Questioni di vita o di morte? Riflessioni sulle dichiarazioni anticipate di trattamento

Fino a non molto tempo fa vi erano linee di riflessione che tendevano a considerare la bioetica come una disciplina sostanzialmente attinente alla sfera privata della coscienza individuale degli operatori direttamente coinvolti e perciò non direttamente connessa a questioni di organizzazione complessiva della società pubblica. Nel corso del tempo la prospettiva si è progressivamente evoluta, dal momento che le questioni bioetiche sollevano molti interrogativi di carattere etico, deontologico e giuridico, divenendo così oggetto di riflessione anche sul versante sociale e politico: potremmo parlare, in altri termini, di biopolitica e biodiritto. Infatti il legislatore è spesso chiamato ad esprimersi su questioni sollevate da “casi” bioeticamente significativi e dovrebbe poterlo fare con cognizione di causa. Il dibattito sulle “Dichiarazioni Anticipate di Trattamento” rappresenta una di tali questioni. Molte e diverse sono le denominazioni utilizzate per indicare lo strumento atto a manifestare le scelte di fine vita. Tutte, però, fanno riferimento ad un documento scritto, contenente le indicazioni espresse da una persona sana e capace di intendere e di volere, avente per oggetto i trattamenti sanitari e assistenziali che si vogliono o non si vogliono ricevere nell’ipotesi in cui, a causa di una malattia grave, inguaribile o di un evento traumatico, tale persona si venisse a trovare in uno stato di incapacità di intendere e di volere. Dietro la diversa terminologia utilizzata, si evidenziano difficoltà di diversa natura: il riferimento alla libertà del singolo e al suo diritto di autodeterminazione, l’ampio concetto di salute, il principio dell’uguaglianza, la nozione di dignità, la questione dell’obiezione di coscienza. L'idea di affrontare questo tema nasce dal desiderio di approfondire uno degli aspetti maggiormente discussi nel settore delle scelte di fine vita; di riflettere sulla legittimità e sulla reale utilità di uno strumento come le DAT; di indagare la reale situazione intorno alle tematiche di fine vita.

Metamorfosi temporali e spaziali: dal “Revisore” di Nikolaj Gogol’ alla “Morte accidentale di un anarchico” di Dario Fo.

La tesi si propone di tracciare un confronto tra due autori molto distanti tra loro sia nel tempo che nello spazio: Nikolaj Gogol’ e Dario Fo; in particolare si analizzano le commedie Il Revisore di Gogol’ (1836) e Morte accidentale di un anarchico di Fo (1970). Il nesso tra le due opere è stato individuato dalla critica italiana (Franco Quadri, Ferdinando Taviani, Paolo Puppa). Tuttavia gli spunti interpretativi e comparativi non sono mai stati sviluppati appieno della critica. Nonostante le grandi distanze temporali e spaziali, l’analisi si propone dunque di evidenziare i numerosi motivi di consonanza tra le due opere e i due autori, che peraltro testimoniano anche della grande fortuna arrisa all’estero all’autore ucraino, attraverso la mediazione del teatro russo-sovietico del XX secolo. L’approccio metodologico adottato si fonda sui testi dei formalisti russi, di Lotman, sulla Stilkritik di Aurbach, sugli studi di Frye sulla Bibbia intesa come “grande canone” della letteratura occidentale, e soprattutto sull’analisi della cultura carnevalesca e popolare condotta da Bachtin. Lo studio è indirizzato su alcuni elementi precisi: la trama, lo scambio della personalità, l’impostura, la paura e il riso. Per ciascun di questi elementi è stata svolta l’analisi comparativa delle due opere, situandole in un contesto letterario e culturale che va all’antichità e al Medio Evo, dal quale entrambi gli autori mutuano molte suggestioni.

