Iloprost treatment reduces TNF-alpha production and TNF-RII expression in critical limb ischemia patients without affecting IL6.

Iloprost, a stable prostacyclin analogue, regulates expression of genes that are involved in inflammation and in cell growth and inhibits the in vitro production of cytokines. We evaluated the effect of an in vivo weekly iloprost treatment on TNF-alpha and IL6 monocyte production (evaluated by ELISA), on monocyte apoptosis (Annexin V/uptake of propidium iodide by flow cytometry) and on peripheral blood mononuclear cell (PBMC) TNF-alpha receptors (TNF-RI and TNF-RII) mRNA expression (RT-PCR) in 14 atherosclerotic critical limb ischemia patients. PBMC were stimulated with LPS for 24h. TNF-alpha production was significantly reduced by iloprost whereas IL6 production was not affected. Iloprost did not accelerate monocyte apoptosis. TNF-RI mRNA expression was not modified by iloprost, whereas TNF-RII mRNA expression was significantly reduced. Our data show that iloprost may have anti-inflammatory effects in addition to the well-known vasodilatatory and anti-aggregant ones.

Short-term and long-term effects of one-week treatment with intravenous iloprost in critical limb ischemia patients (Leriche-Fontaine stage III and IV).

AIM: Iloprost, usually administered through intravenous infusion for 6 hours per day for at least 21 days, is the main medical treatment for critical limb ischemia in patients unsuitable for surgical or endovascular approach. We evaluated the tolerance and the short-term and long-term effects of a single 1-week treatment in critical limb ischemia patients. METHODS: Twenty-nine patients in Leriche-Fontaine III and IV stage were treated with iloprost infusions for 16 hours per day for 7 days, achieving a maximal dose of 1.5 ng/kg/min. Tolerance and clinical assessment after treatment discontinuation and after 1 and 6 months were recorded; clinical evaluation (rest pain, trophic lesions), ankle/brachial pressure index (ABPI) and treadmill exercise test were performed before, immediately after treatment and after 1 and 6 months. RESULTS: No discontinuation of treatment occurred because of intolerance to iloprost. At the end of the treatment 69% of patients were responders, 55.2% at 1 month, 37.9% after 6 months. ABPI and treadmill maximum walking distance were improved by the treatment at every timepoint. After 6 months 10.3% mortality and 3.4% major amputation rates were recorded. There was a higher percentage of non-responders amongst women vs men, in diabetic patients vs non diabetic and in stage IV patients vs stage III. CONCLUSIONS: One-week treatment with iloprost is safe and effective in both Leriche-Fontaine stage III and IV patients. Clinical effects are persistent over time, often lasting up to the 6th month, similarly to the commonly used 28-day treatment, with clear implications in terms of patient's compliance and medical cost containment.

[Use of a new preparation of flunarizine in patients with peripheral obliterating arteriopathy at the second stage. Controlled clinical study]. / Impiego di una nuova preparazione di flunarizina in pazienti con arteriopatia obliterante periferica al secondo stadio. Studio clinico controllato.

The authors report a randomised double-blind clinical study on the efficacy and tolerability of flunarizine. Two groups of patients with obliterating peripheral arterial disease (stage II) were treated for 3 months either with 10 mg flunarizine or with placebo and were examined monthly as to subjective symptoms, laboratory and instrumental parameters. Findings were evaluated by analysis of variance and Student's t-test. After three months, the flunarizine group had a greater increase of the distance walked before the onset of claudication and of maximum post-ischemic blood flow. No changes were observed in laboratory tests and central hemodynamics. The score of subjective symptoms was improved in the flunarizine treated group. Tolerance was good, side effects requiring withdrawal of treatment were not observed.

[Calcium dobesilate, hemorheology, fibrinolysis and endothelium. New perspectives on the prevention of diabetic microangiopathy. Clinical pharmacological study]. / Dobesilato di calcio, emoreologia, fibrinolisi ed endotelio. Nuove prospettive nella prevenzione della microangiopatia diabetica. Studio di farmacologia clinica.

The authors report the results of a double-blind cross-over study on calcium dobesilate in which two groups of eight recent-onset type-II diabetics were treated either p.o. (1 g once daily) or i.v. (500 mg in 100 ml of physiological saline) with calcium dobesilate or with placebo. During oral administration of the drug, blood rheology and total fibrinolytic capacity were assessed by calculating euglobulin lysis time. In view of the evidence for a viscosity-lowering action of the drug (which had already been found in "long-term" studies) and of potentiation of fibrinolytic activity, intravenous treatment was started with the object of elucidating the possible mechanisms of action, evaluating at the same time other parameters concerning the functional fibrinolytic pathways. It has thus been possible to ascertain that the drug has "rheologic" activity, interferes with the function of endothelial cells by stimulating the release of tissue plasminogen activator and thus increases fibrinolytic activity while not interfering with the clotting function and not altering platelet beta-thromboglobulin secretion. These findings appear to confirm the possibilities for therapeutic use of calcium dobesilate which is thought to act on a variety of pathogenetic mechanisms involved in diabetic microangiopathy.

