High-sensitivity troponin I predicts major cardiovascular events after noncardiac surgery

Background

Myocardial injury after noncardiac surgery (MINS) is common and is associated with postoperative major cardiac events and 30-day mortality. We have previously established the diagnostic criteria for MINS with the 4th-generation cardiac troponin T assay (TnT) and 5th-generation high-sensitivity TnT assay (hsTnT) based on prognostically relevant thresholds. Little is known about diagnostic criteria for MINS using the high-sensitivity troponin I (hsTnI) assay.

Purpose

To determine hsTnI thresholds associated with 30-day major cardiac events and death after noncardiac surgery.

Methods

We performed a nested prospective biobank cohort study of 4545 patients from the VISION Study. Patients were aged ≥45 years and underwent in-patient noncardiac surgery under regional or general anesthesia. Patients had samples collected and frozen preoperatively, and on postoperative days 1, 2 and 3. We measured hsTnI on thawed preoperative and postoperative samples. We used iterative Cox proportional hazard models to determine peak postoperative hsTnI thresholds independently associated with major cardiac events (i.e., composite of death, non-fatal cardiac arrest, congestive heart failure within 30 days and non-fatal myocardial infarction from postoperative days 4–30).

Results

Major cardiac events occurred in 89/4545 (2.0%) patients. Peak hsTnI values of <75 ng/L, 75 ng/L to <1000 ng/L, and ≥1000 ng/L were associated with an incidence of major cardiac events of 1.2% (95% CI 0.9–1.6), 7.1% (95% CI 4.8–10.5) and 25.9% (95% CI 16.3–38.4), respectively. Compared to peak hsTnI <75 ng/L (reference), hsTnI values 75 ng/L to <1000 ng/L and ≥1000 ng/L were associated with adjusted hazard ratios (aHR) of 4.53 (95% CI 2.75–7.48) and 16.17 (95% CI 8.70–30.07), respectively. No change from preoperative hsTnI to peak postoperative hsTnI significantly improved the model when included on top of the identified thresholds. Incidence of major cardiac events was 31/343 (9%) in patients with postoperative peak hsTnI ≥75 ng/L versus 52/4178 (1%) in patients with postoperative peak hsTnI <75 ng/L (aHR 5.76; 95% CI 3.64–9.11). A postoperative peak hsTnI ≥75 ng/L was associated with increased risk of major cardiac events either in the presence (aHR 9.35; 95% CI 5.28–16.55) or absence (aHR 3.99; 95% CI 2.19–7.25) of clinical features of myocardial injury (e.g., chest pain, ischemic electrocardiography changes).

Conclusion

A hsTnI elevation within the first 3 days after noncardiac surgery independently predicts major cardiac events at 30 days. A peak postoperative hsTnI ≥75 ng/L was associated with a 6-fold increase in the risk of subsequent major cardiac events at 30 days as compared to peak postoperative hsTnI<75 ng/L. This hsTnI threshold can be used to diagnose MINS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Siemens Healthcare Diagnostics Inc. Canadian Institutes of Health Research

Leukocyte- and platelet-rich fibrin does not provide any additional benefit for tooth extraction in head and neck cancer patients post-radiotherapy: a randomized clinical trial

Background

One of the most important complications of radiotherapy (RT) for head and neck cancer (HNC) is osteoradionecrosis (ORN) of the jaws, arising mainly from tooth extractions. Thus, the present study aimed to evaluate the efficacy of leukocyte- and platelet-rich fibrin (L-PRF) in preventing ORN following tooth extraction in post-irradiated HNC patients, as well as other postoperative complications.

Material and Methods

23 patients previously submitted to conventionally fractionated 3D-conformational RT for HNC underwent atraumatic tooth extractions with perioperative antibiotic therapy. Besides, they were randomly assigned to receive L-PRF clots to fill and cover the extraction sockets (n=11, Test Group) or not (n=12, Control Group). A visual analog scale was used to quantify postoperative pain on the 3rd and 7th days. For ORN diagnosis, patients were clinically assessed for up to 180 days. Other postoperative complications (edema, alveolitis, suture dehiscence, continuous bleeding, and oroantral communication) were also evaluated within this period.

Results

No case of ORN or another surgical complication was observed and there were no differences in the postoperative pain scores between the groups on the 3rd and 7th days.

Conclusions

L-PRF did not seem to provide any additional benefits than those achieved by the combination of the surgical and drug protocols used for tooth extractions in the post-irradiated HNC patients.

Key words:Radiotherapy, osteoradionecrosis, tooth extraction, head and neck cancer.

Biomechanical analysis on total knee replacement patients during gait: Medial pivot or posterior stabilized design?

BACKGROUND

Total Knee Replacement surgery restores joint function in patients with advanced osteoarthritis. There are several prostheses available based on different mechanisms, which guarantee knee stability during Activities of Daily Living. The aim of this study is to compare ball-in-socket (or Medial Pivot) and post-cam mechanisms to detect possible differences in terms of biomechanical parameters between these two prosthesis designs and to evaluate which design is closer to physiological biomechanics.

METHODS

A kinematics, kinetics and electromyography lower limb analyses were performed during gait on sixty subjects: twenty with Medial Pivot prosthesis, twenty with posterior stabilized prosthesis and twenty healthy subjects to obtain a physiologic reference.

FINDINGS

Total Knee Replacement gait pattern for both patient groups were characterized by reduced walking speed, reduced stride length and increased stance time respect to control group. Comparison between Medial Pivot and Posterior Stabilized groups showed a reduction of knee flexion and flexor moment in patients with ball-in-socket mechanism. A prolonged muscular activity of rectus femoris was observed in Medial Pivot patients compared to Posterior Stabilized and control groups.

