Revisione critica dei risultati e nuovi algoritmi decisionali sulla chirurgia dell'OSAS

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is the periodic reduction or cessation of airflow during sleep. The syndrome is associated whit loud snoring, disrupted sleep and observed apnoeas. Surgery aims to alleviate symptoms of daytime sleepiness, improve quality of life and reduce the signs of sleep apnoea recordered by polysomnography. Surgical intervention for snoring and OSAHS includes several procedures, each designed to increase the patency of the upper airway. Procedures addressing nasal obstruction include septoplasty, turbinectomy, and radiofrequency ablation (RF) of the turbinates. Surgical procedures to reduce soft palate redundancy include uvulopalatopharyngoplasty with or without tonsillectomy, uvulopalatal flap, laser-assisted uvulopalatoplasty, and RF of the soft palate. More significant, however, particularly in cases of severe OSA, is hypopharyngeal or retrolingual obstruction related to an enlarged tongue, or more commonly due to maxillomandibular deficiency. Surgeries in these cases are aimed at reducing the bulk of the tongue base or providing more space for the tongue in the oropharynx so as to limit posterior collapse during sleep. These procedures include tongue-base suspension, genioglossal advancement, hyoid suspension, lingualplasty, and maxillomandibular advancement. We reviewed 269 patients undergoing to osas surgery at the ENT Department of Forlì Hospital in the last decade. Surgery was considered a success if the postoperative apnea/hypopnea index (AHI) was less than 20/h. According to the results, we have developed surgical decisional algorithms with the aims to optimize the success of these procedures by identifying proper candidates for surgery and the most appropriate surgical techniques. Although not without risks and not as predictable as positive airway pressure therapy, surgery remains an important treatment option for patients with obstructive sleep apnea (OSA), particularly for those who have failed or cannot tolerate positive airway pressure therapy. Successful surgery depends on proper patient selection, proper procedure selection, and experience of the surgeon. The intended purpose of medical algorithms is to improve and standardize decisions made in the delivery of medical care, assist in standardizing selection and application of treatment regimens, to reduce potential introduction of errors. Nasal Continuous Positive Airway Pressure (nCPAP) is the recommended therapy for patients with moderate to severe OSAS. Unfortunately this treatment is not accepted by some patient, appears to be poorly tolerated in a not neglible number of subjects, and the compliance may be critical, especially in the long term if correctly evaluated with interview as well with CPAP smart cards analysis. Among the alternative options in Literature, surgery is a long time honoured solution. However until now no clear scientific evidence exists that surgery can be considered a really effective option in OSAHS management. We have design a randomized prospective study comparing MMA and a ventilatory device (Autotitrating Positive Airways Pressure – APAP) in order to understand the real effectiveness of surgery in the management of moderate to severe OSAS. Fifty consecutive previously full informed patients suffering from severe OSAHS were enrolled and randomised into a conservative (APAP) or surgical (MMA) arm. Demographic, biometric, PSG and ESS profiles of the two group were statistically not significantly different. One year after surgery or continuous APAP treatment both groups showed a remarkable improvement of mean AHI and ESS; the degree of improvement was not statistically different. Provided the relatively small sample of studied subjects and the relatively short time of follow up, MMA proved to be in our adult and severe OSAHS patients group a valuable alternative therapeutical tool with a success rate not inferior to APAP.

Il ruolo dell'ecografia prenatale nell'infezione congenita da Citomegalovirus

OBJECTIVE: To assess the effectiveness of ultrasound in the antenatal prediction of symptomatic congenital cytomegalovirus infection. STUDY DESIGN: The sonograms of 650 fetuses from mothers with primary cytomegalovirus infection were correlated to fetal/neonatal outcome. Infection status was disclosed by viral urine isolation at birth or CMV tissue inclusions at autopsy. Classification of symptomatic disease was based on postnatal clinical/laboratory findings or macroscopic evidence of tissue damage at autopsy. RESULTS: Ultrasound abnormalities were found in 51/600 (8.5%) mothers with primary infection and in 23/154 congenitally infected fetuses (14.9%). Symptomatic congenital infection resulted in 18/23 and 68/131 cases with or without abnormal sonographic findings, respectively. Positive predictive values of ultrasound versus symptomatic congenital infection was 35.3% relating to all fetuses/infants from mothers with primary infection and 78.3% relating to fetuses/infants with congenital infection. CONCLUSION: When fetal infection status is unknown, ultrasound abnormalities only predict symptomatic congenital infection in a third of cases.

Significato prognostico dell'ecografia cerebrale nei neonati con infezione congenita da citomegalovirus

Background: Congenital cytomegalovirus (CMV) infection may lead to cerebral injury and neurodevelopmental delay. Cranial computed tomography (CT) is currently the standard imaging technique for predicting the outcome of CMV infected patients. Ultrasound (US) is a safe means to assess the extent of cerebral injury due to CMV infection in neonates, and unlike CT, is readily available at the bedside. Aim: To report the accuracy of US in predicting neurodevelopmental and sensorineural outcome in patients with congenital CMV infection. Study design: 57 newborns with congenital CMV infection underwent brain US and were followed prospectively for motor skills, developmental quotient and hearing function. Results: An abnormal US was found in 12/57 newborns. At least one sequela (Developmental Quotient < 85, motor delay, sensorineural hearing loss) was present in 10/11 surviving children with abnormal US (1 patient died in the neonatal period) vs 3/45 newborns with normal US (OR for death or poor outcome: 154, CI 17.3-1219.6, p<0.001, positive predictive value 91.7%, negative predictive value 93.3%). Conclusion: A good correlation is shown between ultrasound abnormalities and the prediction of outcome, suggesting that US may be used to study and follow CMV infected neonates. Our findings await confirmation in a larger population.