Neural network activity in the neonatal acute slice, slice culture and cell culture

Information processing and storage in the brain may be presented by the oscillations and cell assemblies. Here we address the question of how individual neurons associate together to assemble neural networks and present spontaneous electrical activity. Therefore, we dissected the neonatal brain at three different levels: acute 1-mm thick brain slice, cultured organotypic 350-µm thick brain slice and dissociated neuronal cultures. The spatio-temporal properties of neural activity were investigated by using a 60-channel Micro-electrode arrays (MEA), and the cell assemblies were studied by using a template-matching method. We find local on-propagating as well as large- scale propagating spontaneous oscillatory activity in acute slices, spontaneous network activity characterized by synchronized burst discharges in organotypic cultured slices, and autonomous bursting behaviour in dissociated neuronal cultures. Furthermore, repetitive spike patterns emerge after one week of dissociated neuronal culture and dramatically increase their numbers as well as their complexity and occurrence in the second week. Our data indicate that neurons can self-organize themselves, assembly to a neural network, present spontaneous oscillations, and emerge spatio-temporal activation patterns. The spontaneous oscillations and repetitive spike patterns may serve fundamental functions for information processing and storage in the brain.

Functional and Genetic characterization of new genomic islands from an E. coli strain associated with neonatal meningitis.

Enterobacteriaceae genomes evolve through mutations, rearrangements and horizontal gene transfer (HGT). The latter evolutionary pathway works through the acquisition DNA (GEI) modules of foreign origin that enhances fitness of the host to a given environment. The genome of E. coli IHE3034, a strain isolated from a case of neonatal meningitis, has recently been sequenced and its subsequent sequence analysis has predicted 18 possible GEIs, of which: 8 have not been previously described, 5 fully meet the pathogenic island definition and at least 10 that seem to be of prophagic origin. In order to study the GEI distribution of our reference strain, we screened for the presence 18 GEIs a panel of 132 strains, representative of E. coli diversity. Also, using an inverse nested PCR approach we identified 9 GEI that can form an extrachromosomal circular intermediate (CI) and their respective attachment sites (att). Further, we set up a qPCR approach that allowed us to determine the excision rates of 5 genomic islands in different growth conditions. Four islands, specific for strains appertaining to the sequence type complex 95 (STC95), have been deleted in order to assess their function in a Dictyostelium discoideum grazing assays. Overall, the distribution data presented here indicate that 16 IHE3034 GEIs are more associated to the STC95 strains. Also the functional and genetic characterization has uncovered that GEI 13, 17 and 19 are involved in the resistance to phagocitation by Dictyostelium d thus suggesting a possible role in the adaptation of the pathogen during certain stages of infection.

Framing Death. La morte in diretta, tra cinema e media digitali

Come dimostrano i sempre più numerosi casi di cronaca riportati dai notiziari, la preoccupazione per la gestione delle immagini di morte si configura come un nodo centrale che coinvolge spettatori, produttori di contenuti e broadcaster, dato che la sua emersione nel panorama mediale in cui siamo immersi è sempre più evidente. Se la letteratura socio-antropologica è generalmente concorde nel ritenere che, rispetto al passato, oggi la morte si manifesti con meno evidenza nella vita comune delle persone, che tendono a rimuovere i segni della contiguità vivendo il lutto in forma privata, essa è però percepita in modo pervasivo perché disseminata nei (e dai) media. L'elaborato, concentrandosi in maniera specifica sulle produzioni audiovisive, e quindi sulla possibilità intrinseca al cinema – e alle sue forme derivate – di registrare un evento in diretta, tenta di mappare alcune dinamiche di produzione e fruizione considerando una particolare manifestazione della morte: quella che viene comunemente indicata come “morte in diretta”. Dopo una prima ricognizione dedicata alla tensione continua tra la spinta a considerare la morte come l'ultimo tabù e le manifestazioni che essa assume all'interno della “necrocultura”, appare chiaro che il paradigma pornografico risulta ormai inefficace a delineare compiutamente le emersioni della morte nei media, soggetta a opacità e interdizioni variabili, e necessita dunque di prospettive analitiche più articolate. Il fulcro dell'analisi è dunque la produzione e il consumo di precisi filoni quali snuff, cannibal e mondo movie e quelle declinazioni del gore che hanno ibridato reale e fittizio: il tentativo è tracciare un percorso che, a partire dal cinema muto, giunga al panorama contemporaneo e alle pratiche di remix rese possibili dai media digitali, toccando episodi controversi come i Video Nasties, le dinamiche di moral panic scatenate dagli snuff film e quelle di contagio derivanti dalla manipolazione e diffusione delle immagini di morte.

