[The use of RCGO triggers in the obstetric - gynecological procedures: the impact on the reduction of adeverse events. The experience of the Lombardia Region]. / L'utilizzo dei RCOG trigger in area ostetrica - ginecologica e la riduzione degli eventi avversi. L'esperienza della regione Lombardia.

The last few weeks of pregnancy are critical to a baby's health because important organs, including the brain and lungs, are not completely developed until the end of pregnancy. The adverse events during labor and childbirth can have very serious physical, psychological and financial consequences for the child, the family, health professionals and the whole community. These events can be reduced through interventions aimed at improving the safety and quality of care, based on evidence-based knowledge, guidelines and practices that must be widely and effectively applied. This work reports the experience of the Lombardy Region on improvement actions in the obstetric and gynecological procedures for the reduction of adverse events and sentinel events through the monitoring and management of the RCGS trigger tool.

A suitable test for identifying high risk adult patients of moderate-severe obstructive sleep apnea syndrome.

The aim of this study was the evaluation of the usefulness of a 7-items questionnaire, Rome Questionnaire (RQ), in identifying adult patients at risk of obstructive sleep apnoea syndrome (OSAS). 136 adults (76 M, 60 F) with snoring were enrolled. Each patient underwent to an overnight polysomnography (PSG) study and the patient's bed partner answered the "RQ". RQ survey items mainly addressed the presence and frequency of snoring behaviour, breathing pauses, sore throat, oral breathing and wake time sleepiness. Of the 136 initial patients, 111 (63 M, 48 F; mean age 54.6 +/- 10.84) with a complete PSG examination were included in the study. They were divided according to apnea-hypopnea index (AHI) into two groups: group A with a primary snoring or mild OSAS (AHI < or = 15) and group B with moderate-severe OSAS (AHI > 15). The RQ final score was 25.27 +/- 16.1 for group A and 42.29 +/- 15.2 for group B, with a statistically significant (p < 0.0001) difference. Analyzing the RQ score of group B (moderate-severe OSAS) we surprisingly noticed that most of patients (66%) showed an high RQ score (> 40). No patients with moderate-severe OSAS showed a RQ score < 20 and for every point scored in the questionnaire there is an extra 1.07 (0.7%) risk of belonging to group B. Group B showed a mean body mass index (BMI) of 31.53 (+/- 4.95), significantly (p < 0.001) higher than BMI of group A (26,86 +/- 3.28) and BMI results a good predictive factor (p = 0.013) of mild-severe OSAS. In conclusion, the "RQ", together with BMI, seems to be an useful tool to make a selection of the patients at higher risk of moderate-severe OSAS, who need a prompt PSG evaluation. Our findings will require further validation in larger sample of subjects.

Nerve growth factor serum level is reduced in patients with sensorineural hearing impairment: possible clinical implications.

Nerve growth factor (NGF) is the first and best characterised member of a family of neurotrophic factor. NGF is produced by numerous cells and it is present in physiologically relevant amounts in the bloodstream. It is known to promote the survival of peripheral sensory neurons and can be potentially useful as a therapeutic agent in neuronal system. On the both these observations we based our hypothesis that low circulating NGF might lead to sensorineural hearing loss (SNHL). To address this question we measured the levels of NGF in the bloodstream of patients affected by SNHL. The results showed that the amount of circulating NGF in these patients is significantly lower compared to levels found in patients not affected by this deficit. The results of the present study demonstrated that NGF might be a useful candidate for preventing the damage and promoting recovery or degeneration of the auditory pathways in humans.

Nasal and hearing impairment: are they linked?

Hearing impairment is the most prevalent sensory deficit in the human population. Otosclerosis and chronic otitis media are two of the most frequent causes of hearing loss of the Western world and both benefit from middle ear surgery. The success rate is high for both operations, in expert hands, but, in our clinic and in every ENT clinic, there remains a percentage of failure. Some of the most frequent post-operative complications can lead to tubal dysfunction. We believe that a correct and complete evaluation of the rhino-pharyngeal-tubal unit is very important before tympanoplasty and stapedioplasty in order to further reduce the incidence of some post-operative complications and to increase the success rate of middle ear surgery. What is well known in medicine, 'prevention is the best therapy', seems not oddly observed in ear surgery, where is usually operated the effect, while the evaluation and therapy of the causes seems to be underestimated.

Chronic otitis media: histopathological changes: a post mortem study on temporal bones.

The temporal bones of 4 deceased individuals, with concomitant chronic otitis media are studied. The various histopathological changes in the middle ear cleft are examined: suppuration, polyps, granulation tissue. The possibilities of spontaneous healing of a perforated TM and the indications of surgical treatment are discussed.

