Epidemiological data and treatment strategies in children with severe haemophilia in Italy

OBJECTIVES

In a period of important therapeutic changes in the field of haemophilia care, we provide updated statistics on children with severe haemophilia (0-12 years of age) in Italy.

METHODS

Data presented are from the Italian National Registry of Congenital Coagulopathies (NRCC) - survey 2017.

RESULTS

Children with severe Haemophilia A (HA) were 242, those with severe haemophilia B (HB) 48. Prophylaxis was adopted in 92.1% of individuals with severe HA and 88.6% with severe HB. Thirty-nine children (14.8%) were on treatment for inhibitors. FVIII prescribed to children with severe HA represented 11.1% of the total consumption, of which 4.6% was extended half-life (EHL). FIX given to children with HB accounted for 7.2% of the total FIX, of which 19.1% was EHL-FIX.

CONCLUSION

The paediatric population analysed is characterized by a great adherence to therapy, so this data may constitute a benchmark for use of new, alternative therapies in the coming years.

New data from the Italian National Register of Congenital Coagulopathies, 2016 Annual Survey

BACKGROUND

In Italy, the National Register of Congenital Coagulopathies (NRCC) collects epidemiological and therapeutic data from patients affected by haemophilia A (HA), haemophilia B (HB), von Willebrand's disease (vWD) and other rare coagulation disorders. Here we present data from the 2016 annual survey.

MATERIALS AND METHODS

Data are provided by the Italian Haemophilia Centres, on a voluntary basis. Information flows from every Centre to a web-based platform of the Italian Association of Haemophilia Centres, shared with the Italian National Institute of Health, in accordance with current privacy laws. Patients are classified by diagnosis, disease severity, age, gender and treatment-related complications.

RESULTS

In 2016, the total number of patients with congenital coagulopathies in the NRCC was 10,360: 39.8% of these patients had HA, 31.5% had vWD, 8.5% had HB, and 20.2% had less common factor deficiencies. The overall prevalence of HA and HB was 13.9/100,000 males and 3.0/100,000 males, respectively. The overall prevalence of vWD was 5.4/100,000 inhabitants. During 2016, 126 patients had current alloantibodies to factor VIII (FVIII) or factor IX (FIX) and were under treatment with bypassing agents and/or immune tolerance induction. Overall, 388 patients with a history of alloantibodies were recorded in the NRCC of whom 337 with severe HA and 12 with severe HB. Coagulation factor use, evaluated from treatment plans, was approximately 451,000,000 IU of FVIII for HA patients (7.5 IU/inhabitant), and approximately 53,000,000 IU of FIX for HB patients (0.9 IU/inhabitant).

DISCUSSION

The prevalences of HA and HB fall within the ranges reported in more developed countries; the consumption of FVIII and FIX was in line with that of other European countries (France, United Kingdom) and Canada. The NRCC, with its bleeding disorder dataset, is a helpful tool for shaping public health policies, as well as planning clinical and epidemiological research projects.

Italian Registry of Congenital Bleeding Disorders

In Italy, the surveillance of people with bleeding disorders is based on the National Registry of Congenital Coagulopathies (NRCC) managed by the Italian National Institute of Health (Istituto Superiore di Sanità). The NRCC collects epidemiological and therapeutic data from the 54 Hemophilia Treatment Centers, members of the Italian Association of Hemophilia Centres (AICE). The number of people identified with bleeding disorders has increased over the years, with the number rising from approx. 7000 in 2000 to over 11,000 in 2015. The NRCC includes 4020 patients with hemophilia A and 859 patients with hemophilia B. The prevalence of the rare type 3 vWD is 0.20/100,000 inhabitants. Less common congenital bleeding disorders include the following deficiencies: Factor I (fibrinogen), Factor II (prothrombin), Factor V, Factor VII, Factor X, Factor XI and Factor XIII, which affect 1953 patients. Hepatitis C Virus (HCV) infection affects 1561 patients, more than 200 of whom have two infections (HCV + HIV). Estimated hemophilia-related drug consumption in 2015 was approx. 550 million IU of FVIII for hemophilia A patients and approx. 70 million IU of FIX for hemophilia B patients. The NRCC, with its bleeding disorder data set, is a tool that can provide answers to fundamental questions in public health, monitoring care provision and drug treatment, as well as facilitating clinical and epidemiological research.

