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Background and Objectives: In adults, 150 to 300 min a week of moderate-intensity physical activity is the recommended daily level to maintain or improve fitness. In subjects with chronic obstructive pulmonary disease (COPD), reductions in daily physical activity (DPA) amounts are related to clinically significant outcomes. In this study, we ascertain whether or not COPD patients, when clustered into active (DPA ≥ 30 min a day, 5 days a week) and inactive (DPA < 30 min a day, 5 days a week), may differ in exercise capacity, as assessed by a cardiopulmonary exercise test (CPET). Materials and Methods: A large sample of clinically stable COPD patients was retrospectively recruited and then underwent spirometry and an incremental ramp protocol 5–15 watts/min CPET. DPA was assessed by a questionnaire. Results: A total of 83 (female 25%, age range 41–85 y) active and 131 (female 31%, age range 49–83 y) inactive participants were enrolled. They were similar in age, sex distribution, body mass index (BMI) and in spirometry. The two groups were significantly different in dyspnea on exertion, as assessed by the modified Medical Research Council (mMRC), and in cardio-metabolic parameters, but not in ventilatory ones, as confirmed by the CPET. Conclusions: COPD patients experiencing physical activity of at least 30 min a day, 5 days a week, showed a greater exercise capacity and an improved cardiovascular response to exercise, when compared to inactive ones. Active and inactive participants did not differ in terms of airflow obstruction severity as well as in dynamic hyperinflation and ventilatory inefficiency during exercise. This study further suggests the benefits of regular physical activity in COPD.

The prevalence of scoliosis in people with cystic fibrosis (CF) seems to be greater than in the normal population. Over the last two years, a screening for spinal deformities was carried out in patients with CF aged 5 to 18 years, followed up at the CF regional Centre in Parma (Italy). Forty-three patients (twenty-seven males, mean age: 11.8 ± 4.5 years) were enrolled in the study. Nine patients (20.9%) were diagnosed with scoliosis, with a mean Cobb angle of 20.8 ± 9.4 (12–38°). Five patients (11.6%) were diagnosed with a postural kyphosis attitude and one with pathological fixed kyphosis. All patients with scoliosis and postural kyphosis started daily physiotherapeutic scoliosis-specific exercises (PSSE). Compared to people without CF, the prevalence of scoliosis in our paediatric CF population seems to be higher and more present in males; the curves were thoracic and mostly right-sided. CF disease, hyposthenic postural attitude and sedentary lifestyle can contribute to the pathogenesis of this musculoskeletal alteration. Spinal deformities may negatively affect pulmonary function, resulting in disability, pain and a decreased quality of life. Since the prevention of musculoskeletal deformities is easier than restoration, in CF population targeted screening during growth and interventions, including regular physical exercise, are mandatory.

Roberta Pisi,1 Marina Aiello,1 Annalisa Frizzelli,1 Luigino Calzetta,1 Laura Marchi,1 Giuseppina Bertorelli,1 Giovanna Pisi,2 Alfredo Chetta1 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy; 2Department of Pediatrics, Cystic Fibrosis Center, University Hospital, Parma, ItalyCorrespondence: Luigino CalzettaDepartment of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Viale A. Gramsci, 14, Parma, 43126, ItalyEmail luigino.calzetta@unipr.itPurpose: Smoking-induced bronchiolitis with progressive small airway dysfunction (SAD) is a leading cause of chronic obstructive pulmonary disease. We investigated the value of using the impulse oscillometry system (IOS) to detect SAD in asymptomatic smokers with preserved spirometry.Patients and Methods: We included 75 asymptomatic smokers (37 females, mean age 47± 12 years, 26± 17 pack/year) with preserved spirometry [forced expiratory volume at 1st second (FEV1)/forced vital capacity (FVC) ≥ 0.70 and normal FVC] and 34 never-smokers (19 females, mean age 42± 15 years).Results: In smokers, pack/years were significantly related to spirometry and IOS parameters (p < 0.05). The values of the fall in resistance from 5 Hz to 20 Hz (R5 – R20) were significantly and inversely related to the values of the ratio of forced expiratory volume in 3 and in 6 seconds (FEV3/FEV6) (p < 0.05). In addition, the percentage of heavy smokers (≥ 30 pack/year) with R5 – R20 > 0.07 kPa·s·L− 1, considered as IOS index of SAD, but not with FEV3/FEV6 less than a lower limit of normal, a spirometry index of SAD, was significantly higher than that of mild smokers (< 30 pack/year) and never-smokers (p < 0.05).Conclusion: This study demonstrates that IOS has the potential to detect SAD in asymptomatic heavy smokers with preserved spirometry and with FEV3/FEV6 values in the normal range. We confirm that IOS provides parameters which can complement traditional measurements of pulmonary function.Keywords: small airway dysfunction, impulse oscillometry system, spirometry, smokers, COPD

In recent years, advances in diagnosis and treatment have significantly modified the short- and long-term prognosis of cystic fibrosis (CF) patients. However, as in the past, the most important health problem that has significantly reduced the quality of life in CF patients is the progressive deterioration of lung structure and function. In recent years, Achromobacter species have emerged with increasing incidence in the respiratory secretions of CF subjects. The significance of this detection remains debated. In this review article, the characteristics of these pathogens, the importance of their presence in CF patients, and possible antibiotic treatment of treatments for colonization and infection are discussed. Literature analysis shows that Achromobacter species, mainly A. xylosoxidans, are pathogens with intrinsic characteristics that favour persistent lung colonization and several virulence factors and secretion systems that significantly interfere with respiratory cell survival. However, although it seems undebatable that Achromobacterspecies detection is a marker of CF severity, the role of these pathogens as a cause of lung structure and functional deterioration is not definitively established. Nonetheless, there is general agreement about the need for antibiotic therapy to eradicate these pathogens when they are detected in CF patients. Unfortunately, eradication is difficult, and no standard treatment is recommended by scientific societies. New possibilities are potentially offered by some recently developed drugs, such as cefiderocol, but further studies on the dosage, treatment duration and efficacy and safety of this new antibiotic in CF patients of different ages are urgently needed.

