Efficacy and safety of nadroparin in the treatment of pregnant women with antiphospholipid syndrome: a prospective cohort study.

The optimal therapeutic management of patients with antiphospholipid syndrome (APS) during pregnancy is debatable. In the present prospective cohort study the use of a low molecular weight heparin (LMWH) (nadroparin), administered alone twice daily in 30 pregnant women who were diagnosed with APS on the basis of the current classification criteria, is evaluated. Dosage was adjusted according to anti-Xa levels in the patients as the pregnancies progressed. Three women, in whom an important gradual fall in platelet count in the first trimester did not respond to increased nadroparin doses, were shifted to a second-line treatment protocol. Fetal loss occurred in two of the 27 remaining women (7.40%), while 25 (92.59%) delivered 25 live infants, between the 32nd and 40th weeks of gestation. No fetal problems were registered during pregnancies, while maternal complications occurred in two of the 25 patients (8%). Moreover, there were no thrombotic events in any of the women during the study. Patient compliance was good and only minor side-effects were reported. The results of this study indicate that nadroparin alone is useful and safe in the management of pregnant patients with APS. However, in consideration of the good pregnancy outcome obtained in patients with only pregnancy morbidity when heparin and aspirin were used together, other studies comparing nadroparin twice daily with once daily plus Aspirin would be useful to ascertain which is more effective in these patients.

Aggressive angiomyxoma of the vulva: expression of estroprogestinic receptors and follow-up.

PURPOSE OF INVESTIGATION: To analyze aggressive angiomyxoma hormone-dependency. METHOD: Estroprogestinic receptor expression was studied by immunohistochemistry in 5 patients with aggressive angiomyxoma of the vulva. RESULTS: The immunohistochemical results confirm the positivity of angiomyxoma for estrogen and progesterone receptors. CONCLUSIONS: We hypothesized that the concomitant factor favoring neoplastic growth is a different genetic substrate specific in the female sex. Analysis of the data regarding the distribution of angiomyxomas in different age groups has strengthened this hypothesis suggesting that this tumor is correlated with complete maturity, in all probability hormonal. However it cannot be excluded that the tumor begins to develop at an early age, but since it has a slow growth rate, the phenomenon is delayed and is related to hormonal stimulation.

Oral hyposensitization to nickel allergy: preliminary clinical results.

Fifty-one patients presenting a dermatological allergy (erythema, urticaria, angioedema, contact dermatitis) to nickel were treated over 3 years with oral doses of 0.1 ng nickel sulfate per day, following a low-nickel diet. Diagnostic tests comprised patch and oral provocation tests. In 7 cases, the treatment was interrupted because of symptom reactivation, and in 14 cases for other reasons. Among the 30 cases who went through the whole follow-up, symptomatology totally disappeared in 29 cases, and a partial alleviation was achieved in 1 case after 1 year of treatment. Oral provocation tests with these 30 patients showed an overall increase of tolerance. Patch tests showed no variation in 20 cases, a diminution in 5, and were negative in 5. Although the study was not conducted double blind, the results of this attempt to cure nickel allergy are statistically significant.

Rush desensitization in heparin hypersensitivity: a case report.

Among all the known drug intolerances, adverse reactions to heparin are not very common. No desensitization in patients with heparin hypersensitivity has ever been attempted. We report the case of a 55-year-old female patient with mitral stenosis and insufficiency, and tricuspid and aortic insufficiency. The patient underwent heparin treatment, and urticaria occurred with either s.c. calcium heparin or i.v. sodium heparin. Allergy testing (skin tests and patch tests) was negative. A pseudoallergic intolerance was diagnosed. Mitral valve replacement with the extracorporeal circulation method was necessary; therefore, heparin treatment was administered. A heparin rush desensitization together with antihistamine drugs (4 mg clorpheniramine maleate for 3 d) was started: 50 UI (0.5 mg) s.c. sodium heparin were first administered; within 4 d, 5000 UI (50 mg) sodium heparin was administered i.v. with no side-effects. A full-dosage heparin treatment was then administered and heart surgery was easily performed. During the postsurgical course, i.v. sodium heparin was smoothly replaced with s.c. calcium heparin (25,000 UI s.c. per day) and with oral anticoagulants (sodium warfarin).

Anaphylactic shock after skin test with phytohaemoagglutinin.