Kaposi's sarcoma of lymph nodes associated with multicentric angiofollicular hyperplasia.

A case of multicentric angiofollicular hyperplasia (hyaline-vascular type) associated with Kaposi sarcoma of lymph nodes is reported. The patient was a 75-year-old man who suffered from edema, fever, maculopapular skin rashes and polyclonal hypergammaglo-bulinemia and died 10 days after admission to hospital for acute tubular necrosis and pulmonary edema. No other localizations of Kaposi's sarcoma were detected at autopsy; this is a very uncommon finding in Western countries and in adult people.

Allopurinol prevents ischaemia-dependent haemorheological changes.

Pre-treatment with allopurinol is able markedly to attenuate the deterioration in blood viscosity (BV) and whole blood filterability (WBF) that occurs after ischaemia during exercise. It also reduces the exercise-induced increase in serum oxidase activity, although this action is slightly less effective in peripheral obliterative arterial disease (POAD) patients. Conversely, allopurinol is completely ineffective in modifying haemorheological parameters in vitro, and it does not affect superoxide anion generation or enzyme release from neutrophils stimulated in vitro with formyl-methionyl-leucyl-phenylalanine (FMLP). It is suggested that allopurinol may attenuate changes in BV and WBF by affecting xanthine-oxidase-dependent free radical formation in tissues.

Primary and secondary blood hyperviscosity syndromes, and syndromes associated with blood hyperviscosity.

Despite the methodological difficulties of evaluating the role of a single rheological component, some clinical situations characterised by an increase of blood viscosity can be identified. These are classified as 'blood hyperviscosity syndromes' and can be divided into 2 groups. The first includes pathophysiological conditions in which a primary blood abnormality causes a decrease of blood flow, as occurs in polycythaemic, sclerocythaemic and seric hyperviscosity syndromes, and may be referred to as 'primary blood hyperviscosity syndromes'. The second group includes pathological conditions in which a primary reduction of blood supply to tissue provokes tissue ischaemia, and an impairment of rheological properties of blood can be observed at microcirculatory level. Thus, these situations have been described as 'secondary blood hyperviscosity syndromes'. Patients with peripheral obliterative arterial disease, ischaemic cardiopathies and cerebrovascular insufficiencies show a diminution in blood fluidity during spontaneous or provoked ischaemic conditions which disappears after reperfusion of the tissue. The pathogenesis of this rheological damage is unclear, but may arise from the complex relationship among blood cells (red cells, leucocytes, platelets), endothelium and plasma components. In addition to these 2 groups of blood hyperviscosity syndromes, several pathological states such as diabetes, shock, surgery, and rheumatic disease have been described in which an increase of blood viscosity can be observed. For these situations, which require much further investigation, the term 'syndromes associated with blood hyperviscosity' could be proposed.

Hemorheological factors in the pathophysiology of acute and chronic cerebrovascular disease.

The hemorheologic changes in three groups of patients suffering from acute and chronic cerebrovascular diseases were studied. Firstly, a horizontal study on 57 patients with definite stroke and on 49 patients with TIA was made. Plasma viscosity, whole blood filtration rate, fibrinogen concentration and hematocrit were evaluated as markers of the rheological property of blood. Blood samples were drawn within 6 h from the onset of vascular syndrome. The findings were compared with values obtained in 112 as controls. At the same time, washed red cell filtration rate, together with lactoferrin, betaglucuronidase and beta-thromboglobulin plasma level were assayed. In both groups the onset of the vascular storm was associated with a marked increase of plasma fibrinogen and of blood and plasma viscosity and a significant decrease of whole blood filterability. Lactoferrin, betaglucuronidase and beta-thromboglobulin levels were also significantly increased. Following this, a longitudinal study was performed on 27 patients with definite stroke and 32 patients with TIA. The clinical regression of acute stroke was associated with the progressive reduction of rheological abnormalities. Finally, 81 patients with clinical diagnosis of cerebrovascular disease due to previous stroke or repeated TIA were studied together. An increase of blood viscosity, of fibrinogen concentration and of hematocrit and a decrease of blood filtration rate together with higher levels of beta-thromboglobulin were registered. These results confirm the existence of an association between CVD and hemorheological alterations and suggest more in depth research directed towards identifying the significance of these alterations in the pathogenesis of tissue ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of reduction of blood viscosity at constant hematocrit on the cerebral blood flow]. / Effetti della riduzione della viscosità ematica ad ematocrito costante sul flusso ematico cerebrale.