INTERPRETATION

"Stiff knee pattern" mechanism was showed for both patient groups but more enhanced in Medial Pivot patients. Even though the Posterior Stabilized design introduces the non-physiological paradoxical motion and the Medial Pivot design seems to better reproduce the physiological condylar movement as gait analysis parameters, including kinematics, kinetics and electromyographic parameters were closer to control group and, in turn, to physiological gait for the Posterior Stabilized than Medial Pivot group parameters.

Bone integration in acetabular revision hip arthroplasty using equine-derived bone grafts: a retrospective study

PURPOSE

During the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction.

METHODS

Records of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed.

RESULTS

Of the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components.

CONCLUSIONS

Results of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

Unassisted quiet standing and walking after crutch usage in patients with total hip replacements: Does crutch length matter?

BACKGROUND

Crutch use is prescribed early in the rehabilitation process following total hip replacement (THR) surgery to improve safety and promote return to active living.

RESEARCH QUESTION

Purpose of this study was to understand mid-term effects of crutch length setup on quiet standing and walking two months post-op when crutch use was no longer required.

METHODS

Thirty patients were evaluated 2 months post-surgery when they had been walking without crutch for a month. The patients had previously been assigned randomly to elbow flexed (EF) or elbow extended (EE) crutch set-ups and evaluated 3 days post-surgery. Quiet standing stability was assessed with participants standing in a comfortable position with each foot on separated force platforms, facing forward for 10 s. In addition, participants walked on the laboratory path, instrumented with motion tracking system and force platforms. For the quiet standing trial, centre of pressure measure, acromial height and lower limbs load bearing symmetry were evaluated. For the walking trial, spatiotemporal and ground reaction force (GRF) parameters were evaluated together with side symmetry indices.

RESULTS

Results showed no significant differences in any standing trial variables between groups. For walking, GRF parameters and symmetry indices were similar for both groups. However, increased base of support width, reduced self-selected walking speed and stride length were found for the EF group.

SIGNIFICANCE

This study showed that crutch set-up influenced gait after patients started to walk unassisted. Patients that previously used crutch adjusted according to the EE setup, demonstrated a more efficient gait with higher self-selected speed and longer and narrower stride. Clinicians may use these results for a proper crutch height adjustment, which improves walking and, in turn, functional recovery in post THR patients.

Shoulder joint loadings in post total hip replacement surgery patients during assisted walking: The influence of the crutch setup

A crutch is prescribed to permit the patient to walk safely and independently immediately after total hip replacement (THR) surgery. Purpose of this study is to evaluate the influence of the crutch setup on upper limbs biomechanics, including shoulder joint kinematics and kinetics parameters that will be evaluated to detect possible differences related to the crutch length. Thirty patients were randomly assigned to elbow flexed (EF) or elbow extended (EE) forearm crutch setup. Subjects were asked to walk on the laboratory path, instrumented with motion tracking system and force platforms. Spatiotemporal gait parameters, crutch ground reaction force (GRF) and crutch displacement (measured as the relative distance between the crutch position on the floor and the shoulder joint center), were evaluated. A three-dimensional (3D) biomechanical model was implemented to determine shoulder joint kinematics and kinetics during crutch walking. Results showed that the stride length significantly decreased, and base of support width increased for the EF group when compared to the EE group. Crutch forces and distance to the body significantly decreased in the EE group. Furthermore, shoulder joint moments in all planes of motion, vertical and lateral forces were significantly reduced in the EE group. The present study showed that crutch setup influenced performance and upper limb loading during walking, with EE setup allowing a more stable walking and reducing stress on the shoulder joint when compared to the EF setup. Results may help therapists in rationalizing crutch length adjustments for patients after THR surgery.

The influence of the crutch setup on stability and weight-bearing parameters in post total hip replacement surgery patients during quiet standing

PURPOSE

The purpose of this study is to evaluate the influence of the crutch setup on standing, in post total hip replacement (THR) surgery patients.

MATERIALS AND METHODS

Thirty patients after THR were randomly assigned to walking with the elbow flexed (EF) or elbow straight (ES) crutch setup. Subjects were asked to stand on a force platform in a comfortable position with the crutch positioned on the unaffected side, facing forward for 10 seconds. Centre of pressure total path and maximal excursion were evaluated in both medio-lateral and anterior-posterior planes. Difference in the asymmetry of left/right acromial height, measured with and without the crutch, was calculated (ACdiff). Percentage of body weight borne by the crutch (Fcr), symmetry (SIload) between operated and healthy limbs loading during the trial, together with shoulder forces and moments were measured.

RESULTS

No significant differences between the two groups (p > .05) were found for stability parameters. ACdiff, Fcr and shoulder load increased significantly (p < .05) in EF group compared to ES group. In addition leg loading symmetry was significantly reduced in the EF group.

CONCLUSIONS

The present study showed that the ES setup reduced the force borne by the crutch, the load on the shoulder joint and it minimized postural and loading asymmetries when compared to EF setup. Conversely, postural stability was not influenced by the crutch setup. Implications for Rehabilitation Static posture and weight-bearing parameters are influenced by crutch setup during quiet standing. Crutch setup does not influence postural stability. Adjusting the crutch according to the elbow straight setup reduces the force borne by the crutch and the asymmetry in lower limbs loading. Forces and moments at the shoulder joint were reduced for the elbow straight setup group.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Clinical outcome of design modifications to the CLS Spotorno Stem in total hip replacement

PURPOSE

historically, the original CLS Spotorno Stem has demonstrated excellent survival. The design of this stem was recently modified, resulting in the introduction of a shorter, modular version (CLS Brevius). The purpose of the current study was to evaluate the functional, radiological and survivorship outcomes of the cementless CLS Brevius Stem in a multi-surgeon, single center, consecutive series study at two years post-surgery.