Atomoxetine in the treatment of attention deficit hyperactivity disorder and suicidal ideation

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric childhood disorder. The most commonly used drugs in the treatment of ADHD are methylphenidate (MPH) and atomoxetine (ATX); the former of the two is prescribed in USA more than it is in Western Europe. Some of the most important safety concerns about ADHD drug treatment are sudden cardiac death and suicidal behavior. In this study, we present a series of cases of Italian children who had presented suicidal ideation during ADHD pharmacological therapy with ATX.

RESEARCH DESIGN AND METHODS

Data were obtained from the ADHD Italian Register. The data assessed the use of MPH and ATX, which had been prescribed to patients who were aged < 18 years and diagnosed with ADHD. All patients enrolled in the ADHD Italian Register treated with ATX or MPH who experienced suicidal thoughts or thoughts of self-harming were considered and assessed.

RESULTS

We describe the clinical cases of seven Italian children (enrolled in the ADHD Italian Register) treated with ATX and affected by suicidal ideation, self-harming or other similar symptoms. Our results highlighted that all seven patients developed suicidal ideation or intentional self-harming during pharmaceutical treatment with ATX and, particularly, after the dose increase of the drug.

CONCLUSION

There is a need to improve our knowledge about the efficacy and safety of ATX, MPH and other drugs used in the treatment of ADHD both in children and adults during the post-marketing experience.

The Italian institutional accreditation model for Haemophilia Centres

BACKGROUND

In Italy, basic health needs of patients with inherited bleeding disorders are met by a network of 50 haemophilia centres belonging to the Italian Association of Haemophilia Centres. Further emerging needs, due to the increased life expectancy of this patient group, require a multi-professional clinical management of the disease and provide a challenge to the organisation of centres.In order to achieve harmonised quality standards of haemophilia care across Italian Regions, an institutional accreditation model for haemophilia centres has been developed.

MATERIAL AND METHODS

To develop an accreditation scheme for haemophilia centres, a panel of experts representing medical and patient bodies, the Ministry of Health and Regional Health Authorities has been appointed by the National Blood Centre. Following a public consultation, a technical proposal in the form of recommendations for Regional Health Authorities has been formally submitted to the Ministry of Health and has formed the basis for a proposal of Agreement between the Government and the Regions.

RESULTS

The institutional accreditation model for Haemophilia Centres was approved as an Agreement between the Government and the Regions in March 2013. It identified 23 organisational requirements for haemophilia centres covering different areas and activities.

DISCUSSION

The Italian institutional accreditation model aims to achieve harmonised quality standards across Regions and to implement continuous improvement efforts, certified by regional inspection systems. The identified requirements are considered as necessary and appropriate in order to provide haemophilia services as "basic healthcare levels" under the umbrella of the National Health Service. This model provides Regions with a flexible institutional accreditation scheme that can be potentially extended to other rare diseases.

Attention-deficit/hyperactivity disorder drugs and growth: an Italian prospective observational study

OBJECTIVE

This study was conducted to assess the long-term effect of methylphenidate (MPH) or atomoxetine (ATX) on growth in attention-deficit/hyperactivity disorder (ADHD) drug-naïve children.

DESIGN

The study was an observational, post-marketing, fourth phase study.

METHODS

Data on height and weight were collected at baseline and every 6 months up to 24 months.

RESULTS

Both ATX and MPH lead to decreased height gain (assessed by means of z-scores); the effect was significantly higher for ATX than for MPH. At any time, height z-score decrease in the ATX group was higher than the corresponding decrease observed in the MPH group, but the difference was significantly relevant only during the first year of treatment. An increment of average weight was observed both in patients treated with MPH and in those treated with ATX. However, using Tanner's percentile, a subset of patients showed a degree of growth lower than expected. This negative effect was significantly higher for ATX than for MPH.

CONCLUSIONS

We conclude that ADHD drugs show a negative effect on linear growth in children in middle term. Such effect appears more evident for ATX than for MPH.

[ADHD register: post-marketing evaluation of the benefit-risk profile of drugs and promotion of the appropriateness]

INTRODUCTION

The Register was aimed at assessing the benefit-risk profile of the treatment of attention deficit hyperactivity disorder (ADHD) with atomoxetine and methylphenidate.

