The altered osteocytic expression of connexin 43 and sclerostin in human cadaveric donors with alcoholic liver cirrhosis: Potential treatment targets

Previous studies suggested that osteocyte lacunar network disruption could play a role in the complex pathophysiology of bone changes in aging and disease. Considering that particular research interest is lacking, we aimed to assess alcoholic liver cirrhosis (ALC)-induced changes in osteocyte lacunar network and bone marrow adiposity. Immunohistochemistry was conducted to assess changes in the micro-morphology of osteocyte lacunar network and bone marrow adiposity, and expression of connexin 43 and sclerostin in vertebral and femoral samples collected from 40 cadaveric men (age range between 44 and 70 years) divided into ALC group (n = 20) and control group (n = 20). Furthermore, the assessment of the potential association between bone changes and the severity of the hepatic disorder (given by Knodell's pathohistologic scoring) was conducted. Our data revealed fewer connexin 43-positive osteocytes per vertebral and femoral bone area (p < 0.01), suggesting defective signal transduction among osteocytes in ALC individuals. Moreover, we found an ALC-induced increase in the number of adipocytes in the vertebral bone marrow (p = 0.038). Considering significant associations between the severity of liver tissue disturbances and impaired functionality of osteocyte lacunar network (Pearson's correlation analyses, p < 0.05), we may assume that timely treatment of the liver disease may delay bone impairment. ALC induced an increase in osteocytic sclerostin expression (p < 0.001), suggesting its role in mediating low bone formation among ALC individuals. Hence, medicaments targeting low bone formation may be beneficial to attenuate the bone changes among ALC patients. However, future clinical studies are required to verify the therapeutic utility of these findings.

Pontomedullary lacerations in unhelmeted motorcyclists and bicyclists: a retrospective autopsy study

Pontomedullary lacerations (PMLs) have often been reported in car occupants and pedestrians, are less frequently described in motorcyclists, and are very rarely described in bicyclists. The aim of this study was to determine the frequency of brainstem PMLs among fatally injured motorcyclists and bicyclists as well as the frequency of concomitant cranial, facial, and cervical spine injuries in such cases. A possible underlying mechanism of PML in fatally injured motorcyclists and bicyclists might thus be established. Of 443 cases of fatally injured motorcyclists and bicyclists, a sample of 381 cases of fatally injured motorcyclists and bicyclists with head injury of Abbreviated Injury Scale score of 3 or greater was formed and further analyzed. This group was composed of 345 men and 36 women. The average age was 48.8 ± 20.8 years (range, 15-99 years). In the analyzed sample group, there were 158 motorcyclists and 223 bicyclists. Partial PMLs were present in 44 cases (12%) within the sample of 381 head injuries, which breaks down to 40 men and 4 women. In our study, the impact area on the head and the specific skull base fracture type were good predictors of either PML occurrence or absence (B = -2.036, Wald = 161.312, P < 0.01, for the whole model). Impact to the chin, with or without a skull base fracture, most often led to this fatal injury due to impact force transmission, either through jawbone or vertebral column. Also, lateral head impact, the most frequent in bicyclists, with subsequent hinge fracture, PML, and frontoposterior hyperextension of the head that is associated with upper spine fracture, could be possible mechanisms of brainstem injury in fatally injured motorcyclists or bicyclists. Our study showed that the jawbone, as well as other facial bones, could act as shock absorbers, and their fracture could diminish energy transfer toward the skull and protect the brain and brainstem from injury.

Comparative Analysis of Femoral Macro- and Micromorphology in Males and Females With and Without Hyperostosis Frontalis Interna: A Cross-Sectional Cadaveric Study

