Inhibition of mannan-binding lectin associated serine protease (MASP)-2 reduces the cognitive deficits in a mouse model of severe traumatic brain injury.

The lectin pathway (LP) of complement mediates inflammatory processes linked to tissue damage and loss of function following traumatic brain injury (TBI). LP activation triggers a cascade of proteolytic events initiated by LP specific enzymes called MASPs (for Mannan-binding lectin Associated Serine Proteases). Elevated serum and brain levels of MASP-2, the effector enzyme of the LP, were previously reported to be associated with the severity of tissue injury and poor outcomes in patients with TBI. To evaluate the therapeutic potential of LP inhibition in TBI, we first conducted a pilot study testing the effect of an inhibitory MASP-2 antibody (α-MASP-2), administered systemically at 4 and 24 h post-TBI in a mouse model of controlled cortical impact (CCI). Treatment with α-MASP-2 reduced sensorimotor and cognitive deficits for up to 5 weeks post-TBI. As previous studies by others postulated a critical role of MASP-1 in LP activation, we conducted an additional study that also assessed treatment with an inhibitory MASP-1 antibody (α-MASP-1). A total of 78 mice were treated intraperitoneally with either α-MASP-2, or α-MASP-1, or an isotype control antibody 4 h and 24 h after TBI or sham injury. An amelioration of the cognitive deficits assessed by Barnes Maze, prespecified as the primary study endpoint, was exclusively observed in the α-MASP-2-treated group. The behavioral data were paralleled by a reduction of the lesion size when evaluated histologically and by reduced systemic LP activity. Our data suggest that inhibition of the LP effector enzyme MASP-2 is a promising treatment strategy to limit neurological deficits and tissue loss following TBI. Our work has translational value because a MASP-2 antibody has already completed multiple late-stage clinical trials in other indications and we used a clinically relevant treatment protocol testing the therapeutic mechanism of MASP-2 inhibition in TBI.

Inhibition of the Lectin Pathway of Complement Activation Reduces Acute Respiratory Distress Syndrome Severity in a Mouse Model of SARS-CoV-2 Infection.

Most patients with COVID-19 in the intensive care unit develop an acute respiratory distress syndrome characterized by severe hypoxemia, decreased lung compliance, and high vascular permeability. Activation of the complement system is a hallmark of moderate and severe COVID-19, with abundant deposition of complement proteins in inflamed tissue and on the endothelium during COVID-19. Using a transgenic mouse model of SARS-CoV-2 infection, we assessed the therapeutic utility of an inhibitory antibody (HG4) targeting MASP-2, a key enzyme in the lectin pathway. Treatment of infected mice with HG4 reduced the disease severity score and improved survival vs mice that received an isotype control antibody. Administration of HG4 significantly reduced the lung injury score, including alveolar inflammatory cell infiltration, alveolar edema, and alveolar hemorrhage. The ameliorating effect of MASP-2 inhibition on the severity of COVID-19 pathology is reflected by a significant reduction in the proinflammatory activation of brain microglia in HG4-treated mice.

Treatment of Achilles insertional tendinopathy: our surgical procedure and medium-term results.

BACKGROUND AND AIM: Achilles insertional tendinopathy (AIT) is a common injury and its pathogenesis is still not entirely clear. It manifests with worsening pain and functional limitations. When conservative treatment fails, surgical treatment is indicated. The purpose of our research is to evaluate the outcome after one year in patients affected by AIT (calcific and non-calcific AIT) who were treated at our centre. METHODS: Between 2014 and 2021, 42 patients suffering from AIT - a total of 47 feet - underwent surgery at our centre. The patients filled in the VISA-A and AOFAS questionnaires at the pre-operative consultation and at the clinical check-up after one year of follow up. RESULTS: Of the 47 feet treated, 28 were calcific AITs treated by medial access and tendon reinsertion using a knotless double suture anchor system (Achilles Suture Bridge™) and 19 were non-calcific tendinopathies treated using a lateral paratendinous approach. The one-year clinical results show an increase in VISA-A scores of 48.6 and AOFAS scores of 44.1 and the absence of complications. Only one patient reported a recurrence of certain symptoms and none of the patients were hospitalized for recurrence. CONCLUSIONS: The literature is unable to establish a gold standard of treatment for AIT. The method we have used has shown excellent short- and medium-term results without any complications. Further studies are needed to prove its effectiveness in the long term.