METHODS

the Authors performed 170 total hip arthroplasties in 155 patients using the shorter, triple-taper stem design (CLS Brevius). The patients' diagnoses were primary hip osteoarthritis (OA) in 74.4%, secondary hip OA in 22.6%, and post-traumatic hip OA in 3%. All operations were performed through a mini-posterior approach, with the patient in the lateral decubitus position. The mean follow-up was 32 months (24-44 months). Outcome was assessed using the Harris Hip Score (HHS).

RESULTS

the mean HHS improved from 32 preoperatively to 92 points at final follow-up, while the stem survival rate was 99.4%. Overall, the results were excellent in148 hips (87%), good in 14 hips (8.2%), fair in six hips (3.6%), and poor in two hips (1.2%). Intraoperative complications included a calcar fissure in three hips (1.7%). Correct femoral offset was reproduced in 97% while the planned center of hip rotation was achieved in 98%. Only one hip underwent early stem revision; this was due to major subsidence.

CONCLUSIONS

the modified CLS stem design showed excellent short-term results with a low rate of early postoperative complications. One of the main findings of this study was the high correlation between the planned femoral offset and center of hip rotation and the final radiographic measurements. This high reproducibility, which indicates the ability of the system to restore normal hip anatomy, is indeed due to the extensive modularity that characterizes this stem system. Long-term follow-up studies are necessary to fully compare the outcomes of the new design with its highly successful predecessor.

LEVEL OF EVIDENCE

Level IV, therapeutic cases series.

Rotational alignment of the tibial component in total knee arthroplasty

Many surgical techniques, correlated to different anatomical landmarks, have been proposed to allow a satisfactory rotational alignment of the tibial component in primary total knee arthroplasty (TKA). Unfortunately, an accurate landmark has not yet been established although many computer models using CT reconstructions and standard radiologic studies have been performed. In this review article, the authors propose a new anatomical rotational reference for a correct positioning of the tibial component during primary TKA; the authors compared the results of their studies with the current literature on rotational alignment references and previously proposed surgical techniques. The authors also analyzed the correlation between classic and newer tibial baseplate designs and different tibial rotational landmarks.

Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study

BACKGROUND

It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF.

METHODS

We retrospectively analyzed the data collected on elderly patients in 66 Italian hospitals, in the frame of the REPOSI project. We analyzed the clinical characteristics of patients with AF and different degrees of CI. Multivariate logistic analysis was used to explore the relationship between variables and mortality.

RESULTS

Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy.

CONCLUSIONS

Elderly hospitalized patients with AF are more likely affected by CI and CKD, two conditions that expose them to a higher mortality risk. Oral anticoagulant therapy, still underused and not optimally enforced, may afford protection from thromboembolic episodes that probably concur to the high mortality.

Risk of recurrence after a first unprovoked venous thromboembolism: external validation of the Vienna Prediction Model with pooled individual patient data

BACKGROUND

In order to stratify patients with a first unprovoked venous thromboembolism (VTE) according to their recurrence risk and to identify those who would actually benefit from indefinite anticoagulation, three prediction models have been developed so far; none of them has been yet externally validated.

OBJECTIVE

To externally validate the Vienna Prediction Model (VPM), a prediction guide for estimating the recurrence risk after a first unprovoked VTE developed through Cox modeling and including sex, D-dimer and index VTE site as predictors.

PATIENTS/METHODS

Nine hundred and four patients pooled from five prospective studies evaluating the prognostic value of D-dimer for VTE recurrence served as the validation cohort. The validity of the VPM in stratifying patients according to their relative recurrence risk (discrimination) and in predicting the absolute recurrence risk (calibration) was tested with survival analysis methods.

RESULTS

The ability of the VPM to distinguish patients' risk for recurrent VTE in the validation cohort was at least as good as in the original cohort, with a calibration slope of 1.17 (95% confidence interval 0.71-1.64; P = 0.456 for the hypothesis of a significant difference from 1), and a c-statistic of 0.626 (vs. 0.651 in the original derivation cohort). The VPM absolute predictions in terms of cumulative rates tended to underestimate the observed recurrence rates at 12 months.

CONCLUSIONS

By using a pooled individual patient database as a validation cohort, we confirmed the ability of the VPM to stratify patients with a first unprovoked VTE according to their risk of recurrence.

Gender-differences in disease distribution and outcome in hospitalized elderly: data from the REPOSI study

BACKGROUND AND PURPOSE

Women live longer and outnumber men. On the other hand, older women develop more chronic diseases and conditions such as arthritis, osteoporosis and depression, leading to a greater number of years of living with disabilities. The aim of this study was to describe whether or not there are gender differences in the demographic profile, disease distribution and outcome in a population of hospitalized elderly people.

METHODS

Retrospective observational study including all patients recruited for the REPOSI study in the year 2010. Analyses are referred to the whole group and gender categorization was applied.

RESULTS

A total of 1380 hospitalized elderly subjects, 50.5% women and 49.5% men, were considered. Women were older than men, more often widow and living alone or in nursing homes. Disease distribution showed that malignancy, diabetes, coronary artery disease, chronic kidney disease and chronic obstructive pulmonary disease were more frequent in men, but hypertension, osteoarthritis, anemia and depression were more frequent in women. Severity and comorbidity indexes according to the Cumulative Illness Rating Scale (CIRS-s and CIRS-c) were higher in men, while cognitive impairment evaluated by the Short Blessed Test (SBT), mood disorders by the Geriatric Depression Scale (GDS) and disability in daily life measured by Barthel Index (BI) were worse in women. In-hospital and 3-month mortality rates were higher in men.

CONCLUSIONS

Our study showed a gender dimorphism in the demographic and morbidity profiles of hospitalized elderly people, emphasizing once more the need for a personalized process of healthcare.