We hypothesized that subjects with hyperostosis frontalis interna (HFI), which represents local, endocranial thickening of the frontal bone, would express extra-calvarial manifestations of this condition. Therefore, we compared femoral bone mineral density, geometry, and microarchitecture of males and females with HFI to those without this condition as well as between males and females with HFI. The sample was taken from human donor cadavers, 38 males (19 with and 19 without HFI) and 34 females (17 with and 17 without HFI) that were age-matched within the same sex. The specimens of femoral bones were scanned using microcomputed tomography and dual-energy X-ray absorptiometry (DXA). Parameters of hip structure analysis (HSA) were calculated from data derived from DXA scans. Females with HFI had increased cortical bone volume fraction and their cortical bone was less porous compared to females without HFI. Males with HFI showed microarchitectural differences only with the trabecular bone. They had increased bone volume fraction and decreased trabecular separation compared to males without HFI, although with borderline significance. These microarchitectural changes did not have significant impact on femoral geometry and bone mineral density. The same, still unknown etiological factor behind HFI might be inducing changes at the level of bone microarchitecture at a remote skeletal site (femoral bone), in both sexes. These alterations still do not have the magnitude to induce obvious, straightforward overall increase of bone mineral density measured by DXA. HFI could be a systemic phenomenon that affects both males and females in a similar manner.

Pontomedullary lacerations and concomitant head and neck injuries: their underlying mechanism. A prospective autopsy study

It is a well-documented fact that pontomedullary lacerations (PML) occur as a result of severe craniocervical injury, but their underlying mechanism has yet to be fully clarified. The aim of this prospective study has been to give greater insight into the underlying mechanism of PML through determining the site of blunt head-impact, as well as the presence of concomitant head and neck injuries in cases of brainstem PML. A total of 56 cases with partial PML have been analysed for this study. The case group was composed of 40 men and 16 women, averaging in age 44.2 ± 19.2 years and consisting of 7 motorcyclists, 4 bicyclists, 18 car occupants, 16 pedestrians, and 10 victims of falls from a height, as well as 1 victim of a fall from standing height. The presented study has shown that there are several possible mechanisms of PML. Impact to the chin, with or without a skull base fracture, most often leads to this fatal injury, due to the impact force transmission either through the jawbone or vertebral column; most likely in combination with a fronto-posterior hyperextension of the head. Additionally, lateral head-impacts with subsequent hinge fractures and PML may also be a possible mechanism. The jawbone and other facial bones are able to act as shock absorbers, and their fracture may diminish the energy transfer towards the skull and protect the brain and brainstem from injury. The upper cervical spine can act as damper and energy absorber as well, and may prevent any occurrence of fracture to the base of the skull.

Unusual osteological findings in sacred relics from the LESJE monastery in central Serbia

An adult male skeleton was submitted to the Department of Anatomy at the University of Belgrade for evaluation. It was believed to represent the remains of a second to third century Christian saint from the Lesje Monastery in central Serbia. Examination of the remains revealed an old crush fracture of a thoracic vertebra and an unusual, probably congenital, malformation of the atlanto-occipital joint with deformation of the left occipital condyle and resultant narrowing of the foramen magnum. Although the occipital malformations were most likely congenital, they may still have caused, or contributed to, death by compression of the underlying upper cervical spinal cord.

Micro-scale assessment of bone quality changes in adult cadaveric men with congestive hepatopathy

Congestive hepatopathy (CH) is a chronic liver disease (CLD) caused by impaired hepatic venous blood outflow, most frequently resulting from congestive heart failure. Although it is known that heart failure and CLDs contribute to increased risk for age-related fractures, an assessment of CH-induced skeletal alterations has not been made to date. The aim of our study was to characterize changes in bone quality in adult male cadavers with pathohistologically confirmed CH compared with controls without liver disease. The anterior mid-transverse part of the fifth lumbar vertebral body was collected from 33 adult male cadavers (age range 43-89 years), divided into the CH group (n = 15) and the control group (n = 18). We evaluated trabecular and cortical micro-architecture and bone mineral content (using micro-computed tomography), bone mechanical competence (using Vickers micro-hardness tester), vertebral cellular indices (osteocyte lacunar network and bone marrow adiposity), and osteocytic sclerostin and connexin 43 expression levels (using immunohistochemistry staining and analysis). Deterioration in trabecular micro-architecture, reduced trabecular and cortical mineral content, and decreased Vickers microhardness were noted in the CH group (p < 0.05). Reduced total number of osteocytes and declined connexin 43 expression levels (p < 0.05) implied that harmed mechanotransduction throughout the osteocyte network might be present in CH. Moreover, elevated expression levels of sclerostin by osteocytes could indicate the role of sclerostin in mediating low bone formation in individuals with CH. Taken together, these micro-scale bone alterations suggest that vertebral strength could be compromised in men with CH, implying that vertebral fracture risk assessment and subsequent therapy may need to be considered in these patients. However, further research is required to confirm the clinical relevance of our findings.