Protein Expression of the Microglial Marker Tmem119 Decreases in Association With Morphological Changes and Location in a Mouse Model of Traumatic Brain Injury.

The activation of microglia and the infiltration of macrophages are hallmarks of neuroinflammation after acute brain injuries, including traumatic brain injury (TBI). The two myeloid populations share many features in the post-injury inflammatory response, thus, being antigenically indistinguishable. Recently Tmem119, a type I transmembrane protein specifically expressed by microglia under physiological conditions, was proposed as a tool to differentiate resident microglia from blood-borne macrophages, not expressing it. However, the validity of Tmem119 as a specific marker of resident microglia in the context of acute brain injury, where microglia are activated and macrophages are recruited, needs validation. Our purpose was to investigate Tmem119 expression and distribution in relation to the morphology of brain myeloid cells present in the injured area after TBI. Mice underwent sham surgery or TBI by controlled cortical impact (CCI). Brains from sham-operated, or TBI mice, were analyzed by in situ hybridization to identify the cells expressing Tmem119, and by Western blot and quantitative immunofluorescence to measure Tmem119 protein levels in the entire brain regions and single cells. The morphology of Iba1+ myeloid cells was analyzed at different times (4 and 7 days after TBI) and several distances from the contused edge in order to associate Tmem119 expression with morphological evolution of active microglia. In situ hybridization indicated an increased Tmem119 RNA along with increased microglial complement C1q activation in the contused area and surrounding regions. On the contrary, the biochemical evaluation showed a drop in Tmem119 protein levels in the same areas. The Tmem119 immunoreactivity decreased in Iba1+ myeloid cells found in the contused cortex at both time points, with the cells showing the hypertrophic ameboid morphology having no Tmem119 expression. The Tmem119 was present on ramifications of resident microglia and its presence was decreased as a consequence of microglial activation in cortical areas close to contusion. Based on the data, we conclude that the decrease of Tmem119 in reactive microglia may depend on the process of microglial activation, which involves the retracting of their branchings to acquire an ameboid shape. The Tmem119 immunoreactivity decreases in reactive microglia to similar levels than the blood-borne macrophages, thus, failing to discriminate the two myeloid populations after TBI.

Mannose-binding lectin promotes blood-brain barrier breakdown and exacerbates axonal damage after traumatic brain injury in mice.

Leukocyte infiltration and blood-brain barrier breakdown contribute to secondary brain damage after traumatic brain injury (TBI). TBI induces neuroimmune responses triggering pathogenic complement activation through different pathways, including the lectin pathway. We investigated mechanisms underlying mannose-binding lectin (MBL)-mediated brain damage focusing on neutrophil infiltration and blood-brain barrier breakdown in a TBI mouse model. Wild type mice and MBL-/- null mice were subjected to controlled cortical impact. We studied neutrophil infiltration and regional localization by confocal microscopy 1, 4 and 15 days post-trauma, and investigated neutrophil extracellular trap (NET) formation. By immunofluorescence and/or Western blotting in various brain regions we studied the presence of fibrin(ogen), pentraxin-3, albumin and immunoglobulin G. Finally, we studied neurofilament proteins, synaptophysin, and αII-spectrin, and assessed white matter content in the injured tissue. TBI triggered an acute wave of neutrophil infiltration at day 1 followed by a more discrete persistence of neutrophils in the injured tissue at least until day 15. We detected the presence of NETs and pentraxin-3 in the injured tissue, as well as accumulation of fibrin(ogen), increased blood-brain barrier permeability, and neurofilament, synaptophysin and white matter loss, and calpain-mediated αII spectrin breakdown. MBL-/- mice showed reduced number of Ly6G+ neutrophils 4 days after TBI, lower accumulation of pentraxin-3 and fibrin(ogen) in the injured tissue, reduced global plasma protein extravasation, and better preservation of axonal and white matter integrity. These results show that MBL participates in secondary neutrophil accumulation and blood-brain barrier breakdown, and promotes axonal and white matter damage after TBI in mice.

