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Abstract
Objectives: Methods: Results: Conclusions:
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A pilot study of circulating levels of TGF-β1 and TGF-β2 as biomarkers of bone healing in patients with non-hypertrophic pseudoarthrosis of long bones. Bone Rep 2021; 16:101157. [PMID: 34950754 PMCID: PMC8671858 DOI: 10.1016/j.bonr.2021.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022] Open
Abstract
Background Pseudoarthrosis or non-union is a complication with an incidence of 5-10% of bone fractures, most frequently located in the diaphysis of long bones. The management of this complication is addressed by means of complex surgical procedures and is a concern for orthopaedic and trauma surgeons nowadays. The use of biomarkers for diagnosing patients at risk of non-union would help us to establish special measures for early corrective treatment. Methods Prospective exploratory pilot study with a cohort of 20 patients diagnosed of non-hypertrophic pseudoarthrosis of long bones who were treated surgically with either autologous bone graft or a Tissue Engineering Product composed of bone marrow-derived Mesenchymal Stromal Cells. Patients were followed for 12 months and plasma blood samples were obtained to determine circulating levels of Transforming Growth Factor Beta 1 and Beta 2 (TGF-β1 and TGF-β2, respectively) at inclusion, and at 1 week, 2 weeks, and months 1, 2, 3, 6 and 12 after surgery. Radiological bone healing was evaluated by the Tomographic Union Score (TUS). Results Basal levels of TGF-β1 and TGF-β2 were determined in the twenty patients (26,702 ± 14,537 pg/mL and 307.8 ± 83.1 pg/mL, respectively). Three of them withdrew from the study, so complete follow-up was conducted on 17 patients (9 successfully healed vs. 8 that did not heal). Statistically significant differences between the bone healing group and the non-union group were found at month 12 for both TGF-β1 (p = 0.005) and TGF-β2 (p = 0.02). Conclusions TGF-β1 and TGF-β2 are biomarkers that correlate with clinical evidence of bone regeneration and may be used to monitor patients, although early predictive value after intervention needs to be further studied in combination with other molecules.
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El-Jawhari JJ, Kleftouris G, El-Sherbiny Y, Saleeb H, West RM, Jones E, Giannoudis PV. Defective Proliferation and Osteogenic Potential with Altered Immunoregulatory phenotype of Native Bone marrow-Multipotential Stromal Cells in Atrophic Fracture Non-Union. Sci Rep 2019; 9:17340. [PMID: 31758052 PMCID: PMC6874596 DOI: 10.1038/s41598-019-53927-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023] Open
Abstract
Bone marrow-Multipotential stromal cells (BM-MSCs) are increasingly used to treat complicated fracture healing e.g., non-union. Though, the quality of these autologous cells is not well characterized. We aimed to evaluate bone healing-related capacities of non-union BM-MSCs. Iliac crest-BM was aspirated from long-bone fracture patients with normal healing (U) or non-united (NU). Uncultured (native) CD271highCD45low cells or passage-zero cultured BM-MSCs were analyzed for gene expression levels, and functional assays were conducted using culture-expanded BM-MSCs. Blood samples were analyzed for serum cytokine levels. Uncultured NU-CD271highCD45low cells significantly expressed fewer transcripts of growth factor receptors, EGFR, FGFR1, and FGRF2 than U cells. Significant fewer transcripts of alkaline phosphatase (ALPL), osteocalcin (BGLAP), osteonectin (SPARC) and osteopontin (SPP1) were detected in NU-CD271highCD45low cells. Additionally, immunoregulation-related markers were differentially expressed between NU- and U-CD271highCD45low cells. Interestingly, passage-zero NU BM-MSCs showed low expression of immunosuppressive mediators. However, culture-expanded NU and U BM-MSCs exhibited comparable proliferation, osteogenesis, and immunosuppression. Serum cytokine levels were found similar for NU and U groups. Collectively, native NU-BM-MSCs seemed to have low proliferative and osteogenic capacities; therefore, enhancing their quality should be considered for regenerative therapies. Further research on distorted immunoregulatory molecules expression in BM-MSCs could potentially benefit the prediction of complicated fracture healing.
