of fresh-frozen plasma to red cell concentrate (FFP:RCC) of 1:1 was given. The 30-day survival rates were higher in the intervention group than in the control group. Mell et al. reported the effect of early plasma transfusion on mortality in patients with rAAA; in their study the FFP:RCC ratio was1:23. These reports suggested that prevention of coagulopathy in patients with rAAA improves the outcome. Pre-operative scoring systems for rAAA are widespread in Europe. The outcome of patients with rAAA undergoing vascular surgery has been evaluated using rAAA scoring systems4–5. In this study, we retrospectively scored the pre-operative status of patients undergoing vascular surgery and examined the relationship between the rAAA score and coagulopathy in a single tertiary care centre in the metropolitan Tokyo area in Japan. To our knowledge, our study is the first to suggest that severe coagulopathy is a predictor of rAAA in patients with a high rAAA score. Tokyo Metropolitan Bokutoh Hospital has 729 acute-care beds and is located in eastern Tokyo. We reviewed the cases of 64 patients with rAAA who underwent vascular surgery from April 2000 to March 2010. The clinical data of the 64 patients with rAAA were reviewed for parameters such as age, gender, clinical manifestations (blood pressure and Glasgow coma scale [GCS]), laboratory test results (haematology, clotting tests and biochemistry), use of transfusion, and rAAA score (Glasgow aneurysm score [GAS], Edinburgh ruptured aneurysm score [ERAS], and Hardman Index [HI]). A rAAA was diagnosed on the basis of computed tomography, open surgery, or post-mortem findings. We evaluated three previously reported rAAA scoring systems4–5. According to their scores, the patients were divided into subgroups from the viewpoint of outcome: (i) GAS: low-score subgroup, 99 points. (ii) ERAS: low-score subgroup, 0–1; high-score subgroup, 2–3. (3) HI: low-score subgroup, 0–1; high-score subgroup, 2–5. This study was performed in accordance with the principles of the Declaration of Helsinki. We noted that the ERAS gave the most striking results among the three rAAA scoring systems. In the ERAS group, we compared the differences between the low-score and high-score groups in terms of clinical manifestations, pre-operative and post-operative laboratory data, and use of blood transfusions. Post-operative laboratory samples were obtained immediately after the patients had been transferred from the operating theatre to the intensive care unit. As shown in Table I, patients with rAAA were mainly elderly and predominantly male. Of the 64 patients undergoing vascular surgery, 42 died in the hospital (in-hospital mortality, 65%). Causes of in-hospital death were mainly haemorrhage and related complications (27 patients, 65%), multiple organ failure (14 patients, 33%), and acute myocardial infarction (1 patient, 2%). Table I A comparison between low-score and high-score groups of ERAS based on clinical characteristics, laboratory findings, and transfusion product usage from admission to the peri-operative stage in rAAA patients undergoing vascular surgery. We first compared the differences between the low-score group (n=43) and high-score (n=21) groups of ERAS in terms of clinical manifestations such as age, gender, blood pressure, GCS at presentation, and rAAA score. There was no significant difference in age between the low-score and high-score groups of ERAS. Systolic blood pressure and GCS scores at presentation were significantly lower in the high-score group than in low-score group. We calculated rAAA scores using three rAAA scoring systems, as shown in Table I. The HI score of the high-score group of ERAS was significantly higher than that of the low-score group, but the GAS score did not differ significantly between the two groups. The pre-operative laboratory results showed that patients in the high-score group of ERAS were significantly more anaemic than those in the low-score group. Furthermore, we noted a significantly stronger association between coagulopathy and low plasma fibrinogen levels in the high-score group of ERAS than in the low-score group (Table I). The platelet count did not differ significantly between the two groups. The post-operative laboratory results showed more severe anaemia in patients in the high-score group than in those in the low-score group. Patients in the