The clinical aspects of SARS-CoV-2 infection, as well as the COVID-19 vaccines’ safety, efficacy and effectiveness in pediatric patients with asthma, are crucial to adapting clinical management in this fragile population and for prevention strategies. The aim of this narrative review was to evaluate the impact of SARS-CoV-2 infection in children with asthma and the impact of COVID-19 vaccination. Systematic research using the principal medical databases was conducted using specific search query strings from the early spreading of COVID-19 globally until March 2023; further relevant data were drawn from the main national and supranational institutions. No significant differences in SARS-CoV-2 incidence and morbidity were found in asthmatic pediatric patients compared to non-asthmatic ones; however, subjects with uncontrolled asthma were found to be at increased risk of developing a serious disease during SARS-CoV-2 infection. Regarding COVID-19 vaccines, accumulating data support their safety, efficacy and effectiveness on asthmatic children regardless of asthma severity. Further cohort-based studies are needed as the evidence of new epidemic waves caused by new viral variants makes the current knowledge outdated.

Banking digitalization is an effort to continue to innovate to provide various facilities and conveniences for customers when conducting financial transactions through their smartphones. The online deposit service is one of the financial product innovations that provide online account opening services, without requiring customers to be physically present. This research uses descriptive methods and literature studies to find various problems when the implementation of online deposit products is carried out. The findings of this research are (1) the number of supporting infrastructure facilities for banking digitalization is still relatively limited, (2) many banking terms are difficult for the public to understand, (3) the number of cybercrimes occurring as a result of the increasing number of users in this industry. In this research, the author provides solutions to overcome the problems that arise, (1) improving IT infrastructure, increasing security, (2) online operator facilities that explain directly, (3) updating security and operator knowledge on various new modes that are developing about crime on the internet. This activity will make people believe, comfortable, and willing to place their money in the bank, especially the placement of deposit funds online. This research contributes to the development of knowledge about banking digitalization efforts in Indonesia.

Patients with cystic fibrosis (CF) are prone to malnutrition and growth failure, mostly due to malabsorption caused by the derangement in the chloride transport across epithelial surfaces. Thus, optimal nutritional care and support should be an integral part of the management of the disease, with the aim of ameliorating clinical outcomes and life expectancy. In this report, we analyzed the nutrition support across the different ages, in patients with CF, with a focus on the relationships with growth, nutritional status, disease outcomes and the use of the CF transmembrane conductance regulator (CFTR) modulators. The nutrition support goal in CF care should begin as early as possible after diagnosis and include the achievement of an optimal nutritional status to support the growth stages and puberty development in children, that will further support the maintenance of an optimal nutritional status in adult life. The cornerstone of nutrition in patients with CF is a high calorie, high-fat diet, in conjunction with a better control of malabsorption due to pancreatic enzyme replacement therapy, and attention to the adequate supplementation of fat-soluble vitamins. When the oral caloric intake is not enough for reaching the anthropometric nutritional goals, supplemental enteral feeding should be initiated to improve growth and the nutritional status. In the last decade, the therapeutic possibilities towards CF have grown in a consistent way. The positive effects of CFTR modulators on nutritional status mainly consist in the improvement in weight gain and BMI, both in children and adults, and in an amelioration in terms of the pulmonary function and reduction of exacerbations. Several challenges need to be overcome with the development of new drugs, to transform CF from a fatal disease to a treatable chronic disease with specialized multidisciplinary care.

Aim of the study: to evaluate root filling remnants after secondary root canal treatments (SRCTs) of oval-shaped canals with X-rays and cone beam computed tomography (CBCT). The SRCTs were performed using reciprocating NiTi instruments. Methods: Single-rooted teeth (N = 64) were randomly treated with Reciproc Blue (RB) and filled with AH Plus/single cone (SC group) or AH Plus/Guttafusion (GF group). After seven days of storage in HBSS (Hanks balanced salt solution), Gates Glidden burs #2/3 and RB #25 and #40 were used for the SRCTs. The time to complete the procedure was measured. X-rays and CBCT were used to calculate, respectively, the area and the volume occupied by the remnants in the coronal, middle, and apical thirds of each canal. Environmental scanning electron microscopy (ESEM) and energy dispersive X-ray spectroscopy (EDX) were used for qualitative evaluation and morphology composition of the remnants in sectioned roots. A statistical analysis was performed using Sigma Plot (version 13, IBM, Armonk, NY, USA). The study was designed according to PRILE guidelines. Results: After the SRCTs, the middle thirds of the root canals showed the presence of remnants in both groups, as demonstrated by X-rays and CBCT. The GF group showed a statistically significant higher volume of remnants than the SC Group only in the middle third. The ESEM supported by the EDX revealed the remnant composition by the detection of trace elements of sealer and gutta-percha in all root canals. Conclusion: The study demonstrated that the middle third of root canals is a critical region where remnants were packed and spread in the buccal-lingual sides of canals. ESEM-EDX detected a fine layer of filling remnants in all root thirds, suggesting a larger canal contamination than the X-rays and CBCT examinations revealed.

