Retrospective assessment of fracture risk through opportunistic radiological screening in a large modern cohort of liver transplant recipients

Objective: Liver transplantation has been associated with a high prevalence of osteoporosis, although most data rely on single-center studies with limited sample size, with most of them dating back to late 1990s and early 2000s. The present thesis aims to assess the prevalence of fragility fractures and contributing factors in a large modern cohort of liver transplant recipients managed in a referral Italian Liver Transplant Center. Design and Methods: Paper and electronic medical records of 429 consecutive patients receiving liver transplantation from 1/1/2010 to 31/12/2015 were reviewed, and 366 patients were selected. Clinically obtained electronic radiological images within 6 months from the date of liver transplant surgery, such as lateral views of spine X-rays or CT abdominal scans, were opportunistically reviewed in a blinded fashion to screen for morphometric vertebral fractures. Clinical fragility fractures reported in the medical records, along with information on etiology of cirrhosis and biochemistries at the time of liver surgery were also recorded. Results: Prevalence of fragility fractures in the whole cohort was 155/366 (42.3%), with no significant differences between sexes. Of patients with fractures, most sustained vertebral fractures (145/155, 93.5%), the majority of which were mild or moderate wedges. Multiple vertebral fractures were common (41.3%). Fracture rates were similar across different etiologies of cirrhosis and were also comparable in patients with diabetes or exposed to glucocorticoids. Kidney function was significantly worse in women with fractures. Independent of age, sex, alcohol use, eGFR, etiology of liver disease, lower BMI was the only independent risk factor for fractures (adjusted OR 1,058, 95%CI 1,001-1,118, P=0.046) in this study population. Conclusions: A considerable fracture burden was shown in a large and modern cohort of liver transplant recipients. Given the remarkably high prevalence of fractures, a metabolic bone disease screening should be implemented in every patient awaiting liver transplantation.

Il trattamento delle fratture e lussazioni vertebrali nei piccoli animali

Treatment of spinal fracture and luxation in small animals Traumatic spinal injuries usually result from a mechanic trauma. Spinal facture and luxations generally occur in the junction between and more mobile parts of the spinal column: close to the skull, thorax and pelvis. Fractures may occur alone or in combination with luxation as fracture/luxation. When the fractures are not stable the best solution is the surgical fixation. Internal and external fixation are the surgical methods for the treatment of vertebral fractures and luxations. The authors report the treatment of 12 cases of thoracic and lumbar vertebral fractures and luxations in small animals using the screws/pins and Polymethylmethacrylate technique. The analysis of results is a contribute I the valutation of surgical technique and complications in the post-surgical period.

Alterazioni del metabolismo osseo e fratture vertebrali dopo trapianto di rene

Introduction:Persistent Hyperparathyroidism after transplantation (HPT),bone disease and vertebral fractures are an important clinical problem in renal transplant patients. Several factors such as renal osteodystrophy, immunosuppressive therapy, deficit/insufficiency Vitamin D may contribute to that.In literature are described different percentages of HPT, vertebral fractures and Osteoporosis/Osteopenia that may be due to the different therapy and to the different employ of steroid. We analyzed 90 patients who received a renal graft between 2005 e 2010. Patients and Methods: 44 male and 46 female. Average age 52,2± 10,1 years, follow-up 31,3±16,6 months, time on dialysis 37±29,6 months. Patients who had creatinine level greater than 2,5 mg/dl were excluded. Immunosuppressive therapy was based on basiliximab, steroids (1.6 to 2 mg/kg/day progressively reduced to 5 mg/day after 45 days from the transplantation) in all patients + calcineurin inhibitor+ mycophenolate mophetil/mycophenolic acid in 88,8% of patients or Everolimus± calcineurin inhibitor in the others. Patients were studied with X-ray of the spine, dual-energy-X-ray, PTH, 25(OH)VitD. Results: 41,1% had HPT; 41,1% had osteopenia at femoral neck and 36,7% at vertebral column; 16,7% had osteoporosis at femoral neck and 15,6% at vertebral column. 10 patients (11%) had vertebral fractures. Patients with normal bone mineral density, compared to those with osteoporosis/osteopenia, are more younger (average age 46,4±11,7 years vs 54.3±8,6); they have spent less time on dialysis (26,5±14,8 months vs 40,7±32,6) and they have values of 25(OH)VitD higher (22,1±7,6 ng/ml vs 17,8±8,5). Patients with vertebral fractures have values of 25(OH)VitD lowest (14,1±6,4 ng/ml vs 19,7±8,5) and they had transplant since more time (29,1±16,2 vs 48,1±8,7 months). There is a significant correlation between HPT and PTH pre transplantation; HPT and levels of VitD (p<0,05) Conclusion: Prevention of Bone disease and vertebral fractures after renal transplant includes: a)treatment before transplantation b)supplementation of vitamin D with cholecalciferol or calcidiol c)shorten the dialysis time.

