Acute coronary syndromes hospitalizations and in-hospital outcomes during and after the lockdown of corona virus disease 19 (COVID-19) pandemic outbreak

Funding Acknowledgements

Type of funding sources: None.

Background

Multiple studies documented an important reduction of acute coronary syndromes (ACS) admissions during the Coronavirus Disease 19 (COVID-19) pandemic. There are few studies regarding the ACS admissions and outcomes during the ongoing pandemic after the initial lockdown.

Purpose

We aimed to study the ACS admissions and in-hospital outcomes during and after the COVID-19 lockdown period.

Methods

A retrograde single-center study was conducted. The data for all admissions were collected from March 9th, (first COVID-19 case) until April 30th, the corresponding period of 2020 total lockdown, for three consecutive years from 2019 to 2021. The control period was considered the year 2019 and the study periods were in 2020 (lockdown) and 2021 (ongoing pandemic). ACS admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA). Incidence rate ratio (IRR [95%CI]) was used to compare all-ACS and subgroups admissions, and risk ratio (RR [95%CI]) to compare the mortality between each study period with the control one.

Results

Were included 550 ACS patients (pts) during 2019, 321 pts during 2020, and 473 pts during 2021 period. The overall-ACS admissions IRR was significantly lower during 2020 lockdown (0.58 [0.44-0.76]), and not significant during 2021 ongoing pandemic (0.86 [0.62-1.18]). During 2020 lockdown, significant reduction for STEMI and UA, the IRR respectively (0.72 [0.56-0.94]) and (0.42 [0.22-0.76]), and not significant during 2021 respectively (0.87 [0.63-1.21]) and (0.86 [0.51-1.46]) were observed. The reduction in NSTEMI admissions was not significant in both periods.

The overall mortality was, importantly increased during the lockdown period (7.45 vs. 3.4 %), RR=2.16 (1.2-3.89). Meanwhile the 2021 mortality was similar (4.2 vs. 3.4%), RR=1.22 (0.66-2.26).

Conclusions

After the initial reduction of admissions in all-ACS, STEMI and UA during the 2020 lockdown period and the increase of all-ACS mortality, the number of admissions and the mortality returned to a similar range during 2021 despite the ongoing COVID-19 pandemic.

Contrast induced nephropathy in interventional cardiology; identification of high-risk patients and its prevention

Funding Acknowledgements

Type of funding sources: None.

Background

CIN is a serious and potentially preventable complication of coronary angiography and/or percutaneous coronary interventions (PCI). The definition of CIN, its incidence and risk factors and therapeutic interventions are not well established .

Purpose

To study incidence and risk factors of CIN in patients undergoing coronary angiography and/or PCI, to investigate high-risk patients with CIN and to evaluate its preventive therapies (Hydration an Acetylcysteine).

Method

This was a prospective trial, in one center with patients undergoing coronary angiography and/or PCI, during 2010-2014. The renal function was evaluated through serum Creatinine (Cr) and GFR (Cockcroft –Gault formula ). CIN was defined as an increase in Creatinine by 25% and/or by 0.5 mg/dL at 48/72 h after the index procedures. Patients with CIN were considered high-risk when Creatinine increased more than 50% and/or by 2 mg/dL, or needing dialysis. We evaluated the major risk factors for CIN such as: Preexisting Renal Lesion (PRL), Age≥65 years, Heart Failure (HF), Diabetes Mellitus (DM), Anemia (Hb < 12 g/dL) and the Quantity of Contrast used. We evaluated the role of hydration with intravenous saline and acetylcysteine (ACC) in the prevention of CIN.

Results

Out of the 1231 patients enrolled, 804 patients fulfilled the inclusion criteria. The incidence of CIN resulted 14.4%, higher in the group of patients with risk factors for CIN (15.3%) versus without risk factors (9.1%); p=0.05. Risk factors HF (OD: 4.63; CI95%: 2.10-10.05, p<0.001), PRL (OD: 1.57; CI95%: 1.02-2.41, p=0.039) and Age ≥ 65 years (OD: 1.82; CI95%: 1.37-3.73, p=0.038 ) resulted independent risk factors, for CIN whereas Anemia (p=0.171), DM (p=0.502) and the Quantity of contrast used (p=0.479) did not result independent risk factors. Creatinine at 24 hours after the procedure resulted a predictive factor for the development of CIN. (sensitivity 64.7%, specificity 91.7%, positive predictive value 63.5%, negative predictive value 92.1% ). Creatinine > 1.5 mg/dL before the procedure resulted an independent risk factor for CIN, with a higher specificity than eGFR < 60 ml/min. The incidence of patients with CIN at high risk was 3.9% and HF resulted the only independent risk factor in this subgroup of patients (OD:4.49, CI 95%: 2.03-9.95). Intravenous hydration with saline resulted efficient in the prevention of the development of CIN (p=0.029), whereas ACC did not (p=0.485).