A young woman (26 years old), with gastrointestinal candidosis of 8 months duration, was hospitalized in our department to study her cell immunity. Five minutes after an id injection of PHA (bactophytohaemoagglutinin M, Difco, 1 mg), mix monilieae, mix tricophyton and PPD Berna, she showed an extensive wheal and flare reaction in the PHA injection area, eyelid oedema and respiratory distress. In spite of adrenaline, corticosteroid and antihistamine drug administration, the patient collapsed and was admitted to the resuscitation department, where she quickly recovered. In the following days, the patient underwent immune and allergy testing: 1) total Ige immuno-enzymatic assay: 72 KU/1; 2) specific IgE and IgE immuno-enzymatic assay for Candida: negative; 3) in vitro lymphocyte transformation test (thymidine 2-C14) with PHA Difco was positive. This finding and the positivity of the id injection with PHA could indicate an allergic type I immunoreaction, the description of which we have not found in the international literature (the presence of IgG STS cannot be totally excluded).

Intranasal treatment with lysine acetylsalicylate in patients with nasal polyposis.

Forty-three patients suffering from nasal polyposis underwent intranasal treatment with increasing doses of lysine acetylsalicylate (LAS) corresponding to 20, 200, and 2000 micrograms of aspirin (ASA), until a maximal dose of 2000 micrograms weekly was reached. The patients were divided in two groups: a group of 28 patients with ASA intolerance, including 20 with ASA triad, and a group of 15 patients without ASA intolerance. The local treatment was usually started 1 month after polypectomy and was well tolerated without side effects. A control group included 191 subjects with nasal polyposis, 130 of whom had ASA intolerance. After polypectomy the controls received no further medical treatment. Patients were examined every 3 months and radiographs of the paranasal sinuses were obtained every 6 months. After 24 months 34 of 43 patients (79.1%) treated with topical LAS had suffered no relapse of polyposis. Only 45 of 191 control patients (23.6%) failed to relapse after 24 months (P less than .0001). Nine of 28 (32.1%) ASA-intolerant patients treated with LAS and 105 of the 130 (80.77%) control subjects relapsed (P less than .0001). None of the 15 ASA-tolerant patients treated with LAS relapsed, but 41 of the 61 (67.21%) nontreated control subjects relapsed (P less than .00001). These data indicate topical LAS is effective in preventing recurrence of nasal polyps after polypectomy.

Nasal provocation test with lysine acetylsalicylate in aspirin-sensitive patients.

The authors have studied nasal provocation testing (NPT) with aspirin in 45 aspirin-sensitive patients (40 affected by nasal polyposis) and in 38 aspirin-tolerant patients (27 affected by nasal polyposis). The test was positive in 37.7% of aspirin-intolerant subjects, but only in 7.9% of subjects in the control group (P less than .01).

Nasal secretion specific IgE in rhinitis patients.

Forty-five subjects with rhinitis of suspected allergic origin underwent immune and allergy testing including skin-tests and immuno-enzymatic assay of serum and nasal secretion specific IgE (RAST). Nasal secretion was collected using a cotton tampon inserted in both middle meati. A statistical analysis comparing the results of skin-tests and serum RAST was performed: the results obtained with these two techniques were very homogeneous (86.7% accuracy). An overall concordance (82.2%) was also observed by comparing skin-tests and nasal secretion RAST. Finally, the results of serum and nasal secretion RAST were compared: in this case totally superimposed data were reported (overall accuracy: 93.3%). In all cases the comparison between RAST classes in serum and nasal secretion was carried out: the difference between the semiquantitative evaluation of reaginic concentration classes using these two methods is not statistically significant (chi-square test). This technique of nasal secretion collection is simple and with no risk involved.

Serum IgE and atopy in drug-sensitive patients.

One of the most interesting aspects of the pathogenesis of the allergic and pseudo-allergic reactions to drugs is the one concerning the possible roles of genetic factors, in general, and the relationship with atopy, in particular. We decided to study the correlation between the serum level of total IgE, the personal and familial history of atopy, and the allergologic tests (skin test, PRIST, RAST, etc) for one or more drugs taken by 465 patients with personal history of allergic reactions. From the data, we observed that the average amount of total IgE lies within the norm, 125.4 KU/L (+/- 209.2), without any significant difference between the allergic (132 KU/L) and the pseudo-allergic (121.8 KU/L) patients. The IgE levels tend to be higher in that part of the tested population which presented a circumstantial atopic status (11.8%) and they are not influenced by an allergic or pseudo-allergic reaction to drugs. According to these results, the relationship between drug hypersensitivity and atopy needs further investigation.

Pancuronium allergy: a case report.

A case of anaphylactic shock to pancuronium bromide is described in which a type I immunological reaction occurred. A 33-yr-old male anaesthetist, with no family or personal history of allergy, collapsed soon after induction of anaesthesia. The drugs used included fentanyl, droperidol, thiopentone and pancuronium. Diffuse erythema occurred, with probable cardiac arrest. The patient was treated with cardiac massage, sympathomimetics and cortisone, and made a complete recovery. Examination (skin tests, passive transfer according to Prausnitz and Küstner, in vitro lymphocyte transformation test, total IgE assay) revealed that the allergic reaction was to pancuronium bromide.