Primary posterior stabilized total knee arthroplasty: analysis of different instrumentation

Background

Intercondylar femoral bone removal during posterior stabilized (PS) total knee arthroplasty (TKA) makes many cruciate substituting implant designs less appealing than cruciate retaining implants. Bone stock conservation is considered fundamental in the prevision of future revision surgeries. The purpose of this study was to compare the quantity of intercondylar bone removable during PS housing preparation using three contemporary PS TKA instrumentations.

Method

We compared different box cutting jigs which were utilized for the PS housing of three popular PS knee prostheses. The bone removal area from every PS box cutting jig was three-dimensionally measured.

Results

Independently from the implant size, the cutting jig for a specific PS TKA always resected significantly less bone than the others: this difference was statistically significant, especially for small- to medium-sized total knee femoral components.

Conclusion

This study does not establish a clinical relevance of removing more or less bone at primary TKA, but suggests that if a PS design is indicated, it is preferable to select a model which possibly resects less distal femoral bone.

Analysis of differences in bone removal during femoral box osteotomy for primary total knee arthroplasty

PURPOSE

this study was conducted to compare the quantity of intercondylar bone removed during femoral box osteotomy for implantation of three contemporary posterior stabilized (PS) total knee arthroplasty designs: Sigma PS (DePuy), Vanguard (Biomet) and Persona (Zimmer).

METHODS

we compared the maximum volumetric bone resection required for the housing of the PS mechanism of these three designs. Bone removal by each PS box cutting jig was three-dimensionally measured. The differences between the three designs were analyzed by the Kruskal-Wallis test. The Mann-Whitney U-test was used for pairwise comparisons. The level of significance was set at p<0.05.

RESULTS

for small-size implants, the average box osteotomy volume of Persona was significantly smaller than the Vanguard and Sigma PS volumes (p=0.003). The mean difference between Vanguard and Sigma PS (p=0.01) was also significant. For medium size implants, the mean difference between Persona and Sigma PS (p=0.008) and the mean difference between Vanguard and Sigma PS (p=0.01) were statistically significant. For large size implants, the mean difference between Vanguard and Sigma PS (p=0.01) and the mean difference between Sigma PS and Persona (p=0.008) were statistically significant.

CONCLUSIONS

irrespective of implant size, the Persona cutting jig always resected significantly less bone than did Vanguard and Sigma PS.

CLINICAL RELEVANCE

although this study does not establish any clinical relevance of removing more or less bone at primary TKA, its results suggest that if a PS design is indicated, it is preferable to select a model which resects less distal femoral bone.

Prevalence of potentially inappropriate medications and risk of adverse clinical outcome in a cohort of hospitalized elderly patients: results from the REPOSI Study

WHAT IS KNOWN AND OBJECTIVE

Inappropriate prescribing is highly prevalent for older people and has become a global healthcare concern because of its association with negative health outcomes including ADEs, hospitalization and resource utilization. Beers' criteria are widely utilized for evaluating the appropriateness of medications, and an up-to-date version has recently been published. To assess the prevalence of patients exposed to PIMs at hospital discharge according to the 2003 and 2012 versions of Beers' criteria and to evaluate the risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up.

METHODS

This cross-sectional study was held in 66 Italian internal medicine and geriatric wards. The sample included 1380 inpatients aged 65 years or older. Prescriptions of PIM were analysed at hospital discharge. We considered all patients with complete 3-month follow-up.

RESULTS AND DISCUSSION

The prevalence of patients receiving at least one PIM was 20·1% and 23·5% according to the 2003 and 2012 versions of the Beers' criteria, respectively. The 2012 Beers' criteria identified more patients with at least one PIM than the 2003 version, although a high percentage of those patients (72·2%) were also identified by the criteria updated in 2003. The main difference in the prevalence of patients receiving a PIM according to the two versions of Beers' criteria involved prescriptions of benzodiazepines for insomnia or agitation, chronic use of non-benzodiazepine hypnotics, prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325 mg/day. Prescription of PIMs was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up in both univariate and multivariate analysis, after adjusting for age, sex and CIRS comorbidity index.

WHAT IS NEW AND CONCLUSIONS

This study found no significant effect of inappropriate drug use according to Beers' criteria on health outcomes among older adults 3 month after discharge. Even though these criteria have been suggested as helpful in promoting appropriate prescribing, reducing drug-related adverse events and associated healthcare costs, to date there is no clear evidence that their application can achieve objective and quantifiable improvements in clinical outcomes. A possible explanation is that both versions of the Beers' criteria have several recognized limitations, one of the main ones being the restricted availability of some drugs in Europe or their limited prescription in everyday clinical practice.

Rotational alignment of the tibial component in total knee arthroplasty: the anterior tibial cortex is a reliable landmark

PURPOSE

to compare the anterior tibial surface curvature, the Akagi's line and the medial third of the tibial tubercle in order to assess which is the most reliable landmark for correct tibial component rotational positioning in total knee arthroplasty.

METHODS

three independent investigators reviewed 124 knee MRI scans. The most suitable tibial baseplate tracing for the Nexgen Total Knee System (Zimmer, Warsaw, USA) was superimposed on the scan matching the anterior tibial cortex with the anterior aspect of the baseplate. The rotation of the tibial baseplate tracing was calculated with respect to the transepicondylar axis (TEA), the medial third of the tibial tubercle line, Akagi's line and the femoral posterior condylar axis (PCA). Customized software was created and used for analysis of the MRI datasets. The reliability of each measurement was then calculated by using the intraclass correlation coefficient for interobserver agreement.

