Glauco Milio

Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis : the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study

Residual vein thrombosis (RVT) indicates a prothrombotic state and is useful for evaluating the optimal duration of oral anticoagulant treatment (OAT). Patients with a first episode of deep vein thrombosis, treated with OAT for 3 months, were managed according to RVT findings. Those with RVT were randomized to either stop or continue anticoagulants for 9 additional months, whereas in those without RVT, OAT was stopped. Outcomes were recurrent venous thromboembolism and/or major bleeding. Residual thrombosis was detected in 180 (69.8%) of 258 patients; recurrent events occurred in 27.2% of those who discontinued (25/92; 15.2% person-years) and 19.3% of those who continued OAT (17/88; 10.1% person-years). The relative adjusted hazard ratio (HR) was 1.58 (95% confidence interval [CI], 0.85-2.93; P = .145). Of the 78 (30.2%) patients without RVT, only 1 (1.3%; 0.63% person-years) had a recurrence. The adjusted HR of patients with RVT versus those without was 24.9 (95% CI, 3.4-183.6; P = .002). One major bleeding event (1.1%; 0.53% person-years) occurred in patients who stopped and 2 occurred (2.3%; 1.1% person-years) in those who continued OAT. Absence of RVT identifies a group of patients at very low risk for recurrent thrombosis who can safely stop OAT. This trial was registered at http://www.ClinicalTrials.gov as no. NCT00438230.

Superficial venous thrombosis: Prevalence of common genetic risk factors and their role on spreading to deep veins

INTRODUCTION Superficial venous thrombosis (SVT) has been considered for a long time a limited clinical condition with a low importance, but this approach has changed in recent years, when several studies demonstrated spreading to deep veins occurring from 7.3 to 44%, with high prevalence of pulmonary embolism. MATERIALS AND METHODS To evaluate the prevalence of genetic risk factors for VTE in patients suffering from SVT on both normal and varicose vein, and to understand their role on spreading to deep veins, we studied 107 patients with SVT, without other risk factors. Ultrasound examination was performed, and the presence of FV Leiden, Prothrombin G20210A mutation, and MTHFR C677T mutation was researched. RESULTS In the patients where SVT occurred in normal veins, the presence of FV Leiden was 26.3% of the non-spreading and 60% of the spreading to deep veins SVT; Prothrombin mutation was found in 7.9% of the former case and in 20% of the latter; MTHFR C677T mutation was found respectively in 23.7% and 40%. In the patients with SVT on varicose veins, the presence of these factors was less evident (6.7%, 4.4% and 6.7% respectively), but their prevalence was considerably higher (35.7%, 7.4% and 21.4% respectively) in SVT spreading to deep veins than in non-spreading. CONCLUSIONS Our data demonstrate the high prevalence of these mutations, especially FV Leiden and associations, in patients with SVT on normal veins and their role in the progression to deep vein system.

The supraventricular tachycardias: Proposal of a diagnostic algorithm for the narrow complex tachycardias

The narrow complex tachycardias (NCTs) are defined by the presence in a 12-lead electrocardiogram (ECG) of a QRS complex duration less than 120ms and a heart rate greater than 100 beats per minute; those are typically of supraventricular origin, although rarely narrow complex ventricular tachycardias have been reported in the literature. As some studies document, to diagnose correctly the NCTs is an arduous exercise because sometimes those have similar presentation on the ECG. In this paper, we have reviewed the physiopathological, clinical, and ECG findings of all known supraventricular tachycardias and, in order to reduce the possible diagnostic errors on the ECG, we have proposed a quick and accurate diagnostic algorithm for the differential diagnosis of NCTs.

Sodium Thiosulfate not Always Resolves Calciphylaxis: An Ambiguous Response

Calciphylaxis is a severe “vascular ossification–calcification,” associated with a very high mortality rate that involves arterial wall, venular wall, and nerves resulting in ischemia and necrosis of skin, subcutaneous fat, visceral organs, and skeletal muscles. Sodium thiosulfate has recently been used as a novel treatment option for calciphylaxis because of its dual role as an antioxidant and a chelator. Multiple case reports demonstrated that such therapy has resulted in pain relief and healing of skin ulceration. We report a case of calciphylaxis of large severity that had an ambiguous response to sodium thiosulfate treatment (improvement of symptomatology and skin lesions, improvement of blood parameters, worsening of general conditions, and consciousness until death).

The Effects of Prostaglandin E-1 in Patients with Intermittent Claudication

Aim of the study is to evaluate the effects of Prostaglandin E-1 (PGE-1) in patients with peripheral arterial disease (PAD) at the 2nd b stage Fontaines classification. The study, controlled, single blinded, enrolled 123 patients with intermittent claudication that were randomised in two groups; the first group received a treatment with PGE-1 while the second one received a pentoxifylline-buflomedil association by venous infusion. We evaluated: Pain Free Walking Distance (PFWD), Maximum Walking Distance (MWD), Rest Flow (RF), Peak Flow (PF), Basal (BVR) and Minimal Vascular Resistance (MVR) with a strain gauge plethysmograph, Resting Flow (RF), Peak Flow (PF), time to reach the Peak Flow (tPF) and time to recovery of the base values (tRF) with laser Doppler flowmeter. After a four weeks treatment, we observed an increase of 370% about PFWD and of 260% in the MWD in patients treated with PGE-1; the other group showed an increase of 110% and 118% respectively. Moreover, the patients of the first group showed a significant increase regarding the plethysmographic Peak Flow (from 9.75+/-1.37 to 16.21+/-1.75, p<0.001), greater than the one observed in the second group (from 9.53+/-1.41 to 13.47+/-1.53, p<0.05); also the laser Doppler parameters showed a significant reduction, more evident in the first group (tPF from 23.0+/-7.5 to 10.5+/-4.9, p<0.001; tRF from 73.5+/-22.7 to 48.3+/-13.5, p<0.001) than in the second one.