Conclusions

The frequency of CIN is higher in the group with risk factors. The HF, PRL, Age≥ 65 years resulted as independent risk factors for, and intravenous hydration with saline was a simple and efficient method for the prevention of CIN. Although our definition of CIN is widely used, the need for a universal definition for CIN is a contemporary need.

Outcomes of ST elevation myocardial infarction (STEMI) hospitalizations during corona virus disease 19 (COVID 19) era

Funding Acknowledgements

Type of funding sources: None.

Multiple studies reports a reduction of STEMI hospitalizations rates during COVID 19 pandemic outbreak. Contradictory STEMI complications rates are reported during COVID 19 pandemic regarding case fatalities rates, cardiogenic shock, life threatening arrhythmias and others.

Purpose. To evaluate the impact of the COVID 19 outbreak on STEMI patient outcomes and complication rates in country with low COVID 19 incidence and mortality and without changes in Cardiology hospital services.

Methods. Was conducted a retrograde study collecting data for STEMI hospitalizations, revascularization procedures and case fatalities and other complications from March 9th 2020 (first COVID 19 case in our country) to April 30th (period of total lockdown) compared with the same period of 2019 in our center. Incidence rate ratio (IRR) was used to compare STEMI admissions and revascularization procedures and risk ratio (RR) to compare case fatality rate and other complications rate.

Results

Hospital admissions for STEMI declined during 2020 (COVID 19 period) from a total of 217 patients in 2019 to 155 patients hospitalization in 2020 representing IRR 0.72 (p = 0.009). Reduction were observed in the number of primary PCI from 168 procedures in 2019 to 113 in 2020 (IRR 0.67 p = 0.001). Symptom onset to our ICU (including regional transportation) was significantly higher in 2020 than in 2019 (939.97 ± 1122 versus 436.15 ± 383 minutes p <0.0001) The STEMI case fatality was importantly increased during pandemic outbreak (13.55%) compared to 2019 (8.3%) (RR= 1.63 p = 0.001), but a similar a primary PCI-STEMI case fatality 6.2% versus 5.95%. Also an increase was observed for cardiogenic shock (IRR =1.75 p = 0.003).

Results; Hospitalizations and related invazive revascularization procedures for STEMI significantly reduced during COVID 19 pandemic. We identified a substantial increase of STEMI case fatalities and cardiogenic shock during pandemic outbreak. Delayed timely reperfusion by primary PCI has an important impact on infarct related mortality.

Impact of coronavirus disease 19 (COVID 19) pandemic on acute coronary syndrome (ACS) hospitalizations, and related invasive procedures

Funding Acknowledgements

Type of funding sources: None.

Background

  Reports from countries affected by the COVID 19 pandemic demonstrate a reduction in ACS hospitalizations and invasive procedures.

Purpose

We aimed to investigate the impact of the COVID 19 pandemic on ACS patient hospitalizations and related invasive procedures in a country with low COVID 19 incidence and without changes in Cardiology hospital services.

Methods

We conducted a retrograde study collecting data for ACS hospitalizations including ST elevation myocardial infarction (STEMI), non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) and related invasive and revascularization procedures from March 9th 2020 (first COVID 19 case in our country) to April 30th (period of total lockdown) compared with the same period of 2019 in our center.