high-score group of ERAS had more severe coagulopathy and elevated fibrinolysis than those in the low-score group, as shown in Table I. RCC (volume; mL) and FFP (volume; mL) were transfused significantly more often in the high-score group than in the low-score group (Table I). However, there were no significant differences between the two groups in terms of FFP:RCC ratio (volume; mL: volume; mL), administration of platelet concentrates, and albumin products. The amount of blood lost was significantly greater in the high-score group than in the low-score group. The reason for the higher mortality in the high-score group than in the low-score group might be low plasma transfusion against bleeding mass. As for ERAS, lower plasma transfusion in the high-score groups of HI (FFP:RCC ratio: 0.54) and GAS (FFP:RCC ratio of middle-score group, 0.62, and of high-score group, 0.51) might have resulted in a poor outcome (mortality rates of the low-score groups of HI and GAS were 58% and 53%, respectively, while those of the high-score group of HI and the middle- and high-score groups of GAS were 75%, 76%, and 80%, respectively), in comparison with the outcome in the low-score groups of HI (FFP:RCC: 0.60) and GAS (FFP:RCC: 0.57). Because there was no difference in post-operative haematological data on anaemia between survivors and non-survivors, transfusion with RCC was sufficient in both groups (pre- and post-operative Hb of survivors [n=22]: 11.5±0.5 g/dL and 9.2±0.4 g/dL, respectively; pre- and post-operative Hb of non-survivors [n=42]: 9.6±0.3 g/dL and 8.6±0.4 g/dL, respectively). However, there was a significant difference in the post-operative results of clotting tests between the survivors and non-survivors (post-operative percent prothrombin time [%PT], activated partial thromboplastin time [aPTT], and plasma fibrinogen levels of survivors (n=22): 59%±4%, 58.5±5.8 s, and 167±23 mg/dL, respectively; post-operative %PT, aPTT, and plasma fibrinogen levels of non-survivors [n=30, data from 12 patients lacking because of the patients’ death]: 37%±4%, 91.6±7.2 s, and 79±12 mg/dL, respectively). These data suggest that plasma transfusions is not sufficient for non-survivors. Thus, severe coagulopathy in the high-score groups of ERAS as well as HI and GAS might cause more bleeding, and failure to control the bleeding may result in death due to haemorrhage. In patients with rAAA, massive haemorrhage has already occurred in the abdomen. We, therefore, consider that the strategy of transfusion for rAAA differs from that for general surgery. Because hypofibrinogenaemia was noted in the high-score group of ERAS, early plasma transfusion was necessary to correct the coagulopathy, as Mell et al. suggested3. Moreover, health insurance limitations in the Japanese Medical Service prevent the use of fibrinogen concentrates and cryoprecipitates in patients with severe, secondary hypofibrinogenaemia. While the FFP:RCC ratio for rAAA was 0.5 as described by Mell et al., it might be over 0.5–1.0 in the metropolitan Tokyo area in Japan, similar to that in Johansson’s report (FFP:RCC=1). The difference between the results obtained by Mell et al. and the results of our clinical interventions might be due to the severity of rAAA or the medical system in Japan, in which no fibrinogen products such as fibrinogen concentrates or cryoprecipitates can be used. Our study has some limitations: it was a retrospective, long-term study (10 years), with a small number of patients (n=64). Over the 10-year study period, various surgeons performed vascular surgery for rAAA, and the drugs and instruments used during the admissions and the operations were different. We, therefore, consider that a prospective, large sample, multi-centre study within a short-term time frame should be performed in order to further clarify the relationship between various rAAA scoring systems and transfusion ratio. This study suggests that patients with high rAAA scores had severe coagulopathy due to rAAA, and that the strategy to improve outcome in patients with a high rAAA score would be sufficient plasma transfusion. In the future, we will consider a transfusion protocol for rAAA using a strategy based on FFP:RCC ratios and rAAA scores. In conclusion, our data suggest that the transfusion strategy for rAAA might be based on an adequate transfusion ratio and evaluation by rAAA scoring.