Ospedale Cisanello

<title>Abstract</title> <bold>Background and aim of the study</bold> : Liver transplant (LT) recipients are a population at elevated cardiovascular (CV) risk, yet conventional assessment tools often fail to capture early myocardial dysfunction. Global longitudinal strain (GLS) has emerged as a sensitive marker of subclinical myocardial dysfunction, although its role in the long-term post-transplant setting remains insufficiently defined. The study aimed to evaluate left ventricular (LV)-GLS in a population of stable LT recipients with mild cardiometabolic burden and explored the possible associations with metabolic, lifestyle, inflammatory, and transplant-related variables. Secondary aims included longitudinal GLS variation over 12 months. <bold>Subjects and methods:</bold> We conducted a cross-sectional observational study in 40 LT recipients. Data on cardiometabolic parameters, body composition (including bioimpedance analysis), diet, physical activity were collected. Carotid ultrasound and echocardiography were performed. Levels of circulating inflammatory cytokines were measured. CV risk scores were calculated. <bold>Results</bold> : GLS impairment was detected in 47.5% of patients, despite preserved ejection fraction. Antihypertensive therapy correlated with more favorable GLS, whereas higher IL-17A and IL-1β levels were paradoxically linked to preserved strain. No association emerged with immunosuppressive regimen or lifestyle indices. GLS remained unchanged at 12 months, irrespective of weight loss or dietary improvement. <bold>Conclusions</bold> : GLS appears more sensitive than EF in detecting subclinical myocardial dysfunction in LT recipients, highlighting its potential role in post-transplant CV surveillance. Antihypertensive treatment may exert protective effects, whereas cytokine patterns suggest non-traditional mechanisms of cardiac modulation. Larger longitudinal studies are needed to confirm prognostic implications and integrate GLS into CV risk stratification pathways post-LT.

Abstract Background Differentiating predominantly inflammatory from fibrotic strictures in Crohn’s disease (CD) is crucial for therapeutic decision-making but remains challenging in clinical practice. Intestinal ultrasound (IUS) is a non-invasive and widely available tool, yet the ultrasound parameters that best predict histological fibrosis are not well established. The aim of our study was to identify ultrasound, clinical, and laboratory parameters associated with the degree of histological fibrosis in patients with stricturing CD undergoing ileocolic resection. Methods We conducted a retrospective single-centre study including 37 patients with stricturing CD who underwent laparoscopic ileocolic resection (2013–2025). For each patient, clinical, laboratory and ultrasound data were collected, including bowel wall thickness, preservation of wall stratification, Limberg score, extra-intestinal findings (mesenteric fat, lymphnodes, fistulas/abscesses) and pre-stenotic dilatation. Fibrosis was assessed on surgical specimens using Chiorean and Higgins histological scores; the Higgins score was used for statistical analyses. Correlation analyses and multivariable models were performed. Results Perfect agreement was observed between Chiorean and Higgins histological scores (Cohen’s k = 1.0). The Limberg score showed a significant inverse correlation with fibrosis severity (r = –0.519; p = 0.001), indicating that lower vascularity on IUS is associated with a higher degree of fibrosis. Bowel wall thickness showed only a non-significant trend toward correlation with fibrosis. Other ultrasound features and serum biomarkers (CRP, faecal calprotectin, albumin, platelets) were not significantly associated with fibrosis grade. In multivariate analysis, a lower Limberg score emerged as the only independent predictor of more severe fibrosis. Conclusion The Limberg score appears to be an indirect ultrasound marker of intestinal fibrosis in stricturing CD, whereas common serum biomarkers do not discriminate fibrosis severity. Case expansion and the development of artificial intelligence models are ongoing to derive a more objective and reproducible ultrasound fibrosis score.