Results

Hospital admissions for ACS declined during 2020 (COVID 19 period) from a total of 550 patients in 2019 to 321 patients hospitalization in 2020 representing a 41.6% reduction (p &lt; 0.001). The reduction was observed for all types of ACS, the greatest reduction was for UA 58% (p &lt; 0.001) followed by NSTEMI 32% (p &lt; 0.001) and for STEMI 28% reduction (p &lt; 0.009). Compared to 2019 the proportion of patients presented with STEMI was higher in 2020 (48.6% vs 39.5% p = 0.01) and lower with UA (43.3% vs 31.5% p = 0.0002)

Reduction was observed also in coronary angiography by 43% (p &lt; 0.001) and in percutaneous coronary interventions with 42% (p &lt; 0.001). Compared to 2019 the proportion of patients with 3 vessels coronary disease(CAD)and left main (LM) was higher during COVID 19 pandemic,  respectively 33% vs 40% p = 0.032 and 8% vs 13% p = 0.046

Conclusions

Hospitalizations and related invasive procedures for ACS significantly dropped during COVID 19 pandemic.  Patients admitted to hospital during pandemic presented more with STEMI and had more 3 vessels CAD and LM. Measures should be taken to ensure patients for the safety of health services and encouraged not to neglect cardiac consultations and treatments.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Characterization of circadian COPD symptoms by phenotype: Methodology of the STORICO observational study

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. The symptoms of COPD are troublesome, variable, can occur during all parts of the 24-h day and have a substantial impact on patients' health status, quality of life and healthcare resource utilization. Reducing symptoms, improving health status and increasing physical activity are major goals in the management of stable COPD. In order to provide effective, patient-oriented care, patients should be evaluated on the basis of lung function, frequency of symptoms and patient-perceived impact of symptoms on their lives and treatment decisions made on a case-by-case basis. The identification of COPD phenotypes is an evolving debate and literature data about the circadian variation of COPD symptoms according to phenotypes are nowadays lacking. The ongoing STORICO (STudio Osservazionale sulla caratteRizzazione dei sIntomi delle 24 ore nei pazienti con BPCO) study (NCT03105999) is aimed to describe by clinically defined phenotypes the frequency and 12-month evolution of early-morning, day- and night-time COPD symptoms in a cohort of 600 Italian patients with stable COPD. Secondary objectives include the description of the 12-month variation of outcomes of interest according to phenotypes and of the healthcare resources utilization (overall and by phenotype) during 12-month observation. An exploratory analysis will be conducted aimed to phenotype COPD patients in an alternative researcher-independent way based on circadian pattern of symptoms combined with measures of respiratory function, health-related quality of life and comorbidity. The present paper describes the methodology of the STORICO study.

Prevalence and associated features of self-reported freezing of gait in Parkinson disease: The DEEP FOG study

Freezing of Gait (FOG) is a common and disabling symptom in patients with Parkinson disease (PD). The relationship between FOG and dopaminergic medication is complex. The aim of the present study was to estimate the prevalence of self-reported FOG, its associated clinical features, and its relationship with wearing-off in a wide PD population. This is an observational multicenter study of 634 consecutive non-demented PD patients. Patients were identified either as freezers or non-freezers based on item-3 of the Freezing of Gait-Questionnaire. FOG was then classified as on, off and onoff freezing based on its relationship with wearing-off. Patients were assessed with Unified Parkinson's Disease Rating Scale, Hoehn and Yahr scale, 8-item Parkinson's disease Questionnaire, Mini-Mental State Examination. Data from 593 patients were analyzed, 325 (54.3%) were freezers of whom 200 (61.6%) experienced FOG only during off state (off-freezers), 6 (1.8%) only during on state and 119 (36.6%) either in on and off states or independently of dopaminergic response-related symptoms (onoff-freezers). Overall, freezers vs non-freezers had longer disease duration, more advanced disease and greater disability. Moreover, freezers more frequently reported wearing-off and experienced worse quality of life. Onoff-freezers vs off-freezers were older, more severely disabled, less likely to experience wearing-off, treated with lower levodopa equivalent daily dose and with poorer cognitive performance. Self-reported FOG is mainly recognizable in advanced PD and is associated with more disability and worse quality of life. Onoff-FOG may represent the result of under-treatment or rather interpretable as a distinct clinical entity.

Anhedonia and cognitive impairment in Parkinson's disease: Italian validation of the Snaith-Hamilton Pleasure Scale and its application in the clinical routine practice during the PRIAMO study

OBJECTIVE

To assess the psychometric properties of the Italian version of the Snaith-Hamilton Pleasure Scale (SHAPS) and to study the relationship between anhedonia, depression and cognitive impairment in patients with Parkinson's disease (PD).