Studio multicentrico sulla prevalenza e sulle principali caratteristiche cliniche e biochimiche nei pazienti in dialisi paratiroidectomizzati in italia

Lo studio CAVE PTX ha lo scopo di valutare la reale prevalenza della paratiroidectomia nei pazienti dializzati in Italia, verificare l’aderenza ai targets ematochimici proposti dalle linee guida internazionali K/DOQI e ricercare la presenza di fratture vertebrali e calcificazioni vascolari. Al momento attuale riportiamo i dati preliminari sulla prevalenza e le caratteristiche cliniche generali dei pazienti finora arruolati. Il nostro studio ha ricevuto contributi da 149 centri dialisi italiani, su un totale di 670, pari al 22%. La popolazione dialitica dalla quale sono stati ottenuti i casi di paratiroidectomia è risultata pari a 12515 pazienti;l’87,7% dei pazienti effettuava l’emodialisi mentre il 12,3% la dialisi peritoneale. Cinquecentoventotto, pari al 4,22%, avevano effettuato un intervento di paratiroidectomia (4,5%emodializzati, 1,9% in dialisi peritoneale;p<0.001). Abbiamo considerato tre gruppi differenti di PTH: basso (<150 pg/ml), ottimale (150 -300 pg/ml) ed elevato (>300 pg/ml). I valori medi di PTH e calcemia sono risultati significativamente diversi (più alti) tra casi e controlli nei due gruppi con PTH basso (PTX = 40±39 vs controllo = 92±42 pg/ml; p<.0001) e PTH alto (PTX= 630 ± 417 vs controllo 577 ±331; p<.05). La percentuale di pazienti con PTH troppo basso è risultata più elevata nei pazienti chirurgici rispetto al resto della popolazione (64vs23%; p<0.0001), mentre la percentuale dei casi con PTH troppo alto è risultata significativamente più alta nel gruppo di controllo (38%vs19%; p<0.003). Il 61% dei casi assumeva vitamina D rispetto al 64 % dei controlli; l’88% vs 75% un chelante del fosforo ed il 13%vs 35% il calciomimentico. In conclusione, la paratiroidectomia ha una bassa prevalenza in Italia, i pazienti sono più spesso di sesso femminile, in emodialisi e con età relativamente giovane ma da più tempo in dialisi.

Image analysis in the morphological and morphometric study of teeth

The subject of this doctoral dissertation concerns the definition of a new methodology for the morphological and morphometric study of fossilized human teeth, and therefore strives to provide a contribution to the reconstruction of human evolutionary history that proposes to extend to the different species of hominid fossils. Standardized investigative methodologies are lacking both regarding the orientation of teeth subject to study and in the analysis that can be carried out on these teeth once they are oriented. The opportunity to standardize a primary analysis methodology is furnished by the study of certain early Neanderthal and preneanderthal molars recovered in two caves in southern Italy [Grotta Taddeo (Taddeo Cave) and Grotta del Poggio (Poggio Cave), near Marina di Camerata, Campania]. To these we can add other molars of Neanderthal and modern man of the upper Paleolithic era, specifically scanned in the paleoanthropology laboratory of the University of Arkansas (Fayetteville, Arkansas, USA), in order to increase the paleoanthropological sample data and thereby make the final results of the analyses more significant. The new analysis methodology is rendered as follows: 1. Standardization of an orientation system for primary molars (superior and inferior), starting from a scan of a sample of 30 molars belonging to modern man (15 M1 inferior and 15 M1 superior), the definition of landmarks, the comparison of various systems and the choice of a system of orientation for each of the two dental typologies. 2. The definition of an analysis procedure that considers only the first 4 millimeters of the dental crown starting from the collar: 5 sections parallel to the plane according to which the tooth has been oriented are carried out, spaced 1 millimeter between them. The intention is to determine a method that allows for the differentiation of fossilized species even in the presence of worn teeth. 3. Results and Conclusions. The new approach to the study of teeth provides a considerable quantity of information that can better be evaluated by increasing the fossil sample data. It has been demonstrated to be a valid tool in evolutionary classification that has allowed (us) to differentiate the Neanderthal sample from that of modern man. In a particular sense the molars of Grotta Taddeo, which up until this point it has not been possible to determine with exactness their species of origin, through the present research they are classified as Neanderthal.