Status of patch and other skin tests in diagnosis of systemic penicillin allergy.

It is generally accepted that cell-mediated immunity is responsible for contact dermatitis, but controversy still exists about the involvement of Type IV immune-reactions in other clinical manifestations following inhalant, oral and parenteral administration of penicillin and semi-synthetic penicillin or cephalosporins. The aim of the present study was to contribute to a better understanding of the pathogenetic mechanism responsible for these reactions. Detailed history taking, clinical and immuno-allergological investigation on 161 patients with a history of an allergic reaction to penicillin and/or semisynthetic penicillins and/or cephalosporins was carried out with the following tests: skin tests, patch tests, RAST, PRIST and lymphocyte transformation test. The statistical evaluation of data was performed by X2 test. Comparative studies were focused on groups of patients who presented a positive reaction to patch test (37) skin test (scratch and intradermal) (42), simultaneous skin and patch test (5) and negative skin test (87). No significant difference was observed among the groups studied, although in positive and skin test, a higher frequency is observed to be associated with anaphylactic shock and eczematous type of reaction. It is not possible however not only, to establish whether this is due to a combined immune-reaction (Type I and IV), orto a causal coexistence of the two mechanisms but even to determine either of allergic or pseudoallergic phenomenon without any accurate immunoallergological test. It is suggested that patch tests be carried out as routine investigations on patients with a systematic reaction to penicillins and/or cephalosporins, regardless of the route of administration.

ASA disease: the clinical relationship of nasal polyposis to ASA intolerance.

We studied the complex relationship between nasal polyposis and ASA (acetylsalicylic acid) intolerance in 154 patients with nasal polyps. The clinical histories of all patients were reviewed, and diagnostic tests for immune or allergic causes and the responsiveness of patients to challenges with ASA-substitutive drugs were analyzed. A third of our patients tested were found to have positive personal histories of atopy and 35% showed ASA intolerance. Although 40% had bronchial asthma, only 16.8% of all patients had positive tests for allergy. We were unable to find a specific mechanism to explain the relationship between nasal polyposis and ASA intolerance and further investigations are still required.

Malignant trophoblastic neoplasias. Clinical experiences.

The Authors describe a treatment program for malignant trophoblastic disease based on a combination chemotherapy. The results of their clinical experience concerning 41 cases confirms the high cure rate for low risk metastatic disease (100%) with the only failures limited to the high risk patients (64.7% cure rate).

Hormonal receptors in vulvar tissues.

Since 1982 we have been associating the study of hormonal receptors with the histological examination of the vulvar lesions in an attempt to interpret the action mechanism of steroids on the vulva, to find possible correlations between histological pictures and receptorial order and to find a possible predictive "marker" toward therapeutic and prognostic ends. In our Laboratory assays for androgen, estrogen and progesterone receptors were performed with the Dextran-Charcoal technique in 41 patients with vulvar dystrophy; 20 of whom had atrophic dystrophy and 21 with hypertrophic dystrophy. Another 24 patients with vulvar carcinoma were studied; 23 with epidermoid carcinoma of various differentiation grades and only one case of Paget's Disease. None of the three receptors assayed could be considered a predictive or prognostic marker in the approach to neoplastic forms. The levels of the progesterone receptor appears increased in the case of dystrophies. This justifies the hypothesis of a hormonal involvement in the pathogenesis of the lesion, as has already been documented by the beneficial effects of therapy with topical steroids.

Colpocytology in children: 3 cases of botryoid sarcoma.

We have examined some aspects of the colpocytological preparations of 3 children affected by leucorrhea accompanied by bleed up, from which was diagnosed botryoid sarcoma. The characteristic element met in the preparations was the altered epithelial maturation in prepuberal children; the presence of groups of intermediate and superficial cells, with nuclei sometimes diskaryotic, of anucleate scales and of discharging phenomena. In one case it was possible to observe even neoplastic and slightly differentiated cells. The Authors underline the usefulness of carrying out a colpocytological examination in the initial diagnostic stage with children affected by leucorrhea, above all if this is accompanied by bleeding.

Steroids receptors in physiological and pathological features of the cervix.

The presence of ER and PgR in human cervical tissues was investigated. The material consisted of receptor measurements in tissue sample obtained from normal and abnormal colposcopical pictures (leukoplakia, mosaic, punctation, atypical transformation), in 38 outpatients. The receptor assays were performed by a dextran-coated-charcoal (DCC) technique.