RESULTS

observer agreement on the position of the Akagi's line was within 3° in 64% of the cases and within 5° in 85% of the cases. Agreement on the position of the medial third of the tibial tubercle was within 3° in 29% of the cases and within 5° in 70% of the cases. Agreement on the localization of the anterior tibial surface curvature was within 3° in 89% of the cases and within 5° in 99% of the cases. Component alignment along the anterior cortex guaranteed full matching ± 3° with the epicondylar axis in 75% of the knees.

CONCLUSIONS

the anterior tibial surface curvature was found to be a more reliable and more easily identifiable landmark for correct tibial component alignment than either Akagi's line or the medial third of the tibialtubercle.

LEVEL OF EVIDENCE

level III, retrospective cohort study.

Inhibitor development in previously treated hemophilia A patients: a systematic review, meta-analysis, and meta-regression

BACKGROUND

The development of neutralizing alloantibodies (inhibitors) is the most serious complication of factor VIII (FVIII) replacement therapy in patients with hemophilia A. Unlike previously untreated patients, no definite risk factors for inhibitor development are known for previously treated patients (PTPs). The investigation of the development of inhibitors in PTPs is hindered by several methodological limitations in the available literature. We conducted a systematic review to account for these limitations.

METHODS

We considered the studies reporting on PTPs that were included in the Wight and Paisley meta-analysis and a systematic search of MEDLINE, EMBASE, and The Cochrane Library was conducted to identify studies published after 2003. Studies that investigated the development of inhibitors in hemophilia A PTPs who were treated with any type of FVIII concentrate and that included at least 25 patients with follow-up were included in the analysis.

RESULTS

Thirty-three independent cohorts of PTPs with 4323 subjects and 43 incident de novo inhibitors were found and analyzed. The pooled incidence rate of inhibitor development for the 25 studies providing data on follow-up was 3 (95% confidence interval 1-4) per 1000 person-years. A significant association was not found between putative risk factors and inhibitor development in PTPs at meta-regression analysis and subgroup analysis, but the model was sensitive enough to the inclusion of the reports on the Belgian-Dutch experience with a highly immunogenic factor VIII.

CONCLUSION

We confirmed a low overall rate of de novo inhibitors in PTPs, without any significant effect of putative predictors, including the type of factor VIII concentrate.

A multimodal approach in total hip arthroplasty preoperative templating

OBJECTIVES

Accurate preoperative planning is mandatory for a successful total hip arthroplasty (THA). Templating helps to achieve multiple technical goals, including offset restoration, leg-length equality, and components positioning. This study aims to measure how successful a new stepwise method for preoperative radiographic templating is in achieving postoperative restoration of anatomy.

METHODS

We measured the relationship of several radiographic landmarks on the affected limb in comparison to the unaffected limb to define the appropriate position of the components. One hundred consecutive patients with unilateral disease undergoing THA were retrospectively analyzed. The preoperative templates were compared with the postoperative radiographs.

RESULTS

Accuracy in achieving the desired offset, leg-length discrepancy within 5 mm, was 93 % and 100 % respectively. Acetabular component positioning within 2° was replicated in 92 %.

CONCLUSION

We conclude that this technique can help the surgeon to accurately reproduce the anatomy of the contralateral unaffected hip.

Comparison of disease clusters in two elderly populations hospitalized in 2008 and 2010

BACKGROUND

As chronicity represents one of the major challenges in the healthcare of aging populations, the understanding of how chronic diseases distribute and co-occur in this part of the population is needed.

OBJECTIVES

The aims of this study were to evaluate and compare patterns of diseases identified with cluster analysis in two samples of hospitalized elderly.

METHODS

Data were obtained from the multicenter 'Registry Politerapie SIMI (REPOSI)' that included people aged 65 or older hospitalized in internal medicine and geriatric wards in Italy during 2008 and 2010. The study sample from the first wave included 1,411 subjects enrolled in 38 hospitals wards, whereas the second wave included 1,380 subjects in 66 wards located in different regions of Italy. To analyze patterns of multimorbidity, a cluster analysis was performed including the same diseases (19 chronic conditions with a prevalence >5%) collected at hospital discharge during the two waves of the registry.

RESULTS

Eight clusters of diseases were identified in the first wave of the REPOSI registry and six in the second wave. Several diseases were included in similar clusters in the two waves, such as malignancy and liver cirrhosis; anemia, gastric and intestinal diseases; diabetes and coronary heart disease; chronic obstructive pulmonary disease and prostate hypertrophy.

CONCLUSION

These findings strengthened the idea of an association other than by chance of diseases in the elderly population.

Candida glabrata prosthetic hip infection

We present a case of a 60-year-old Caucasian woman carrying a 2-year-old hip prosthesis infected by Candida glabrata dose-dependent susceptible to fluconazole and voriconazole. Resection arthroplasty was performed. Six weeks of caspofungin plus liposomal amphotericin combination therapy achieved joint sterilization and allowed a successfully reimplantation arthroplasty. In addition we review 9 cases of C. glabrata prosthetic joint infection described to date in the literature.

Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score (DASH)

BACKGROUND

In patients with unprovoked venous thromboembolism (VTE), the optimal duration of anticoagulation is anchored on estimating the risk of disease recurrence.

OBJECTIVES

We aimed to develop a score that could predict the recurrence risk following a first episode of unprovoked VTE, pooling individual patient data from seven prospective studies.

METHODS

One thousand eight hundred and eighteen cases with unprovoked VTE treated for at least 3 months with a vitamin K antagonist were available for analysis. Optimism-corrected Cox regression coefficients were used to develop a recurrence score that was subsequently internally validated by bootstrap analysis.

