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Background: Careful assessment of bleeding history is the first step in the evaluation of patients with mild/moderate bleeding disorders, and the use of a bleeding assessment tool (BAT) is strongly encouraged. Although a few studies have assessed the utility of the ISTH-BAT in patients with inherited platelet function disorders (IPFD) none of them was sufficiently large to draw conclusions and/or included appropriate control groups. Objectives: The aim of the present study was to test the utility of the ISTH-BAT in a large cohort of patients with a well-defined diagnosis of inherited platelets disorder in comparison with two parallel cohorts, one of patients with type-1 von Willebrand disease (VWD-1) and one of healthy controls (HC). Patients/Methods: We enrolled 1098 subjects, 482 of whom had inherited platelet disorders (196 IPFD and 286 inherited platelet number disorders [IT]) from 17 countries. Results: IPFD patients had significantly higher bleeding score (BS; median 9) than VWD-1 patients (median 5), a higher number of hemorrhagic symptoms (4 versus 3), and higher percentage of patients with clinically relevant symptoms (score > 2). The ISTH-BAT showed excellent discrimination power between IPFD and HC (0.9

Summary. Haemophilia A (HA) is an X-linked recessive bleeding disorder caused by a lack or decrease of coagulation factor VIII activity. The molecular diagnosis of HA is challenging and a variety of different mutations have been identified throughout the F8 gene. Our aim was to detect the causative mutation in 266 HA patients from Emilia-Romagna region (Italy) and in all suspected carriers. Molecular analysis of F8 in 201 HA patients (152 index cases) was performed with a combination of several indirect and direct molecular approaches, such as long distance polymerase chain reaction, multiplex ligation-dependent probe amplification, denaturing high performance liquid chromatography and direct sequencing. The analysis revealed 78 different mutations, 23 of which were novel, not having been reported in national or international databases. The detection rate was 100%, 86% and 89% in patients with severe, moderate and mild HA, respectively. The information provided by this registry will be helpful for monitoring the treatment of HA patients in Emilia-Romagna and also for reliable genetic counselling of affected families in the future.

A Registry of inherited bleeding disorders was set up in the Region of Emilia-Romagna (RER) to collect information about these diseases and to improve the quality of care. From January 2003, the eight Haemophilia Centres (HC) in the RER began to use computerized clinical records; every 6 months, they send data to Parma Hospital to be processed and published in a website (http://www.registroemofiliarer.it). Great efforts are made to ensure high quality of data. Results of general interest are included in a free 'public area' and more sensitive data in a 'reserved area' (open only to HC and to health authorities). A total of 610 individuals are included: 249 haemophilia A (HA), 63 haemophilia B (HB), 173 von Willebrand's disease, 69 rare bleeding disorders, seven platelet disorders and 49 haemophilia carriers; 131 were genotyped, 188 were tested for inhibitors (16 affected). The most frequent bleeding was haemarthrosis. The joint score (evaluated in 104 haemophiliacs) was higher in severe HA. There were 22 HIV-positive and 182 hepatitis C virus-positive patients (21% have chronic hepatitis, two hepatocellular carcinoma). In 2005, two patients received primary prophylaxis, 47 secondary prophylaxis, four children were on immune-tolerance induction. From 2003 to 2005 the use of recombinant products was greatly increased and the majority of patients received them. The mean clotting factor consumption for prophylaxis was higher than on-demand treatment. The main features of registry are to collect high quality and comprehensive data of all patients followed by HC, to improve quality of care and it's availability on the web.

