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To assess the effectiveness of maxillomandibular adavancement for treatment of adults with obstructive sleep apnoea, we report the results obtained after maxillomandibular advancement. A group of 16 patients were studied before surgery, at 6 months after surgery and at followup. The analysis included: upper airway endoscopy during Mueller's manoeuvre, lateral cephalometry, polysomnography and Epworth Sleepiness Scale. The results of surgical treatment were divided into "surgical success" and "surgical cure". The former was defined as an AHI20 events/hour and a50% reduction in AHI after surgical procedure, while the latter was defined as an AHI5 events/hour after surgical procedure. At follow-up, all patients had AHI20 events/hour with a surgical success rate of 100%. The surgical cure rate was 37.5%, with 6 patients having an AHI5 events/hour. Surgical success and long term stability of outcomes confirm the efficacy and safety of MMA for treatment of obstructive sleep apnoea syndrome. However, a continuous follow-up of these patients is necessary to control their lifestyle and to detect possible relapse.Obbiettivo del nostro studio è stato valutare l'efficacia dell'avanzamento maxillo-mandibolare come trattamento dell'apnea ostruttiva del sonno negli adulti. Sedici pazienti sono stati studiati prima dell'intervento chirurgico, a sei mesi dopo l'intervento ed al follow-up. L'analisi includeva: l'endoscopia delle vie aeree superiori durante la manovra di Mueller, la cefalometria laterale, la polisonnografia e la scala della sonnolenza di Epworth. I risultati del trattamento chirurgico sono stati riportati in termini di successo chirurgico (riduzione superiore al 50% dell' AHI con valori inferiori a 20 eventi / ora) e successo terapeutico (AHI5 eventi / ora dopo l'intervento chirurgico) Al follow up (T2) tutti i pazienti avevano AHI20 eventi / h con un "successo chirurgico" del 100%. Il tasso di "successo terapeutico" è stato del 37,5%, con 6 pazienti con un AHI5 eventi / h. Il successo chirurgico e la stabilità a lungo termine dei risultati confermano l'efficacia e la sicurezza dell'avanzamento maxillo-mandibolare per il trattamento della OSAS. Tuttavia, un continuo follow-up di questi pazienti è necessario per controllare il loro stile di vita e di rilevare eventuali possibili recidive.

SUMMARY In 1997, supported by experimental work, Argenta published a clinical report describing a variety of complicated wounds whose treatment responded successfully to negative pressure dressings using a vacuum-assisted closure system (VAC) (Kinetic Concepts Inc., San Antonio, TX). This system has been successfully used in the fields of orthopaedics and traumatology, general surgery, plastic and reconstructive surgery and gynaecology/obstetrics for a large variety of complicated wounds located in several regions, particularly in the torso and extremities. To the best of our knowledge, the use of the VAC therapy in treating free flaps surgical wounds has not been discussed in the literature. Since 2009 at the Novara Major Hospital, we have been using the VAC therapy in selected cases for difficult and complicated wounds of the maxillofacial region. The purpose of this study is to describe and discuss three cases undergoing VAC therapy followed by loco-regional flaps in the management of exposed bone after fibular free flap. The advantages and disadvantages of VAC therapy in treating complicated wounds have been reported by several studies; compared with conventional wet-to-dry dressings, this system eliminates interstitial oedema, exudates and debrides while increasing blood perfusion leading to a more rapid promotion of wound healing with less bacterial loading. Although surgical debridement, wet-to-dry dressing changes and antibiotic treatment are the mainstay in managing maxillofacial wounds, VAC therapy can be used to obtain primary closure or to prepare the wound bed until definitive reconstruction is carried out. In our opinion, the VAC technique is an innovative therapy, and at our institution represents the standard of care for the majority of complicated wounds.