RESULTS

Abnormal D-dimer after stopping anticoagulation, age <50 years, male sex and VTE not associated with hormonal therapy (in women) were the main predictors of recurrence and were used to derive a prognostic recurrence score (DASH, D-dimer, Age, Sex, Hormonal therapy) showing a satisfactory predictive capability (ROC area =0.71). The annualized recurrence risk was 3.1% (95% confidence interval [CI], 2.3-3.9) for a score ≤ 1, 6.4% (95% CI, 4.8-7.9) for a score=2 and 12.3% (95% CI, 9.9-14.7) for a score ≥ 3. By considering at low recurrence risk those patients with a score ≤ 1, life-long anticoagulation might be avoided in about half of patients with unprovoked VTE.

CONCLUSIONS

The DASH prediction rule appears to predict recurrence risk in patients with a first unprovoked VTE and may be useful to decide whether anticoagulant therapy should be continued indefinitely or stopped after an initial treatment period of at least 3 months.

Contemporary femoral designs in total knee arthroplasty: effects on the patello-femoral congruence

PURPOSE

The objective of this study was to evaluate the radiological and clinical correlations between implant design and patellar positioning in patients who underwent TKA utilizing femoral implants with modern designs.

METHODS

Thirty consecutive PFC PS Sigma TKAs, characterized by a new prolonged anterior flange and a "smoother" trochlea, were prospectively reviewed. All patellae were replaced. All patients were evaluated pre-operatively and prospectively at two years follow-up both clinically according to the Knee Society score as well as radiographically. This included computed tomography (CT); patellar tilt, patellar conformity angle, patellar lateralization, and femoral component external-rotation in relation to the clinical trans-epicondylar axis.

RESULTS

Average patellar tilt at follow-up was 3° (±7.5°) with respect to a pre-operative 18.5° (±8.5°). Average patellar congruence angle at follow-up was -3° (range, -11° to +9°) with respect to a pre-operative 10.3° (range, + 1.5° to 25.5°). Average lateralization index at follow-up was 2.7 mm (range, -3.4 mm to +7.1 mm) with respect to a pre-operative 12.2 mm (± 4.8 mm). Femoral component positioning related to the trans-epicondylar axis showed an external rotation of 2.80° (± 2.10°) at follow-up with respect to 5.7° (± 1.80°). Clinically, two (6.6%) patients reported patello-femoral complications related to imperfections in the surgical technique more than the implant's design.

CONCLUSIONS

This study highlighted that modern femoral designs in TKA allow for a correct reproducibility of a normal patello-femoral conformity. Strict surgical principles are paramount to avoid patello-femoral complications even when modern implants are used.

In-hospital death according to dementia diagnosis in acutely ill elderly patients: the REPOSI study

OBJECTIVE

The aim of the study was to explore the association of dementia with in-hospital death in acutely ill medical patients.

METHODS

Thirty-four internal medicine and 4 geriatric wards in Italy participated in the Registro Politerapie SIMI-REPOSI-study during 2008. One thousand three hundred and thirty two in-patients aged 65 years or older were enrolled. Logistic regression models were used to evaluate the association of dementia with in-hospital death. Socio-demographic characteristics, morbidity (single diseases and the Charlson Index), number of drugs, and adverse clinical events during hospitalization were considered as potential confounders.

RESULTS

One hundred and seventeen participants were diagnosed as being affected by dementia. Patients with dementia were more likely to be women, older, to have cerebrovascular diseases, pneumonia, and a higher number of adverse clinical events during hospitalization. The percentage of patients affected by dementia who died during hospitalization was higher than that of patients without dementia (9.4 versus 4.9%). After multiadjustment, the diagnosis of dementia was associated with in-hospital death (OR = 2.1; 95% CI = 1.0-4.5). Having dementia and at least one adverse clinical event during hospitalization showed an additive effect on in-hospital mortality (OR = 20.7; 95% CI = 6.9-61.9).

CONCLUSIONS

Acutely ill elderly patients affected by dementia are more likely to die shortly after hospital admission. Having dementia and adverse clinical events during hospital stay increases the risk of death.

Prevalence and appropriateness of drug prescriptions for peptic ulcer and gastro-esophageal reflux disease in a cohort of hospitalized elderly

BACKGROUND

Proton pump inhibitors (PPI) are among the most commonly prescribed medicines and their overuse is widespread in both primary and secondary care. Inappropriate prescription is of particular concern among elderly patients, who have often multiple comorbidities and need many drugs.

METHODS

We evaluate the appropriateness of drugs for peptic ulcer or gastro-esophageal reflux disease (GERD) in a sample of elderly patients (65 years old or older) at admission and discharge in 38 internal medicine wards between January 2008 and December 2008, according to the presence of specific conditions or gastro-toxic drug combinations.

RESULTS

Among 1155 patients eligible for the analysis, 466 (40.3%) were treated with drugs for GERD or peptic ulcer were at hospital admission and 647 (56.0%) at discharge; 62.4% of patients receiving a drug for peptic ulcer or GERD at admission and 63.2% at discharge were inappropriately treated. Among these, the number of other drugs prescribed was associated with greater use of drugs for peptic ulcer or GERD, even after adjustment for age, sex and number of diagnoses at admission (OR 95% CI=1.26 (1.18-1.34), p=.0001) or discharge (OR 95% CI=1.11 (1.05-1.18), p=0.0003).

CONCLUSIONS

Prevalence of inappropriate prescription of drugs for peptic ulcer or GERD remained almost the same at admission and discharge. Inappropriate use of these drugs is related to the concomitant use of other drugs. Careful assessment of clinical conditions and stricter adherence to evidence-based guidelines are essential for a rational and cost-effective use of drugs for peptic ulcer or GERD.

In-hospital death and adverse clinical events in elderly patients according to disease clustering: the REPOSI study

OBJECTIVE

The aim of the study was to recognize clusters of diseases among hospitalized elderly and to identify groups of patients at risk of in-hospital death and adverse clinical events according to disease clustering.