Introduction: An extensive medical literature (Petrini & Seuser, 2009) regarding adolescents with chronic illness shows that during adolescence there is an abandonment of treatment regimens and a reduced adherence to medical prescriptions. The aim of the research was to understand the phenomenon of the reduction of compliance in adolescents and young adults with chronic illness, particularly hemophilia, in regard to the representations of illness, the identity and the normalization processes. Methods: The research involved 20 adolescents and young adults suffering from a chronic hemorrhagic illness and 15 adolescents and young adults affected by diabetes. We administered semi-structured interview to all the participants. The interviews were analyzed using the Thematic Analysis of Elementary Context from T-Lab software (Lancia, 2004, Reinert, 1995). Results: In our hypothesis, from a psychosocial point of view, the reduction of compliance is related to different representations of the illness and such representations highlight how hemophilia is included in the process of construction of the Self, specifically referring to the increasing autonomy from the family and the socialization with peers. Discussion/Conclusion: The results suggest different themes that organize the affective and cognitive representations of both chronic diseases. In respect to haemophilia, the recourse to a therapeutic regime like prophylaxis looks like more associated to an integration of the illness in the Self and in the daily life, while the therapy on demand is more associated to a representation of the Hemophilia as external to the Self and concerning only the body. Furthermore, different ranges of age are linked to different kinds of representation: Hemophilia is considered by the adolescents like a body’s break, while it is considered by young adults as a mystery for which researching causes in the family history. In respect to diabetes, the analysis are still in progress.

Background. This paper is intended as an exploration of the Social Representations of haemophilia, and the normalization process in adolescents and young adults affected by congenital hemorrhagic diseases. An extensive medical literature (Petrini & Seuser, 2009) regarding adolescents with chronic illness shows that during adolescence there is an abandonment of treatment regimens and reduced adherence to medical prescriptions. The purpose of the research was to understand the phenomenon reported in the scientific literature of the reduction of compliance in adolescence in regard to the social representation of haemophilia. In our hypothesis, such representations highlight how haemophilia is included in the process of construction of the Self, specifically referring to the increasing autonomy from the family and the socialization with peers. Materials and methods. The research involved 20 adolescents and young adults suffering from congenital hemorrhagic diseases. We administered semi-structured interview to all the participants. The interviews were analyzed using the Thematic Analysis of Elementary Context from T-Lab software (Lancia, 2004), with the aim of exploring the lexical worlds (Reinert, 1995). Results and Conclusions. The results suggest different themes that organize the affective and cognitive signification process of haemophilia. The recourse to a therapeutic regime like prophylaxis looks like more associated to an integration of the illness in the Self and in the daily life, while the therapy on demand is more associated to a representation of the haemophilia as external to the Self and concerning only the body. Furthermore, different ranges of age are linked to different kinds of representation: haemophilia is considered by the adolescents like a body's break, while it is considered by young adults as a mystery for which researching causes in the family history.

Recurrent transient neurological deficits have been described in human immunodeficiency virus (HIV)-infected subjects, but their frequency, pathogenesis, and outcome are still unsettled. We describe 10 HIV-infected patients with transient neurological deficits (0.8% of all patients followed in our department during the last decade). All patients were in the advanced stage of immunological disease. None of the clinical or special investigations performed outside of the attacks indicated an underlying structural lesion of the central nervous system. In 80% of these patients, anticardiolipin antibodies were present. The final outcome was unrelated to these transient neurological deficits which, per se, had a benign course. We discuss the possible etiopathogenetic mechanisms of such episodes and suggest that they may be "migrainelike" events, possibly related to transient functional circulatory abnormalities secondary to an immunological antiphospholipid antibody-dependent mechanism.

Haemophilia A (HA) is an X-linked recessive bleeding disorder caused by a lack or decrease of coagulation factor VIII activity. The molecular diagnosis of HA is challenging and a variety of different mutations have been identified throughout the F8 gene. Our aim was to detect the causative mutation in 266 HA patients from Emilia-Romagna region (Italy) and in all suspected carriers. Molecular analysis of F8 in 201 HA patients (152 index cases) was performed with a combination of several indirect and direct molecular approaches, such as long distance polymerase chain reaction, multiplex ligation-dependent probe amplification, denaturing high performance liquid chromatography and direct sequencing. The analysis revealed 78 different mutations, 23 of which were novel, not having been reported in national or international databases. The detection rate was 100%, 86% and 89% in patients with severe, moderate and mild HA, respectively. The information provided by this registry will be helpful for monitoring the treatment of HA patients in Emilia-Romagna and also for reliable genetic counselling of affected families in the future.