The Influence of Fractures on Vulnerability to Pollution of a Carbonate Aquifer: Monte Conero (Italy)

The carbonate outcrops of the anticline of Monte Conero (Italy) were studied in order to characterize the geometry of the fractures and to establish their influence on the petrophysical properties (hydraulic conductivity) and on the vulnerability to pollution. The outcrops form an analog for a fractured aquifer and belong to the Maiolica Fm. and the Scaglia Rossa Fm. The geometrical properties of fractures such as orientation, length, spacing and aperture were collected and statistically analyzed. Five types of mechanical fractures were observed: veins, joints, stylolites, breccias and faults. The types of fractures are arranged in different sets and geometric assemblages which form fracture networks. In addition, the fractures were analyzed at the microscale using thin sections. The fracture age-relationships resulted similar to those observed at the outcrop scale, indicating that at least three geological episodes have occurred in Monte Conero. A conceptual model for fault development was based on the observations of veins and stylolites. The fracture sets were modelled by the code FracSim3D to generate fracture network models. The permeability of a breccia zone was estimated at microscale by and point counting and binary image methods, whereas at the outcrop scale with Oda’s method. Microstructure analysis revealed that only faults and breccias are potential pathways for fluid flow since all veins observed are filled with calcite. According this, three scenarios were designed to asses the vulnerability to pollution of the analogue aquifer: the first scenario considers the Monte Conero without fractures, second scenario with all observed systematic fractures and the third scenario with open veins, joints and faults/breccias. The fractures influence the carbonate aquifer by increasing its porosity and hydraulic conductivity. The vulnerability to pollution depends also on the presence of karst zones, detric zones and the material of the vadose zone.

Characterization of fold-related fractures in the carbonate rocks of the Cingoli anticline, northern Apennines, Italy

Thrust fault-related folds in carbonate rocks are characterized by deformation accommodated by different structures, such as joints, faults, pressure solution seams, and deformation bands. Defining the development of fracture systems related to the folding process is significant both for theoretical and practical purposes. Fracture systems are useful constrains in order to understand the kinematical evolution of the fold. Furthermore, understanding the relationships between folding and fracturing provides a noteworthy contribution for reconstructing the geodynamic and the structural evolution of the studied area. Moreover, as fold-related fractures influence fluid flow through rocks, fracture systems are relevant for energy production (geothermal studies, methane and CO2 , storage and hydrocarbon exploration), environmental and social issues (pollutant distribution, aquifer characterization). The PhD project shows results of a study carried out in a multilayer carbonate anticline characterized by different mechanical properties. The aim of this study is to understand the factors which influence the fracture formation and to define their temporal sequence during the folding process. The studied are is located in the Cingoli anticline (Northern Apennines), which is characterized by a pelagic multilayer characterized by sequences with different mechanical stratigraphies. A multi-scale analysis has been made in several outcrops located in different structural positions. This project shows that the conceptual sketches proposed in literature and the strain distribution models outline well the geometrical orientation of most of the set of fractures observed in the Cingoli anticline. On the other hand, the present work suggests the relevance of the mechanical stratigraphy in particular controlling the type of fractures formed (e.g. pressure solution seams, joints or shear fractures) and their subsequent evolution. Through a multi-scale analysis, and on the basis of the temporal relationship between fracture sets and their orientation respect layering, I also suggest a conceptual model for fracture systems formation.

The "Orthoplastic" combined surgical approach to open tibia fractures: a multicentric prospective outcome study

Introduction: Open fractures of the leg represent a severe trauma. The combined approach, shared between plastic and orthopaedic surgeons, is considered to be important, although this multidisciplinary treatment is not routinely performed. Aim of this study was to verify whether the orthoplastic treatment is of any advantage over the traditional simply orthopedic treatment, through a multicentric inclusion of these unfrequent injuries into a prospective study. Material and methods: The following trauma centres were involved: Rizzoli Orthopaedic Institute/University of Bologna (leading centre) and Maggiore Hospital (Bologna, Italy), Frenchay Hospital (Bristol, United Kingdom), Jinnah Hospital (Lahore, Pakistan). All patients consecutively hospitalized in the mentioned centres between January 2012 and December 2013 due to tibial open fractures were included in the study and prospectively followed up to December 2014. Demographics and other clinical features were recorded, including the type of treatment (orthopaedic or orthoplastic). The considered outcome measures included duration of hospitalization, time for bone union and soft tissue closure, Enneking score at 3, 6 and 12 months, the incidence of osteomyelitis and other complications. Results: A total of 164 patients were included in the study. Out of them 68% were treated with an orthoplastic approach, whereas 32% received a purely orthopedic treatment. All considered outcome measures showed to be improved by the orthoplastic approach, compared to the orthopaedic one: time for soft tissue closure (2 versus 25 weeks), duration of hospital stay (22 versus 55 days), time for bone union (6 versus 8.5 months) , number of additional operations (0.6 versus 1.2) and functional recovery of the limb at 12 months (27 versus 19, Enneking’s score). All results were statistically significant. Conclusion: The combined orthoplastic approach to the treatment of open tibia fractures, in particular for high grade injuries (Gustilo 3B), is proven to improve the outcome of these severe injuries.