Age-at-death estimation based on micro-CT assessment of pubic symphysis: Potentially new methodological approach

BACKGROUND

Although various methods for age-at-death estimation of skeletal remains are available, this is still an unsolved issue in forensic anthropology, especially concerning elderly individuals. Moreover, the lack of population-specific methods often made age-at-death estimation unreliable in other populations.

AIM

Our study aimed to examine whether micro-computed tomography (micro-CT) analysis of pubic bone samples obtained from the contemporary Serbian population could be used in anthropological and forensic practice for age-at-death estimation.

METHODOLOGY

This study encompassed 62 pubic samples obtained from 26 adult male and 36 adult female cadaveric donors (age range: 22-91 years). Initially, staging according to the Suchey-Brooks phases was performed by two experienced investigators, followed by micro-CT assessment of pubic bone trabecular and cortical compartments (spatial resolution of the scans was 10 µm).

RESULTS

Our results revealed an age-associated decline in trabecular and cortical micro-architecture of elderly male and female individuals, with the most prominent changes present in trabecular bone volume fraction and total porosity of the anterior and posterior cortical surface of the pubic bone. Those parameters were used to generate age-at-death estimation equations. One sample t-test did not reveal a significant difference between estimated age-at-death and real (known) age-at-death in the overall sample (mean absolute error [MAE] of 4.76 years), female (MAE of 9.66 years) and male cadaveric donors (MAE of 6.10 years, p > 0.05).

CONCLUSION

Our data indicated that micro-architectural features of trabecular and cortical compartments of pubic bone could potentially be applied as an additional reliable method for age-at-death estimation in the Serbian population.

The Importance of a Hierarchical Approach in Investigating the Connection Between Peripheral Artery Disease and Risk for Developing Low-Trauma Fractures: A Narrative Literature Review

Considering that skeletal changes are often asymptomatic during routine clinical examination, these disorders are frequently overlooked in patients with peripheral artery disease (PAD). Keeping in mind the inclining prevalence of PAD and bone fragility, especially in older individuals, this narrative literature review aimed to provide a comprehensive overview of skeletal alterations in patients with PAD, focusing on the importance of the multi-scale and multidisciplinary approach in the assessment of the bone hierarchical organization. Several observational studies have shown a connection between PAD and the risk of developing low-trauma fractures, but numerous ambiguities remain to be solved. Recent data indicate that evaluating additional bone properties at various levels of bone hierarchical structure may help in understanding the factors contributing to bone fragility in individuals with PAD. Further research on bone structural alterations (especially on micro- and nano-scale) may enhance the understanding of the complex etiopathogenesis of skeletal disorders in patients with PAD, which may lead to advancements in optimizing the clinical management of these individuals. Since osteoporosis and PAD have numerous overlapping risk factors, it is meaningful to evaluate vascular status in individuals with osteoporosis and examine bone health in individuals with PAD to identify individuals who require treatment for both diseases.

Micro-scale vertebral features in postmenopausal women with alcohol-associated and metabolic-associated fatty liver disease: ex vivo bone quality analyses

PURPOSE

Although epidemiological studies indicate increased fracture risk in women with alcohol-associated liver disease (AALD) and metabolic-associated fatty liver disease (MAFLD), data about their micro-scale bone features are still limited. We aimed to characterize bone quality changes in the anterior mid-transverse part of the first lumbar vertebral body collected from 32 adult postmenopausal females. Based on pathohistological assessment of the liver tissue, individuals were divided into AALD (n = 13), MAFLD (n = 9), and control group (n = 10).

METHODS

We analyzed trabecular and cortical micro-architecture (using micro-computed tomography), bone mechanical properties (using Vickers microhardness tester), osteocyte lacunar network and bone marrow adiposity morphology (using optic microscopy). Data were adjusted to elude the covariant effects of advanced age and body mass index on our results.