METHODS

Post-marketing observational study, phase IV. Prescription medication to children and adolescents with ADHD aged between 6 and 18 years in the centres of reference for ADHD accredited by the Italian regions.

RESULTS

In the period from September 2007 to October 2011, 1098 children and adolescents were treated with methylphenidate and 951 with atomoxetine. 411 (21.5%) patients are released from the register: 274 treated with atomoxetine and 167 with methylphenidate, with a greater risk of discontinuation for atomoxetine: RR 1.4 (1.3-1.6) p<0.001. The length of treatment at the time of removal from the register is 4.1 months for atomoxetine and 2 months for methylphenidate. Patients treated with atomoxetine are more likely to experience an adverse event compared to those treated with methylphenidate (RR 2.8; 1.9-4.2). The total number of serious adverse events observed was 110: 82 (75%) patients treated with atomoxetine and 28 (25%) individuals treated with methylphenidate. For 98 patients with serious adverse events, the adverse event led to the interruption of treatment with exit from the registry. The chance of a serious adverse event among those treated with atomoxetine compared to those with methylphenidate is RR 2.8 (1.8-4.2). There have been 14 cardiovascular events, all grown positively. 69 were found with a ECG alterations, with an increased risk for methylphenidate (RR 2.4; 1.4-4.2). The incidence of suicidal ideation was 4.5/1000 patients treated with atomoxetine. Hepatic alterations occurred with an incidence of 1/1000 subjects treated with methylphenidate and 4/1000 of those who received atomoxetine.

DISCUSSION

The survey was carried out on a population which represents appropriately the paediatric population. The observed prevalence of ADHD corresponds to the expectation based on data from previous epidemiological investigations in Italy but considerably lower than what is reported in the international scientific literature. The rate of exposure to pharmacological treatments is similar to that of other European countries.

Models for institutional and professional accreditation of haemophilia centres in Italy

The Health Commission of the Conference between the Italian State and Regions recognized the need to establish an institutional accreditation model for Haemophilia Centres (HCs) to be implemented by 21 Regions in order to provide patients with haemophilia and allied inherited coagulations disorders with high and uniform standards of care. The Italian National Blood Centre, on behalf of the Commission, convened a panel of clinicians, patients, experts, representatives from Regions and Ministry of Health. The agreed methodology included: systematic literature review and best practice collection, analysis of provisions and regulations of currently available services, priority setting, definition of principles and criteria for the development of recommendations on the optimal requirements for HCs. The result was the formulation of two recommendations sets. Two sets of recommendations were produced. The first concerns regional policy planning, in which the following aspects of comprehensive haemophilia care should be considered for implementation: monitoring and auditing, multidisciplinary approach to clinical care, protocols for emergency management, home treatment and its monitoring, patient registries, drug availability and procurement, recruitment and training of health care professionals. The second set concerns the accreditation process and lists 23 organizational requirements for level 1 HCs and 4 additional requirements for level 2 HCs. These recommendations help to provide Italian Regional Health Authorities with an organizational framework for the provision of comprehensive care to patients with inherited coagulation disorders based on current scientific evidence.

Cardiovascular measures in children and adolescents with attention-deficit/hyperactivity disorder who are new users of methylphenidate and atomoxetine

OBJECTIVE

The purpose of this study was to assess the cardiovascular effects of drugs used for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents treated in community care centers in Italy.

METHODS

This study was an open, prospective, observational study of youth with ADHD treated with atomoxetine (ATX) and methylphenidate (MPH). Measurements of blood pressure and heart rate, and electrocardiogram (ECG) assessment were performed at baseline and at regular intervals up to 24 months.

RESULTS

By June 2010, 1758 youth were enrolled in the Italian ADHD National Registry. Statistically significant increases were observed in cardiovascular measures: in the MPH group after 6 months in heart rate (+2.01, p = 0.01); in the ATX group after 6 months in diastolic pressure (+1.60, p = 0.01) and in heart rate (+2.93, p = 0.001), and after 12 months in heart rate (+3.26, p = 0.003). Compared with the baseline, 59 patients had an alteration of ECG during the follow-up period. Although at 12 months, the probability of detecting an abnormal ECG was higher in the MPH group than in the ATX group, only 2 out of 30 cases at 6 months with altered ECG were considered to have experienced serious adverse events. One case was treated with ATX and one with MPH, and arrhythmia was the detected abnormality.