Abstract Problem Statement. In the wine sector, sustainability and producing a genuine product have long been priorities, with organic and agroecological practices becoming widespread. However, sustainability assessments often rely on tools like life cycle assessments (LCA), carbon footprints and water footprints, which overlook certain ecological and socio‐economic factors and fail to effectively communicate sustainability performance. Tools such as SAFA (Sustainability Assessment of Food and Agriculture Systems), TAPE (Tool for Agroecology Performance Evaluation) and OASIS (Original Agroecological Survey Indicator System) offer comprehensive evaluations of agri‐food systems, considering environmental, productive and social dimensions. The SWAT (Sustainable Wine Assessment Tool) framework, developed for the wine industry, includes socio‐cultural, governance and environmental indicators for sustainability assessment. Approach and Methods. This article applies the Agro‐Environmental Sustainability Information System (AESIS) framework to two wineries, assessing multiple dimensions of agroecosystems (physical, ecological, productive and social). AESIS uses indicators aligned with the principles of the aforementioned tools to evaluate two case studies in Tuscany and Lombardy, Italy. The Tuscany case study, Tenuta Casadei, employs the organic and biodynamic‐based BioIntegrale (BIOINT) method, while Castello di Cigognola in Lombardy uses conventional farming (CONV) and organic farming with precision techniques (ORGP). Results. The assessment used agro‐environmental indicators based on a conceptual sustainability framework, comparing CONV, ORGP and BIOINT against sustainability thresholds or critical limits for each indicator. Results showed a sustainability gradient: CONV &lt; ORGP &lt; BIOINT. BIOINT achieved 92% compliance with thresholds, ORGP 87% and CONV only 47%. Practical Implication. Despite differences, both case studies could benefit from agroecological interventions: improving ecological and social sustainability at Castello di Cigognola, and enhancing the physical dimension at Tenuta Casadei. AESIS provided valuable insights into the sustainability of both farms, offering multiple entry points for farmers to improve sustainability across various dimensions.

To evaluate associations between the first trimester SIMPLE nutritional score, early placental markers, and pregnancy outcome. This is a longitudinal prospective multicenter observational cohort study recruiting healthy women with no comorbidities and singleton viable pregnancies undergoing first trimester prenatal screening. The SIMPLE nutritional score, biochemical (pregnancy-associated plasma protein A (PAPP-a), free ß-human chorionic gonadotropin (β-HCG)) and ultrasound (placental volume, uterine artery Doppler velocimetry) markers of placental function were collected at enrollment. Birth outcomes were collected at delivery. Multivariate generalized linear and logistic regression models were performed to investigate associations between SIMPLE score subgroups (<6 versus ≥6) and items, placental markers, and pregnancy outcomes. Out of 2363 women enrolled, 325 were classified at high nutritional risk based on a first trimester SIMPLE score lower than 6. Multi-adjusted models showed that the SIMPLE score subgroup was significantly associated with first trimester PAPP-a concentrations (SIMPLE score ≥6 versus <6: β = 0.047 (95% CI 0.004;0.089), p < 0.05), as well as with the emergency cesarean section rates (SIMPLE score ≥6 versus <6: aOR = 0.73 (95% CI -1.38;-0.07), p < 0.05). The single item related to the first trimester hemoglobin concentrations higher than 110 g/L was significantly associated with early placental markers, birth (β = -116.2 (95% CI -213.6;18.7), p < 0.05) and placental weights (β = -28.2 (95% CI -50.4;6.0), p < 0.05) in multi-adjusted models. The observed associations support the introduction of the SIMPLE score in clinical practice as a useful tool for predicting early placental development and pregnancy outcome.

IntroductionInvasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug–drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.MethodsA multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.ResultsThe final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.ConclusionSystemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

IntroductionVentral mesh rectopexy (VMR) has gained popularity as a surgical solution for rectal prolapse. However, significant variability exists in patient selection criteria, preoperative evaluation, and reporting standards. This scoping review analyzes indications for robotic VMR (RVMR) and highlights areas requiring further standardization.MethodsThe review was conducted according to PRISMA-ScR guidelines. Comprehensive searches of PubMed, Scopus, and Web of Science were completed through December 4, 2024. Studies reporting on RVMR were screened in a three-step process, with disagreements resolved by consensus. Key data extracted included patient demographics, indications, preoperative workup, and surgical details. Superseded studies, reviews, and non-relevant articles were excluded.ResultsOf 783 articles identified, 24 studies comprising 930 patients met inclusion criteria. External rectal prolapse was the most common indication (47%), followed by intussusception (38%), rectocele (9%), combined abnormalities (5%), and enterocele (1%). Preoperative imaging was inconsistently reported, with only 67% of studies describing imaging protocols. Symptom-based indications using standardized scoring systems were rare (17%). Synthetic mesh was used in 87% of cases. RVMR showed favorable functional outcomes, with low recurrence and complication rates.ConclusionsSignificant heterogeneity exists in indications and preoperative evaluation for RVMR, limiting comparability across studies. While evidence supports its safety and efficacy, future research should focus on standardizing selection criteria and evaluating long-term outcomes.

Intraductal papillary mucinous neoplasms (IPMNs) are precursors to pancreatic cancer, but not all IPMNs progress to cancer. The objective of this study was to identify the germline genetic variants associated with IPMN clinical progression by conducting the first genome-wide association study (GWAS) and computing a polygenic hazard score (PHS) in 338 patients with IPMN. The study population was divided into two subsets, and a Cox analysis adjusted for sex, age, cyst size at diagnosis, and the top 10 principal components was performed. A PHS was calculated using the genotypes of common variants associated with IPMN progression identified. Eight loci with significant associations (p<5×10-8) were identified, and the most significant was 7q21.11-rs117620617 (hazard ratio, 16.35; 95% confidence interval, 6.93-38.60; p=1.80×10-10). All variants were associated with inflammatory processes, suggesting that alleles that predispose to an inflammatory prone phenotype may promote progression. The PHS indicated a statistically significant association (hazard ratio, 18.05; 95% confidence interval, 7.96-45.80; p=6.18×10-11) with IPMN progression among individuals who had the highest number of effect alleles (fourth quartile) compared with those who had the lowest number (first quartile). The current results study advance the understanding of individual predisposition to IPMN progression and underscore the potential use of genetics in the stratification of patients who have IPMN.

Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes2,3. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening4-6. Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach7; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios. When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability. When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented implant. In order to minimize the risk of intraoperative cardiopulmonary events and complicated subsequent revision surgeries8, the use of cement should be avoided if at all possible. Shoulder surgeons have reported grafting techniques, analogous to hip impaction grafting, that have yielded good success3. The technique that we describe utilizes a matchstick structural autograft that helps improve cementless fixation in primary humeral implantation cases and allows for the use of a smaller stem. The structural shape of the graft allows this technique to be utilized even in selected proximal humeral fractures. Other studies have reported on the use of softer cancellous autografts to stabilize humeral implants in shoulder arthroplasty. In a study of 286 arthroplasties with a minimum follow-up of 2 years, Lucas et al. reported that 267 humeral stems (93.3%) had not subsided3. Humphrey and Bravman used cancellous autograft to achieve metaphyseal centering of the humeral component in 53 patients, with no cases of humeral implant loosening at 12 months2. Lo et al. reported 91% tuberosity healing in their series of cementless reverse total shoulder arthroplasties augmented with matchstick autografts1, with no cases of aseptic humeral stem loosening. Montemaggi et al. used matchstick autografts to augment 46 primary cementless reverse total shoulder arthroplasties and found zero instances of humeral loosening at 1-year follow-up9. The strongest humeral matchstick grafts come from the subchondral surface.After creating the graft, it is palpated for structural integrity. A stiffer or softer graft can be chosen, depending on surgeon preference.Surgeons can try impacting the graft with humeral trials to assess the stem stability prior to final implantation. RTSA = reverse total shoulder arthroplastyFX = fracture3D CT = 3-dimensional computed tomographyXR = x-rayFU = follow-up.