RESULTS

Our data indicated a minor trend toward deteriorated bone quality in MAFLD women, presented in impaired trabecular and cortical micro-architectural integrity, which could be associated with bone marrow adiposity alterations noted in these women. Additionally, we observed a significant decline in micro-architectural, mechanical, and osteocyte lacunar features in lumbar vertebrae collected from the AALD group. Lastly, our data indicated that vertebral bone deterioration was more prominent in the AALD group than in the MAFLD group.

CONCLUSION

Our data suggested that MAFLD and AALD are factors that could play a part in compromised vertebral strength of postmenopausal women. Also, our data contribute to understanding the multifactorial nature of bone fragility in these patients and highlight the necessity for developing more effective patient-specific diagnostic, preventive, and therapeutic strategies.

Behavioral response of people in Belgrade to the bombing campaign during 1999

INTRODUCTION

In contrast to numerous reports on long-term psychological consequences of disasters, the literature addressing the acute impact of intentional collective disaster is limited.

OBJECTIVE

This research aimed to examine the impact of the bombing campaign on the behavior of people living in Belgrade during the air attacks in 1999.

METHODS

The questionnaire was designed and administered to 231 participants. Psychological distress symptoms were assessed using the Symptom Checklist-Revised (SCL-90-R).

RESULTS

Participants reported fear and anger as dominant feelings, and the majority of them complained about sleep disturbance, body weight change, and loss of interest for sexual activity. Regression analysis of the scores of the SCL-90-R revealed significant effects of the duration of living under the stress of air attacks, age and gender of the participants and living in the risky areas of the city, upon the scores on Anxiety and Depression dimension.

CONCLUSION

The results of the study contributed to our understanding of the processes through which individuals pass during a long lasting bombardment. It can be beneficial for mental health services in evaluating which actions of care and support could be most suitable.

Ex vivo analysis of cortical microarchitecture of the distal clavicle: implications for surgical management of fractures

BACKGROUND

Cortical thickness and porosity are two main determinants of cortical bone strength. Thus, mapping variations in these parameters across the full width of the distal end of the clavicle may be helpful for better understanding the basis of distal clavicle fractures and for selecting optimal surgical treatment.

METHODS

Distal ends of 11 clavicles (6 men, 5 women; age: 81.9 ± 15.1 years) were scanned by micro-computed tomography at 10-µm resolution. We first analyzed cortical thickness and porosity of each 500-μm-wide area across the superior surface of distal clavicle at the level of conoid tubercle in an antero-posterior direction. This level was chosen for detailed evaluation because previous studies have demonstrated its superior microarchitecture relative to the rest of the distal clavicle. Subsequently, we divided the full width of distal clavicle to three subregions (anterior, middle, and posterior) and analyzed cortical porosity, pore diameter, pore separation, and cortical thickness.

RESULTS

We found the largest number of low-thickness and high-porosity areas in the anterior subregion. Cortical porosity, pore diameter, pore separation, and cortical thickness varied significantly among the three subregions (p < 0.001 p = 0.016, p = 0.001, p < 0.001, respectively). Cortex of the anterior subregion was more porous than that of the middle subregion (p < 0.001) and more porous and thinner than that of the posterior subregion (p < 0.001, p = 0.030, respectively). Interaction of site and sex revealed higher porosity of the anterior subregion in women (p < 0.001). The anterior subregion had larger pores than the middle subregion (p = 0.019), whereas the middle subregion had greater pore separation compared with the anterior (p = 0.002) and posterior subregions (p = 0.006). In general, compared with men, women had thinner (p < 0.001) and more porous cortex (p = 0.03) with larger cortical pores (p < 0.001).

CONCLUSIONS

Due to high cortical porosity and low thickness, the anterior conoid subregion exhibits poor bone microarchitecture, particularly in women, which may be considered in clinical practice.

LEVELS OF EVIDENCE

Level IV.