Clinical diagnosis of deep venous thrombosis (DVT) of the leg is unreliable. An accurate diagnosis is important for therapeutic decision since anticoagulant treatment, though potentially dangerous, is useless in case of a false positive diagnosis, whereas a false negative diagnosis may lead to withdrawal of an extremely necessary anticoagulation. Contrast venography is still recognized as the gold standard method for the diagnosis of DVT, but in recent years a variety of accurate non-invasive methods has been developed. The ultrasound compression sonography (CUS) is considered a simple non invasive test highly sensitive and specific for proximal DVT in symptomatic outpatients, though non adequately sensitive and specific for isolated calf DVT. Plasma D-dimer levels (DD, fibrin degradation products) have a high negative predictive value for DVT. The aim of this study, performed in outpatients with suspected leg DVT, was to validate, versus venography, a non-invasive, easy to perform and fast diagnostic procedure based on a combination of CUS and D-dimer test. End points of the procedure were: confirmation or exclusion of proximal DVT; suspicion of isolated calf DVT in which case the test would be repeated in a few days to detect any possible proximalization of thrombosis.Sixty-eight consecutive outpatients, 37 male, with clinically suspected first episode of leg DVT were eligible and examined with CUS, DD test and venography.The results showed that the diagnostic procedure under examination has a high sensibility and specificity for DVT.It can thus be recommended as routine diagnostic procedure in symptomatic outpatients with suspected DVT reserving venography special cases only.

B19 infection can be acquired by transmission with blood factors in patients with congenital bleeding disorders, requiring clotting factor concentrates. In immunodeficient patients, the failure of immunity to clear B19 virus may produce persistent infections. The presence of B19 DNA in blood samples from seven haemophilic patients with concomitant HIV-1 infection was studied over a period of three-to-four years. Dot blot hybridization assays with DNA and RNA probes were used to detect medium high viremias, and polymerase chain reaction (PCR) to detect very low viremic titres. Three patients were negative for B19 DNA in all the blood samples, while four patients were persistently positive for B19 DNA. Viral persistence, which in one patient was detected throughout the study period (40 months), occurred at low titre in all four positive patients with some recurrent increases in viral titre. In the four patients persistently positive for B19 DNA, acute or chronic clinical symptoms and signs that could be associated with B19 were not noted when virus was present at low titre (B19 DNA detectable only by PCR). When patients had a higher viral titre (B19 DNA detectable by dot blot hybridization) acute manifestations (aplastic crisis, Fifth disease, fevers, pneumonitis) were found.

In July 1985, all coagulation factor concentrates were withdrawn from the market in Italy and replaced with virally inactivated concentrates. A retrospective survey comparing the prevalence of the antibody to the hepatitis C virus (anti-HCV) in hemophiliacs multitransfused with nonvirally inactivated concentrates until 1985 with that in previously untreated hemophiliacs transfused exclusively with virally inactivated concentrates since 1985 has been conducted in 9 Italian hemophilia centers. The centers, which follow about one-fourth of all the Italian hemophiliacs, provided information about 708 patients infused for the first time before 1985 (group A) and 80 patients infused for the first time between 1985 and 1991 (group B). The prevalence of anti-HCV was 83% (591/708) in group A and 6% (5/80) in group B. For the 5 anti-HCV-seropositive patients from group B, dry heating, hydrophobic interaction chromatography plus dry heating (2 patients), hot vapor and pasteurization were the virucidal methods used for the concentrates implicated in HCV transmission. In the case associated with pasteurization, there is the possibility of intrafamilial transmission of HCV. It appears from this retrospective analysis that there has been a substantial reduction in the risk of HCV transmission since the adoption of virucidal methods. However, these methods do not eliminate completely the risk, which might be further reduced by the recent adoption of anti-HCV screening for plasma donations used to manufacture concentrates.