Neural network activity in the neonatal rat barrel cortex in vivo

Coordinated patterns of electrical activity are important for the early development of sensory systems. The spatiotemporal dynamics of these early activity patterns and the role of the peripheral sensory input for their generation are essentially unknown. There are two projects in this thesis. In project1, we performed extracellular multielectrode recordings in the somatosensory cortex of postnatal day 0 to 7 rats in vivo and observed three distinct patterns of synchronized oscillatory activity. (1) Spontaneous and periphery-driven spindle bursts of 1–2 s in duration and ~10 Hz in frequency occurred approximately every 10 s. (2) Spontaneous and sensory-driven gamma oscillations of 150–300 ms duration and 30–40 Hz in frequency occurred every 10–30 s. (3) Long oscillations appeared only every ~20 min and revealed the largest amplitude (250–750 µV) and longest duration (>40 s). These three distinct patterns of early oscillatory activity differently synchronized the neonatal cortical network. Whereas spindle bursts and gamma oscillations did not propagate and synchronized a local neuronal network of 200–400 µm in diameter, long oscillations propagated with 25–30 µm/s and synchronized 600-800 µm large ensembles. All three activity patterns were triggered by sensory activation. Single electrical stimulation of the whisker pad or tactile whisker activation elicited neocortical spindle bursts and gamma activity. Long oscillations could be only evoked by repetitive sensory stimulation. The neonatal oscillatory patterns in vivo depended on NMDAreceptor-mediated synaptic transmission and gap junctional coupling. Whereas spindle bursts and gamma oscillations may represent an early functional columnar-like pattern, long oscillations may serve as a propagating activation signal consolidating these immature neuronal networks. In project2, Using voltage-sensitive dye imaging and simultaneous multi-channel extracellular recordings in the barrel cortex and somatosensory thalamus of newborn rats in vivo, we found that spontaneous and whisker stimulation induced activity patterns were restricted to functional cortical columns already at the day of birth. Spontaneous and stimulus evoked cortical activity consisted of gamma oscillations followed by spindle bursts. Spontaneous events were mainly generated in the thalamus or by spontaneous whisker movements. Our findings indicate that during early developmental stages cortical networks self-organize in ontogenetic columns via spontaneous gamma oscillations triggered by the thalamus or sensory periphery.

LPS-induced modifications in spontaneous network activity causes neuronal apoptosis in neonatal cerebral cortex

During the perinatal period the developing brain is most vulnerable to inflammation. Prenatal infection or exposure to inflammatory factors can have a profound impact on fetal neurodevelopment with long-term neurological deficits, such as cognitive impairment, learning deficits, perinatal brain damage and cerebral palsy. Inflammation in the brain is characterized by activation of resident immune cells, especially microglia and astrocytes whose activation is associated with a variety of neurodegenerative disorders like Alzheimer´s disease and Multiple sclerosis. These cell types express, release and respond to pro-inflammatory mediators such as cytokines, which are critically involved in the immune response to infection. It has been demonstrated recently that cytokines also directly influence neuronal function. Glial cells are capable of releaseing the pro-inflammatory cytokines MIP-2, which is involved in cell death, and tumor necrosis factor alpha (TNFalpha), which enhances excitatory synaptic function by increasing the surface expression of AMPA receptors. Thus constitutively released TNFalpha homeostatically regulates the balance between neuronal excitation and inhibition in an activity-dependent manner. Since TNFalpha is also involved in neuronal cell death, the interplay between neuronal activity MIP-2 and TNFalpha may control the process of cell death and cell survival in developing neuronal networks. An increasing body of evidence suggests that neuronal activity is important in the regulation of neuronal survival during early development, e.g. programmed cell death (apoptosis) is augmented when neuronal activity is blocked. In our study we were interested on the impact of inflammation on neuronal activity and cell survival during early cortical development. To address this question, we investigated the impact of inflammation on neuronal activity and cell survival during early cortical development in vivo and in vitro. Inflammation was experimentally induced by application of the endotoxin lipopolysaccharide (LPS), which initiates a rapid and well-characterized immune response. I studied the consequences of inflammation on spontaneous neuronal network activity and cell death by combining electrophysiological recordings with multi-electrode arrays and quantitative analyses of apoptosis. In addition, I used a cytokine array and antibodies directed against specific cytokines allowing the identification of the pro-inflammatory factors, which are critically involved in these processes. In this study I demonstrated a direct link between inflammation-induced modifications in neuronal network activity and the control of cell survival in a developing neuronal network for the first time. Our in vivo and in vitro recordings showed a fast LPS-induced reduction in occurrence of spontaneous oscillatory activity. It is indicated that LPS-induced inflammation causes fast release of proinflammatory factors which modify neuronal network activity. My experiments with specific antibodies demonstrate that TNFalpha and to a lesser extent MIP-2 seem to be the key mediators causing activity-dependent neuronal cell death in developing brain. These data may be of important clinical relevance, since spontaneous synchronized activity is also a hallmark of the developing human brain and inflammation-induced alterations in this early network activity may have a critical impact on the survival of immature neurons.