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Affiliation(s)
- Jehan J El-Jawhari
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK. .,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK. .,Clinical pathology department, Mansoura University, Mansoura, Egypt.
| | - George Kleftouris
- Academic Department of Trauma and Orthopaedic, Leeds General Infirmary, School of Medicine, University of Leeds, Leeds, UK
| | - Yasser El-Sherbiny
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,Clinical pathology department, Mansoura University, Mansoura, Egypt.,Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - Hany Saleeb
- Academic Department of Trauma and Orthopaedic, Leeds General Infirmary, School of Medicine, University of Leeds, Leeds, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Elena Jones
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.,Academic Department of Trauma and Orthopaedic, Leeds General Infirmary, School of Medicine, University of Leeds, Leeds, UK
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Klinische Anwendung von Platelet-rich plasma und Wachstumsfaktoren am Bewegungsapparat. DER ORTHOPADE 2018; 48:105-116. [DOI: 10.1007/s00132-018-3643-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Chaverri D, Vives J. Toward the clinical use of circulating biomarkers predictive of bone union. Biomark Med 2017; 11:1125-1133. [PMID: 29182015 DOI: 10.2217/bmm-2017-0180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Current methods for diagnosis of bone healing after treatment of trauma injuries rely on clinical findings and the use of imaging methodologies that provide conclusive results but only at mid/long-term post-intervention. In this Perspective we present and discuss incipient evidence on biomarkers that may serve for monitoring the progression of bone healing as well as predicting eventual nonunion outcomes.
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Affiliation(s)
- Daniel Chaverri
- Hospital ASEPEYO Sant Cugat, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, 08174 Barcelona, Spain
| | - Joaquim Vives
- Servei de Teràpia Cel·lular, Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain
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Qian Y, Han Q, Chen W, Song J, Zhao X, Ouyang Y, Yuan W, Fan C. Platelet-Rich Plasma Derived Growth Factors Contribute to Stem Cell Differentiation in Musculoskeletal Regeneration. Front Chem 2017; 5:89. [PMID: 29164105 PMCID: PMC5671651 DOI: 10.3389/fchem.2017.00089] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/16/2017] [Indexed: 12/24/2022] Open
Abstract
Stem cell treatment and platelet-rich plasma (PRP) therapy are two significant issues in regenerative medicine. Stem cells such as bone marrow mesenchymal stem cells, adipose-derived stem cells and periodontal ligament stem cells can be successfully applied in the field of tissue regeneration. PRP, a natural product isolated from whole blood, can secrete multiple growth factors (GFs) for regulating physiological activities. These GFs can stimulate proliferation and differentiation of different stem cells in injury models. Therefore, combination of both agents receives wide expectations in regenerative medicine, especially in bone, cartilage and tendon repair. In this review, we thoroughly discussed the interaction and underlying mechanisms of PRP derived GFs with stem cells, and assessed their functions in cell differentiation for musculoskeletal regeneration.
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Affiliation(s)
- Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Sixth People's Hospital East Campus, Shanghai University of Medicine and Health, Shanghai, China
| | - Qixin Han
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Sixth People's Hospital East Campus, Shanghai University of Medicine and Health, Shanghai, China
| | - Jialin Song
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Sixth People's Hospital East Campus, Shanghai University of Medicine and Health, Shanghai, China
| | - Xiaotian Zhao
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanming Ouyang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Sixth People's Hospital East Campus, Shanghai University of Medicine and Health, Shanghai, China
| | - Weien Yuan
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Dufrane D, Docquier PL, Delloye C, Poirel HA, André W, Aouassar N. Scaffold-free Three-dimensional Graft From Autologous Adipose-derived Stem Cells for Large Bone Defect Reconstruction: Clinical Proof of Concept. Medicine (Baltimore) 2015; 94:e2220. [PMID: 26683933 PMCID: PMC5058905 DOI: 10.1097/md.0000000000002220] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Long bone nonunion in the context of congenital pseudarthrosis or carcinologic resection (with intercalary bone allograft implantation) is one of the most challenging pathologies in pediatric orthopedics. Autologous cancellous bone remains the gold standard in this context of long bone nonunion reconstruction, but with several clinical limitations. We then assessed the feasibility and safety of human autologous scaffold-free osteogenic 3-dimensional (3D) graft (derived from autologous adipose-derived stem cells [ASCs]) to cure a bone nonunion in extreme clinical and pathophysiological conditions. Human ASCs (obtained from subcutaneous adipose tissue of 6 patients and expanded up to passage 4) were incubated in osteogenic media and supplemented with demineralized bone matrix to obtain the scaffold-free 3D osteogenic structure as confirmed in vitro by histomorphometry for osteogenesis and mineralization. The 3D "bone-like" structure was finally transplanted for 3 patients with bone tumor and 3 patients with bone pseudarthrosis (2 congenital, 1 acquired) to assess the clinical feasibility, safety, and efficacy. Although minor clones with structural aberrations (aneuploidies, such as tri or tetraploidies or clonal trisomy 7 in 6%-20% of cells) were detected in the undifferentiated ASCs at passage 4, the osteogenic differentiation significantly reduced these clonal anomalies. The final osteogenic product was stable, did not rupture with forceps manipulation, did not induce donor site morbidity, and was easily implanted directly into the bone defect. No acute (<3 mo) side effects, such as impaired wound healing, pain, inflammatory reaction, and infection, or long-term side effects, such as tumor development, were associated with the graft up to 4 years after transplantation. We report for the first time that autologous ASC can be fully differentiated into a 3D osteogenic-like implant without any scaffold. We demonstrated that this engineered tissue can safely promote osteogenesis in extreme conditions of bone nonunions with minor donor site morbidity and no oncological side effects.