Cystic fibrosis (CF), the most common genetically inherited disease in Caucasian populations, is a multi-systemic life-threatening autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. In 2012, the arrival of CFTR modulators (potentiators, correctors, amplifiers, stabilizers, and read-through agents) revolutionized the therapeutic approach to CF. In this review, we examined the physiopathological mechanism of chronic dysregulated innate immune response in the lungs of CF patients with pulmonary involvement with particular reference to phagocytes, critically analyzing the role of CFTR modulators in influencing and eventually restoring their function. Our literature review highlighted that the role of CFTR in the lungs is crucial not only for the epithelial function but also for host defense, with particular reference to phagocytes. In macrophages and neutrophils, the CFTR dysfunction compromises both the intricate process of phagocytosis and the mechanisms of initiation and control of inflammation which then reverberates on the epithelial environment already burdened by the chronic colonization of pathogens leading to irreversible tissue damage. In this context, investigating the impact of CFTR modulators on phagocytic functions is therefore crucial not only for explaining the underlying mechanisms of pleiotropic effects of these molecules but also to better understand the physiopathological basis of this disease, still partly unexplored, and to develop new complementary or alternative therapeutic approaches.

In patients with cystic fibrosis (CF), multidrug-resistant (MDR) bacteria can predispose to exacerbations, limit the effectiveness of antibiotic treatments and promote the progression of lung disease. The aim of this retrospective study was to compare pulmonary exacerbations (Pex), hospitalizations, lung function and nutritional status in a group of children and adolescents with CF colonized by MDR bacteria and in a noncolonized control group. Overall, 7/54 pediatric patients (12.9%) were colonized by MDR bacteria and enrolled (3 with Achromobacter xyloxidans, 3 with Stenotrophomonas maltophilia and 1 with Burkholderia cepacia). The control group included 14 sex- and age-matched CF patients (8/14 colonized by Staphylococcus aureus, 2/14 by Pseudomonas aeruginosa, 2/14 by both microorganisms and 2/14 germ free). At the time of enrollment and 12 months before the first detection of the MDR microorganism, children colonized by MDR bacteria showed lower body mass index (BMI) and lower FEV1/FVC compared to the control group. Over the previous year before the first detection, children colonized with MDR had more Pex compared to control group; those colonized by S. maltophilia experienced the highest number of Pex. In the 12 months following the first detection of MDR bacteria, all seven patients colonized by MDR had at least one Pex and patients colonized by S. maltophilia had the highest number (mean ± SD: 6 ± 2.6 vs. 1.7 ± 2.3). Our study suggests that CF pediatric patients infected by MDR bacteria have lower BMI, more obstructive disease and experience more exacerbations than patients without MDR bacteria. These differences are present even before being infected, suggesting that children and adolescents with more severe disease are predisposed to be colonized by MDR bacteria. S. maltophilia appeared to be the most aggressive pathogen. Further studies and the implementation of antimicrobial stewardship programs are necessary to clarify when and how to treat patients with CF and MDR bacteria in order to avoid the improper use of antibiotics and the development of antibiotic resistance.

Abstract Introduction In Cystic Fibrosis (CF), exercise ventilatory inefficiency and dynamic hyperinflation (DH) cause exercise limitation and induce poor exercise tolerance. High-resolution computed tomography (HRCT) of the lung can detect pulmonary abnormalities in CF patients. We aimed to identify the determinants of exercise ventilatory inefficiency and DH using HRCT-derived metrics. Methods Fifty-two adult CF patients were prospectively enrolled; all participants underwent cardio-pulmonary exercise test (CPET) and HRCT. Radiological impairment was evaluated by the Brody II scoring system. Slope and intercept of the minute ventilation/CO2 production (V’E/V’CO2) regression line and the ratio of inspiratory capacity/total lung capacity (IC/TLC) at rest and at peak of exercise were measured. Results Four groups of patients were identified based on the combination of ventilatory efficiency (Vef) or inefficiency (Vin) and the presence/absence of DH. Compared to other groups, CF adults with Vin and DH had worse functional status and higher total (T), bronchiectasis (B) and air trapping (AT) scores at HRCT. Significant correlations were found between V’E/V’CO2 intercept and V’E/V’CO2 slope (ρ − 0.455, p = 0.001) and between V’E/V’CO2 intercept and Δ inspiratory capacity (IC) (ρ − 0.334, p = 0.015). Regression analysis identified AT score (cut-off 7.9, odds ratio-OR 3.50) as the only independent predictor of Vin and T (cut-off 53.6, OR 4.98), B (cut-off 16.1, OR 4.88), airways wall thickening (AWT) (cut-off 13, OR 3.41), and mucous plugging (MP) scores (cut-off 11.7, OR 4.18) as significant predictors of DH. Conclusion In adult CF cohort, values of HRCT metrics are determinants of Vin (AT) and DH (T, B, AWT, MP).

In the last 20 years, gut microbiota in patients with cystic fibrosis (CF) has become an object of interest. It was shown that these patients had gut dysbiosis and this could explain not only the intestinal manifestations of the disease but also part of those involving the respiratory tract. The acquisition of previously unknown information about the importance of some bacteria, i.e., those partially or totally disappeared in the gut of CF patients, in the regulation of the activity and function of the gut and the lung was the base to suggest the use of probiotics in CF patients. The main aim of this paper is to discuss the biological basis for probiotic administration to CF patients and which results could be expected. Literature analysis showed that CF intestinal dysbiosis depends on the same genetic mutations that condition the clinical picture of the diseases and is aggravated by a series of therapeutic interventions, such as dietary modifications, the use of antibiotics, and the administration of antacids. All this translates into a significant worsening of the structure and function of organs, including the lung and intestine, already deeply penalized by the genetic alterations of CF. Probiotics can intervene on dysbiosis, reducing the negative effects derived from it. However, the available data cannot be considered sufficient to indicate that these bacteria are essential elements of CF therapy. Further studies that take into account the still unsolved aspects on how to use probiotics are absolutely necessary.