It is well established that cerebral blood flow (CBF) is low in patients with high hematocrit and is high in anemic patients. An inverse relationship between CBF and hematocrit has been found. Furthermore, if hematocrit is reduced, CBF increases. There is some debate as to whether these observations are due to viscosity or to oxygen carrying capacity of the blood. In order to further elucidate this problem, CBF, blood viscosity and hematocrit were measured in 4 patients with paraproteinemias before and after paraproteins had been removed by plasmapheresis without changes in hematocrit. After plasmapheresis, blood viscosity significantly decreases and CBF increases by a mean of 24.4 ml/100 g/min. Mean arterial blood pressure and hematocrit were not influenced by plasmapheresis. These results indicate that blood viscosity is an important factor in determining CBF. This does not exclude the role of oxygen transport as an associated factor, but it is evident that oxygen transport and blood viscosity are independent variables in the control of CBF.

[Assay of erythrocyte ATP by chemoluminescence. Protective action induced by pentoxifylline on the depletion of energy from stored erythrocytes]. / Valutazione dell'ATP eritrocitario per chemiluminescenza. Azione protettiva indotta dalla pentossifillina sulla deplezione energetica da conservazione delle emazie.

A new method to measure erythrocyte ATP levels is used. The authors have incubated 6 whole blood samples and 7 samples containing washed red blood cells for 6 h. They measured ATP levels and confirmed an important decrease of the values during the time. If the same samples were incubated with pentoxifylline (1.4 X 10(-4) M), the ATP decrease was less relevant.

[A syllectrometric method to study erythrocyte aggregation]. / Considerazioni su una metodica sillectometrica per lo studio dell'aggregabilità eritrocitaria.

The authors show a new method to study erythrocyte aggregation; the results of in vitro study, obtained by modification of several parameters (hematocrit, immunoglobulins, fibrinogen concentrations), are exposed. The authors did not find in vivo correlations between MAE and hemorheological parameters in different diseases; they found low MAE values only in myelomatous subjects. Adding erythrocytes from healthy donors to myelomatous plasma and vice versa, they found low MAE values only in samples containing erythrocytes and plasma from myeloma. These results suggest that many factors, not only erythrocyte aggregability, contribute to determine MAE (Mean Aggregation Entity).

[Hemorrheological changes in ischemic heart disease]. / Le alterazioni emoreologiche della cardiopatia ischemica.

Ischemic cardiopathy in its various clinical manifestations, whether acute (angina pectoris or myocardial infarction) or chronic (chronic coronary insufficiency), has shown in recent years particular hemorheological characteristics of its own. The observation of patients with such diseases has allowed us to record the existence of modifications in the parameters indicative of rheological damage. Numerous studies have been made, many of which are still in progress, with the aim of clarifying the relationships between these data and the disease. In our experience an increase in blood and plasma viscosity and a decrease in red cell deformability are often present in a manner which is statistically significant, if these patients are compared with normal subjects. Hemorheological change is more evident in the acute forms of myocardial ischemia. In fact, in angina pectoris the occurrence of pain is always accompanied by an increase in blood viscosity and by a worsening of red cell deformability both during spontaneous crises and during provocative tests. The hemorheological damage tends to diminish fairly rapidly when the crisis is over, even if the level of stabilization proves to be still higher than normal. In myocardial infarction higher levels of viscosity appear for a brief period after the onset with a slight tendency to diminish up until the 30th day. With the aim of ascertaining whether the alteration is more evident precisely at the point where the ischemia occurs, we chose a necessarily limited number of subjects, undergoing coronarography and atrial pacing for diagnostic purposes, and decided to control the hemorheological data not only in the systemic venous blood but also in the blood taken from the coronary sinus. Our data has shown that the level of viscosity and of red cell filtrability, in the blood taken from the coronary sinus, is worse than those of the systemic venous blood and that, after atrial pacing, in negative pacing subjects the variations are of slight significance whilst in positive pacing subjects we observe a rapid increase in viscosity and a decrease in red cell filtrability. This seems to confirm what we have already observed in the limbs affected by peripheral ischemia, and to demonstrate the existence of a local hyperviscosity syndrome which, even in the myocardium, appears to be dependent on the tissue ischemia.

[Methodological survey of whole blood filtration in the evaluation of erythrocyte deformability. I. Effect of temperature]. / Rilievi metodologici sulla filtrazione del sangue intero nella valutazione della deformabilità eritrocitaria. I. Effetto della temperatura.

We have demonstrated how temperature affects whole blood filterability. The filtration index appears to be dependent on temperature; the higher temperature is, the higher it rises. At body temperature of 37 degrees C the method resulted more reliable.

[Methodological survey of whole blood filtration in the evaluation of erythrocyte deformability. II. Effect of preservation time at various temperatures]. / Rilievi metodologici sulla filtrazione del sangue intero nella valutazione della deformabilità eritrocitaria. II. Effetto del tempo di conservazione a varie temperature.

We have demonstrated how conservation time affects whole blood filterability. The filtration index decay appears just after withdrawal and is present, with different characteristics, both at room temperature and at 37 or 4 degrees C. It is absolutely necessary to take measurements immediately after blood withdrawal.