METHODS

The SHAPS (14 items) was translated into Italian and pre-tested in a pilot study. Two items evaluating physical anhedonia related to sexual issues were added. The Italian version of SHAPS was validated in 274 consecutive PD patients, divided into patients with major depression according to DSM-IV criteria (dPD) and patients without depression (nPD), and in healthy subjects. To test the feasibility of the instrument and to determine whether clinical data affect anhedonia, we also administered SHAPS to 1307 patients with different types of parkinsonism.

RESULTS

The Italian SHAPS proved to be easy to understand as regards the question and answer modes. Intraclass coefficient for test-retest reliability was 0.65 for the total score. KR index was 0.61. ANOVA of the SHAPS total score revealed that scores were higher in dPD patients than in healthy controls and nPD (p<0.05). In the 1307 patients with various types of parkinsonism, the SHAPS data showed that anhedonia was related to age, type of parkinsonism, apathy, depression and cognitive impairment. Anhedonia was correlated with frontal dysfunctions in supranuclear palsy and PD patients (r=-0.682 and -0.264 respectively, p<0.05).

CONCLUSION

The Italian version of the SHAPS is a reliable tool with which to assess anhedonia in patients with PD and other forms of parkinsonism.

Agreement between oncology guidelines and clinical practice in Italy: the 'right' program. A project of the Italian Association of Medical Oncology (AIOM)

BACKGROUND

RIGHT (Research for the Identification of the most effective and hIGhly accepted clinical guidelines for the cancer Treatment) is a project promoted by the Italian Association of Medical Oncology (AIOM) to measure the concordance between oncology guidelines and clinical practice. The goal of this pilot phase was to develop and test a reliable process to measure this concordance nationwide.

MATERIALS AND METHODS

Twenty Italian centers participated to the survey. Breast cancer (BC) and colorectal cancer (CRC): guidelines issued by AIOM in 2003 were selected. A total of 29 indicators linked to the process of care were abstracted. Patients who had their first visit at the oncology center between February 2004 and June 2005, with a diagnosis of invasive BC (stage 1 or 2), colon cancer (stage 3), rectal cancer (stage T3-4 or N1-2) or advanced CRC were enclosed.

RESULTS AND CONCLUSION

One hundred and sixty-one patients (80%) were analyzed. On average, 93% of BC and 80.3% of colorectal patients received recommended care. These first results indicate that the RIGHT system provides a valid measurement of oncology care to assess agreement with guidelines. A second larger phase of this nationwide monitoring program will enable results to be generalized.

Psychological distress and coping strategies in patients with psoriasis: the PSYCHAE Study

OBJECTIVE

Our objectives were to determine the prevalence of psychological distress in a large sample of Italian patients with psoriasis; to establish whether disease severity and psychological distress are associated; to identify the strategies employed to cope with psoriasis; to evaluate the coping strategies employed by dermatologists; and to identify potential predictors of psychological distress.

DESIGN

Cross-sectional.

SETTING

Thirty-nine Italian dermatology centres.

SUBJECTS

One thousand five hundred and eighty (1580) patients with psoriasis.

METHODS

Minor psychological distress was evaluated using the General Health Questionnaire-12 (GHQ-12) and major psychopathological distress using the Brief Symptom Inventory (BSI); coping strategies were evaluated using the Brief COPE questionnaire; disease severity was evaluated using the body surface area index.

RESULTS

Patients were aged 44 +/- 13 years (mean +/- SD) and were mainly men (57%). Minor psychological distress was present in 46% of patients and major psychopathological distress in 11% of them. Both minor (54% vs. 40%, P < 0.0001) and major (17% vs. 7%, P < 0.0001) distress were more frequent in women than in men. The psychological status of women was worse than that of men independently from the extension of psoriasis. There was no association between the presence of distress and the treatment prescribed by dermatologists. Planning and active coping were the strategies most commonly employed by patients to cope with psoriasis, but there were between-gender differences. Most dermatologists employed a 'problem-orientated' attitude in caring for patients.

CONCLUSIONS

(i) Psychological distress was relatively frequent in our patients with psoriasis; (ii) female gender was the most important predictive factor for psychological distress; (iii) there was no association between psoriasis severity and psychological distress; (iv) planning and active coping were the coping strategies most frequently employed by patients; and (v) most dermatologists employed a problem-orientated attitude in caring for patients.

