International cooperation in endourology: percutaneous and flexible ureteroscopic treatment of lower pole kidney stones

Introduction Lower pole kidney stones represent at time a challenge for the urologist. The gold standard treatment for intrarenal stones <2 cm is Extracorporeal Shock Wave Lithotripsy (ESWL) while for those >2 cm is Percutaneous Nephrolithotomy (PCNL). The success rate of ESWL, however, decreases when it is employed for lower pole stones, and this is particularly true in the presence of narrow calices or acute infundibular angles. Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones <2 cm, but this is not reflected by either the European or the American guidelines. The aim of this study is to present the results of a large series of flexible ureteroscopies and PCNLs for lower pole kidney stones from high-volume centers, in order to provide more evidences on the potential indications of the flexible ureteroscopy for the treatment of kidney stones. Materials and Methods A database was created and the participating centres retrospectively entered their data relating to the percutaneous and flexible ureteroscopic management of lower pole kidney stones. Patients included were treated between January 2005 and January 2010. Variables analyzed included case load number, preoperative and postoperative imaging, stone burden, anaesthesia (general vs. spinal), type of lithotripter, access location and size, access dilation type, ureteral access sheath use, visual clarity, operative time, stone-free rate, complication rate, hospital stay, analgesic requirement and follow-up time. Stone-free rate was defined as absence of residual fragments or presence of a single fragment <2 mm in size at follow-up imaging. Primary end-point was to test the efficacy and safety of flexible URS for the treatment of lower pole stones; the same descriptive analysis was conducted for the PCNL approach, as considered the gold standard for the treatment of lower pole kidney stones. In this setting, no statistical analysis was conducted owing to the different selection criteria of the patients. Secondary end-point consisted in matching the results of stone-free rates, operative time and complications rate of flexible URS and PCNL in the subgroup of patients harbouring lower pole kidney stones between 1 and 2 cm in the higher diameter. Results A total 246 patients met the criteria for inclusion. There were 117 PCNLs (group 1) and 129 flexible URS (group 2). Ninety-six percent of cases were diagnosed by CT KUB scan. Mean stone burden was 175±160 and 50±62 mm2 for groups 1 and 2, respectively. General anaesthesia was induced in 100 % and 80% of groups 1 and 2, respectively. Pneumo-ultrasonic energy was used in 84% of cases in the PCNL group, and holmium laser in 95% of the cases in the flexible URS group. The mean operative time was 76.9±44 and 63±37 minutes for groups 1 and 2 respectively. There were 12 major complications (11%) in group 1 (mainly Grade II complications according to Clavidien classification) and no major complications in group 2. Mean hospital stay was 5.7 and 2.6 days for groups 1 and 2, respectively. Ninety-five percent of group 1 and 52% of group 2 required analgesia for a period longer than 24 hours. Intraoperative stone-free rate after a single treatment was 88.9% for group 1 and 79.1% for group 2. Overall, 6% of group 1 and 14.7% of group 2 required a second look procedure. At 3 months, stone-free rates were 90.6% and 92.2% for groups 1 and 2, respectively, as documented by follow-up CT KUB (22%) or combination of intra-venous pyelogram, regular KUB and/or kidney ultrasound (78%). In the subanalysis conducted comparing 82 vs 65 patients who underwent PCNL and flexible URS for lower pole stones between 1 and 2 cm, intreoperative stone-free rates were 88% vs 68% (p= 0.03), respectively; anyway, after an auxiliary procedure which was necessary in 6% of the cases in group 1 and 23% in group 2 (p=0.03), stone-free rates at 3 months were not statistically significant (91.5% vs 89.2%; p=0.6). Conversely, the patients undergoing PCNL maintained a higher risk of complications during the procedure, with 9 cases observed in this group versus 0 in the group of patients treated with URS (p=0.01) Conclusions These data highlight the value of flexible URS as a very effective and safe option for the treatment of kidney stones; thanks to the latest generation of flexible devices, this new technical approach seems to be a valid alternative in particular for the treatment of lower pole kidney stones less than 2 cm. In high-volume centres and in the hands of skilled surgeons, this technique can approach the stone-free rates achievable through PCNL in lower pole stones between 1 and 2 cm, with a very low risk of complications. Furthermore, the results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, with no difference detectable between the prone and supine position.

Social Housing e Periferie Urbane: Riqualificazione e tecniche Comunicative

Il campo d’interesse della ricerca è stato l’attuale processo di ricentralizzazione del Social Housing nelle periferie urbane in una parte del contesto internazionale, che sembra stia portando le città a ricrearsi e ripensarsi grazie alla presa di coscienza delle differenze esistenti, rispetto al passato, nei nuovi processi di trasformazione nei quali la città è intesa sia come spazio costruito ma anche sociale. In virtù di quest’ultimi due aspetti complementari della città, oggi, il ruolo della periferia contemporanea sembra essere diversamente interpretato, così come gli interventi di riqualificazione di tipo assistenziale - migliorativo tenderebbero a trasformarne i suoi caratteri alla ricerca del “modello di città”. L’interesse alla tematica è inoltre scaturito dalla constatazione che alla base della crisi dei modelli d’intervento pubblico starebbero sia l’insostenibilità economica ma soprattutto l’errata lettura dei bisogni delle famiglie nella loro specificità e diversità e che in tal senso l’eventuale partecipazione della cittadinanza costituirebbe effettivamente una proposta valida, anche per risolvere la crescente domanda abitativa che si pone a livello mondiale. L’obiettivo della ricerca è stato quello d’analizzare, nel contesto internazionale del Social Housing, le caratteristiche di partecipazione e sussidiarietà che connotano particolarmente gli interventi di riqualificazione destinati a famiglie economicamente carenti, nello specifico analizzando i metodi e gli strumenti atti alla comunicazione partecipativa del progetto in aree urbane periferiche italiane e brasiliane. Nella prima e seconda fase della ricerca è stato svolto, rispettivamente, un lavoro di analisi bibliografica sul tema dell’emergenza casa e sulle nuove politiche abitative di sviluppo urbano ed uno specifico sulla tematica della riqualificazione partecipata del Social Housing in aree della periferia urbana, infine nella terza fase sono stati analizzati i casi di studio prescelti dando rilievo all’analisi delle caratteristiche e requisiti prestazionali delle tecniche partecipative di rappresentazione - comunicazione, più idonee ad influenzare positivamente il suddetto processo.

