Antiphospholipid Syndrome: State of the Art of Clinical Management.

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a "rare disease" that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the "protective" role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.

Hereditary coagulation factor XI deficiency: a rare or neglected disease? Results from a retrospective, single-centre cohort in northern Italy.

To examine real-life clinical data regarding hereditary factor XI (FXI) deficiency from a secondary care centre. Retrospective review of clinical records for every FXI:C 0.7 IU/ml or less reported from 2012 to 2020. Seventy-nine patients were included. Six (7.6%) had a severe deficiency (FXI:C <0.2 IU/ml). Only 55 (69.6%) patients were referred to the Haemostasis Centre. Among them, six (15%) were subsequently not identified at increased haemorrhagic risk before a surgical/obstetrical procedure. Thirty-three (41.8%) experienced at least one bleeding event, minor (25 patients) and/or major (16 patients). Minor bleedings were predominantly spontaneous and more frequent in women, major events were mainly provoked. No correlation was found between FXI:C and risk of bleeding ( P  = 0.9153). Lower FXI:C, but not a positive bleeding history, was related with higher likelihood of being referred to the Haemostasis Centre ( P  = 0.0333). Hereditary FXI deficiency prevalence is likely underestimated, real-life clinical practices outside reference centres could be suboptimal.

Four cases of acquired hemophilia A following immunization with mRNA BNT162b2 SARS-CoV-2 vaccine.

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by neutralizing autoantibodies against coagulation Factor VIII. Immunomodulatory effects of SARS-CoV-2 vaccination are still poorly understood, with reports of immune-mediated conditions developing after immunization. In the province of Reggio Emilia, Northern Italy, we observed four cases of AHA following SARS-CoV-2 immunization with mRNA BNT162b2 vaccine (produced by Pfizer-BioNTech) during the first eight months from the beginning of SARS-CoV-2 vaccination campaign. During this time frame, 235,597 people received at least one dose of BNT162b2 vaccine. The total population of Reggio Emilia province is 526,349. The unusual observation of four cases of AHA in our province could be of interest and could sensitize healthcare personnel toward a possible complication of SARS-Cov-2 immunization. Nonetheless, vaccination benefits exceed potential side effects and play a central role in individual and public health to effectively protect people from COVID-19 and to stop the pandemic.

The coronary slow flow phenomenon: a new cardiac "Y" syndrome?

The coronary slow flow phenomenon (CSFP) is an angiographic finding that is characterised by delayed progression of the contrast medium during coronary angiography. The mechanism of this phenomenon remains unknown. In the present paper, we revise the current evidence regarding this phenomenon and discuss recent findings from our group reporting increased resting resistances in patients with the CSFP. We report that these patients had preserved blood flow responses to the intracoronary infusion of the vasodilator papaverine, demonstrating that the CSFP is not necessarily associated with an abnormal coronary flow reserve. Based on these findings and on the review of the current literature, we concur with the concept proposed by Beltrame et al. that the CSFP should be considered a separate clinical entity. Further studies are necessary to describe the clinical characteristics, including the prognosis, of these patients and to identify potential treatments.

The mechanism of nitrate-induced preconditioning.

Nitroglycerin (GTN) has been shown, in both human and animal studies, to induce a protective phenotype that limits tissue damage after ischemia and reperfusion. This phenomenon is similar to ischemic preconditioning, and several reports suggest that also the molecular pathways involved in this protective effect of nitrates are the same that determine ischemic preconditioning. Our group conducted a series of studies aimed at investigating, using a human model of endothelial IR injury, the mechanism of nitrate-induced preconditioning and particularly the role of reactive oxygen species formation and of the opening of mitochondrial permeability transition pores. Our data demonstrate that GTN protects the endothelium against postischemic endothelial dysfunction in a mechanism that is mediated by oxygen free radical release and opening of mitochondrial permeability transition pores. In contrast, the protective effect of pentaerithrityl tetranitrate appears to be independent of these mechanisms, and it seems to be mediated by induction of antioxidant genes. Finally, isosorbide mononitrate seems to be devoid of a significant protective effect. These data are summarized and discussed in the present paper.

[Infected pressure ulcers: evaluation and management]. / Valutazione e gestione delle infezioni delle ulcere da pressione.

Pressure ulcers in elderly individuals can cause significant morbidity and mortality and are a major economic burden to the health care system. Prevention should be the ultimate objective of pressure ulcer care, and it requires an understanding of the pathophysiology leading to pressure ulcers and the means of reducing both intrinsic and extrinsic risk factors. Clinical examination often underestimates the degree of deep-tissue involvement, and its findings are inadequate for the detection of associated osteomyelitis. Microbiological data, if obtained from deep-tissue biopsy, are useful for directing antimicrobial therapy, but they are insufficient as the sole criterion for the diagnosis of infection. Imaging studies, such as computed tomography and magnetic resonance imaging, are useful, but bone biopsy and histopathological evaluation remain the "gold standard" for the detection of osteomyelitis. The goals of treatment of pressure ulcers should be resolution of infection and promotion of wound healing. A combination of surgical debridement and medical interventions may be required. Systemic antimicrobial therapy should be used for patients with serious pressure ulcers infections, including those with spreading cellulitis, bacteremia or osteomyelitis.

Efeito de emulsoes lipidicas sobre mecanismos de defesa organica na agressao infecciosa / Effect of lipidic emulsions on organic defense mechanisms in infective aggression

Constitui-se o objetivo da presente pesquisa o estudo do efeito de emulsoes lipidicas comercialmente disponiveis de Triglicerides de Cadeia Longa (TCL) e de Triglicerides de Cadeia Media (TCM) e Longa (TCM/TCL) a 10 por cento sobre a funcao de polimorfonucleares (LPMN) de sangue de ratos apos transfusao endovenosa continua em ratos submetidos a agressao infecciosa por meio da inoculacao intraperitoneal de E. coli. Efetuaram-se provas de funcao dos LPMN (atividades fagocitaria, bactericida e quimiotatica), hemoculturas seriadas, avaliacao clinica, autopsia e avaliacao histopatologica do figado e baco e analise de taxa de mortalidade. Nao se observaram diferencas significativas no comportamento funcional dos LPMN do sangue de ratos