Elevated plasma levels of factor VIII in women with early recurrent miscarriage

AIMS

Inherited and acquired thrombophilia have been found to be associated with recurrent pregnancy loss. This paper examines whether or not elevated factor (F)VIII:C plasma levels, which have been demonstrated to be an independent risk factor for venous thromboembolism, are a risk factor for early recurrent miscarriages also.

PATIENTS AND METHODS

Consecutive women referred to our clinic with a history of early recurrent abortion (at least three pregnancy losses before week 13 of gestation) were eligible for the study. Exclusion criteria were endocrine, immunological, anatomical and genetic causes of embryo demise, as well as any thrombophilic abnormality, either congenital or acquired, or a personal or familial history of venous thromboembolism. FVIII:C plasma levels were determined in 51 cases and in 51 controls matched for age, ethnicity and blood group.

RESULTS

The mean FVIII:C level in the control subjects was 106.8 IU dL-1, compared with 128.2 IU dL-1 in the patients group (P = 0.0002). Thirteen (25.5%) of the 51 patients had FVIII:C values exceeding the 90th centile of the control population (145 IU dL-1), compared with four subjects in the control group (chi2 = 4.52; P = 0.033; odds ratio = 4.02, 95% confidence interval 1.09, 16.05). No cases with increase in FVIII:C levels attributable to an acute-phase reaction, as assessed by C-reactive protein plasma concentration, were found.

CONCLUSIONS

We found FVIII:C levels significantly higher in women with early recurrent miscarriage compared with controls. This finding suggests a possible association between this thrombophilic condition and early reproductive failures.

A simple and safe nomogram for the management of oral anticoagulation prior to minor surgery

In 80 consecutive, anticoagulated patients scheduled for minor surgery, we reduced warfarin daily dosage by 50% on days 4, 3 and 2 before the surgery, restoring the original dose the day immediately before surgery. The evening after surgery, patients took a double warfarin dose, and then the usual maintenance dose was reintroduced. The mean International Normalized Ratio (INR) value assessed 1 week before surgery was 2.63 (range 1.88-3.87); it decreased at the moment of performing surgery to 1.68 (range 1.42-2.20; P < 0.05 with respect to the preoperative value), and returned to 2.43 7 days after (range 1.96-3.51, P = ns with respect to the preoperative value). No significant difference was found comparing prothrombin fragment 1.2 (F1.2) levels 1 week before surgery and on the morning of surgery (0.49 ng/ml vs 0.67 ng/ml, P = ns), suggesting that no activation of blood coagulation had taken place following the reduction of anticoagulant therapy. Patients developed neither major nor minor bleeding, nor thromboembolism during the procedures or up to 1 month after surgery. In our experience, this method for the management of anticoagulation before minor surgery has been shown to be safe and useful, avoiding the cumbersome shift to either intravenous or subcutaneous heparin.

Genetic characterization of the body attributed to the evangelist Luke

Historical sources indicate that the evangelist Luke was born in Syria, died in Greece, and then his body was transferred to Constantinople, and from there to Padua, Italy. To understand whether there is any biological evidence supporting a Syrian origin of the Padua body traditionally attributed to Luke, or a replacement in Greece or Turkey, the mtDNA was extracted from two teeth and its control region was cloned and typed. The sequence determined in multiple clones is an uncommon variant of a set of alleles that are common in the Mediterranean region. We also collected and typed modern samples from Syria and Greece. By comparison with these population samples, and with samples from Anatolia that were already available in the literature, we could reject the hypothesis that the body belonged to a Greek, rather than a Syrian, individual. However, the probability of an origin in the area of modern Turkey was only insignificantly lower than the probability of a Syrian origin. The genetic evidence is therefore compatible with the possibility that the body comes from Syria, but also with its replacement in Constantinople.

Genetic structure of Quechua-speakers of the Central Andes and geographic patterns of gene frequencies in South Amerindian populations

A sample of 141 Quechua-speaking individuals of the population of Tayacaja, in the Peruvian Central Andes, was typed for the following 16 genetic systems: ABO, Rh, MNSs, P, Duffy, AcP1, EsD, GLOI, PGM1, AK, 6-PGD, Hp, Gc, Pi, C3, and Bf. The genetic structure of the population was analyzed in relation to the allele frequencies available for other South Amerindian populations, using a combination of multivariate and multivariable techniques. Spatial autocorrelation analysis was performed independently for 13 alleles to identify patterns of gene flow in South America as a whole and in more specific geographic regions. We found a longitudinal cline for the AcP1*a and EsD*1 alleles which we interpreted as the result of an ancient longitudinal expansion of a putative ancestral population of modern Amerindians. Monmonnier's algorithm, used to identify areas of sharp genetic discontinuity, suggested a clear east-west differentiation of native South American populations, which was confirmed by analysis of the distribution of genetic distances. We suggest that this pattern of genetic structures is the consequence of the independent peopling of western and eastern South America or to low levels of gene flow between these regions, related to different environmental and demographic histories.