Long pentraxin PTX3 is upregulated systemically and centrally after experimental neurotrauma, but its depletion leaves unaltered sensorimotor deficits or histopathology.

Long pentraxin PTX3, a pattern recognition molecule involved in innate immune responses, is upregulated by pro-inflammatory stimuli, contributors to secondary damage in traumatic brain injury (TBI). We analyzed PTX3 involvement in mice subjected to controlled cortical impact, a clinically relevant TBI mouse model. We measured PTX3 mRNA and protein in the brain and its circulating levels at different time point post-injury, and assessed behavioral deficits and brain damage progression in PTX3 KO mice. PTX3 circulating levels significantly increased 1-3 weeks after injury. In the brain, PTX3 mRNA was upregulated in different brain areas starting from 24 h and up to 5 weeks post-injury. PTX3 protein significantly increased in the brain cortex up to 3 weeks post-injury. Immunohistochemical analysis showed that, 48 h after TBI, PTX3 was localized in proximity of neutrophils, likely on neutrophils extracellular traps (NETs), while 1- and 2- weeks post-injury PTX3 co-localized with fibrin deposits. Genetic depletion of PTX3 did not affect sensorimotor deficits up to 5 weeks post-injury. At this time-point lesion volume and neuronal count, axonal damage, collagen deposition, astrogliosis, microglia activation and phagocytosis were not different in KO compared to WT mice. Members of the long pentraxin family, neuronal pentraxin 1 (nPTX1) and pentraxin 4 (PTX4) were also over-expressed in the traumatized brain, but not neuronal pentraxin 2 (nPTX2) or short pentraxins C-reactive protein (CRP) and serum amyloid P-component (SAP). The long-lasting pattern of activation of PTX3 in brain and blood supports its specific involvement in TBI. The lack of a clear-cut phenotype in PTX3 KO mice may depend on the different roles of this protein, possibly involved in inflammation early after injury and in repair processes later on, suggesting distinct functions in acute phases versus sub-acute or chronic phases. Brain long pentraxins, such as PTX4-shown here to be overexpressed in the brain after TBI-may compensate for PTX3 absence.

Plasma-derived and recombinant C1 esterase inhibitor: Binding profiles and neuroprotective properties in brain ischemia/reperfusion injury.

C1 esterase inhibitor (C1INH) is known to exert its inhibitory effect by binding to several target proteases of the contact and complement systems. One of C1INH's targets comprise mannose-binding lectin (MBL), a critical player in post-stroke pathophysiology. We therefore explored the effects of recombinant human (rh) and plasma derived (pd) C1INH in C57BL/6J mice subjected to transient occlusion of the middle cerebral artery (tMCAo), receiving 15U/mouse of pd or rhC1INH intravenously, at reperfusion. We analyzed the compounds' (i)neuroprotective effects, (ii) plasma presence, (iii)effects on circulating and brain MBL, (iv)time course of endothelial deposition, and (v) effects on the formation of active complement products. rhC1INH-treated mice had neuroprotective effects, including reduced behavioral deficits and neuronal loss, associated with decreased MBL brain deposition and decreased formation of complement C4b active fragments. In contrast, pdC1INH did not show these neuroprotective effects despite its longer plasma residence time. We also analyzed the response to tMCAo in C1INH-deficient mice, observing a poorer ischemic outcome compared to the wild type mice, which could be partially prevented by rhC1INH administration. In conclusion, we show that rhC1INH exhibits stronger neuroprotective effects than the corresponding plasma-derived protein after experimental ischemia/reperfusion injury in the brain, placing it as a promising drug for stroke. Differential effects are likely related to more effective MBL inhibition which further confirms it as a useful pharmacological target for stroke.

Initiators of Classical and Lectin Complement Pathways Are Differently Engaged after Traumatic Brain Injury-Time-Dependent Changes in the Cortex, Striatum, Thalamus and Hippocampus in a Mouse Model.