ObjectiveTo describe the symptoms and clinical course of SARS-CoV-2 infection in patients with cystic fibrosis (CF).MethodsWe carried out a prospective multicentre cohort study based on 32 CF centres and 6597 patients. Centres were contacted to collect baseline and follow-up data of patients who reported symptoms suggestive of COVID-19 or who had contact with a positive/suspected case between the end of February and July 2020. Symptoms and clinical course of the infection were compared between patients who tested positive by molecular testing (cases) and those who tested negative (controls).ResultsThirty patients were reported from the centres, 16 of them tested positive and 14 tested negative. No differences in symptoms and outcome of the disease were observed between groups. Fever, cough, asthenia and dyspnea were the most frequently reported symptoms. Eight cases (50%) were hospitalized but none required ICU admission. Two adults with a history of lung transplant required non-invasive ventilation, none required ICU admission and all patients fully recovered without short-term sequelae.ConclusionsThe course of SARS-CoV-2 in our patients was relatively favorable. However, COVID-19 should not be considered a mild disease in CF patients, particularly for those with severely impaired respiratory function and organ transplant.

Background. The clinical relevance of Aspergillus fumigatus (Af) in cystic fibrosis (CF) is controversial. The aims of the study were to assess the prevalence of Af disease in our cohort of CF patients and evaluate whether allergic bronchopulmonary aspergillosis (ABPA) and sensitization to Af affected lung function, body mass index (BMI) and exacerbations. Methods. Clinical data and lung function of CF patients aged 6–18 years followed at the CF Centre of Parma (Italy) were recorded. Patients were classified as: patients with no signs of Af, patients sensitized or colonized by Af, patients with ABPA or patients with Aspergillus bronchitis (Ab). Results. Of 38 CF patients (14.2 years (6.2–18.8) M 23), 8 (21%) showed Af sensitization, 7 (18.4%) showed ABPA, 1 (2.6%) showed Af colonization and 1 (2.6%) showed Ab. Compared to non-ABPA, patients with ABPA had lower BMI (15.9 ± 1.6 vs. 19.7 ± 3.4, p < 0.005), lower lung function (FEV1 61.5 ± 25.9% vs. 92.3 ± 19.3%, p < 0.001) and more exacerbations/year (4.43 ± 2.44 vs. 1.74 ± 2.33, p < 0.005). Patients with Af sensitization showed more exacerbations/year than non-Af patients (3.5 ± 3.2 vs. 0.9 ± 1.2, p < 0.005). ABPA and sensitized patients had more abnormalities on chest CT scans. Conclusion. This study showed the relevant clinical impact of ABPA and Af sensitization in terms of exacerbations and lung structural damage.

Cystic fibrosis (CF) is an autosomal recessive disorder, caused by genetic mutations in CF transmembrane conductance regulator protein. Several reports have indicated the presence of specific fatty acid alterations in CF patients, most notably decreased levels of plasmatic and tissue docosahexaenoic acid (DHA), the precursor of specialized pro-resolving mediators. We hypothesized that DHA supplementation could restore the production of DHA-derived products and possibly contribute to a better control of the chronic pulmonary inflammation observed in CF subjects. Sputum samples from 15 CF and 10 chronic obstructive pulmonary disease (COPD) subjects were collected and analyzed by LC/MS/MS, and blood fatty acid were profiled by gas chromatography upon lipid extraction and transmethylation. Interestingly, CF subjects showed increased concentrations of leukotriene B4 (LTB4), prostaglandin E2 (PGE2), and 15-hydroxyeicosatetraenoic acid (15-HETE), when compared with COPD patients, whereas the concentrations of DHA metabolites did not differ between the two groups. After DHA supplementation, not only DHA/arachidonic acid (AA) ratio and highly unsaturated fatty acid index were significantly increased in the subjects completing the study (p < 0.05) but also a reduction in LTB4 and 15-HETE was observed, together with a tendency for a decrease in PGE2, and an increase in 17-hydroxy-docosahexaenoic acid (17OH-DHA) levels. At the end of the washout period, LTB4, PGE2, 15-HETE, and 17OH-DHA showed a trend to return to baseline values. In addition, 15-HETE/17OH-DHA ratio in the same sample significantly decreased after DHA supplementation (p < 0.01) when compared with baseline. In conclusion, our results show here that in CF patients, an impairment in fatty acid metabolism, characterized by increased AA-derived metabolites and decreased DHA-derived metabolites, could be partially corrected by DHA supplementation.

The current work deals with multi-objective optimisations including financial merit factors in the multi-disciplinary conceptual design of a commercial aircraft with a specific focus on noise social cost. The results of optimisations using financial and performance-oriented objective functions have been analysed and combined in a multi-objective optimisation problem using a three-dimensional objective vector. The main novelty of the present work is the analysis of social cost noise fees effectiveness integrated in financial models embracing a wider group of stakeholders’ interests. The foundations of this research lie on the air traffic increase envisaged in the next decades and the contextual growth of the urban areas nearby airport facilities. This scenario requires the aeronautical industry to handle the environment challenge taking into account all the social and economic effects. Indeed, the consolidated technology has approached a saturation point, therefore breakthrough concepts and configurations are mandatory. This matter is addressed as a highly multi-disciplinary problem within conceptual design framework. The financial model proposed is shown to highlight the need of appropriate noise fees as instruments to push all stakeholders towards a technology radical renewal and encourage the aeronautical industry towards a shared strategy in the development of an eco-friendly commercial aviation system.

Cystic fibrosis (CF) is the most common life-limiting inherited disease in Caucasian populations, affecting approximately 80,000 people worldwide. CF is a complex multi-organ monogenic autosomal recessive disorder caused by a mutation in cystic fibrosis transmembrane conductance regulator (CFTR) gene. Since the discovery of the CFTR gene in 1989, more than 2000 mutations have been identified so far and about 240 can cause CF. Until recently, the treatment for CF was aimed to prevent and manage the manifestations of CFTR dysfunction, primarily recurrent pulmonary infections and pancreatic exocrine failure. Over the past few decades, the therapeutic approach to CF has been revolutionized by the development of a new class of small molecules called CFTR modulators that target specific defects caused by mutations in the CFTR gene. CFTR modulators have been shown to change profoundly the clinical course of the CF, leading to meaningful improvements in the lives of a large proportion of people of CF heterozygous for F508del, especially if started in young children. Further studies are needed to extend the use of triple CFTR modulation therapy also for young children in order to prevent the irreversible effects of the disease and for patients with very rare mutations with a personalized approach to treatment.