Model reduction techniques in flexible multibody dynamics with application to engine cranktrain simulation

The development of a multibody model of a motorbike engine cranktrain is presented in this work, with an emphasis on flexible component model reduction. A modelling methodology based upon the adoption of non-ideal joints at interface locations, and the inclusion of component flexibility, is developed: both are necessary tasks if one wants to capture dynamic effects which arise in lightweight, high-speed applications. With regard to the first topic, both a ball bearing model and a journal bearing model are implemented, in order to properly capture the dynamic effects of the main connections in the system: angular contact ball bearings are modelled according to a five-DOF nonlinear scheme in order to grasp the crankshaft main bearings behaviour, while an impedance-based hydrodynamic bearing model is implemented providing an enhanced operation prediction at the conrod big end locations. Concerning the second matter, flexible models of the crankshaft and the connecting rod are produced. The well-established Craig-Bampton reduction technique is adopted as a general framework to obtain reduced model representations which are suitable for the subsequent multibody analyses. A particular component mode selection procedure is implemented, based on the concept of Effective Interface Mass, allowing an assessment of the accuracy of the reduced models prior to the nonlinear simulation phase. In addition, a procedure to alleviate the effects of modal truncation, based on the Modal Truncation Augmentation approach, is developed. In order to assess the performances of the proposed modal reduction schemes, numerical tests are performed onto the crankshaft and the conrod models in both frequency and modal domains. A multibody model of the cranktrain is eventually assembled and simulated using a commercial software. Numerical results are presented, demonstrating the effectiveness of the implemented flexible model reduction techniques. The advantages over the conventional frequency-based truncation approach are discussed.

Social housing: interventions of densification in urban regeneration (1995-2010). Critical analysis of strategies adopted in Milan, London, São Paulo

The prospect of the continuous multiplication of life styles, the obsolescence of the traditional typological diagrams, the usability of spaces on different territorial scales, imposes on contemporary architecture the search for new models of living. Limited densities in urban development have produced the erosion of territory, the increase of the harmful emissions and energy consumption. High density housing cannot refuse the social emergency to ensure high quality and low cost dwellings, to a new people target: students, temporary workers, key workers, foreign, young couples without children, large families and, in general, people who carry out public services. Social housing strategies have become particularly relevant in regenerating high density urban outskirts. The choice of this research topic derives from the desire to deal with the recent accommodation emergency, according to different perspectives, with a view to give a contribution to the current literature, by proposing some tools for a correct design of the social housing, by ensuring good quality, cost-effective, and eco-sustainable solutions, from the concept phase, through management and maintenance, until the end of the building life cycle. The purpose of the thesis is defining a framework of guidelines that become effective instruments to be used in designing the social housing. They should also integrate the existing regulations and are mainly thought for those who work in this sector. They would aim at supporting students who have to cope with this particular residential theme, and also the users themselves. The scientific evidence of either the recent specialized literature or the solutions adopted in some case studies within the selected metropolitan areas of Milan, London and São Paulo, it is possible to identify the principles of this new design approach, in which the connection between typology, morphology and technology pursues the goal of a high living standard.

Silicon Photonics Integrated Circuits for Flexible Optical Systems

This dissertation deals with the design and the characterization of novel reconfigurable silicon-on-insulator (SOI) devices to filter and route optical signals on-chip. Design is carried out through circuit simulations based on basic circuit elements (Building Blocks, BBs) in order to prove the feasibility of an approach allowing to move the design of Photonic Integrated Circuits (PICs) toward the system level. CMOS compatibility and large integration scale make SOI one of the most promising material to realize PICs. The concepts of generic foundry and BB based circuit simulations for the design are emerging as a solution to reduce the costs and increase the circuit complexity. To validate the BB based approach, the development of some of the most important BBs is performed first. A novel tunable coupler is also presented and it is demonstrated to be a valuable alternative to the known solutions. Two novel multi-element PICs are then analysed: a narrow linewidth single mode resonator and a passband filter with widely tunable bandwidth. Extensive circuit simulations are carried out to determine their performance, taking into account fabrication tolerances. The first PIC is based on two Grating Assisted Couplers in a ring resonator (RR) configuration. It is shown that a trade-off between performance, resonance bandwidth and device footprint has to be performed. The device could be employed to realize reconfigurable add-drop de/multiplexers. Sensitivity with respect to fabrication tolerances and spurious effects is however observed. The second PIC is based on an unbalanced Mach-Zehnder interferometer loaded with two RRs. Overall good performance and robustness to fabrication tolerances and nonlinear effects have confirmed its applicability for the realization of flexible optical systems. Simulated and measured devices behaviour is shown to be in agreement thus demonstrating the viability of a BB based approach to the design of complex PICs.