The 3' portion of the coagulation factor VII gene, containing the activation and serine protease domains, was investigated in four subjects with factor VII deficiency by temperature gradient gel electrophoresis and sequencing of polymerase chain reaction (PCR) products. Molecules displaying an altered melting behaviour were detected in three subjects, and direct sequencing showed two mutations. A G-to-T transversion causing a missense mutation, Cys-310 to Phe, suppresses a disulphide bond conserved in the catalytic domain of all serine proteases. This mutation, which in the homozygous form causes a severe reduction in protease activity (4%), was found in two patients from different Italian regions. A G-to-A transition, which gives rise to a missense mutation, Arg-304 to Gln, and is associated with the factor VII padua variant, was found in the heterozygous form in a subject also affected by von Willebrand disease. Two polymorphic alleles, which differ in one repeat monomer element, were precisely mapped in a region spanning the exon-intron 7 border of the factor VII gene and studied in families with factor VII or X deficiency.

Acute intravenous administration in man of defibrotide (CAS 83712-60-1), a polynucleotide derivative, induces increase of 6-keto-PGF1 alpha and PGE2 production from appropriately stimulated whole blood. In the present study including acute and chronic experiments, defibrotide (Prociclide) orally administered during two weeks to healthy volunteers significantly increased the amounts of 6-keto-PGF1 alpha generated after appropriate stimulation in whole blood and in a neutrophilic leukocytes-platelet suspension. Similar effects were observed for PGE2, while TXB2 production was unchanged. Furthermore, platelet aggregation induced by calcium ionophore A23817 and production of leukotriene B4 from whole blood and isolated polymorphonuclear neutrophils were inhibited. The observed results suggest that defibrotide is biochemically active also by the oral route although the pharmacological and clinical value of the observed changes needs to be assessed.

The presence and inheritance of restriction fragment length polymorphisms (RFLPs) and gene lesions in the coagulation factor VIII gene were investigated in 15 hemophilia families. An abnormal HindIII 2.6-kb band, previously detected in a severe hemophiliac, was observed in a not severely affected patient and also in the normal gene of a woman carrying a hemophilic gene in which the lesions was found. The TaqI site in exon 24 of this defective gene was removed by a C to T transition causing an amino acid change (Arg----Gln). Very low amounts of factor VIII activity and antigen were detected in the severely affected grandson. The presence of the HindIII 2.6-kb fragment in both normal and pathological genes indicates that a factor VIII RFLP without functional meaning was found. Its frequency, determined in 60 chromosomes, is 0.18. Double digestions enabled us to map the polymorphic site 3' to the exon 19.

We tested serum samples from 11 HIV-seropositive and 32 HIV-seronegative Italian patients with hemophilia A or B for the presence of lymphocytotoxic antibodies (LCTAs). No patients had the acquired immune deficiency syndrome and all had received over many years heat-untreated commercial clotting factors. LCTAs directed mainly to B cells, were significantly present in 5/6 HIV-seropositive patients with hemophilia A and in 5/5 HIV-seropositive patients with hemophilia B. The presence of LCTAs in HIV-seronegative hemophiliacs was significantly correlated with both a decrease of T cells and an increase in serum levels of IgG and IgM.

DNAs from 15 haemophilia A patients from different families have been hybridized to FVIII cDNA probes for the exons 14-26.In a severely affected patient (FVIII:C 2 %) the TaqI site of exon 24 is absent originating an abnormal band of 4.2 Kb. A C toT transition in the CG dinucleotide of the TaqI site (TCGA) is the probable gene mutation. Since the transition in the sense strand should originate an additional Hind III site, which is not detected in our patient, we infer that the mutation occurred in the antisensestrand causing an aminoacid change (CGA →CAA, Arg → Gin). This isin accordance with the low activity of FVIII and with the absence of inhibitor. Infact Gitschier et Al reported in a patient with ahigh titre of anti-FVIII antibody and with In the Hindlll pattern from a moderately affected patient (FVIII:C 4%) the fragment containing the exon 18 is 2.5 Kb in size (normal 2.6 Kb). Since the patterns with other restriction enzymes are indistinguishable from normal a small mutation originating a new Hind III site is likely. Both altered patterns have been detected in the patients' mothers.Work supported by Ricerca Sanitaria Finalizzata Regione Emilia Romagna