CONCLUSIONS

Treatment with MPH and ATX in youth appears to have a small but significant impact on the cardiovascular system. The long-term impact of these medications is unknown. Several clinically meaningless ECG alterations were observed mostly in MPH-treated youth. We therefore suggest evaluating cardiovascular risks at baseline.

The reverse transcription inhibitor abacavir shows anticancer activity in prostate cancer cell lines

BACKGROUND

Transposable Elements (TEs) comprise nearly 45% of the entire genome and are part of sophisticated regulatory network systems that control developmental processes in normal and pathological conditions. The retroviral/retrotransposon gene machinery consists mainly of Long Interspersed Nuclear Elements (LINEs-1) and Human Endogenous Retroviruses (HERVs) that code for their own endogenous reverse transcriptase (RT). Interestingly, RT is typically expressed at high levels in cancer cells. Recent studies report that RT inhibition by non-nucleoside reverse transcriptase inhibitors (NNRTIs) induces growth arrest and cell differentiation in vitro and antagonizes growth of human tumors in animal model. In the present study we analyze the anticancer activity of Abacavir (ABC), a nucleoside reverse transcription inhibitor (NRTI), on PC3 and LNCaP prostate cancer cell lines.

PRINCIPAL FINDINGS

ABC significantly reduces cell growth, migration and invasion processes, considerably slows S phase progression, induces senescence and cell death in prostate cancer cells. Consistent with these observations, microarray analysis on PC3 cells shows that ABC induces specific and dose-dependent changes in gene expression, involving multiple cellular pathways. Notably, by quantitative Real-Time PCR we found that LINE-1 ORF1 and ORF2 mRNA levels were significantly up-regulated by ABC treatment.

CONCLUSIONS

Our results demonstrate the potential of ABC as anticancer agent able to induce antiproliferative activity and trigger senescence in prostate cancer cells. Noteworthy, we show that ABC elicits up-regulation of LINE-1 expression, suggesting the involvement of these elements in the observed cellular modifications.

Determinants of virologic and immunologic outcomes in chronically HIV-infected subjects undergoing repeated treatment interruptions: the Istituto Superiore di Sanita-Pulsed Antiretroviral Therapy (ISS-PART) study

BACKGROUND

Factors influencing the outcome of structured treatment interruptions (STIs) in HIV chronic infection are not fully elucidated.

METHODS

In ISS-PART, 273 subjects were randomly assigned to arm A (137 assigned to continuous highly active antiretroviral therapy [HAART]) and arm B (136 assigned to 5 STIs of 1, 1, 2, 2, and 3 months' duration, each followed by 3 months of therapy). Main outcome measures were the proportion of subjects with a CD4 count >500 cells/mm3, the rate of virologic failure, and the emergence of resistance at 24 months.

RESULTS

The proportion of subjects with a CD4 count >500 cells/mm3 was higher in arm A than in arm B (86.5% vs. 69.1%; P = 0.0075). Pre-HAART CD4 cell count and male gender were independent predictors of a CD4 count >500 cells/mm3 in arm B. The overall risk of virologic failure was not increased in arm B; however, it was higher in the 38 subjects who had resistance mutations in the rebounding virus. Archived mutations at baseline and the use of a regimen that included an unboosted protease inhibitor (PI), compared with nonnucleoside reverse transcriptase inhibitor-based HAART, independently predicted the emergence of plasma mutations during STI (P = 0.002 for DNA mutations and P = 0.048 for PI-based HAART).

CONCLUSIONS

Our results suggest that patients with preexisting mutations and treated with unboosted PI-based HAART should not be enrolled in studies of time-fixed treatment interruptions, being at higher risk of developing plasma mutations during STI and virologic failure at therapy reinstitution.

ISSQoL: A New Questionnaire for Evaluating the Quality of Life of People Living with HIV in the HAART Era*

OBJECTIVE

To design a Health-related Quality of Life (HRQoL) instrument for HIV-infected people in the era of highly active antiretroviral therapy (HAART).