The present work deals with a multi-objective optimisation approach to incorporate up-to-date financial models in the multidisciplinary conceptual design of a commercial aircraft. Design optimisations based on financial objective functions are compared to standard performance-based optimal solutions. The main novelty is in the extension of the financial models to the long-term investments of a wider group of stakeholders. The rationale underlying this research stems from two considerations: (i) the environmentally sustainable development of the air transportation system in the next 20 years is subordinate to breakthrough technologies, since the consolidated ones have reached their saturation point; (ii) the economic impacts of highly innovative concepts on the stakeholders chain is still uncertain. The problem is addressed at the conceptual design level and the analysis is performed within a comprehensive multidisciplinary framework, adopting all the technical constraints required in aeronautical design. The Pareto fronts obtained using performance and financial merit factors, reveal that the proposed financial model yields highly efficient, technically sound concepts. The design space point corresponding to the negative cash flows minimum turned out to be very close to the one corresponding to minimum acoustic emissions, confirming that the financial model drives the optimiser towards environment-friendly designs.

Children infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can suffer from severe coronavirus disease 2019 (COVID-19). However, compared to adults and the elderly, susceptibility to SARS-CoV-2 infection in children seems to be lower; when infection does develop, most infected children remain asymptomatic or develop a mild disease. Understanding why children seem generally protected from severe COVID-19 and only rarely develop clinical conditions that can cause hospitalization, admission to the pediatric intensive care unit and death can be important. More details on the mechanism of action of SARS-CoV-2 could be defined. Moreover, the role played by children in virus diffusion should be better analyzed, and the development of effective preventive and therapeutic measures against COVID-19 could be favored. The main aim of this paper is to discuss the present knowledge on immunological and molecular mechanisms that could explain differences in COVID-19 clinical manifestations between children and adults. Literature analysis showed that although most children are clearly protected from the development of severe COVID-19, the reasons for this peculiarity are not fully understood. Developmental variations in immune system function together with the potential role of repeated antigen stimulation in the first periods of life on innate immunity are widely studied. As the few children who develop the most severe form of pediatric COVID-19 have certain alterations in the immune system response to SARS-CoV-2 infection, studies about the relationships between SARS-CoV-2 and the immune system of the host are essential to understand the reasons for the age-related differences in the severity of COVID-19.

Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from ‘1’ (extremely inappropriate) to ‘9’ (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.

Bronchiolitis (BR), a lower respiratory tract infection mainly caused by respiratory syncytial virus (RSV), can be very severe. Presently, adequate nutritional support and oxygen therapy remain the only interventions recommended to treat patients with BR. For years, mild BR cases were treated with noninvasive standard oxygen therapy (SOT), i.e., with cold and poorly or totally non-humidified oxygen delivered by an ambient headbox or low-flow nasal cannula. Children with severe disease were intubated and treated with invasive mechanical ventilation (IMV). To improve SOT and overcome the disadvantages of IMV, new measures of noninvasive and more efficient oxygen administration have been studied. Bi-level positive air way pressure (BiPAP), continuous positive airway pressure (CPAP), and high-flow nasal cannula (HFNC) are among them. For its simplicity, good tolerability and safety, and the good results reported in clinical studies, HFNC has become increasingly popular and is now widely used. However, consistent guidelines for initiation and discontinuation of HFNC are lacking. In this narrative review, the role of HFNC to treat infants with BR is discussed. An analysis of the literature showed that, despite its widespread use, the role of HFNC in preventing respiratory failure in children with BR is not precisely defined. It is not established whether it can offer greater benefits compared to SOT and when and in which infants it can replace CPAP or BiPAP. The analysis of the results clearly indicates the need for multicenter studies and official guidelines. In the meantime, HFNC can be considered a safe and effective method to treat children with mild to moderate BR who do not respond to SOT.

Respiratory viral infections represent the leading cause of hospitalization in infants and young children worldwide and the second leading cause of infant mortality. Among these, Respiratory Syncytial Virus (RSV) represents the main cause of lower respiratory tract infections (LRTIs) in young children worldwide. RSV manifestation can range widely from mild upper respiratory infections to severe respiratory infections, mainly bronchiolitis and pneumonia, leading to hospitalization, serious complications (such as respiratory failure), and relevant sequalae in childhood and adulthood (wheezing, asthma, and hyperreactive airways). There are no specific clinical signs or symptoms that can distinguish RSV infection from other respiratory pathogens. New multiplex platforms offer the possibility to simultaneously identify different pathogens, including RSV, with an accuracy similar to that of single polymerase chain reaction (PCR) in the majority of cases. At present, the treatment of RSV infection relies on supportive therapy, mainly consisting of oxygen and hydration. Palivizumab is the only prophylactic method available for RSV infection. Advances in technology and scientific knowledge have led to the creation of different kinds of vaccines and drugs to treat RSV infection. Despite the good level of these studies, there are currently few registered strategies to prevent or treat RSV due to difficulties related to the unpredictable nature of the disease and to the specific target population.