METHOD

This was a cross-sectional study conducted in 38 internal medicine and geriatric wards in Italy participating in the Registro Politerapie SIMI (REPOSI) study during 2008. The subjects were 1,332 inpatients aged 65 years or older. Clusters of diseases (i.e., two or more co-occurrent diseases) were identified using the odds ratios (OR) for the associations between pairs of conditions, followed by cluster analysis. Logistic regression models were used to evaluate the effect of disease clusters on in-hospital death and adverse clinical events.

RESULTS

A total of 86.7% of the patients were discharged, 8.3% were transferred to another hospital unit, and 5.0% died during hospitalization; 36.4% of the patients had at least one adverse clinical event. Patients affected by the clusters, including heart failure (HF) and either chronic renal failure (CRF) or chronic obstructive pulmonary disease, had a significant association with in-hospital death (OR, 4.3;95% confidence interval [CI], 1.6-11.5; OR, 2.9; 95% CI, 1.1-8.3, respectively), as well as patients affected by CRF and anemia (OR, 6.1; 95% CI, 2.3-16.2). The cluster including HF and CRF was also associated with adverse clinical events (OR, 3.5; 95% CI, 1.5-7.8). The effect of both HF and CRF and anemia and CRF on in-hospital death was additive.

CONCLUSION

Several groups of older patients at risk of in-hospital death and adverse clinical events were identified according to disease clustering. Knowledge of the relationship among co-occurring diseases may help developing strategies to improve clinical practice and preventative interventions.

Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards

INTRODUCTION

Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings.

AIMS

To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription.

METHODS

We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS(2) score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age >80years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge.

RESULTS

Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS(2) score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS(2) score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age >80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%.

CONCLUSION

Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guidelines.

Does the clinical presentation and extent of venous thrombosis predict likelihood and type of recurrence? A patient-level meta-analysis

AIM

To determine if the mode of presentation of venous thromboembolism (VTE), as deep vein thrombosis (DVT) or pulmonary embolism (PE), predicts the likelihood and type of recurrence.

METHODS

We carried out a patient-level meta-analysis of seven prospective studies in patients with a first VTE who were followed after anticoagulation was stopped. We used Kaplan-Meier analysis to determine the cumulative incidence of recurrent VTE according to mode of presentation, and multivariable Cox regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for mode of and extent of DVT as potential risk factors for recurrence.

RESULTS

The 5-year cumulative rate of recurrent VTE in 2554 patients was 22.6%. In 869 (36.1%) patients with PE, the 5-year rate of any recurrence (DVT or PE) was 22.0%, and recurrence as PE was 10.6%. In 1365 patients with proximal DVT, the 5-year recurrence rate was 26.4%, and recurrence with PE was 3.6%. The risk of recurrence as PE was 3.1-fold greater in patients presenting with symptomatic PE than in patients with proximal DVT (HR, 3.1; 95% CI, 1.9-5.1). Patients with proximal DVT had a 4.8-fold higher cumulative recurrence rate than those with distal DVT (HR, 4.8; 95% CI, 2.1-11.0).

CONCLUSION

Whilst DVT and PE are manifestations of the same disease, the phenotypic expression is predetermined. Patients presenting with PE are three times more likely to suffer recurrence as PE than patients presenting with DVT. Patients presenting with calf DVT are at low risk of recurrence and at low risk of recurrence as PE.

Rate of inhibitor development in previously untreated hemophilia A patients treated with plasma-derived or recombinant factor VIII concentrates: a systematic review

BACKGROUND

Different rates of inhibitor development after either plasma-derived (pdFVIII) or recombinant (rFVIII) FVIII have been suggested. However, conflicting results are reported in the literature.

OBJECTIVES

To systematically review the incidence rates of inhibitor development in previously untreated patients (PUPs) with hemophilia A treated with either pdFVIII or rFVIII and to explore the influence of both study and patient characteristics.

METHODS

Summary incidence rates (95% confidence interval) from all included studies for both pdFVIII and rFVIII results were recalculated and pooled. Sensitivity analysis was used to investigate the effect of study design, severity of disease and inhibitor characteristics. Meta-regression and analysis-of-variance were used to investigate the effect of covariates (testing frequency, follow-up duration and intensity of treatment).

RESULTS

Two thousand and ninety-four patients (1965 treated with pdFVIII, 887 with rFVIII; median age, 9.6 months) from 24 studies were investigated and 420 patients were observed to develop inhibitors. Pooled incidence rate was 14.3% (10.4-19.4) for pdFVIII and 27.4% (23.6-31.5) for rFVIII; high responding inhibitor incidence rate was 9.3% (6.2-13.7) for pdFVIII and 17.4% (14.2-21.2) for rFVIII. In the multi-way anova study design, study period, testing frequency and median follow-up explained most of the variability, while the source of concentrate lost statistical significance. It was not possible to analyse the effect of intensity of treatment or trigger events such as surgery, and to completely exclude multiple reports of the same patient or changes of concentrate.

CONCLUSIONS

These findings underscore the need for randomized controlled trials to address whether or not the risk of inhibitor in PUPs with hemophilia A differs between rFVIII and pdFVIII.

Analysis of the masseter muscle in patients with systemic sclerosis: a study by magnetic resonance imaging

OBJECTIVES

The aim of this study was to investigate the relationship between mandibular osteolysis and the T1 and T2 tissue signal strength and morphology of the masseter muscle in patients with systemic sclerosis (SS).

METHODS

All patients with SS underwent panoramic radiography to detect mandibular osteolysis. MRI of the masseter was performed on 15 patients with SS and 10 healthy control subjects.

