Fibrinogen apheresis in the treatment of peripheral arterial disease.

BACKGROUND: Fibrinogen is mainly responsible for determining the viscosity of whole blood. In peripheral arterial disease (PAD) the fibrinogen concentration seems to affect the microcirculation flow. AIM: To study the effects of an abrupt reduction of fibrinogen on the hemodynamics of the lower extremities and the clinical picture of patients with PAD. METHODS: Ten patients affected by various stages of PAD underwent 1 session of fibrinogen apheresis (TheraSorb, Miltenyi Biotec, Germany). Laboratory parameters of endothelial activation were assessed before and after the session, as well as walking distance (WD), the ankle-brachial index and laser Doppler flowmetry. RESULTS: A significant reduction in the laboratory parameters was observed: fibrinogen (50%), total cholesterol (18%), LDL cholesterol (24%), sE-selectin (23%), sICAM-1 (19%) and sVCAM-1 (10%). The procoagulant factors, factor VIII and von Willebrand factor, did not vary significantly. Both pain-free and total WD were significantly improved (p < 0.003 and p <0.006, respectively), the ankle-brachial index remained unchanged, and laser Doppler flowmetry showed a modest but not significant increase. CONCLUSIONS: Fibrinogen apheresis allowed us to study the effects of an acute modification of fibrinogen in PAD, on both some aspects of the endothelial function and on the hemodynamics, demonstrating an improvement of WD and a minimal increase in the skin microcirculation.

A protocol for oral desensitization in children with IgE-mediated cow's milk allergy.

OBJECTIVES: To desensitize children with severe immunoglobulin (Ig)E-mediated cow's milk allergy in a period of 6 months by introducing increasing daily doses of cow's milk (CM) in order to enable the child to assume 200 ml of CM daily, or to induce tolerance of the highest possible CM dose. STUDY DESIGN: Twenty-one children at least 6 years old with severe IgE-mediated CM allergy were admitted to the study. A convincing history of IgE-mediated CM allergy or a positive double-blind placebo-controlled food challenge with CM confirmed the diagnosis. Oral desensitization was performed with increasing doses starting from 0.06 mg of CM proteins. RESULTS: Overall, 15 of 21 children (71.4%) achieved the daily intake of 200 ml during a 6-month period; three of 21 children (14.3%) tolerated 40-80 ml/day of undiluted CM; three of 21 children (14.3%) failed the desensitization because they presented allergic symptoms after ingesting minimal amounts of diluted CM. CONCLUSIONS: We successfully desensitized 15 of 21 children with severe IgE-mediated CM allergy in a period of 6 months. We stress the importance of the partial outcome in those three of 21 children who could not reach the maximum amount of 200 ml/day of whole CM, but were able to tolerate 40-80 ml/day of CM. In this way we dramatically reduced the risk of severe reactions after accidental or unnoticed introduction of low quantities of CM. We do not propose generalizing this method beyond trained staff.

[Carotid endarterectomy in the elderly]. / L'endoarterectomia carotidea negli anziani.

The elderly population has the highest risk for developing stroke and the annual death rate is some 394/100,000 population. Moreover, the elderly are the fastest growing segment in our society. In carefully selected patients carotid endarterectomy may provide to prophylaxis against stroke. With a careful selection, acceptable low operative motality and morbidity rates may be achieved, comparable to the 4.3% and the 2.3% of the Veterans Affair and ACAS studies, in which the patients' mean ages were 64.1 and 67 years respectively.

Thalassemic syndromes in Latium: epidemiological evaluation.

BACKGROUND AND OBJECTIVE: After the first National Census of transfusion-dependent thalassemics (1984), in 1992 the Italian Association of Pediatric Hematology and Oncology and the National Health Institute organized its 3rd edition. Here, results concerning Latium are presented and discussed. DESIGN AND METHODS: Data for Latium, as in the rest of Italy, were collected by a single reference center; among all eventual care centers for thalassemia initially contacted, only those with patients were sent data forms. For new cases, a questionnaire was submitted to parents to obtaining social data, and information on their knowledge of thalassemia. RESULTS: Collected data were divided into 2 groups: old cases, before June 30, 1988, and new cases, between July 1, 1988 and December 31, 1992. On the whole, 262 transfusion-dependent thalassemics (127 m., 135 f.) could be counted. Sixteen percent were affected with thalassemia intermedia, severe enough as to need regular transfusions. New patients (last 5 years): the birth of almost 80% of them was due to combined mistakes of parents and doctors. Disease evolution: 19/262 patients had been submitted to BMT (presently transfusion-free). Causes of death: 22 patients died in the considered period, mostly for cardiologic complications. INTERPRETATION AND CONCLUSIONS: Data emerging from censuses on specific pathologies of high social impact (such as thalassemia) may help health plans to rationalize public expenditure, especially by improving working conditions of care centers.