The complement system is involved in promoting secondary injury after traumatic brain injury (TBI), but the roles of the classical and lectin pathways leading to complement activation need to be clarified. To this end, we aimed to determine the ability of the brain to activate the synthesis of classical and lectin pathway initiators in response to TBI and to examine their expression in primary microglial cell cultures. We have modeled TBI in mice by controlled cortical impact (CCI), a clinically relevant experimental model. Using Real-time quantitative polymerase chain reaction (RT-qPCR) we analyzed the expression of initiators of classical the complement component 1q, 1r and 1s (C1q, C1r, and C1s) and lectin (mannose binding lectin A, mannose binding lectin C, collectin 11, ficolin A, and ficolin B) complement pathways and other cellular markers in four brain areas (cortex, striatum, thalamus and hippocampus) of mice exposed to CCI from 24 h and up to 5 weeks. In all murine ipsilateral brain structures assessed, we detected long-lasting, time- and area-dependent significant increases in the mRNA levels of all classical (C1q, C1s, C1r) and some lectin (collectin 11, ficolin A, ficolin B) initiator molecules after TBI. In parallel, we observed significantly enhanced expression of cellular markers for neutrophils (Cd177), T cells (Cd8), astrocytes (glial fibrillary acidic protein-GFAP), microglia/macrophages (allograft inflammatory factor 1-IBA-1), and microglia (transmembrane protein 119-TMEM119); moreover, we detected astrocytes (GFAP) and microglia/macrophages (IBA-1) protein level strong upregulation in all analyzed brain areas. Further, the results obtained in primary microglial cell cultures suggested that these cells may be largely responsible for the biosynthesis of classical pathway initiators. However, microglia are unlikely to be responsible for the production of the lectin pathway initiators. Immunofluorescence analysis confirmed that at the site of brain injury, the C1q is localized in microglia/macrophages and neurons but not in astroglial cells. In sum, the brain strongly reacts to TBI by activating the local synthesis of classical and lectin complement pathway activators. Thus, the brain responds to TBI with a strong, widespread and persistent upregulation of complement components, the targeting of which may provide protection in TBI.

Traumatic brain injury in mice induces changes in the expression of the XCL1/XCR1 and XCL1/ITGA9 axes.

BACKGROUND: Every year, millions of people suffer from various forms of traumatic brain injury (TBI), and new approaches with therapeutic potential are required. Although chemokines are known to be involved in brain injury, the importance of X-C motif chemokine ligand 1 (XCL1) and its receptors, X-C motif chemokine receptor 1 (XCR1) and alpha-9 integrin (ITGA9), in the progression of TBI remain unknown. METHODS: Using RT-qPCR/Western blot/ELISA techniques, changes in the mRNA/protein levels of XCL1 and its two receptors, in brain areas at different time points were measured in a mouse model of TBI. Moreover, their cellular origin and possible changes in expression were evaluated in primary glial cell cultures. RESULTS: Studies revealed the spatiotemporal upregulation of the mRNA expression of XCL1, XCR1 and ITGA9 in all the examined brain areas (cortex, thalamus, and hippocampus) and at most of the evaluated stages after brain injury (24 h; 4, 7 days; 2, 5 weeks), except for ITGA9 in the thalamus. Moreover, changes in XCL1 protein levels occurred in all the studied brain structures; the strongest upregulation was observed 24 h after trauma. Our in vitro experiments proved that primary murine microglial and astroglial cells expressed XCR1 and ITGA9, however they seemed not to be a main source of XCL1. CONCLUSIONS: These findings indicate that the XCL1/XCR1 and XCL1/ITGA9 axes may participate in the development of TBI. The XCL1 can be considered as one of the triggers of secondary injury, therefore XCR1 and ITGA9 may be important targets for pharmacological intervention after traumatic brain injury.

The CCL2/CCL7/CCL12/CCR2 pathway is substantially and persistently upregulated in mice after traumatic brain injury, and CCL2 modulates the complement system in microglia.