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Affiliation(s)
- Denis Dufrane
- From the Endocrine Cell Therapy, Center of Tissue and Cell Therapy, Cliniques Universitaires Saint-Luc, Brussels, Belgium (DD, WA, NA); Orthopedic Surgery Service, Department of Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium (P-LD, CD); and Center for Human Genetics, Cliniques Universitaires Saint-Luc - Université Catholique de Louvain, Brussels, Belgium (HAP)
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Vériter S, André W, Aouassar N, Poirel HA, Lafosse A, Docquier PL, Dufrane D. Human Adipose-Derived Mesenchymal Stem Cells in Cell Therapy: Safety and Feasibility in Different "Hospital Exemption" Clinical Applications. PLoS One 2015; 10:e0139566. [PMID: 26485394 PMCID: PMC4615620 DOI: 10.1371/journal.pone.0139566] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023] Open
Abstract
Based on immunomodulatory, osteogenic, and pro-angiogenic properties of adipose-derived stem cells (ASCs), this study aims to assess the safety and efficacy of ASC-derived cell therapies for clinical indications. Two autologous ASC-derived products were proposed to 17 patients who had not experienced any success with conventional therapies: (1) a scaffold-free osteogenic three-dimensional graft for the treatment of bone non-union and (2) a biological dressing for dermal reconstruction of non-healing chronic wounds. Safety was studied using the quality control of the final product (genetic stability, microbiological/mycoplasma/endotoxin contamination) and the in vivo evaluation of adverse events after transplantation. Feasibility was assessed by the ability to reproducibly obtain the final ASC-based product with specific characteristics, the time necessary for graft manufacturing, the capacity to produce enough material to treat the lesion, the surgical handling of the graft, and the ability to manufacture the graft in line with hospital exemption regulations. For 16 patients (one patient did not undergo grafting because of spontaneous bone healing), in-process controls found no microbiological/mycoplasma/endotoxin contamination, no obvious deleterious genomic anomalies, and optimal ASC purity. Each type of graft was reproducibly obtained without significant delay for implantation and surgical handling was always according to the surgical procedure and the implantation site. No serious adverse events were noted for up to 54 months. We demonstrated that autologous ASC transplantation can be considered a safe and feasible therapy tool for extreme clinical indications of ASC properties and physiopathology of disease.
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Affiliation(s)
- Sophie Vériter
- Endocrine Cell Therapy, Centre of Tissular and Cellular Therapy, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Wivine André
- Endocrine Cell Therapy, Centre of Tissular and Cellular Therapy, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Najima Aouassar
- Endocrine Cell Therapy, Centre of Tissular and Cellular Therapy, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Hélène Antoine Poirel
- Center for Human Genetics, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Aurore Lafosse
- Plastic Surgery, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | | | - Denis Dufrane
- Endocrine Cell Therapy, Centre of Tissular and Cellular Therapy, Cliniques Universitaires Saint Luc, Brussels, Belgium
- * E-mail:
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Pickett TA. The challenges of accurately estimating time of long bone injury in children. J Forensic Leg Med 2015; 33:105-10. [DOI: 10.1016/j.jflm.2015.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 11/24/2022]
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Perut F, Filardo G, Mariani E, Cenacchi A, Pratelli L, Devescovi V, Kon E, Marcacci M, Facchini A, Baldini N, Granchi D. Preparation method and growth factor content of platelet concentrate influence the osteogenic differentiation of bone marrow stromal cells. Cytotherapy 2013; 15:830-9. [PMID: 23731763 DOI: 10.1016/j.jcyt.2013.01.220] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/06/2012] [Accepted: 01/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AIMS An extensive debate about the clinical benefits of autologous platelet concentrates used as a treatment option for patients with orthopedic injuries is ongoing. The aim of this study was to determine whether different compositions of platelet concentrates may affect the osteogenic differentiation of bone marrow stromal cells (BMSC). METHODS Pure platelet-rich plasma (P-PRP) and leukocyte-PRP (L-PRP) were characterized for platelet and leukocyte content. As an indicative marker of the delivery of growth factors (GFs), the release of basic fibroblast growth factor (bFGF) from platelet gel (PG) was measured at 1, 18, 48 and 72 h and at 7 d. The ability of different PGs to induce proliferation and differentiation of BMSC was evaluated by using bioactivity assays. RESULTS The platelet recovery was significantly higher in L-PRP, either fresh or frozen. PGs derived from L-PRP and P-PRP showed significant differences in terms of bFGF release and biological activity. bFGF release was faster both in fresh and frozen L-PRP preparations. Moreover, L-PRP samples were able to induce a significantly higher proliferation of BMSC compared with P-PRP or PPP samples. Even though all PG preparations allowed the deposition of mineral nodules in BMSC cultures, the mineralization activity correlated significantly with bFGF levels. CONCLUSIONS The biological activity of platelet concentrates differs according to preparation technique, which affects platelet and leukocyte content and GF availability. Because GF levels are not always optimal in subjects with defective bone healing, composition and bioactivity of PRP should be analyzed to test the reliability and potential effectiveness of the regenerative treatment.
