Patients with antiphosholipid syndrome and thrombotic recurrences: A real world observation (the Piedmont cohort study).

BACKGROUND: Patients with antiphospholipid syndrome (APS) often have thrombotic recurrences, sometimes despite appropriate ongoing anticoagulant treatment. Identifying APS vascular patients at high risk for thrombotic recurrences is still an unsolved issue. OBJECTIVES: To report the real-life experience of thrombotic recurrences in APS patients included in the Piedmont observational cohort study, and evaluate clinical and laboratory risk factors for thrombotic recurrences. PATIENTS: A multi-centre observational study was performed by enrolling 177 patients with vascular APS (primary APS in 99 subjects (56%)); the median follow-up was five years (range 1-26 years). RESULTS: The observed thrombotic recurrence rate was about 7.5/100 patient years in the first five years after the first thrombotic event. While the first recurrence often occurred (45%) in patients who were not on oral anticoagulant therapy (OAT), the second recurrence mainly occurred despite ongoing OAT (80%). However, due to the real-life observational nature of this study, treatment was based on the treating physician's judgement, and no structured therapeutic protocol was applied. Moreover, compliance with OAT was not available. No differences in antiphospholipid antibodies (aPL) profile were observed between patients with or without thrombotic recurrences, but a high risk aPL profile (Miyakis type 1 and 2a) was present in 96% of our patients, 26% of whom had triple positivity. Diabetes (p < 0.01, OR 10), inherited thrombophilia (p < 0.0078, OR 4) and OAT withdrawal were independent risk factors for recurrences. CONCLUSIONS: With the limit of a real-life observational cohort study, the thrombotic recurrence rate in APS was as high as 7.5/100 patient years in the first five years after the first thrombotic event. OAT discontinuation, diabetes and inherited thrombophilia, when associated with a high-risk aPL profile, are risk factors for thrombotic recurrences.

Antiphospholipid syndrome in northwest Italy (APS Piedmont Cohort): demographic features, risk factors, clinical and laboratory profile.

We report the experience from the Antiphospholipid Antibodies (aPL) Regional Consortium in northwest Italy, meant to support clinical research and foster collaboration among health professionals regarding the diagnosis and management of antiphospholipid syndrome (APS) patients. This cohort-study (APS Piedmont Cohort) was designed to register the clinical characteristics at inception and associated immunological manifestations at diagnosis (if any) of patients who strictly fulfilled the current criteria for APS, all recruited at the Piedmont and Valle d'Aosta regions. Clinical and laboratory data from 217 APS patients (171 with vascular events, 33 with pregnancy morbidity and 13 with both), from 16 centres within the geographical area were collected. Venous thrombosis was recorded in 45.6% of patients, arterial thrombosis in 35%, small-vessel thrombosis in 1.12% and mixed arterial and venous thrombosis in the remaining 19.4% of the cases. Pregnancy morbidity included 19 patients with unexplained fetal death beyond the 10th week of pregnancy, 17 with premature birth before the 34th week and 10 with three or more unexplained spontaneous abortions before the 10th week of gestation. This consortium represents an instrument by which to audit clinical practice, to provide counselling to local centres and to sustain future basic and clinical APS research.

Local versus central assessment of venographies in a multicenter trial on the prevention of deep vein thrombosis in neurosurgery.

Venography is the diagnostic method of choice for end-point measurement in multicenter trials on the prevention of postoperative deep vein thrombosis (DVT). The aim of the study was to determine the inter-observer agreement between the local and central assessment of venographies in a multicenter trial comparing enoxaparin and placebo in the prevention of DVT after elective neurosurgery. The study was run in seven centers experienced in venography trials on DVT prevention. The central and local adjudication panels were both blind with respect to the assigned treatment. The central panel was unaware of the local adjudication. Venographies were adjudicated as positive, negative or inadequate for adjudication and positive venographies as proximal or distal DVT. Inter-observer agreement was assessed according to the Cohen's inter-observer variability index (K index). All 266 venographies (8 monolateral) were considered adequate for adjudication by both the central and local panels. A disagreement was found in 25 cases; K index = 0.75. Fourteen venographies adjudicated as negative centrally were considered positive locally (3 were proximal DVT). Eleven venographies adjudicated as positive centrally (1 was a proximal DVT) were considered negative locally. Enoxaparin was found to be more effective than placebo according to both the central and local adjudication: 16.9% versus 32.6% (Relative risk, RR = 0.52; CI 95% 0.33-0.82) according to central adjudication; 18.5% versus 33.3% (RR = 0.56; CI 95% 0.36-0.87) according to local adjudication. We conclude that a good inter-observer agreement in the assessment of venography was observed between the central and local adjudication in a study on DVT prevention run in a restricted experienced study framework. The cost and work overloading of central assessment of venographies in this study framework seems not to be justified.