RESULTS

All patients presented mean T1 values that were statistically equal. The patients with osteolysis presented mean T2 values that were the same as those of patients without osteolysis and normal individuals. The patients without osteolysis showed stronger T2 signals than did the normal individuals. The morphological analysis showed more atrophy, fatty replacement and rectified morphology in relation to the healthy subjects.

CONCLUSIONS

The patients with SS presented more atrophy, fat replacement and rectification than did the normal individuals. The T2 signal was significantly stronger among the patients with SS without osteolysis than among normal individuals and among patients with SS and osteolysis.

Mortality and causes of death in Italian persons with haemophilia, 1990-2007

Although a number of studies have analysed so far the causes of death and the life expectancy in haemophilic populations, no investigations have been conducted among Italian haemophilia centres. Thus, the aim of this study was to investigate mortality, causes of deaths, life expectancy and co-morbidities in Italian persons with haemophilia (PWH). Data pertaining to a total of 443 PWH who died between 1980 and 2007 were retrospectively collected in the 30 centres who are members of the Italian Association of Haemophilia Centres that chose to participate. The mortality rate ratio standardized to the male Italian population (SMR) was reduced during the periods 1990-1999 and 2000-2007 such that during the latter, death rate overlapped that of the general population (SMR 1990-1999: 1.98 95% CI 1.54-2.51; SMR 2000-2007: 1.08 95% CI 0.83-1.40). Similarly, life expectancy in the whole haemophilic population increased in the same period (71.2 years in 2000-2007 vs. 64.0 in 1990-1999), approaching that of the general male population. While human immunodeficiency virus infection was the main cause of death (45%), 13% of deaths were caused by hepatitis C-associated complications. The results of this retrospective study show that in Italian PWH improvements in the quality of treatment and global medical care provided by specialized haemophilia centres resulted in a significantly increased life expectancy.

Clinical trials and haemophilia: does the Bayesian approach make the ideal and desirable good friends?

When the disease is rare and/or the outcome is uncommon the trial design does not warrant precise and unbiased estimates due to a lack of power or the expected length of recruitment and observation periods. Is there any reliable method to control for bias and consequently achieve an advantage from estimates generated by different study designs? An interesting statistical approach suitable to solve this problem has been theorized by Thomas Bayes. A Bayesian analysis is aimed at answering the question 'How this trial will modify our belief about that treatment effect?' In summary, the Bayesian approach can be defined as the explicit and quantitative use of any kind of external evidence in the design, analysis, and interpretation of an experimental trial. The results of a Bayesian analysis is the 95% credible interval in which we believe the estimate to lie with a probability of 95%, or the estimate of the probability that the quantity of interest is less than a specific value. The principal advantages of the Bayesian approach are that it allows to directly make probability statements about quantities of interest; it allows to easily make predictive statements, conditional on the current state of knowledge; it enables evidence from a variety of sources to be taken into account within a coherent modelling framework; it requires the investigator to explicit prior beliefs and demands. Exemplifications of the advantages of the Bayesian approach will be given discussing some papers published in Haemophilia.

Identification and characterisation of heel strike transient

This study set out to ascertain the incidence of a heel strike transient (HST) and to verify whether modifications of muscle activation time could be correlated with the presence and the characteristic of a HST. Lower limb kinematics, kinetics and surface electromyography (SEMG) of normal subjects were examined during barefoot walking. A short-lived sharp HST was present in 76% of the trials while a smooth HST, of longer duration was seen in 13.3% of the trials. The transient phenomenon was absent in the remaining 10.7% of trials. The SEMG showed that alteration in the activation timing of muscles correlated with the presence of a HST.

Rehabilitation after primary total hip replacement. Comparison between Italian and international protocols

AIM

In intensive rehabilitation departments (Code 56) there is a high case-load of patients with recent total hip replacement (THR). Whereas there has been a progressive standardisation and perfecting of prosthetic materials and surgical techniques, time-frames and modalities of rehabilitation programmes are still very variable. Following the Ministerial Guidelines, issued in 1998 by the Italian National Health System, and the introduction of Accreditation Requirements, methods must become more uniform and there must be increased scientific rigour in treatment so as to reduce variability and the subjective nature of the service provided. Ana-lysis of the working methods of large Rehabilitation Centres may help to focus on the problems more clearly and stimulate any improvements that may be required. The study analyses and compares rehabilitation protocols for hip replacement patients adopted in Italian and international rehabilitation centres.

METHODS

Thirty-four post-THR rehabilitation protocols were analysed; 14 Italian plus 20 international.

RESULTS

The analysis revealed that some factors are unanimously considered important and are therefore codified: 1) posture and positioning; 2) prevention of deep vein thrombosis; 3) rapid return to mobility; 4) education of patients to joint care.

CONCLUSIONS

Weight-bearing on the operated limb is not yet a standardised aspect and thus the physiatrist's attention should be focused on this for a return to walking that is safe (for patients and for implanted prosthesis) correct (from the biomechanical and kinematic standpoints) and that plays a normal role in performing activities of daily living.

Quality control of 2721 cornea transplantations of issued by Center of Corneal Analysis and conservation by the Bank of Tissue and Cells of Tuscany

Knowledge of the clinical evolution of corneal transplantation is fundamental to its improvement by upgrading the modalities and conservation methods in eye banking. The purpose of this retrospective study was to review of the results obtained with corneal transplantation performed at 50 Italian hospitals supplied by our center. From July 1997 through December 2002, 2721 corneas were used for transplantation. A questionnaire was mailed to every transplant center, that included queries about the number of corneal transplants performed, the number of primary and late failures, and the prevalence of posttransplant endopthalmitis. Preliminary results revealed no correlation between primary/late failures and the morphologic properties of the cornea, donor age, although a few failures seemed related to the pathology of the recipient.