Otosclerosis and cochlear otosclerosis: a post mortem study on temporal bones.

We have chosen among many temporal bones of donors deceased individuals with concomitant otosclerosis, three particular cases, one with classic otosclerosis, another with cochlear otosclerosis with concomitant oval window ankylosis and another with cochlear otosclerosis without stapes fixation. The different histopathologic features are discussed and clinical and therapeutical guidelines are proposed.

Cholesteatomatous otitis media: histopathological changes. A post mortem study on temporal bones.

The histopathological changes in the temporal bones of 3 deceased donors individuals with concomitant chronic cholesteatomatous otitis media have been studied. The different forms of cholesteatoma are analyzed: the primary congenital, the primary acquired and the secondary acquired. The different clinical relevance and the different therapeutic guidelines are discussed.

Ménière's disease. Histopathological changes: a post mortem study on temporal bones.

The histopathological changes in the temporal bones of two deceased donors individuals with concomitant Ménierè's disease have been studied. In one temporal bone we have found a blockage of the endolymphatic duct by abnormal bone. The histopathological modifications and the different therapeutic options are discussed. Clinical guidelines are proposed.

Cochlear implant. Histopathological guide to indications and contraindications: a post mortem study on temporal bones.

We have studied the temporal bones of 4 deceased donors, individuals one with cochlear saccular degeneration, another with Mondini dysplasia, another with an ossification of the basal turn of the cochlea and the round window, post meningitis and the fourth who was implanted 10 years before. The indications and contraindications for cochlear implant placement are discussed.

Acoustic neuromas and meningiomas. Histopathological aspect: a post mortem study on temporal bones.

The histopathological changes in the temporal bones of three deceased donors individuals, two with concomitant acoustic tumors and one with concomitant petroclival meningioma have been studied. The differences between neuromas and meningiomas are examined. The different clinical relevance and the different therapeutic guidelines are discussed.

Neurofibromatosis and brainstem implants: what to do?

The histopathological changes in the temporal bones of one donor individual deceased for complications of neurofibromatosis type 2 are studied. The different modalities of presentation of neurofibromatosis and the criteria for the differential diagnosis are presented. The possibilities of the auditory brainstem implants in this pathology are discussed.

Acute otitis media. Histopathological changes: a post mortem study on temporal bones.

A classification of otitis media is proposed and the histopathological changes of otitis media with effusion are reviewed post mortem on two temporal bones. A case of adhesive otitis media is observed on temporal bone slides. The clinical and therapeutic aspect are examined and treatment guidelines are proposed.

Cholesterol granuloma of the petrous apex. A post mortem study on temporal bones.

Otitis media (OM) is an infection localized in the middle ear: mastoid, middle ear cavity, Eustachian tube. The classification of OM includes otitis media with effusion, otitis media without effusion, and chronic otitis media. A rare complication of chronic otitis is cholesterol granuloma of the petrous apex. It may develop in any aerated portion of the temporal bone but most commonly develops when a pathologic process obstruct the air cell tracts to the petrous apex preventing normal aeration.

Menierè's disease: is it a bilateral disease?

BACKGROUND: Bilateral Meniere's disease (MD) is still controversial due to different criteria used to assess the involvement of the primarily affected ear and the contralateral one. We evaluated the percentage of bilateral forms in 49 patients with MD. METHODS: 49 patients with (MD) were studied. All were selected according to the following requirements: history, tonal audiometry, glycerol test, Auditory Brainstem Response (ABR), vestibular examination. Magnetic Resonance (MR) was performed in 14 patients. RESULTS: A raised hearing threshold in the contralateral ear was found in 23 patients, but only 7 (14.3%) fulfilled the requirements to be considered affected by bilateral MD. The delay of occurrence in the contralateral ear was 7 years (from 5 to 12 years). Submillimeter Magnetic Resonance is determinant for differential diagnosis with Meniere-like syndromes. CONCLUSIONS: A conservative approach in surgical treatment of unilateral Meniere's disease is recommended because of the possibility of evolution in a bilateral form, that can occur even after 10 years from the onset of the disease.

Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?

PURPOSE: The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects. PATIENTS AND METHODS: Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed. RESULTS: Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported. CONCLUSIONS: In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.

Misleading clinical features in Wegener's granulomatosis. A case report.

Wegener's granulomatosis is a systemic vasculitis that may present with a variety of findings and be difficult to diagnose. We report a case of a patient who presented with serous otitis media and subsequently developed a suspected primary lung tumour. Thoracotomy and pulmonary mass excision were required to establish the diagnosis. Otological manifestations of Wegener's granulomatosis, differential diagnosis, pathological findings and c-ANCA test role are discussed.