In June 2013, widespread flooding and consequent damage and losses occurred in Central Europe, especially in Germany. This paper explores what data are available to investigate the adverse impacts of the event, what kind of information can be retrieved from these data and how well data and information fulfil requirements that were recently proposed for disaster reporting on the European and international levels. In accordance with the European Floods Directive (2007/60/EC), impacts on human health, economic activities (and assets), cultural heritage and the environment are described on the national and sub-national scale. Information from governmental reports is complemented by communications on traffic disruptions and surveys of flood-affected residents and companies. Overall, the impacts of the flood event in 2013 were manifold. The study reveals that flood-affected residents suffered from a large range of impacts, among which mental health and supply problems were perceived more seriously than financial losses. The most frequent damage type among affected companies was business interruption. This demonstrates that the current scientific focus on direct (financial) damage is insufficient to describe the overall impacts and severity of flood events. The case further demonstrates that procedures and standards for impact data collection in Germany are widely missing. Present impact data in Germany are fragmentary, heterogeneous, incomplete and difficult to access. In order to fulfil, for example, the monitoring and reporting requirements of the Sendai Framework for Disaster Risk Reduction 2015–2030 that was adopted in March 2015 in Sendai, Japan, more efforts on impact data collection are needed.

(Series Information) European Papers - A Journal on Law and Integration, 2016 1(1), 245-261 | European Forum Insight of 16 April 2016 | (Table of Contents) I. Introduzione. - II. La giurisprudenza della Corte in materia d'autonomia procedurale e le spese di giudizio come ostacolo ad una tutela giurisdizionale effettiva. - III. La questione pregiudiziale. - IV. Le conclusioni dell'Avvocato generale. - V. La pronuncia della Corte di giustizia nel caso Orizzonte Salute. - VI. Osservazioni conclusive. | (Abstract) This Insight focuses on the recent judgment of the Court of Justice in Orizzonte Salute (case C-61/14). The Court was asked to clarify whether EU Law - more particularly Art. 1 of Directive 89/665/EEC of the Council on the coordination of the laws, regulations and administrative provisions relating to the application of review procedures to the award of public supply, and public works contract, the principles of effectiveness and equivalence and Art. 47 of the Charter - precludes a national legislation which requires the payment of high amounts as the standard court fee to access judicial review proceedings relating to the award of public supply and public works contracts subject to Directive 2004/18/EC of the European Parliament and of the Council on the coordination of procedures for the award of public works contracts, public supply contracts and public service contracts. In the same case, the Court was also requested to clarify whether European Union (EU) Law precludes a national legislation which charges multiple court fees to an individual who brings several court actions concerning the same award or who raises supplementary pleas concerning the same award within ongoing judicial proceedings. The Insight starts with a brief summary of the case law of the EU Court of Justice and the European Court of Human Rights regarding, respectively, the principle of procedural autonomy of the Member States and the fundamental right to access to justice, the latter examined in its relationship with the imposition of court fees. Then, it proceeds to review the arguments of the referring Court, the opinion of the Advocate General and the judgment of the EU Court of Justice. The last part of this Insight criticises the choice of the Court to favour - in the interpretation of Directive 89/665 - the procedural autonomy of EU member States over the pursuit of a better level of coordination between national procedural rules, even in a field so deeply harmonised like the one of public procurements.

Cystic fibrosis (CF), the most common autosomal-recessive genetic disease in the Caucasian population, is characterized by frequent respiratory infections and progressive lung disease. Fungal species are commonly found in patients with CF, and among them, Aspergillus fumigatus is the most frequently isolated. While bacteria, particularly Pseudomonas aeruginosa, have a well-established negative effect on CF lung disease, the impact of fungal infections remains unclear. In patients with CF, inhalation of Aspergillus conidia can cause allergic bronchopulmonary aspergillosis (ABPA), a Th2-mediated lung disease that can contribute to disease progression. Clinical features, diagnostic criteria and treatment of ABPA are still a matter of debate. Given the consequences of a late ABPA diagnosis or the risk of ABPA overdiagnosis, it is imperative that the diagnostic criteria guidelines are reviewed and standardized. Along with traditional criteria, radiological features are emerging as tools for further classification as well as novel immunological tests. Corticosteroids, itraconazole and voriconazole continue to be the bedrock of ABPA therapy, but other molecules, such as posaconazole, vitamin D, recombinant INF-γ and Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators, have been showing positive results. However, few studies have been conducted recruiting CF patients, and more research is needed to improve the prevention and the classification of clinical manifestations as well as to personalize treatment. Early recognition and early treatment of fungal infections may be fundamental to prevent progression of CF disease. The aim of this narrative review is to give an update on ABPA in children with CF.

Zygomatic implant rehabilitation is a challenging procedure that requires an accurate prosthetic and implant plan. The aim of this study was to evaluate the malar bone available for three-dimensional zygomatic implant placement on the possible trajectories exhibiting optimal occlusal emergence. After a preliminary analysis on 30 computed tomography (CT) scans of dentate patients to identify the ideal implant emergencies, we used 80 CT scans of edentulous patients to create two sagittal planes representing the possible trajectories of the anterior and posterior zygomatic implants. These planes were rotated clockwise on the ideal emergence points and three different hypothetical implant trajectories per zygoma were drawn for each slice. Then, the engageable malar bone and intra- and extra-sinus paths were measured. It was possible to identify the ideal implant emergences via anatomical landmarks with a high predictability. Significant differences were evident between males and females, between implants featuring anterior and those featuring posterior emergences, and between the different trajectories. The use of internal trajectories provided better bone engagement but required a higher intra-sinus path. A significant association was found between higher intra-sinus paths and lower crestal bone heights.