METHODS

The self-administered questionnaire was developed by an Italian network including researchers, physicians, people living with HIV, national institutions and community-based organizations (CBO) through several steps: (1) review of existing HRQoL literature and questionnaires for HIV-infected people; (2) selection of relevant domains measuring HRQoL in HIV-infected people, and identification of new domains related to new aspects of HRQoL concerning HAART-treated individuals; (3) conduction of two pre-test analyses in independent groups of Italian HIV-positive people (n approximately =100) distributed throughout the country. The objectives of the first pre-test were to verify the usefulness of the questionnaire, to construct a form easily understandable by everyone, to define the domains and their significance; the second pre-test aimed at evaluating and reshaping the questionnaire based on a statistical analysis of the outcomes of first pre-test; (4) validation analysis. A large cohort of people with HIV infection was recruited for the last step.

RESULTS

The internal consistence reliability (Cronbach's alpha) was >or=0.70 for all domains. Most domains had Cronbach's coefficient >0.80. All domains demonstrated convergent and discriminant validity. The final version of ISSQoL includes two sections: HRQoL Core Evaluation Form (9 domains) and Additional Important Areas for HRQoL (6 domains). The ISSQoL was administered together with two additional forms: a Daily Impact of Symptoms Form and a Demographic Information Form. The Additional Important Areas for HRQoL include social support, interaction with medical staff, treatment impact, body changes, life planning, and motherhood/fatherhood.

CONCLUSION

The data reported in the present paper provide preliminary evidence of the reliability and validity of the ISSQoL questionnaire for the measurement of HRQoL in HIV-infected people. The direct involvement of HIV-positive people in all the phases of the project was a key aspect of our work.

[Association between sea recreational water and gastroenteritis]

Gastrointestinal infections represent one of the main cause of morbidity both in developing and industrialized areas. Quality of coastal waters is particularly important for countries as Italy that has several regions on coasts. Public health and economy aspects could be hardly affected by poor quality of sea waters. Several studies have been addressed to the association between sea recreational water and development of gastrointestinal infection but in Italy only sporadic cases of infection have been reported especially in immunocompromised hosts. Results of this study, either in the case control or in the active surveillance study seem to confirm the absence of an association between sea exposure and intestinal infections. One of the main risk factors for the development of these infections is still represented by the seafood consumption especially shellfish.

Survival of patients with blood-borne AIDS in Italy

BACKGROUND

AIDS represents an important public health problem in Italy. Long-term health care policy planning requires knowledge about the variability of the risk of mortality. The AIDS Surveillance Registry (RAIDS), maintained by the AIDS Operational Centre (COA) of the National Health Institute of Italy, provides valuable information to study the determinants of survival after diagnosis with AIDS. This study aimed to estimate the trends among people infected by the human immunodeficiency virus (HIV) through blood-related products.

METHODS

Study subjects were 595 persons with AIDS whose sole ascertained risk factors were either blood transfusions or plasma-concentrate infusions, diagnosed from the beginning of the epidemic in 1985 through June 1995 and reported to RAIDS by the end of June 1996. The Kaplan-Meier technique was used to estimate the survival distribution; log-rank and Wilcoxon tests were both performed to assess the effects of demographic and clinical factors. Cox proportional hazards models were used to identify those factors independently and significantly associated with death: model building and fitting were performed in a stepwise fashion, by using the score and martingale residuals, based on a new class of graphical and numerical methods developed recently for checking the assumptions underlying the model.

RESULTS AND CONCLUSIONS

In Italy the median survival time for AIDS patients infected by contaminated blood, was estimated to be 12.7 months. In univariate analyses it was found that women, younger patients (age < 35) and those diagnosed more recently with a higher value of CD4 cell counts (>37 cells m(-3)) have better survival. Patients diagnosed with AIDS-associated neurological disease (neuro-AIDS), or lymphoma, had a median survival significantly shorter. Patients diagnosed in the south of Italy tend to have a survival time shorter than patients diagnosed in the north. In a multivariate time-dependent regression analysis, only type of AIDS indicator disease, age and calendar time of diagnosis proved to be significant prognostic factors. It was not possible to estimate the effect of risk category (haemophiliacs versus transfused) due to the lack of proportionality in the estimated hazard. In conclusion, survival time is found to improve over time, indicating a likely positive effect of better care in treating HIV and AIDS patients.