Lower microhardness along with less heterogeneous mineralization in the femoral neck of individuals with type 2 diabetes mellitus indicates higher fracture risk

There is still limited understanding of the microstructural reasons for the higher susceptibility to fractures in individuals with type 2 diabetes mellitus (T2DM). In this study, we examined bone mineralization, osteocyte lacunar parameters, and microhardness of the femoral neck trabeculae in 18 individuals with T2DM who sustained low-energy fracture (T2DMFx: 78 ± 7 years, 15 women and 3 men) and 20 controls (74 ± 7 years, 16 women and 4 men). Femoral necks of the T2DMFx subjects were obtained at a tertiary orthopedic hospital, while those of the controls were collected at autopsy. T2DMFx individuals had lower trabecular microhardness (P = .023) and mineralization heterogeneity (P = .001), and a tendency to a lower bone area with mineralization above 95th percentile (P = .058) than the controls. There were no significant intergroup differences in the numbers of osteocyte lacunae per bone area, mineralized lacunae per bone area, and total lacunae per bone area (each P > .05). After dividing the T2DMFx group based on the presence of vascular complications (VD) to T2DMFxVD (VD present) and T2DMFxNVD (VD absent), we observed that microhardness was particularly reduced in the T2DMFxVD group (vs. control group, P = .02), while mineralization heterogeneity was significantly reduced in both T2DMFx subgroups (T2DMFxNVD vs. control, P = .002; T2DMFxVD vs. control, P = .038). The observed changes in mineralization and microhardness may contribute to the increased hip fracture susceptibility in individuals with T2DM.

Hepatocellular carcinoma and musculoskeletal system: A narrative literature review

Musculoskeletal alterations in hepatocellular carcinoma (HCC) are less common than liver-related complications. However, they can significantly impact the quality of life and overall prognosis of patients with HCC. The main obstacle in the clinical assessment of HCC-induced musculoskeletal alterations is related to effective and timely diagnosis because these complications are often asymptomatic and unapparent during routine clinical evaluations. This narrative literature review aimed to provide a comprehensive overview of the contemporary literature related to the changes in the musculoskeletal system in patients with HCC, focusing on its clinical implications and underlying etiopathogenetic mechanisms. Osteolytic bone metastases are the most common skeletal alterations associated with HCC, which could be associated with an increased risk of low-trauma bone fracture. Moreover, previous studies reported that osteopenia, sarcopenia, and myosteatosis are associated with poor clinical outcomes in patients with HCC. Even though low bone mineral density and sarcopenia are consistently reported as reliable predictors of pretransplantation and post-transplantation mortality in HCC patients, these complications are frequently overlooked in the clinical management of patients with HCC. Taken together, contemporary literature suggests that a multidisciplinary approach is essential for early recognition and clinical management of HCC-associated musculoskeletal alterations to improve patient prognosis. Further research into the mechanisms and treatment options for musculoskeletal complications is warranted to enhance our understanding and clinical management of this aspect of HCC.

Three-dimensional mapping of cortical porosity and thickness along the superolateral femoral neck in older women

Although several studies have analyzed inter-individual differences in the femoral neck cortical microstructure, intra-individual variations have not been comprehensively evaluated. By using microCT, we mapped cortical pore volume fraction (Ct.Po) and thickness (Ct.Th) along the superolateral femoral neck in 14 older women (age: 77.1 ± 9.8 years) to identify subregions and segments with high porosity and/or low thickness-potential "critical" spots where a fracture could start. We showed that Ct.Po and Ct.Th significantly differed between basicervical, midcervical, and subcapital subregions of the femoral neck (p < 0.001), where the subcapital subregion showed the lowest mean Ct.Th and the highest mean Ct.Po. These cortical parameters also varied substantially with age and with the location of the analyzed microsegments along the individual's neck (p < 0.001), showing multiple microsegments with high porosity and/or low thickness. Although the highest ratio of these microsegments was found in the subcapital subregion, they were also present at other examined subregions, which may provide an anatomical basis for explaining the fracture initiation at various sites of the superolateral neck. Given that fractures likely start at structurally and mechanically weaker spots, intra-individual variability in Ct.Po and Ct.Th should be considered and the average values for the entire femoral neck should be interpreted with caution.