Patterns of gene flow inferred from genetic distances in the Mediterranean region

The analysis of population structure may lead to inferences about demographic phenomena. In particular, regions of sharp genetic differentiation suggest the existence of factors that impaired gene flow and increased the evolutionary role of genetic drift. Here, we present an analysis of a data set of 10 allele frequencies in 39 populations of the Mediterranean region. As a preliminary step, we describe spatial patterns of allele frequencies using spatial autocorrelation analysis. We then construct a network connecting localities and estimate genetic distances along the edges of the network. By applying specific algorithms, we locate on the map the areas of sharpest genetic differentiation, or genetic boundaries. The main boundaries separate the northern and the southern coasts, especially in their western portions; in addition, several localities appear genetically isolated. The comparatively high genetic differentiation across the western Mediterranean, where the sea distances between localities are shorter, strongly suggests that the sea distance by itself can hardly be regarded as a major isolating factor among these populations. On the contrary, the decrease in genetic resemblance between populations of the 2 coasts as one proceeds westward may reflect an increased genetic exchange in the eastern Mediterranean basin or independent human dispersal along the 2 coasts or both.

Patients with severe von Willebrand disease are insensitive to the releasing effect of DDAVP: evidence that the DDAVP-induced increase in plasma factor VIII is not secondary to the increase in plasma von Willebrand factor

It is generally held that factor VIII (FVIII) does not increase in the plasma of severe von Willebrand disease (vWD) patients treated with DDAVP because they lack von Willebrand factor (vWF), which is the plasma carrier for FVIII. To test this hypothesis, FVIII plasma levels were monitored in severe vWD patients treated with DDAVP after normalization of vWF plasma levels with infusions of cryoprecipitate. Each of four severe vWD patients underwent four different treatments at intervals of at least 15 d: (1) cryoprecipitate plus DDAVP; (2) cryoprecipitate plus saline; (3) cryoprecipitate plus recombinant FVIII (rFVIII); (4) saline plus rFVIII. Cryoprecipitate increased the plasma levels of FVIII and vWF. The infusions of saline or DDAVP after cryoprecipitate did not further increase FVIII and vWF plasma levels and had no effect on the plasma levels of tissue plasminogen activator (tPA), which are raised by DDAVP in normal subjects and in patients with vWD of other types. The infusion of rFVIII further increased by 182 +/- 32 U/dl (mean +/- SEM) the plasma levels attained after cryoprecipitate, which disappeared from the circulation with a half-life of 11.95 +/- 0.86 h. In contrast, the infusion of rFVIII after saline increased by only 107 +/- 18 U/dl the plasma levels of FVIII, which disappeared from the circulation with a half-life of 2.68 +/- 0.14 h, indicating that the vWF infused with cryoprecipitate is able to bind additional FVIII. These studies indicate that DDAVP does not increase the plasma levels of FVIII in patients with severe vWD even after normalization of plasma vWF. The possibility is discussed that severe vWD patients may be insensitive to the releasing effect of DDAVP.

Prevalence of pancreatic disorders in HIV-infected hemophiliacs: diagnostic methods and their clinical significance

Pancreatic damage has been well described in HIV+ patients and can occur both for therapy and opportunistic infections, but its prevalence is not clear. The aim of our study was to evaluate the prevalence of pancreatic damage in a cohort of HIV+ hemophiliacs together with the clinical and prognostic value of the diagnostic methods commonly used. We studied 75 HIV+ patients and 26 HIV- as a control group: they were evaluated by biochemical tests, indirect pancreatic functional tests, abdominal ultrasound (US) and computed tomography (CT). No differences were observed between HIV+ and HIV- in elevation of pancreatic enzymes. Eleven patients had slight CT alterations and none had abnormal US. In HIV+ there was no relationship between enzyme elevation and CDC group, CD4+ cell count or therapy. In conclusion, pancreatic disorders have a very low prevalence in HIV+ hemophiliacs and biochemical alterations we found had a doubtful clinical significance. Lipase and isoamylase are the more reliable tests and lipase, being the cheapest and easiest to perform, has to be considered as the first test of choice for monitoring pancreatic damage in HIV+ patients.