Hypertension and Peripheral Arterial Disease: A Plethysmographic Study

Sixty patients suffering from arterial hypertension and/or obliterative arteriopathy of the lower limbs (20 hypertensive uncomplicated [H group], 20 normotensive affected by obliterative arteriopathy [A group], 20 suffering from both hypertension and peripheral arterial disease [HA group]) were studied, by strain gauge plethysmography, in compar ison with 20 healthy subjects (N group). The aims were to evaluate the arterial and venous hemodynamics of the lower limbs in such conditions and also to determine whether the vascular damage is primary or represents a consequence of the hypertensive pathology in the patients affected by both hypertension and peripheral arterial disease. The resting blood flow did not show significant differences in the mean values, even if lightly decreased in hypertensive patients (with or without peripheral arteriopathy). The peak flow was reduced significantly both in the H group and in the A and HA groups. The half-time (t½) and total time (tT), which indicate vascular reactivity, were signifi cantly decreased in the H group, but they were increased in the A and HA groups. Finally, the venous compliance was decreased in the H group, did not vary significantly in the A group, and showed an intermediate behavior in the HA group. These results suggest that hypertensive and arteriopathic patients develop similar arterial structural changes. However, they show a different behavior with regard to vascular reactivity and venous hemodynamics, as demonstrated by venous plethysmography.

Hypertension and Peripheral Arterial Hemodynamics

Sixty uncomplicated hypertensive patients (30 stable and 30 borderline) were studied, by strain gauge plethysmography, in comparison with 25 normotensive subjects, in order to evaluate the arterial hemodynamics of the lower limbs in essential hypertension and to verify the different pattern in borderline and in stable hypertensives. Resting blood flow, even if slightly decreased in hypertensive groups, did not show significant differences in its mean values; peak flow, instead, was reduced proportionally to the severity of hypertension in all the hypertensive patients, but only in the stable hypertensives was it statistically significant. Minimal vascular resistance showed a similar behavior: it was significantly increased only in the stable hypertensives, whereas basal vascular resistance was raised in all hypertensive patients and also in the borderline group. Finally, the half-time and the total hyperemic response time, which indicate vascular reactivity, were significantly decreased in all the hypertensives. These results suggest that the stable hypertensive patients develop principally arterial structural changes, while the borderline hypertensive patients have only functional modi fications, such as a reduced compliance and a hyperdynamic condition.

Antiplatelet treatment in ischemic stroke treatment.

Antiplatelets represent a diverse group of agents that share the ability to reduce platelet activity through a variety of mechanisms. Antithrombotic agents are effective in the secondary prevention of ischemic strokes. Most strokes are caused by a sudden blockage of an artery in the brain (called an ischaemic stroke) that is usually due to a blood clot. Immediate treatment with antiplatelet drugs such as aspirin may prevent new clots from forming and hence improve recovery after stroke. Several studies have evaluated the role of one antiplatelet agent, aspirin, in reducing stroke severity. The International Stroke Trial (IST) of 20,000 patients with acute stroke from other countries. In this study there was a significant 14% proportional reduction in mortality during the scheduled treatment period (343 [3.3%] deaths among aspirin-allocated patients vs 398 [3.9%] deaths among placebo-allocated patients; 2p = 0.04). There were significantly fewer recurrent ischaemic strokes in the aspirin-allocated than in the placebo-allocated group (167 [1.6%] vs 215 [2.1%]; 2p = 0.01) but slightly more haemorrhagic strokes (115 [1.1%] vs 93 [0.9%]. Few studies examined the role of ticlopidin in acute stroke setting the results showed treatment with ticlopidine improved the neurologic outcome. In the Examining the Safety of Loading of Aspirin and Clopidogrel in Acute Ischemic Stroke and TIA (LOAD) study, 40 consecutive ischemic stroke patients were treated with 325 mg of aspirin and 375 mg of clopidogrel within 36 hours of symptom onset. Overall, 37.5% (n = 15) of the patients had an improvement of 2 or more points on the NIHSS 24 hours after antiplatelet administration. The antiplatelet efficacy of aspirin in preventing secondary stroke was established by three studies conducted in the late 1980s and early 1990s: the Swedish Aspirin Low-dose Trial (SALT) trials have demonstrated that aspirin-even in doses as low as 30 mg/day-reduces secondary stroke, MI, or vascular death in patients with. Clopidogrel and aspirin have been used in combination in patients with diverse arterial vascular diseases However, combinations of antithrombotic agents do not necessarily improve clinical efficacy and are typically associated with increased toxicity.

Ticlopidine in the treatment of multiple atherosclerotic arteriopathy: a strain Gauge plethysmography and Döppler spectrum analysis evaluation

The effect of ticlopidine was compared with flunarizine in patients with iliac–femoral and / or femoral–popliteal arteriosclerotic arteriopathy accompanied by lesions of the cervical arteries of no haemodynamic significance. In the lower limbs, plethysmography (strain gauge measurements) and Döppler ultrasonography integrated by spectral analysis of the cervical arteries showed qualitative and quantitative improvements of the regional haematic flow. Side-effects were negligible which suggests that ticlopidine is useful in the treatment of multiple arteriosclerotic arteriopathy.