Safety of direct oral anticoagulants in patients with hereditary hemorrhagic telangiectasia.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular dysplasia resulting in visceral arteriovenous malformations and smaller mucocutaneous telangiectasia. Most patients experience recurrent nosebleeds and become anemic without iron supplementation. However, thousands may require anticoagulation for conditions such as venous thromboembolism and/or atrial fibrillation. Over decades, tolerance data has been published for almost 200 HHT-affected users of warfarin and heparins, but there are no published data for the newer direct oral anticoagulants (DOACs) in HHT. METHODS: To provide such data, a retrospective audit was conducted across the eight HHT centres of the European Reference Network for Rare Multisystemic Vascular Diseases (VASCERN), in Denmark, France, Germany, Italy, the Netherlands and the UK. RESULTS: Although HHT Centres had not specifically recommended the use of DOACs, 32 treatment episodes had been initiated by other clinicians in 28 patients reviewed at the Centres, at median age 65 years (range 30-84). Indications were for atrial fibrillation (16 treatment episodes) and venous thromboembolism (16 episodes). The 32 treatment episodes used Apixaban (n = 15), Rivaroxaban (n = 14), and Dabigatran (n = 3). HHT nosebleeds increased in severity in 24/32 treatment episodes (75%), leading to treatment discontinuation in 11 (34.4%). Treatment discontinuation was required for 4/15 (26.7%) Apixaban episodes and 7/14 (50%) Rivaroxaban episodes. By a 4 point scale of increasing severity, there was a trend for Rivaroxaban to be associated with a greater bleeding risk both including and excluding patients who had used more than one agent (age-adjusted coefficients 0.61 (95% confidence intervals 0.11, 1.20) and 0.74 (95% confidence intervals 0.12, 1.36) respectively. Associations were maintained after adjustment for gender and treatment indication. Extreme hemorrhagic responses, worse than anything experienced previously, with individual nosebleeds lasting hours requiring hospital admissions, blood transfusions and in all cases treatment discontinuation, occurred in 5/14 (35.7%) Rivaroxaban episodes compared to 3/15 (20%) Apixaban episodes and published rates of ~ 5% for warfarin and heparin. CONCLUSIONS: Currently, conventional heparin and warfarin remain first choice anticoagulants in HHT. If newer anticoagulants are considered, although study numbers are small, at this stage Apixaban appears to be associated with lesser bleeding risk than Rivaroxaban.

High-calcium mineral water as a calcium supplementing measure for post-thyroidectomy hypocalcemia.

AIM: The aim of this study was to test the possibility of enhancing blood calcium levels in totally thyroidectomized patients by supplementation with 1 L/d carbonate-bicarbonate-high-calcium mineral water. METHODS: This study enrolled 95 outpatients, totally thyroidectomized four months earlier, and hence treated with oral calcium and vitamin-D. At recruitment, ionized blood calcium was either below (Group A; N. 55) or above (Group B; N. 40, randomly divided in Group B1 [N. 20] and Group B2 [N.20]) the lower limit of the normal range (1.12 mmol/L). For one month, Group A was treated with 1 L/d high-calcium (483 mg/L) mineral water and continued the usual therapy with Ca and vitamin-D. In contrast, Group B1 and Group B2 substituted their Ca and vitamin-D therapy with 1 L/d high-calcium mineral water (Group B1) or 1 L/d of placebo mineral water (Ca:80 mg/L) (Group B2). RESULTS: After one month, a significant 7.5% increase in blood ionized-calcium levels was observed in Group A, no change in Group B1 and a significant drop below normality in Group B2 (Group B2 vs Group B1, P<0.001). Thereafter, 1 L/d of the high-calcium mineral water, given to Group B2 instead of placebo for an additional month, significantly enhanced ionized-calcium levels above the lower limit of normality (Group B2 vs Group B1, NS). CONCLUSION: These experiments show that calcium supplementation as 1 L/d of a high-calcium mineral water may efficaciously enhance blood calcium levels in thyroidectomized patients. This complementary treatment might at least in part contribute to the prevention and/or treatment of hypocalcemia and substitute vitamin-D and calcium therapies after thyroidectomy.

[Study of pollen of allergologic significance in the urban atmosphere of Parma in the years 1983-1984]. / Studio di alcuni pollini di interesse allergologico nell'atmosfera urbana di Parma negli anni 1983-1984.

From 1983 to 1984 pollen air samples from Parma's urban atmosphere were collected weekly by means of a Burkard recording volumetric spore trap. Data regarding a few of the meteorologic variables were also collected at the same time: temperature, insulation, water precipitation, humidity and wind speed. Some of the more allergenic pollens and their concentration/m3 air were determined from the collected samples: Graminea, Urticaceae, Fagaceae, Salicaceae and Betulaceae. Looking at the results from the period of study, it can be seen that Graminea and Urticaceae were the most represented in comparison with the other families. Graminea was most represented in May 1983, in June 1984 and during the first week of September 1984; Urticaceae in September 1983, May 1984 and September 1984. These pollen concentrations were also compared to the meteorologic data.