Basic and Advanced Operative Techniques in Orthognathic Surgery

Preeclampsia is characterized by an exaggerated systemic inflammatory state as well as shallow placentation. In the decidual implantation site, preeclampsia is accompanied by an excessive number of both macrophages and dendritic cells as well as their recruiting chemokines, which have been implicated in the impairment of endovascular trophoblast invasion. Granulocyte-macrophage colony-stimulating factor is known to regulate the differentiation of both macrophages and dendritic cells, prompting both in vivo and in vitro evaluation of granulocyte-macrophage colony-stimulating factor expression in human decidua as well as in a mouse model of preeclampsia. This study revealed increased granulocyte-macrophage colony-stimulating factor expression levels in preeclamptic decidua. Moreover, both tumor necrosis factor-alpha and interleukin-1 beta, cytokines that are implicated in the genesis of preeclampsia, markedly up-regulated granulocyte-macrophage colony-stimulating factor production in cultured first-trimester human decidual cells. The conditioned media of these cultures promoted the differentiation of both macrophages and dendritic cells from a monocyte precursor. Evaluation of a murine model of preeclampsia revealed that the decidua of affected animals displayed higher levels of immunoreactive granulocyte-macrophage colony-stimulating factor as well as increased numbers of both macrophages and dendritic cells when compared to control animals. Because granulocyte-macrophage colony-stimulating factor is a potent inducer of differentiation and activation of both macrophages and dendritic cells, these findings suggest that this factor plays a crucial role in the pathogenesis of preeclampsia. (Am J Pathol 2010, 177:2472-2482; DOI: 10.2353/ajpath.2010.091247)

Chorioamnionitis is associated with intense neutrophil infiltration of the decidua. We therefore determined whether chorioamnionitis enhances decidual interleukin-8 (IL-8) expression and examined cytokine-regulated decidual IL-8 expression. Decidua from chorioamnionitis-complicated pregnancies, but not term controls, displayed marked IL-8 immunohistochemical staining and a dense neutrophil infiltrate. Reverse transcriptase-polymerase chain reaction of microdissected decidual cells identified IL-8 mRNA, confirming decidual synthesis of IL-8. Confluent leukocyte-free term decidual cells were primed with 10(-8) mol/L estradiol (E2) or E2 + 10(-7) mol/L medroxyprogesterone acetate to mimic the steroidal milieu of pregnancy. Compared with cultures maintained in E2 alone, E2 + medroxyprogesterone acetate neither significantly affected IL-8 levels nor altered the response to the cytokines. The addition of 1.0 ng/ml tumor necrosis factor-alpha (TNF-alpha) or interleukin-1 beta (IL-1beta) increased IL-8 secretion levels by 236.6 +/- 51.4- and 1062.6 +/- 254.3-fold, respectively (n = 8, mean +/- SEM, P0.05), as measured by enzyme-linked immunosorbent assay. Concentration-response studies revealed that 0.01 ng/ml TNF-alpha and IL-1beta elevated IL-8 output by 10- and 100-fold, respectively. Western blotting confirmed these results, and quantitative reverse transcriptase-polymerase chain reaction demonstrated parallel changes in mRNA levels. In conclusion, IL-8 is strongly expressed in term decidua during chorioamnionitis, and TNF-alpha and IL-1beta enhance IL-8 expression in term decidual cells, suggesting that these cytokines are important regulators of chorioamnionitis-related decidual neutrophil infiltration.

Macrophage migration inhibitory factor (MIF) was originally identified for its capacity to inhibit the random migration of macrophages in vitro. To date, the role of MIF as a pro-inflammatory cytokine, pituitary hormone, and counter-regulator of glucocorticoid action on the immune response is commonly recognized. Although recent studies suggest an involvement of MIF in reproduction, no data exist on the expression of this cytokine in early human pregnancy. In this study, we evaluated the presence of MIF protein and mRNA in specimens of chorionic villi from first-trimester human placenta. Tissues were obtained at 6-10 wk of gestation and analyzed by Western blotting, reverse transcription-polymerase chain reaction, and immunohistochemistry. Our results demonstrate that human villous tissue is a novel site of MIF synthesis. In addition, immunohistochemical analysis identified MIF protein in the cytotrophoblasts of both the inner layer of villi and in the trophoblastic cell islands. We speculate that in view of its proinflammatory features, MIF might play a critical role in human implantation and in early embryonic development.