Central neuroplasticity and pathological pain.

The traditional specificity theory of pain perception holds that pain involves a direct transmission system from somatic receptors to the brain. The amount of pain perceived, moreover, is assumed to be directly proportional to the extent of injury. Recent research, however, indicates far more complex mechanisms. Clinical and experimental evidence shows that noxious stimuli may sensitize central neural structures involved in pain perception. Salient clinical examples of these effects include amputees with pains in a phantom limb that are similar or identical to those felt in the limb before it was amputated, and patients after surgery who have benefited from preemptive analgesia which blocks the surgery-induced afferent barrage and/or its central consequences. Experimental evidence of these changes is illustrated by the development of sensitization, wind-up, or expansion of receptive fields of CNS neurons, as well as by the enhancement of flexion reflexes and the persistence of pain or hyperalgesia after inputs from injured tissues are blocked. It is clear from the material presented that the perception of pain does not simply involve a moment-to-moment analysis of afferent noxious input, but rather involves a dynamic process that is influenced by the effects of past experiences. Sensory stimuli act on neural systems that have been modified by past inputs, and the behavioral output is significantly influenced by the "memory" of these prior events. An increased understanding of the central changes induced by peripheral injury or noxious stimulation should lead to new and improved clinical treatment for the relief and prevention of pathological pain.

Endogenous opiates: 1999.

This paper is the twenty-second installment of the annual review of research concerning the opiate system. It summarizes papers published during 1999 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; learning, memory, and reward; eating and drinking; alcohol and other drugs of abuse; sexual activity, pregnancy, and development; mental illness and mood; seizures and other neurologic disorders; electrical-related activity; general activity and locomotion; gastrointestinal, renal, and hepatic function; cardiovascular responses; respiration and thermoregulation; and immunologic responses.

Endogenous opiates: 2000.

This paper is the twenty-third installment of the annual review of research concerning the opiate system. It summarizes papers published during 2000 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; learning, memory, and reward; eating and drinking; alcohol and other drugs of abuse; sexual activity, pregnancy, and development; mental illness and mood; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; gastrointestinal, renal, and hepatic function; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Endogenous opiates: 1997.

This paper is the twentieth installment of our annual review of research concerning the opiate system. It summarizes papers published during 1997 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; eating and drinking; alcohol; gastrointestinal, renal, and hepatic function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurologic disorders; electrical-related activity; general activity and locomotion; sex, pregnancy, and development; immunologic responses; and other behaviors.

Endogenous opiates: 1998.

This paper is the twenty-first installment of our annual review of research concerning the opiate system. It summarizes papers published during 1998 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; eating and drinking; alcohol; gastrointestinal, renal, and hepatic function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurologic disorders; electrical-related activity; general activity and locomotion; sex, pregnancy, and development; immunologic responses; and other behaviors.

Tolerance and morphine-induced cross-tolerance are not shown to Tyr-W-MIF-1 analgesia.

Tolerance and cross-tolerance between Tyr-W-MIF-1, a mixed micro-agonist/antagonist, and morphine were examined. Opiate dependence also was examined. Rats were pretreated with Tyr-W-MIF-1, morphine, or saline for 4 days. On day 5, the animals were tested for Tyr-W-MIF-1 analgesia, morphine analgesia, or naloxone-precipitated withdrawal. Tyr-W-MIF-1- and morphine-pretreated animals showed similar levels of dependence. Animals pretreated with Tyr-W-MIF-1 failed to express tolerance to Tyr-W-MIF-1 analgesia but did display cross-tolerance to morphine analgesia. Animals pretreated with morphine displayed tolerance to morphine analgesia but did not express cross-tolerance to Tyr-W-MIF-1 analgesia. Therefore, tolerance and morphine-induced cross-tolerance were not expressed to Tyr-W-MIF-1 analgesia.