Thrombin generation is not increased in the blood of hemophilia B patients after the infusion of a purified factor IX concentrate

Prothrombin complex concentrates (PCC), licensed for the treatment of hemophilia B, are known to carry a significant risk of thromboembolic complications. Although the reasons for thrombogenicity are not completely understood, several manufacturers have developed purified factor IX concentrates that contain negligible amounts of the other vitamin K-dependent factors. To evaluate whether or not the infusion of such a factor IX concentrate is followed by lesser activation of the hemostatic system than by the infusion of a PCC, we performed a series of coagulation assays on 11 hemophilia B patients before and after the administration of these two types of concentrate using a randomized cross-over design. The levels of prothrombin fragment F1 + 2, a sensitive measure of the in vivo cleavage of prothrombin by factor Xa, was significantly increased in plasma after PCC, but not after factor IX concentrate. Plasma fibrinopeptide A, a sensitive index of the enzymatic activity of thrombin on fibrinogen, also increased significantly after PCC but not after factor IX concentrate. The fragment B beta 15-42, a sensitive index of the enzymatic action of plasmin on fibrin II, did not change after either concentrate. There were also no differences in less sensitive coagulation measurements, such as plasma fibrinogen, antithrombin III, and fibrin monomers, nor in indices of platelet activation, such as beta-thromboglobulin and platelet factor 4. These findings show that the infusion of a purified factor IX concentrate can result in substantially less activation of the coagulation cascade than may be seen with PCC.

Hepatitis B virus infection in multitransfused haemophiliacs

A longitudinal study of 44 haemophilic children, all in a treatment programme with factor concentrates, was undertaken to evaluate the occurrence, characteristics, and evolution of hepatitis B virus (HBV) infection. Twenty four children (55%) (group I) showed signs of HBV infection, while 20 (45%) (group II) did not. Age at onset of treatment, number of infusions, and total amount of concentrate received did not show significant differences between the two groups. In group I only four children (16%) had symptomatic acute hepatitis. Chronic liver disease was present in nine patients (38% of infected children). The early age of infection would seem to be an important factor for predicting chronic evolution. Evidence of delta infection in three children with severe liver disease seemed to confirm the high pathogenicity of this agent. Because of the risks associated with chronic HBV infection a careful follow up of patients positive for hepatitis B surface antigen is mandatory.

[Effectiveness of piperacillin in childhood infections]

Piperacillin is a semisynthetic penicillin with a broad-spectrum: in particular it is active against Gram positive, Gram negative, aerobic and anaerobic bacteria often resistant to other antibiotics of the same group. We report a trial carried out on 38 children with severe and moderate infections treated with piperacillin. We have considered ESR, all leucocytes count and body temperature. No severe side effects have been reported. Piperacillin must be used as a first choice in pediatric age, mostly in case of mixed bacterial infections and in immunocompromised patients.

[Chronic lead poisoning in childhood: clinical experience]

Since 1978, 818 children living near an industrial source of pollution have been screened for lead poisoning. Biochemical evidences of increased lead absorption have been found in 114 cases and in 62 of them it was of such degree to guarantee further investigations. Those 62 children received a thorough neuropsychologic evaluation revealing a significant reduction of IQ, learning difficulties, poor concentration and behavioral abnormalities. We also documented an increased rate of abnormal mathafases and breaks of chromatides in children with increased lead absorption compared with age and sex matched controls.

[The prevention of liver disease in the hemophilic child]

The modern replacement therapy of inherited bleeding disorders has proved to be a major advance in the management of haemophilic children. However, the haemophiliacs, early treated with commercial clotting factor concentrates obtained from large amounts of plasma, are exposed to blood borne viruses responsible for post-transfusion hepatitis (PTH) and for their possible harmful long-term sequelae. Infact high prevalence of infection with hepatitis B virus, non-A, non-B agents, delta agent has been documented among haemophilic children. In this study we analyze the measures of surveillance at present available in order to reduce the risk of PTH in young haemophilic patients. Among these measures of prevention we point out the magnitude of administrating hepatitis B vaccine to susceptible children and of using antihaemophilic factor heat-treated to reduce infectivity in those children who have never been treated and without signs of active viral infections.