Fusarium crown rot (FCR), an important disease of wheat and barley, is mainly caused by Fusarium graminearum, F. culmorum and F. pseudograminearum, which are also responsible for mycotoxin production. This is the first comparative investigation of their colonization on barley plants after stem base inoculation. At plant maturity, FCR symptoms were visually evaluated, fungal biomass was quantified by Real-Time quantitative PCR and deoxynivalenol (DON) was detected by enzyme-linked immunosorbent assay (ELISA). All the inoculated strains caused the typical FCR necrotic symptoms. Real-Time PCR analysis showed that F. graminearum and F. culmorum were present in the head tissues, while F. pseudograminearum colonized only up to the area including the second node of the stem. Conversely, DON was detected up to the head for all the three species. This study shows that, as already demonstrated in previous research for wheat, DON may be detected up to the head as a consequence of stem base infection by the three FCR agents

Our objective was to evaluate the efficacy of a standardised work-up in the diagnosis of pleural tuberculosis (TB) that included fibreoptic bronchoscopy and medical thoracoscopy. A consecutive series of 52 pleural TB patients observed during the period 2001–2015 was evaluated retrospectively. 20 females, mean (range) age 39.7 (18–74) years, and 32 males, mean (range) age 45.75 (21–83) years, were included (28 non-EU citizens (53.8%)). The diagnosis of TB infections was established by identification (using stains, culture or molecular tests) of Mycobacterium tuberculosis in the pleura, sputum and/or bronchial specimens, or by evidence of caseous granulomas on pleural biopsies. Patients with and without lung lesions were considered separately. The diagnostic yield of the microbiological tests on pleural fluid was 17.3% (nine out of 52 patients). Among the 18 patients with lung lesions, bronchial samples (washing, lavage or biopsy) were positive in 50% of cases (nine patients). Cultures of pleural biopsies were positive in 63% of cases (29 out of 46 patients); pleural histology was relevant in all patients. Without pleural biopsy, a diagnosis would have been reached in 15 out of 52 patients (28.6%) and in four of them only following culture at 30–40 days. An integrated diagnostic work-up that includes all the diagnostic methods of interventional pulmonology is required for a diagnosis of pleural TB. In the majority of patients, a diagnosis can be reached only with pleural biopsy.

Upper limb recovery is one of the main goals of post-stroke rehabilitation due to its importance for autonomy in Activities of Daily Living (ADL). Although the efficacy of upper limb Robot-assisted Therapy (RT) is well established in literature, the impact of the initial status of the patient on the effects of RT is still understudied. This paper aims to identify whether demographic, clinical and motor characteristics of stroke patients may influence the ability to independently perform ADL after RT.A retrospective study was conducted on sixty stroke patients who conducted planar upper limb goal-directed tasks with the InMotion 2.0 robot. The RT was administered 5 days/week for 4 weeks and each session lasted 45 minutes. The primary outcome measure was the Modified Barthel Index (BI), dichotomized into favourable (BI ≥75) and unfavourable (BI

Roberta Pisi,1 Marina Aiello,1 Andrea Zanini,2 Panagiota Tzani,1 Davide Paleari,3 Emilio Marangio,1 Antonio Spanevello,2,4 Gabriele Nicolini,5 Alfredo Chetta1 1Department of Clinical and Experimental Medicine, University of Parma, Parma, 2Division of Pneumology, IRCCS Rehabilitation Institute of Tradate, Salvatore Maugeri Foundation, Tradate, 3Medical Department, Chiesi Farmaceutici SpA, Parma, 4Department of Clinical and Experimental Medicine, University of Insubria, Varese, 5Corporate Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy Background: We investigated whether a relationship between small airways dysfunction and bronchodilator responsiveness exists in patients with chronic obstructive pulmonary disease (COPD).Methods: We studied 100 (20 female; mean age: 68±10 years) patients with COPD (forced expiratory volume in 1 second [FEV1]: 55% pred ±21%; FEV1/forced vital capacity [FVC]: 53%±10%) by impulse oscillometry system. Resistance at 5 Hz and 20 Hz (R5 and R20, in kPa·s·L-1) and the fall in resistance from 5 Hz to 20 Hz (R5 – R20) were used as indices of total, proximal, and peripheral airway resistance; reactance at 5 Hz (X5, in kPa·s·L-1) was also measured. Significant response to bronchodilator (salbutamol 400 µg) was expressed as absolute (≥0.2 L) and percentage (≥12%) change relative to the prebronchodilator value of FEV1 (flow responders, FRs) and FVC (volume responders, VRs).Results: Eighty out of 100 participants had R5 – R20 >0.03 kPa·s·L-1 (> upper normal limit) and, compared to patients with R5 – R20 ≤0.030 kPa·s·L-1, showed a poorer health status, lower values of FEV1, FVC, FEV1/FVC, and X5, along with higher values of residual volume/total lung capacity and R5 (P

INTRODUCTION: Urinary tract infections (UTI) among transplant recipients are usually caused by gram-negative microorganisms and can provoke a high incidence of morbidity and mortality. The aim of this study was to evaluate the risk factors associated with the acquisition of UTIs during the first year after renal transplantation. METHODS: Here, we report a single-center retrospective cohort study of 99 renal transplant patients followed for the first year after surgery. The definition of a UTI episode was a urine culture showing bacterial growth and leucocyturia when patients presented with urinary symptoms. The absence of infection (asymptomatic bacteriuria) was defined as an absence of symptoms with negative urine culture or bacterial growth with any number of colonies. RESULTS: Ninety-nine patients were included in the study. During the study, 1,847 urine cultures were collected, and 320 (17.3%) tested positive for bacterial growth. Twenty-six (26.2%) patients developed a UTI. The most frequent microorganisms isolated from patients with UTIs were Klebsiella pneumoniae (36%), with 33% of the strains resistant to carbapenems, followed by Escherichia coli (20%). There were no deaths or graft losses associated with UTI episodes. CONCLUSIONS: Among the UTI risk factors studied, the only one that was associated with a higher incidence of infection was female sex. Moreover, the identification of drug-resistant strains is worrisome, as these infections have become widespread globally and represent a challenge in the control and management of infections, especially in solid organ transplantation.

