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.

Influence of processing conditions on quality aspects of potato-based fresh pasta

Gnocchi is a typical Italian potato-based fresh pasta that can be either homemade or industrially manufactured. The homemade traditional product is consumed fresh on the day it is produced, whereas the industrially manufactured one is vacuum-packed in polyethylene and usually stored at refrigerated conditions. At industrial level, most kinds of gnocchi are usually produced by using some potato derivatives (i.e. flakes, dehydrated products or flour) to which soft wheat flour, salt, some emulsifiers and aromas are added. Recently, a novel type of gnocchi emerged on the Italian pasta market, since it would be as much similar as possible to the traditional homemade one. It is industrially produced from fresh potatoes as main ingredient and soft wheat flour, pasteurized liquid eggs and salt, moreover this product undergoes steam cooking and mashing industrial treatments. Neither preservatives nor emulsifiers are included in the recipe. The main aim of this work was to get inside the industrial manufacture of gnocchi, in order to improve the quality characteristics of the final product, by the study of the main steps of the production, starting from the raw and steam cooked tubers, through the semi-finished materials, such as the potato puree and the formulated dough. For this purpose the investigation of the enzymatic activity of the raw and steam cooked potatoes, the main characteristics of the puree (colour, texture and starch), the interaction among ingredients of differently formulated doughs and the basic quality aspects of the final product have been performed. Results obtained in this work indicated that steam cooking influenced the analysed enzymes (Pectin methylesterase and α- and β-amylases) in different tissues of the tuber. PME resulted still active in the cortex, it therefore may affect the texture of cooked potatoes to be used as main ingredient in the production of gnocchi. Starch degrading enzymes (α- and β-amylases) were inactivated both in the cortex and in the pith of the tuber. The study performed on the potato puree showed that, between the two analysed samples, the product which employed dual lower pressure treatments seemed to be the most suitable to the production of gnocchi, in terms of its better physicochemical and textural properties. It did not evidence aggregation phenomena responsible of hard lumps, which may occur in this kind of semi-finished product. The textural properties of gnocchi doughs were not influenced by the different formulation as expected. Among the ingredients involved in the preparation of the different samples, soft wheat flour seemed to be the most crucial in affecting the quality features of gnocchi doughs. As a consequence of the interactive effect of the ingredients on the physicochemical and textural characteristics of the different doughs, a uniform and well-defined split-up among samples was not obtained. In the comparison of different kinds of gnocchi, the optimal physicochemical and textural properties were detected in the sample made with fresh tubers. This was probably caused not only by the use of fresh steam cooked potatoes, but also by the pasteurized liquid eggs and by the absence of any kind of emulsifier, additive or preserving substance.

Therapeutic strategies for modulation of the vaginal microbiota

The vaginal microbiota of healthy women consists of a wide variety of anaerobic and aerobic bacteria, dominated by the genus Lactobacillus. The activity of lactobacilli is essential to protect women from genital infections and to maintain the natural healthy balance of the vaginal ecosystem. This role is particularly important during pregnancy because vaginal infection is one of the most important mechanisms for preterm birth. The most common vaginal disorder is bacterial vaginosis (BV). BV is a polymicrobial disorder, characterized by a depletion of lactobacilli and an increase in the concentration of other bacteria, including Gardnerella vaginalis, anaerobic Gram-negative rods, anaerobic Gram-positive cocci, Mycoplasma hominis, and Mobiluncus spp. An integrated molecular approach based on real-time PCR and PCR-DGGE was used to investigate the effects of two different therapeutic approaches on the vaginal microbiota composition. (i) The impact of a dietary supplementation with the probiotic VSL#3, a mixture of Lactobacillus, Bifidobacterium and Streptococcus strains, on the vaginal microbial ecology and immunological profiles of healthy women during late pregnancy was investigated. The intake was associated to a slight modulation of the vaginal microbiota and cytokine secretion, with potential implications in preventing preterm birth. (ii) The efficacy of different doses of the antibiotic rifaximin (100 mg/day for 5 days, 25 mg/day for 5 days, 100 mg/day for 2 days) on the vaginal microbiota of patients with BV enrolled in a multicentre, double-blind, randomised, placebo-controlled study was also evaluated. The molecular analyses demonstrated the ability of rifaximin 25 mg/day for 5 days to induce an increase of lactobacilli and a decrease of the BV-associated bacteria after antibiotic treatment, and a reduction of the complexity of the vaginal microbial communities. Thus, confirming clinical results, it represents the most effective treatment to be used in future pivotal studies for the treatment of BV.