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Affiliation(s)
- Francesca Perut
- Laboratory for Orthopaedic Pathophysiology and Regenerative Medicine, Rizzoli Orthopedic Institute, Bologna, Italy.
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Pountos I, Georgouli T, Pneumaticos S, Giannoudis PV. Fracture non-union: Can biomarkers predict outcome? Injury 2013; 44:1725-32. [PMID: 24075219 DOI: 10.1016/j.injury.2013.09.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2013] [Indexed: 02/02/2023]
Abstract
Delayed bone healing and non-union occurs in approximately 10-15% of long bone fractures. Both pathologies may result in prolonged period of pain, disability and repetitive operative interventions. Despite intense investigations and progress done in understanding the pathophysiologic processes governing bone healing, the diagnostic tools have not been altered. The clinical findings and radiographic features remain the two important landmarks of diagnosing non-union and even when the diagnosis is established there is debate on the ideal timing and mode of intervention. Emerging evidence suggest that there are certain molecules and genes that can serve as predictors of potentially unsuccessful fracture union. This article summarises the current evidence on the available 'bio-markers'to predict fracture non-union.
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Affiliation(s)
- I Pountos
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, UK; Leeds Biomedical Research Unit, Leeds, UK
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Giuliani N, Lisignoli G, Magnani M, Racano C, Bolzoni M, Dalla Palma B, Spolzino A, Manferdini C, Abati C, Toscani D, Facchini A, Aversa F. New insights into osteogenic and chondrogenic differentiation of human bone marrow mesenchymal stem cells and their potential clinical applications for bone regeneration in pediatric orthopaedics. Stem Cells Int 2013; 2013:312501. [PMID: 23766767 PMCID: PMC3676919 DOI: 10.1155/2013/312501] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
Human mesenchymal stem cells (hMSCs) are pluripotent adult stem cells capable of being differentiated into osteoblasts, adipocytes, and chondrocytes. The osteogenic differentiation of hMSCs is regulated either by systemic hormones or by local growth factors able to induce specific intracellular signal pathways that modify the expression and activity of several transcription factors. Runt-related transcription factor 2 (Runx2) and Wnt signaling-related molecules are the major factors critically involved in the osteogenic differentiation process by hMSCs, and SRY-related high-mobility-group (HMG) box transcription factor 9 (SOX9) is involved in the chondrogenic one. hMSCs have generated a great interest in the field of regenerative medicine, particularly in bone regeneration. In this paper, we focused our attention on the molecular mechanisms involved in osteogenic and chondrogenic differentiation of hMSC, and the potential clinical use of hMSCs in osteoarticular pediatric disease characterized by fracture nonunion and pseudarthrosis.
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Affiliation(s)
- Nicola Giuliani
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Gina Lisignoli
- SC Laboratorio di Immunoreumatologia e Rigenerazione Tissutale e Laboratorio RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Marina Magnani
- Paediatric Orthopaedics and Traumatology, Rizzoli Orthopaedic Institute, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Costantina Racano
- Paediatric Orthopaedics and Traumatology, Rizzoli Orthopaedic Institute, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Marina Bolzoni
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Benedetta Dalla Palma
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Angelica Spolzino
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Cristina Manferdini
- SC Laboratorio di Immunoreumatologia e Rigenerazione Tissutale e Laboratorio RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Caterina Abati
- Paediatric Orthopaedics and Traumatology, Rizzoli Orthopaedic Institute, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Denise Toscani
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Andrea Facchini
- SC Laboratorio di Immunoreumatologia e Rigenerazione Tissutale e Laboratorio RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Franco Aversa
- Hematology, Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43126 Parma, Italy
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