Modello bayesiano per la riduzione dell'incertezza nella previsione delle piene del fiume Reno

Many efforts have been devoting since last years to reduce uncertainty in hydrological modeling predictions. The principal sources of uncertainty are provided by input errors, for inaccurate rainfall prediction, and model errors, given by the approximation with which the water flow processes in the soil and river discharges are described. The aim of the present work is to develop a bayesian model in order to reduce the uncertainty in the discharge predictions for the Reno river. The ’a priori’ distribution function is given by an autoregressive model, while the likelihood function is provided by a linear equation which relates observed values of discharge in the past and hydrological TOPKAPI model predictions obtained by the rainfall predictions of the limited-area model COSMO-LAMI. The ’a posteriori’ estimations are provided throw a H∞ filter, because the statistical properties of estimation errors are not known. In this work a stationary and a dual adaptive filter are implemented and compared. Statistical analysis of estimation errors and the description of three case studies of flood events occurred during the fall seasons from 2003 to 2005 are reported. Results have also revealed that errors can be described as a markovian process only at a first approximation. For the same period, an ensemble of ’a posteriori’ estimations is obtained throw the COSMO-LEPS rainfall predictions, but the spread of this ’a posteriori’ ensemble is not enable to encompass observation variability. This fact is related to the building of the meteorological ensemble, whose spread reaches its maximum after 5 days. In the future the use of a new ensemble, COSMO–SREPS, focused on the first 3 days, could be helpful to enlarge the meteorogical and, consequently, the hydrological variability.

Altinópolis, una utopia brasiliana. Analisi di una esperienza di educazione alla pace e non violenza come pratica alternativa dell'educazione popolare

The present thesis has as its object of study a project called “Education towards Peace and No Violence”, developed in the town of Altinópolis, in the inner part of the state of São Paulo, Brazil. Based on the analysis and the studies that were carried out, it was possible to identify the difficulties in the implementation of the project, as well as the positive results evidenced by the reduction of the reports of violence in the town. Through a careful research of the historical facts, it shall be demonstrated the progress of education, particularly in Brazil, throughout the years. In addition, a panoramic view of the studies and programs for peace developed in North America and Occidental Europe will be presented. The education for peace based in the holistic concept of human development appeared as a new educational paradigm that works as a crucial instrument in the construction process towards a peaceful and more human society based in social justice.

La "responsabilità sociale" dell'imprenditore negli ambienti cattolici lombardi dagli anni Trenta alla Ricostruzione

My research focuses on the mentality of catholic entrepreneurs and managers in Italy between the 1930's and the 1950's. The main source of my study is the archive of an organization called Unione Cristiana Imprenditori Dirigenti [Christian Entrepreneurs and Managers Association], which was founded in Milan in 1945 with the pedagogic intent to foster higher moral standards and social responsibility in the milieux of catholic entrepreneurs, in the spirit of the Social Doctrine of the Church. This experience was set in the social and political context of the Italian post-war years, but it was also rooted in the debate – started during the 1930s - on the rise of a new catholic leadership in society.

L'anno che non fu? L'anno dell'Europa e la crisi nelle relazioni transatlantiche, 1973/74

The 1970s are in the limelight of a growing historiographic attention, partly due to the recent opening of new archival resources. 1973, in particular, has a special interest in the historian’s eyes, as many are the events that happened that year: to name but a few, the Chilean coup, the October War, the ensuing oil crisis, the Vietnamese peace treaty. So it is may be not entirely surprising that not much attention has been paid to the Year of Europe, a nebulous American initiative destined to sum up to nothing practical - as Kissinger himself put it, it was destined to be the Year that never Was.1 It is my opinion, however, that its failure should not conceal its historical interest. Even though transatlantic relations have sometimes been seen as an uninterrupted history of crisis,2 in 1973 they reached what could then be considered as their unprecedented nadir. I believe that a thorough analysis of the events that during that year found the US increasingly at odds with the countries of Western Europe is worth carrying out not only to cast a new light on the dynamics of transatlantic relations but also to deepen our comprehension of the internal dynamics of the actors involved, mainly the Nixon administration and a unifying Europe. The Nixon administration had not carefully planned what the initiative actually should have amounted to, and its official announcement appears to have been one of Kissinger’s coups de theatre. Yet the Year of Europe responded to the vital priority of revitalising the relations with Western Europe, crucial ally, for too long neglected. But 1973 did not end with the solemn renewal of the Atlantic Declaration that Kissinger had sought. On the contrary, it saw, for the first time, the countries of the newly enlarged EC engaged in a real, if short-lived, solidarity on foreign policy, which highlighted the Nixon administration’s contradictions regarding European integration. Those, in addition to the numerous tensions that already strained transatlantic relations, gave birth to a downward spiral of incomprehensions and misperceptions, which the unexpected deflagration of the October war seriously worsened. However, even though the tensions did not disappear, the European front soon started to disintegrate, mainly under the strains imposed by the oil crisis. Significant changes in the leadership of the main European countries helped to get the tones back to normal. During the course of 1974-5, the substantial failure of the Euro-Arab dialogue, the Gymlich compromise, frequent and serene bilateral meetings bear witness that the worst was over.