[Sports and adolescence: the effect of competitive athletics on menstrual function]. / Sport e adolescenza: influenza dell'agonismo sulla funzione mestruale.

A group of 381 girls, 12 up to 19-years-old, engaging in competitive sports (athletics, basketball, dancing, gymnastics, swimming, ski-ing, tennis, volley-ball) was examined. Age at menarche and menstrual characteristics were correlated with the body weight, the competitive practice start age, the kind of the sport and the amount of training hours/week. Collected data were compared with the ones from a pool of 387 girls of equivalent mean age, not playing any sport. Delay of menarche and larger frequency of menstrual disorders, found among athletes, turned out to be directly proportional to the amount of time devoted to training and to the kind of performed sports. Irregular cycles are more frequent in athletes having a normal or lower body weight and do not normalise proceeding in sporting activities.

[Treatment of secondary adolescent amenorrhea with purified FSH]. / Terapia dell'amenorrea secondaria adolescenziale con FSH purificato.

The dysfunctional features of adolescent secondary amenorrhea are here considered: anovulation, immaturity of estrogenic feed back, multi-follicular ovary. We described the opportunity of using gonadotrophin in the treatment of hypogonadotrophic amenorrhea. Among 64 patients with menstrual delay, we examined a group of 23 selected girls, 21 of them affected by secondary amenorrhea and 2 affected by primary amenorrhea; their average age is 17 years. The selection excludes organic and psychiatric pathologies, while includes anovulation, low rates of FSH and inadequate response to LHRH test, multi-follicular ovary. Some patients were also affected by acne, hypertrichosis, weight disorders, emotional stress. The therapeutic approach with purified FSH (urofollitrophin) is described on an amount of 48 treatments. We used 75/225 UI/day at 3 degrees to 5 degrees/7 degrees of each menstrual cycle, and for 3/5 cycles. Doses are in some subjects modified during the treatment in relation to menstrual response. Hormonal, echographic and clinical evaluation were given before and after each treatment. The results of giving FSH demonstrate an 81.2% of immediate success, while an 43.7% up to 12 months. We observed a significant reduction of LH rates as well as estrogenic increase and subsequent menstrual response. Ovarian follicles increased in number and volume, while no hyperstimulation effects appeared. In general we suppose these data are satisfactory; nevertheless we point out the opportunity of only treat selected patients, even in considering the complaint due to this therapeutic engagement and the eventual consequent renouncing.

[Peripheral facial palsy in middle ear surgery: case report and review of literature]. / La paresi periferica del facciale nella chirurgia dell'orecchio medio: caso clinico e revisione della letteratura.

We present a case of a patient who experienced right facial palsy after being operated for otosclerosis. Seventeen years before our patient had yet undergone the same operation on the contralateral ear and had presented a facial palsy. We also report another case of facial palsy and middle ear damage after an operation for otosclerosis. Facial palsy is a rare complication of middle ear surgery. It is probably caused by a viral relapse and it recedes after few weeks if a proper therapy is administrated to the patient. Thus we deem it is useless to perform immediately advanced, invasive and expensive tests. On the contrary we believe that it is useful, in those cases in which an otosclerotic patient has a history of herpes simplex virus infection, to administer a preventive antiviral therapy before the operation.

Benign paroxysmal positional vertigo: diagnosis and treatment.

Benign paroxysmal positional vertigo (BPPV) has been recognized as the most common vestibular disorder; it is a term coined in 1952 by Dix and Hallpike, and it is most commonly used to describe a disease with a characteristic clinical presentation believed to be caused by free-floating particles leaving the macula and entering one of the semicircular canals, usually the posterior one, more rarely the horizontal or superior ones. A lot of studies showed as the prevalence is higher in females than in males with a ratio of 2:1; furthermore, prevalence increases with the age: the mean age at onset is 54 years, with a range of 11 to 84 years. The most important clinical manifestations of BPPV are: vertigo, lightheadedness, dysequilibrium and sometimes nausea, vomiting, pallor and sweating. The diagnosis of BPPV is very simple through the Dix-Hallpike test or the diagnostic Semont's maneuver; the increasing information about the BPPV's pathogenesis has led most authors to consider the rehabilitative therapy, and in particular the so-called Semont's "liberatory" maneuver, as the first choice treatment of BPPV, in relation to its quickness and efficacy. In this treatment the debris are moved from the posterior semicircular canal to another location within the vestibular labyrinth. In our review we consider the possible pathogenesis of this disease and the best therapies, like repositioning maneuvers, in a patient affected by BPPV.