Tyr-W-MIF-1-induced conditioned place preference.

Based on the evidence that Tyr-Pro-Trp-Gly NH2 (Tyr-W-MIF-1) produced dose-dependent, mu-opiate agonistic/antagonistic effects, we investigated whether Tyr-W-MIF- exhibited similar properties in the conditioned place preference (CPP) test. To examine the opiate agonistic effects on CPP, rats were conditioned with alternating ICV injections of saline and Tyr-W-MIF-1 (0 or 200 microg). This procedure resulted in Tyr-W-MIF-1-induced CPP. To examine the opiate antagonistic properties of low doses of Tyr-W-MIF-1, morphine-induced CPP was challenged with Tyr-W-MIF-1 (0, 25, 50, or 100 microg). Morphine-induced CPP was not affected by Tyr-W-MIF-1 at these doses. These findings show that in the CPP test Tyr-W-MIF-1 produced opiate agonistic effects at the high dose and was without opiate antagonistic properties at lower doses.

Descending modulation of central neural plasticity in the formalin pain test.

Subcutaneous injection of formalin produces a biphasic profile of pain response: a transient early phase followed by a tonic late phase. A number of studies have indicated that the development of the late phase of formalin pain is dependent upon prolonged changes in central neural function produced by neural activity that is generated during the early phase (i.e. central sensitization). In support of this, the present demonstrates that stimulation- or morphine-produced analgesia derived from the periaqueductal grey (PAG) during the early phase prevents the development of the phase. These results suggest that descending mechanisms of pain inhibition, as reflected by PAG stimulation- and morphine-produced analgesia, can prevent the development of central neural plasticity following injury.

Reduction of autotomy following peripheral neurectomy by a single injection of bupivacaine into the cingulum bundle of rats.

Peripheral neurectomy in rats is followed by autotomy of the denervated zone, which is assumed to represent an index of pain or dysesthesia. In the present study, we examined whether a single injection of a local anesthetic (bupivacaine) into the cingulum bundle at the time of nerve section could reduce autotomy. It was found that a temporary anesthetic blockade of the cingulum at the time of nerve section delayed the onset and reduced the overall degree of autotomy. However, injections given shortly after nerve section had no significant effects. These results demonstrate that temporary blockade of cingulum activity at the time of nerve section reduces autotomy for periods that exceed the duration of the anesthetic block.

Stress-induced analgesia prevents the development of the tonic, late phase of pain produced by subcutaneous formalin.

Subcutaneous injection of formalin produces a biphasic pain response: a transient early phase followed by a tonic late phase. It has recently been suggested that development of the late phase depends upon the presence of the early one. In support of this suggestion, we now demonstrate that blocking the early phase by stress-induced analgesia prevents development of the late phase, whereas the same stressor given after the first phase does not. Both phases are manifested when stress-induced analgesia is blocked by the N-methyl-D-aspartate (NMDA) or opiate antagonists, MK-801 and naloxone.

Central nervous system plasticity in the tonic pain response to subcutaneous formalin injection.

Evidence is presented which suggests that central neural changes occur during the brief early phase after subcutaneous formalin injection that are essential for the expression of pain during the long-lasting (tonic) later phase. First, tonic pain responses to subcutaneous formalin injections are abolished only if the injected hindpaw is locally anesthetized at the time of injection as well as the time of testing (30-60 min later). Second, tonic formalin pain is substantially reduced by brief spinal anesthesia given 5 min before, but not 5 min after the formalin injection.

Delayed application of MK-801 attenuates development of morphine tolerance in rats.

To investigate the possible involvement of enduring or delayed changes at the N-methyl-D-aspartic acid (NMDA) receptor in the mechanisms of morphine tolerance, rats were treated with the specific NMDA receptor antagonist, MK-801 (0.15 mg/kg) 2 h after morphine injection (20 mg/kg) during a 4-day induction period of tolerance. On the fifth day rats were injected only with morphine (15 mg/kg), and analgesia was assessed using the hot-plate test. Morphine tolerance was significantly reduced by MK-801. These findings suggest that long-lasting or delayed changes at the NMDA receptor underlie the development of morphine tolerance. Moreover, because MK-801 was delivered 2 h after morphine and therefore could not serve as a cue for morphine administration, these findings indicate that the attenuating effect of MK-801 on the development of morphine tolerance is not attributable to state-dependent learning.