Clinical Indicators of Bone Deterioration in Alcoholic Liver Cirrhosis and Chronic Alcohol Abuse: Looking beyond Bone Fracture Occurrence

Although previous studies indicated that chronic alcohol abuse (CAA) and alcoholic liver cirrhosis (ALC) are associated with increased bone fragility, understanding bone fragility determinants is still modest in these individuals. We used a comprehensive individualized clinical fracture risk assessment approach (vertebral osteodensitometry, femoral osteodensitometry and geometry, and serum bone turnover biomarkers) to compare adult male patients with ALC who have not previously had femoral or vertebral fractures (n = 39), patients with CAA (without liver cirrhosis, n = 78) who have not previously had femoral or vertebral fractures and healthy age- and sex-matched controls (n = 43). Our data suggested that intertrochanteric bone mineral density was significantly lower in ALC and CAA patients than in controls. Also, the trabecular bone score was considerably lower in ALC patients compared with CAA and control individuals. The most significant inter-group differences in femoral geometry were noted on the femoral shaft. Patients with ALC and CAA have a higher 10-year risk of major osteoporotic fractures compared to the controls. Analysis of bone turnover biomarkers showed increased osteoprotegerin and beta-C-terminal telopeptide serum concentrations and decreased insulin growth factor-1 concentrations in patients with ALC compared to CAA and control groups. Our data revealed that bone alterations are present in patients with ALC and CAA even if they did not sustain a nontraumatic bone fracture, but it is also indicative that current bone-assessing clinical methods are not entirely reliable. Thus, future studies should focus on developing a reliable integrative clinical tool that can be used to accurately predict and prevent bone fracture occurrences in patients with ALC and CAA.

Metal(oid) profiling of the common site of osteoporotic fractures with bone microarchitecture correlation analysis: a comparative study of hip fracture patients and healthy individuals

Increased urine and blood concentrations of heavy metals are linked to an elevated hip fracture risk, but studies dedicated to directly measuring metal(oid) concentrations in the femoral neck are limited. We investigated whether individuals with fractures exhibit a different pattern of metal(oid) bioaccumulation in the femoral neck and examined potential correlations between the concentrations of various metal(oid)s in the femoral neck and trabecular microarchitecture. To address these objectives, we collected femoral neck specimens from 23 individuals, namely 11 individuals with a positive history of contralateral hip fracture (9 women and 2 men, mean age 77.7 ± 8.1 years) and 12 individuals without fractures (10 women and 2 men, mean age 79.5 ± 5.6 years). All samples were subject to microcomputed tomography (micro-CT) to evaluate bone microarchitecture and inductively coupled plasma-mass spectrometry to determine tissue concentrations of metal(oid)s. In the fully adjusted model (adjusted for bone volume, age, and calcium tissue concentration), individuals with hip fractures exhibited higher aluminum levels (p = 0.047) and lower vanadium levels (p < 0.001). Individuals who sustained fragility fractures also showed lower BV/TV, Tb.Th, Tb.N, and higher Tb.Sp in the femoral neck trabeculae compared with the control group. Several different metal(oid)s were associated with altered patterns of trabecular microarchitecture. In summary, higher aluminum and lower vanadium concentrations in the trabeculae of the femoral neck provide a potential background for the gradual increase in fracture risk. Correlational analysis revealed an association between exposure to certain metals and deteriorated trabecular microarchitecture; however, larger studies are needed to determine the elements independently affecting bone microarchitecture.

Biparietal osteodystrophy: Macroscopic appearance, computed tomography imaging and microarchitectural analysis

Anatomical or morphological variations of the skull bones usually do not attract much attention among forensic pathologists. However, these variations can sometimes be an important marker in forensic identification of a person or represent a missing piece when solving a cranial trauma puzzle. In this article, we were interested in peculiar presentation of the thinning of both parietal bones (biparietal osteodystrophy). The course and etiology of this condition still remain unknown. In three autopsy cases with biparietal osteodystrophy (three females aged 95, 90 and 83) and no head trauma, we used conventional (CT) and microcomputed tomography (micro-CT) imaging of the skull and parietal bone specimens containing normal bone, transitional zone and thinned bone with osteodystrophy. CT images demonstrated an oval-shaped resorptive parietal bone depression with smooth contours, without marginal osteosclerotic changes or involvement of cranial sutures. In the transitional zone, micro-CT scans showed a decrease in total bone thickness and the thickness of diplöe, while inner and outer tables showed increased porosity. At the site of maximal thinness of the parietal bone, inner and outer tables fused and formed a thin layer of cortical bone. Skull thinning appeared due to the reduced thickness of diplöe, leading to egg-shell thinning in the central area of the parietal bones. A forensic pathologist should be familiar with this benign condition in order not to confuse it with resorptive bone diseases.