Regional survival differences across Europe in HIV-positive people: the EuroSIDA study

OBJECTIVES

To analyse the survival differences between macro-regions of Europe (northern, central and southern Europe) between 1994 and early 1999, and their possible association with antiretroviral treatment differences.

DESIGN

From September 1994 the EuroSIDA study has prospectively followed non-selected HIV-infected people from 50 clinical sites in 18 European countries (n = 7331).

METHODS

Cox proportional hazards models were used to compare death rates between regions and to investigate the relationship between treatment usage and regional mortality rates. Kaplan-Meier curves were used to compare survival from the first CD4 lymphocyte count of < 200 x 10(6)/l or < 50 x 10(6)/l.

RESULTS

At the time of analysis, the median follow-up was 21 months and there was a total of 1544 deaths. In people with a CD4+ cell count that fell below 200 or 50 x 10(6)/l those from central Europe had a better prognosis compared with those from the two other regions (P < 0.05). Patients from central Europe were more frequently exposed to reverse transcriptase inhibitors and protease inhibitors compared with patients from other regions (P < 0.001). There was a significant difference in risk of death between regions after adjustment for baseline differences in demography, presence of AIDS and level of immunodeficiency (risk of death in central Europe was 37% lower than that in southern Europe (P < 0.0001) and 33% lower than in northern Europe (P < 0.0001)). After adjustment for use of individual antiretroviral agents, intensity of treatment regimen, CD4 lymphocyte count, weight, haemoglobin and development of AIDS as time-dependent covariates, the differences became much smaller (risk in central Europe 13% lower than that in southern Europe (P = 0.071) and 15% lower than in northern Europe (P = 0.054).

CONCLUSION

Antiretroviral therapy has been used more aggressively in Europe in recent years, resulting in improved prognosis. In this study we observed that the HIV mortality rate in central Europe was significantly lower than those in northern and southern Europe in the period 1994 to early 1999. This finding appears to be due to the effect on survival of different treatment policies and drug availability in the three regions of Europe during this time period, with central European countries, on average, having introduced more aggressive treatment strategies earlier.

Direct detection of Clostridium perfringens enterotoxin in patients' stools during an outbreak of food poisoning

An outbreak of diarrhoea in a hotel affected 25 time keepers attending the 1997 Mediterranean Games. Epidemiological investigation implicated a 'pasta al ragù' consumed at the hotel's restaurant and Clostridium perfringens food poisoning was identified by direct detection of C. perfringens enterotoxin in patients' stools. This report confirms that a careful evaluation of epidemiological features, together with the availability of direct and rapid laboratory methods, may lead to a prompt identification of C. perfringens food poisoning.

The impact of antiviral therapy with zidovudine: a retrospective study on HIV-positive hemophiliacs in Italy. Italian Group of Congenital Coagulopathies

BACKGROUND

The effects of zidovudine (ZDV) treatment on progression to AIDS are not completely clear. This study evaluated the effects of ZDV treatment on the progression to AIDS in HIV-positive hemophiliacs.

METHODS

A retrospective study was carried out on HIV-infected hemophiliacs: it included 238 individuals, 119 each from the treated and the non-treated groups. For the group receiving ZDV, we included those for whom a CD4+ count was available prior (median = 1 month) to beginning therapy. The cumulative incidence of developing AIDS was estimated by the Kaplan-Meier method. To identify factors independently associated with progression to AIDS, a Cox proportional hazards model was used.

RESULTS

The cumulative incidence of developing AIDS at 8 years after HIV seroconversion was 10.4% [standard error (SE) = 2.8%] for the treated group and 17.1% (SE = 3.8%) for the non-treated group. The difference was statistically significant (p = 0.01). By multivariate analysis, ZDV therapy and CD4+ T-cell count > 200/mm3 were the parameters independently associated with a slower progression to AIDS.

CONCLUSIONS

Treatment with zidovudine seems to slow the progression to AIDS in HIV-positive hemophiliacs.