NMDA receptor antagonists, MK-801 and ACEA-1011, prevent the development of tonic pain following subcutaneous formalin.

Subcutaneous injection of formalin produces a biphasic pain response: an early, transient phase followed by a late tonic phase. The present study examined the involvement of the N-methyl-D-aspartic acid (NMDA) receptor in the development of the late pain produced following subcutaneous injection of formalin into the hind paw in mice. Blockade of the NMDA receptor by its non-competitive antagonist, MK-801, prior to formalin injection, but not after, reduced pain during the late phase. Similarly, blockade of the NMDA receptor allosteric site by the novel glycine site antagonist, ACEA-1011, also reduced the pain response in the late phase. These results suggest that the development of the late phase of formalin pain is due to NMDA-mediated activity during the early phase.

Morphine fails to produce tolerance when administered in the presence of formalin pain in rats.

The present study examined the development of tolerance to morphine analgesia under conditions in which morphine was administered in the presence or absence of pain induced by subcutaneous injection of 50 microliters of 2.5% formalin into the hind paw of rats. Animals were injected with morphine (25 mg/kg, i.p.) or saline for 3 consecutive days either in the presence of pain (10 min after formalin injection) or in the absence of pain (6 h prior to formalin injection). On the 4th day, tolerance to the analgesic effect of test doses of morphine (6 or 10 mg/kg) was assessed in the formalin and tail-flick tests, respectively. Significant tolerance in both tests was observed in animals receiving morphine in the absence of pain during the tolerance induction period, but not in animals receiving morphine in the presence of pain.

The NMDA receptor antagonist MK-801 prevents long-lasting non-associative morphine tolerance in the rat.

Several studies have demonstrated that the N-methyl-D-aspartate (NMDA) antagonist MK-801 attenuates the development of morphine tolerance and withdrawal. These studies employed repeated morphine injections to induce tolerance, a procedure in which learning has been suggested to play a significant role in tolerance development. MK-801 has been reported to block some types of learning, and it is unclear, therefore, whether the effect of MK-801 on tolerance development is due to its antagonism of associative (learning) or non-associative factors. Moreover, previous studies have tested the effects of MK-801 on morphine tolerance only up to 48 h after its induction; yet morphine tolerance can persist for many months, and it is not known whether MK-801 can block long-lasting tolerance. In the present study, therefore, we adopted a model of morphine tolerance in which the involvement of learning is minimized by using a single injection of morphine in a sustained-release preparation, and we tested tolerance for up to 56 days. In the first experiment, simultaneously administering MK-801 (0.2 mg/kg, s.c.) and morphine (60 mg/kg, s.c.), each in a sustained-release preparation, abolished tolerance that lasted at least 12 days. Analgesia was measured in the hot-plate test following a test dose of morphine (15 mg/kg, i.p.). In the second experiment, delivering MK-801 and morphine as before, the duration of morphine-induced catalepsy and analgesia was prolonged. Nevertheless, 24 h later one symptom of naloxone-precipitated withdrawal was significantly attenuated in these same animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Formalin-induced pain antagonizes the development of opiate dependence in the rat.

Clinical studies have suggested that patients who take morphine for pain relief do not show a high degree of dependence. The present study examined the development of naloxone-precipitated withdrawal in rats receiving morphine in the presence or absence of formalin-induced pain. Morphine (10 mg/kg, i.p.) or saline was administered for 4 consecutive days 10 min after a subcutaneous injection of 50 microliters of 2.5% formalin or saline into the hind-paw. On the 5th day, rats were injected with naloxone (1 mg/kg, i.p.) and observed for signs of precipitated withdrawal (ptosis, teeth chattering and excretion/diarrhea). Naloxone-precipitated withdrawal symptoms were significantly greater in rats that received morphine in the absence of pain than in rats that received morphine in the presence of pain.