[Thermographic monitoring of the evolution and therapy of chronic synovitis and cysts in hemophiliacs]

The authors have studied the evolution of chronic synovitis and of cysts in hemophilic patients, through measurement of the articular circumference or of the cyst. To obtain this, they have used a folding rule and liquid cristal strips, that have the characteristic, that they change colours from braunish to orange, from greenish to bluish according to the thermic gradient revealed. The authors have studied 21 hemophilic patients, affected from chronic synovitis for a total of 23 articulations and 5 patients with cyst. All patients have undergone several controls reporting dates revealed at 2,6 and 12 months from beginning of disease. The authors conclude, underlining the usefulness of this simple methodic that permits: - a reliable valutation of the therapeutic (profilatic) scheme applied to every single patient and gives a prognostic precision; - distinguishing, in fact, the recovery from the clinical recovery of the synovitis in order to avoid the appearance of unpleasant relapses.

[Intra-familial transmission of HBV infection]

We investigated 63 household contacts of 29 children positive for serologic markers of hepatitis B virus, in order to assess the intrafamiliar spread of HBV infection. 40 relatives of 15 children affected by chronic hepatitis B (Group I) and 23 relatives of 14 patients affected by hemophilia (Group II) were studied. HBV markers (HBsAg, anti-HBs, anti-HBc, HBeAg, anti-HBe) were tested in all the subjects by RIA. Positive markers were found in 39 (62%) of the subjects; the combined prevalence for all HBV markers was 75% in the Group I, and 39% in the Group II. The higher prevalence rate in Group I can be explained by the possible previous infection of another member of the family, whereas in Group II the child is almost surely the first infected subject. Besides, subjects of Group I have probably been in contact with HBV infected children a longer time, compared to subjects in Group II. Our data suggest that household contacts of children with HBV infection are at high risk and should therefore be immunized against HBV.

[Clinical evaluation of a new factor VIII concentrate in hemophilic children]

Studies of in vivo recovery, longevity and dose response of factor VIII following infusions of a new factor VIII concentrate (Koate, Cutter Laboratories) yielded results similar to those reported using other sources of factor VIII. Koate has been demonstrated to be clinically effective in classic hemophilia. This preparation was produced by refinements of the methods first described by Hershgold, Pool and Pappenhagen in 1966. By these procedures a high purity factor VIII concentrate is obtained being some 65 to 170 fold purified. This factor VIII concentrate was clinically evaluated in 11 hemophilic children (one of them with 7 Bethesda Units inhibitor) who received a total of 13 separate infusions. Biologic half-life values determined in two subjects resulted 12 and 9,5 hours comparing favorably with those previously reported. Initial 50% disappearance averaged 5,4 and 4,8 hours respectively. In vivo recovery of the infused factor VIII activity averaged 98 +/- 12,75%. Dose response measurements showed that 1 unit/Kg gave an in vivo increase in circulating activity of 1,97 +/- 0,93%.

[New considerations on the role of the mouse skin surface lipids on the "in vivo" penetration of "Schistosoma mansoni" cercariae (author's transl)]

The authors have studied the effect of delipitizing and of the previously extracted skin lipids reapplication on mice experimental infected with Schistosoma mansoni cercariae. The results demonstrated that the amount of living cercariae, not penetrated, recovered after the exposition to the parasite is greater in the delipitized mice than in the other ones. The low amount of worms recovered from the treated mice might be due to the effect of the mouse skin surface lipids not only on stimulating cercarial penetration but also on allowing cercarial transformation to schistosomula during skin crossing.

[The importance of man, mouse and rat skin surface lipid fractions on the "in vitro" penetration of "Schistosoma mansoni" cercariae (author's transl)]

The AA. have studied in this research, the rôle explicated in vitro from the lipids contained in a man's skin, in a rat of the Wistar experimental group and in a mouse of the Swiss one. They have seen that some lipids fractions, as triglycerides, waxes and squalenes explicate an action that favours the penetration of the cercariae in vitro on a plate of agar and that such an action is due to the unsaturation in the above said fractions of sebaceous origin. On the contrary the lipids of skin origin as sterols and their esters inhibit the penetration.