Traumatic brain injury (TBI) is the leading cause of death in the global population. Disturbed inflammatory processes after TBI exacerbate secondary brain injury and contribute to unfavorable outcomes. Multiple inflammatory events that accompany brain trauma, such as glial activation, chemokine release, or the initiation of the complement system cascade, have been identified as potential targets for TBI treatment. However, the participation of chemokines in the complement activation remains unknown. Our studies sought to determine the changes in the expression of the molecules involved in the CCL2/CCL7/CCL12/CCR2 pathway in the injured brain and the effect of CCL2, CCL7, and CCL12 (10, 100, and 500 ng/mL) on the classic and lectin complement pathways and inflammatory factors in microglial cell cultures. Brain injury in mice was modeled by controlled cortical impact (CCI). Our findings indicate a time-dependent upregulation of CCL2, CCL7, and CCL12 at the mRNA and protein levels within the cortex, striatum, and/or thalamus beginning 24 h after the trauma. The analysis of the expression of the receptor of the tested chemokines, CCR2, revealed its substantial upregulation within the injured brain areas mainly on the mRNA level. Using primary cortical microglial cell cultures, we observed a substantial increase in the expression of CCL2, CCL7, and CCL12 after 24 h of LPS (100 ng/mL) treatment. CCL2 stimulation of microglia increased the level of IL-1ß mRNA but did not influence the expression of IL-18, IL-6, and IL-10. Moreover, CCL2 significantly increased the expression of Iba1, a marker of microglia activation. CCL2 and CCL12 upregulated the expression of C1qa but did not influence the expression of C1ra and C1s1 (classical pathway); moreover, CCL2 increased ficolin A expression and reduced collectin 11 expression (lectin pathway). Additionally, we observed the downregulation of pentraxin 3, a modulator of the complement cascade, after CCL2 and CCL12 treatment. We did not detect the expression of ficolin B, Mbl1, and Mbl2 in microglial cells. Our data identify CCL2 as a modulator of the classical and lectin complement pathways suggesting that CCL2 may be a promising target for pharmacological intervention after brain injury. Moreover, our study provides evidence that CCL2 and two other CCR2 ligands may play a role in the development of changes in TBI.

Surgical treatment of talar osteo-chondral lesions with micro-fractures, mesenchymal cells grafting on membrane, or allograft: Mid-term clinical and magnetic resonance assessment.

Talar dome osteo-chondral lesions (OCL) are defects of the cartilaginous surface and subchondral bone often associated with sport practice. This retrospective observational work has the purpose of assessing: a) The clinical outcomes in the patients study group and in the three sub-groups; b) medium-term morphological and qualitative outcomes of the newly formed tissue by magnetic resonance imaging; c) if there is the correlation between new formed tissue clinical, morphological RM evaluation and qualitative clinical outcomes.

Changes in macrophage inflammatory protein-1 (MIP-1) family members expression induced by traumatic brain injury in mice.

A deep knowledge of the profound immunological response induced by traumatic brain injury (TBI) raises the possibility of novel therapeutic interventions. Existing studies have highlighted the important roles of C-C motif ligands in the development of neuroinflammation after brain injury; however, the participation of macrophage inflammatory protein-1 (MIP-1) family members in this phenomenon is still undefined. Therefore, the goal of our study was to evaluate changes in macrophage inflammatory protein-1 (MIP-1) family members (CCL3, CCL4, and CCL9) and their receptors (CCR1 and CCR5) in a mouse model of TBI (induced by controlled cortical impact (CCI)). We also investigated the pattern of activation of immunological cells (such as neutrophils, microglia and astroglia), which on one hand express CCR1/CCR5, and on the other hand might be a source of the tested chemokines in the injured brain. We investigated changes in mRNA (RT-qPCR) and/or protein (ELISA and Western blot) expression in brain structures (the cortex, hippocampus, thalamus, and striatum) at different time points (24 h, 4 days, 7 days, 2 weeks, and/or 5 weeks) after trauma. Our time-course studies revealed the upregulation of the mRNA expression of all members of the MIP-1 family (CCL3, CCL4, and CCL9) in all tested brain structures, mainly in the early stages after injury. A similar pattern of activation was observed at the protein level in the cortex and thalamus, where the strongest activation was observed 1 day after CCI; however, we did not observe any change in CCL3 in the thalamus. Analyses of CCR1 and CCR5 demonstrated the upregulation of the mRNA expression of both receptors in all tested cerebral structures, mainly in the early phases post injury (24 h, 4 days and 7 days). Protein analysis showed the upregulation of CCR1 and CCR5 in the thalamus 24 h after TBI, but we did not detect any change in the cortex. We also observed the upregulation of neutrophil marker (MPO) at the early time points (24 h and 7 days) in the cortex, while the profound activation of microglia (IBA-1) and astroglia (GFAP) was observed mainly on day 7. Our findings highlight for the first time that CCL3, CCL4, CCL9 and their receptors offer promising targets for influencing secondary neuronal injury and improving TBI therapy. The results suggest that the MIP-1 family is an important target for pharmacological intervention for brain injury.