Time from diagnosis of acquired immune deficiency syndrome (AIDS) to death among persons with blood-borne AIDS in Italy

The objective of the study reported here was to analyze survival time and factors associated with more rapid death among persons with acquired immune deficiency syndrome (AIDS) in Italy who acquired human immunodeficiency virus (HIV) infection through the transfusion of blood (n = 115) or blood components (n = 111). Subjects included all persons with AIDS all reported to the Italian AIDS Registry. The Kaplan-Meier method was used to estimate both the median survival time from the date of AIDS diagnosis to the date of death and the median survival time stratified by age at diagnosis, time of diagnosis, and AIDS-indicator disease. The Cox proportional-hazard model was used to assess factors independently associated with death. The prognosis for persons with blood-borne AIDS in Italy remains poor: overall median survival time was estimated to be 9.2 months, with no significant differences between hemophiliacs and transfusion recipients (p = 0.91). The median survival time for subject > 60 years old was 6.0 months, which is a significantly shorter time than that for younger subjects (p < 0.001). Subjects diagnosed prior to 1988 had a median survival time of 8.2 months, which is a significantly shorter time than that for subjects diagnosed after 1987 (p < 0.03). Subjects neurologically affected by AIDS had a median survival time of 4.1 months, which is a significantly shorter time than that for subjects diagnosed with any other disease (p = 0.03). Such factors were independently associated with more rapid death.

Splenectomy outcome in a hemophilic patient with HIV-related immune thrombocytopenia

We report the case of a young hemophilic patient with antibodies against the human immunodeficiency virus (HIV) who was affected by immune thrombocytopenic purpura (ITP). This condition did not respond to pharmacological therapy with steroids and alpha-2b-r-IFN, and the patient was splenectomized. Immune status evaluation was performed before and after surgery and during follow-up with CD4-CD8 monoclonal antibodies and cytofluorimetric analysis in order to explore possible correlations between splenectomy and the cytologic immune regulatory system. Splenectomy resulted in a resolution of ITP with consequent disappearance of the hemorrhagic diathesis related to thrombocytopenia. Moreover, at 30 months from splenectomy the patient is still in remission, his CD4 count is not decreased, and no progression to AIDS has been evidenced. These aspects are analyzed and briefly discussed.

Intranasal DDAVP: biological and clinical evaluation in mild factor VIII deficiency

We report a study undertaken to test the biological effect of intranasal 1-deamino-8-D-arginine vasopressin (DDAVP) and its efficacy in the treatment of bleedings in patients with mild factor VIII deficiency. The biological study was carried out in 20 patients: an increase of factor VIII:C and von Willebrand factor antigen levels was observed after inhalation of DDAVP at average post/pre inhalation ratios of 2.80 and 1.72, respectively. No relevant alterations of fibrinolysis were noted. In fact, we only observed a simultaneous increase of tissue plasminogen activator and plasminogen activator inhibitor, without modification of D-dimer. In 10 cases intranasal DDAVP has been used in the prevention or in the treatment of bleeding complications: no bleedings were observed.

Essential thrombocythemia: a retrospective study on the clinical course of 100 patients

We report a study concerning 100 patients affected by essential thrombocythemia: 90 adult (age greater than 20 years) and 10 pediatric subjects. The diagnosis was made by chance (78%), because of hemorrhages (10%), thrombosis (9%), vasomotor symptoms (29%). In the adult group, single-agent chemotherapy was performed with good remission using pipobroman or interferon. Antiaggregant agents were used in all patients at diagnosis. During the clinical course only a few complications occurred.

Carrier detection and prenatal diagnosis in haemophilia A and B

Sixty probable carriers of haemophilia from 25 families were studied by using coagulation phenotype and DNA analysis: 33 with haemophilia A and 27 with haemophilia B. Coagulation phenotype was based on factor VIII/IX assay and DNA analysis on the examination of restriction fragment length polymorphisms (RFLPs) within and closely linked to factor VIII or IX: 3 RFLP for factor VIII and 3 for factor IX. The comparison between the coagulation phenotype and RFLP analysis showed the misclassification of 15 females (6 for haemophilia A and 9 for haemophilia B). Four prenatal haemophilia A diagnosis were made by DNA analysis of chorionic villi, taken with a transcervical trophoblastic biopsy, between the 18th and the 11th week.