"Orationi al cepo overo a la scala": le laude della Confraternita bolognese di S. Maria della morte

La Confraternita bolognese di S. Maria della Morte, istituita nel 1336 sull’onda della predicazione del frate domenicano Venturino da Bergamo, è la più antica e meglio documentata compagnia italiana ‘di giustizia’. Possedeva un laudario conosciuto attraverso 12 manoscritti redatti tra XV e XVI secolo, dove le laude seguono il “confortatorio” che insegnava ai confratelli come relazionarsi col condannato e prepararlo a morire in perfetto spirito cristiano. Nelle laude l’identificazione poetica tra Cristo e il condannato era funzionale allo scopo di convertire il criminale in santo, convincendolo che la sua morte aveva una funzione redentrice per sé e la città stessa. L’assoluzione plenaria poteva essere ottenuta solo tramite una morte completamente accettata e un pentimento sincero. La dissertazione indaga le tematiche espresse dalle laude e le motivazioni forti che spingevano i confortatori a intraprendere questa peculiare attività assistenziale.

Long-term potentiation and neural network activity in the neonatal rat cerebral cortex in vivo

Long-term potentiation in the neonatal rat rnbarrel cortex in vivo rnLong-term potentiation (LTP) is important for the activity-dependent formation of early cortical circuits. In the neonatal rodent barrel cortex LTP has been so far only studied in vitro. I combined voltage-sensitive dye imaging with extracellular multi-electrode recordings to study whisker stimulation-induced LTP for both the slope of field potential and the number of multi-unit activity in the whisker-to-barrel cortex pathway of the neonatal rat barrel cortex in vivo. Single whisker stimulation at 2 Hz for 10 min induced an age-dependent expression of LTP in postnatal day (P) 0 to P14 rats with the strongest expression of LTP at P3-P5. The magnitude of LTP was largest in the stimulated barrel-related column, smaller in the surrounding septal region and no LTP could be observed in the neighboring barrel. Current source density analyses revealed an LTP-associated increase of synaptic current sinks in layer IV / lower layer II/III at P3-P5 and in the cortical plate / upper layer V at P0-P1. This study demonstrates for the first time an age-dependent and spatially confined LTP in the barrel cortex of the newborn rat in vivo. These activity-dependent modifications during the critical period may play an important role in the development and refinement of the topographic map in the barrel cortex. (An et al., 2012)rnEarly motor activity triggered by gamma and spindle bursts in neonatal rat motor cortexrnSelf-generated neuronal activity generated in subcortical regions drives early spontaneous motor activity, which is a hallmark of the developing sensorimotor system. However, the neuronal activity patterns and functions of neonatal primary motor cortex (M1) in the early movements are still unknown. I combined voltage-sensitive dye imaging with simultaneous extracellular multi-electrode recordings in the neonatal rat S1 and M1 in vivo. At P3-P5, gamma and spindle bursts observed in M1 could trigger early paw movements. Furthermore, the paw movements could be also elicited by the focal electrical stimulation of M1 at layer V. Local inactivation of M1 could significantly attenuate paw movements, suggesting that the neonatal M1 operates in motor mode. In contrast, the neonatal M1 can also operate in sensory mode. Early spontaneous movements and sensory stimulations of paw trigger gamma and spindle bursts in M1. Blockade of peripheral sensory input from the paw completely abolished sensory evoked gamma and spindle bursts. Moreover, both sensory evoked and spontaneously occurring gamma and spindle bursts mediated interactions between S1 and M1. Accordingly, local inactivation of the S1 profoundly reduced paw stimulation-induced and spontaneously occurring gamma and spindle bursts in M1, indicating that S1 plays a critical role in generation of the activity patterns in M1. This study proposes that both self-generated and sensory evoked gamma and spindle bursts in M1 may contribute to the refinement and maturation of corticospinal and sensorimotor networks required for sensorimotor coordination.rn