Infinity ankle arthroplasty with traditional instrumentation and PSI prophecy system: preliminary results.

Ankle arthrodesis has been considered the surgical Gold Standard for advanced ankle arthritis; prosthetic replacement of the tibio-talar joint played a secondary role.The introduction of last generation ankle prostheses lead to better outcome and a lower rate of complication. PSI represents the most recent innovations introduced on the market of ankle arthroplasty:PSI is proposed as a surgical technique capable of making ankle arthroplasty more accurate and more reproducible compared to standard referencing guides Aim of the study is to report early clinical and radiographic outcomes obtained from a single surgeon experience by implanting the same ankle prosthesis using a standard (STD) or a PSI instrumentation Unlike no difference in the average increment of normalized sub score related to function in each group (PSI vs STD), the analysis of normalized pain sub score pointed out a greater average improvement in the PSI group(+75%)compared to the STD group(+62%);this result has been adovacated to the absence of post operative gutter impingement syndrome in the PSI group compared to the STD referencing group. The analysis of radiographic angles revealed a more accurate and reproducible positioning of the components in the PSI group; ankle arthroplasty performed with PSI reported a reduction of both surgical times and the need of intraop.fluoroscopy. PSI ankle arthroplasty achived more accurate and reproducible clinical and radiographic results compared to STD instrumentation;long-term follow-up are needed to demonstrate whether a better positioning of the implant is associated with an increased survival of the prosthesis and therefore justifies the additional costs of PSI.

Specific contribution of mannose-binding lectin murine isoforms to brain ischemia/reperfusion injury.

Mannose-binding lectin (MBL), an initiator of the lectin pathway (LP) of complement activation, is detrimental in ischemic stroke, as shown in clinical studies and rodent models. Whereas humans have one functional MBL protein, rodents have two isoforms, MBL-A and MBL-C, whose functions relative to that of human MBL are unknown. To permit the clinical translation of preclinical data, we aimed to define the specific contributions of MBL-A and MBL-C to brain ischemia. We subjected mice with double (MBL-/-) or single (MBL-A-/- or MBL-C-/-) MBL isoform depletion to transient middle cerebral artery occlusion (tMCAo). MBL-/- mice had fewer neurological deficits and smaller ischemic lesions than WT mice. MBL-A-/- mice had smaller lesions than WT mice and exhibited no significant behavioral defects, whereas MBL-C-/- mice did not differ from WT mice. The induction of Mbl1 and Mbl2 (the MBL-A and MBL-C genes) expression 48 h after tMCAo was similar across genotypes. The time course of Mbl1 and Mbl2 expression in WT ischemic mice showed that Mbl1 activation occurred earlier (24 h) than Mbl2 activation (48 h). The plasma levels of MBL-A and MBL-C in MBL-C-/- and MBL-A-/- mice, respectively, were similar to those in WT mice both at baseline and at 48 h after tMCAo. At 48 h, MBL-A-/- ischemic mice showed higher MBL-C levels in the brain than WT mice. WT and MBL-C-/- ischemic mice had higher LP activity in plasma and, accordingly, higher levels of C3 deposition in the brain than MBL-A-/- and MBL-/- mice. In conclusion, mice with depletion of both MBL isoforms exhibited strong protection from ischemia/reperfusion injury. MBL-A was the main contributor to injury, likely owing to its earlier activation after ischemia and more efficient activation of the complement system than MBL-C.

Bone scan in painful knee arthroplasty: obsolete or actual examination?

ptic loosening, instability and infection are the major causes of TKA failure. For many years, nuclear medicine (NM) imaging was helpful to frame a painful total joint arthroplasty. The differentiation of septic from aseptic prosthetic loosening is critical. The latest AAOS guidelines to detect periprosthetic joint infection (PJI) restrict the role of NM scintigraphy. On the other hand, several studies suggest that NM imaging plays an important role in the evaluation of patients with painful prosthesis, but its specificity in differentiating aseptic loosening from infection is low. Moreover, scintigraphic exams showed different diagnostic accuracy in TKA compared to total hip arthroplasty (THA). PURPOSE: To assess and discuss current knowledges about the diagnostic value of the various scans in TKA failure alone. METHODS: We perform a pubmed/medline search to identify all papers published in the literature matching the following key words: "total knee arthroplasty", "bone", "scintigraphy", "imaging", "three-phase", "triple-phase", "99mTc-HDP", "99mTc-MDP", "99mTc-hydroxymethane diphosphonate", and "99m Tc-methylenediphosphonate", "leukocyte scanning", "labeled leukocyte scintigraphy", "antigranulocyte", "nuclear medicine", "septic loosening", "aseptic loosening" and "infection". RESULTS: Three phases bone scintigraphy results an early diagnostic screening test or part of the preoperative tests for painful TKA and when PJI is suspected. Instead, leukocyte/bone marrow scintigraphy is superior to other scintigraphic tools in diagnosis of TKA infections. Granulocyte scintigraphy, seems to be an excellent choice when the diagnosis is unclear. Moreover, nuclear diagnostic tests showed different diagnostic accuracy between TKA and THA. CONCLUSIONS: Although nuclear diagnostic tests for THA failure are superior in  diagnostic accuracy compared to TKA, NM scintigraphy is still an effective tool in the identification of chronic, low grade PJI. To date, scintigraphic exams have an higher levels of sensitivity, specificity and accuracy. Currently, leukocyte/bone marrow scintigraphy is considered the gold standard for this aim.  Nevertheless, further studies are needed to assess and improve the accuracy of the scintigraphic exams in order to discriminate the causes of failure for painful TKA.

Death secondary to a donkey's bites.

We present a unique case of death due to the assault and bites of a donkey on a 65-year-old man. The farmer, found dead in his farmyard, had a very deep wound in the anterior region of the neck, with a sharp transection of the trachea and severe bleeding by several minor vessels wall disruptions. The cause of death was established to be massive bleeding combined with asphyxia due to aspiration of the blood. Moreover, multiple contusions with associated skin abrasions and perforations were present. The general impression of the injuries was consistent with an animal's bite marks. Herbivorous or omnivorous bite attacks on humans are rare; instead, these animals attack by kicking, trampling, and kneeling, resulting in secondary blunt injuries. The donkey is usually a docile animal, but its behavior can be aggressive during the mating season, and the possibility of biting should not be underestimated, as illustrated by the 2 cases published previously as well as by the case presented here.

Asphyxia in a confined space: a case report.

We describe a death in a hospital wardrobe of a 40-year-old male suffering from HIV infection and lobar pneumonia. On the basis of circumstantial evidence and autopsy findings we conclude that the cause of death was asphyxia in a confined space as a result of several pathomechanical factors. As well as establishing the cause and manner of death, the interpretation of the case involves the evaluation of the professional responsibility of the medical personnel. This report discusses different aspects concerning the cause, mechanism, and manner of death and illustrates various problems encountered in forensic pathology.

Adrenal Schwannoma. Report of two cases.

Adrenal tumours are frequently incidental discoveries, and their therapy is a subject of controversial discussions. Herein we describe two cases of adrenal schwannoma discovered during autopsy. The accidental observation of two benign schwannomas of the adrenal gland on asymptomatic patients led to the hypothesis that the real frequency of this type of lesion was underestimated. Furthermore, the adrenal origin of the superior retro-peritoneum schwannomas represents a diagnostic hypothesis to be considered when the original structure of the neoplasia can't be established.

Fatal pulmonary arterial dissection and sudden death as initial manifestation of primary pulmonary hypertension: a case report.

We report a rare case of sudden death due to cardiac tamponade following intrapericardial rupture of a main pulmonary artery dissecting aneurysm. On pathology examination, the pulmonary artery showed an intimal tear in an arterial wall area with reduced thickness. However, no degenerative, inflammatory or necrotic processes were evident within the vessel wall. Hypertrophy of the wall of vasa vasorum in the adventitia of the pulmonary artery was found, as well as bilaterally diffuse myointimal arterial hyperplasia of the lung vasculature. According to these findings, we conclude that pulmonary artery rupture occurred in a patient with chronic unrecognized primary pulmonary hypertension.