The growing interest towards essential oils stems from their biological capabilities that include antibacterial and antioxidant effects. Such properties may be extremely useful in the reproductive field; nonetheless essential oils show toxic effects that can lead to cell disruption. The present study aimed to evaluate and compare the effects of tea tree oil (TTO) and its principal component terpinen-4-ol (TER) on the morpho-functional parameters of swine spermatozoa. Experimental samples were prepared by suspending 15 × 107 spermatozoa in 5 mL of medium with different concentrations of the above-mentioned compounds: from 0.2 to 2 mg/mL at an interval of 0.2 for TTO, while TER concentrations were adjusted according to its presence in TTO (41.5%). After 3 h incubation at 16 °C, samples were analyzed for pH, viability, acrosome status, and objective motility. The results highlighted a concentration-dependent effect of TTO with total motility as the most sensitive parameter. TER was better tolerated, and the most sensitive parameters were related to membrane integrity, suggesting a different pattern of interaction. The study confirms the importance of evaluating the effects of natural compounds on spermatozoa before exploiting their beneficial effects. Spermatozoa seem to be good candidates for preliminary toxicological screenings in the light of their peculiar properties.

Wheat is one of the main crops in Mediterranean countries, and its cultivation has an important role in the Syrian economy. In Syria, Fusarium head blight (FHB) has not been reported so far. Mycological analysis of 48 samples of wheat kernels collected from cultivation areas with different climatic conditions were performed in 2009 and 2010. Fungal isolates were identified at the genus level morphologically; Fusarium species were characterized morphologically and by species-specific PCR. The most frequent fungal genera found were Alternaria spp. and Cladosporium spp., with frequencies of 24.7% and 8.1%, respectively, while the frequency of Fusarium spp. was 1.5% of kernels. Most frequent Fusarium species were F. tricinctum (30% of all Fusarium isolates), F. culmorum (18%), F. equiseti (14%) and F. graminearum (13%). The mycotoxin production potential of selected Fusarium isolates was assessed by HPLC-MS analysis of rice cultures; chemotyping by PCR was carried out for comparison. All six F. graminearum strains tested produced small amounts (100 mg/kg); four strains produced NIV and six strains produced deoxynivalenol (DON) and 3-acetyl-deoxynivalenol (3Ac-DON). PCR chemotyping lead to an oversimplified picture, because all 3Ac-DON chemotype strains produced more DON than 3Ac-DON; furthermore, the strongest NIV producers produced significant amounts of DON. All tested strains of F. culmorum, F. graminearum, F. pseudograminearum (two strains) and most F. equiseti strains (five of six strains) produced zearalenone. Grains of durum wheat were more frequently colonized by Fusarium spp. than grains of soft wheat. Incidence of Fusarium spp. in irrigated fields was higher than in rainfed fields. The incidence of Fusarium strains producing mycotoxins raises concerns about the risk of Fusarium head blight to Syria and its consequences for public health.

This paper presents the results of the comparison of different analytical techniques (Differential Scanning Calorimetry - DSC, Low Field Nuclear Magnetic Resonance - LF-NMR, Light Microscopy - LM and Transmission Electron Microscopy - TEM) in order to evaluate the mass transfer, water status and cellular compartment modifications of the kiwifruit outer pericarp tissue during osmotic dehydration treatment (OD). Two kiwifruit species, A. deliciosa and A. Chinensis were submitted to OD. OD was performed in a 61.5 % w/v sucrose solution at three different temperatures (25, 35 and 45°C), with treatment time from 0 to 300 min. Peleg's model highlighted that the main response differences between the two kiwifruit species occurred during the initial phase of the osmotic treatment. DSC parameters appeared to be sensitive to water and solid exchange between fruits and osmotic solution. LF-NMR proton T2 revealed the consequences of the water-solid exchange on the cell compartments, namely vacuole, cytoplasm plus extracellular space and cell wall. During OD, the reduction of the vacuole proton pool, detected by LF-NMR, suggested a shrinkage of such compartment, confirmed by LM. Cell walls of outer pericarp showed considerable changes in size, structure and stain uptake during OD observed at TEM. The proposed multianalytical approaches should enable better design of combined processing technologies permitting the evaluation of their effects on tissue response.

Essential oils possess a variety of biological properties (i.e., antioxidant, antibacterial, and cytotoxic) that could possibly be applied in reproductive medicine, but their effects on spermatozoa are still partially unknown. The aim of the study was to describe the effects of Thymbra capitata (L.) Cav. and Rosmarinus officinalis (L.) essential oils on the main morpho-functional parameters of swine spermatozoa. Essential oils were preliminary characterized by gas chromatography and added with emulsifiers to facilitate diffusion. Experimental samples were prepared by suspending a fixed number of spermatozoa in 5 mL of medium with 10 different concentrations of essential oil (0.2–2 mg/mL, at intervals of 0.2). After 3 h of incubation, samples were analyzed for pH, viability, objective motility, and acrosome status. Results showed that the effects of the essential oils are concentration-dependent and that R. officinalis is well tolerated up to 0.6 mg/mL. T. capitata impaired the spermatozoa starting from the lowest concentration, with complete spermicidal effect from 0.4 mg/mL. The patterns of damage, confirmed by SEM, were different and quite distinct. As expected, spermatozoa proved to be sensitive to external stimuli and capable of showing different functional patterns, providing interesting insights to the action/toxicity mechanisms. The results of the present work represent the first step towards the systematic characterization of the effects of these compounds on spermatozoa. This kind of studies are necessary to strengthen the idea of future applications of essential oils in the reproductive field due to their antioxidant, antibacterial, or spermicidal properties.

Fusarium Head Blight caused by phytopathogenic Fusarium spp. with Fusarium graminearum as main causal agent is a major disease of durum wheat (Triticum durum Desf.). Mycotoxins in wheat are dominated by trichothecenes B. Fumonisins have only occasionally been reported from wheat; their occurrence was attributed to Fusarium proliferatum and Fusarium verticillioides. We investigated kernels of durum wheat grown in Italy in 2008 - 2010 for colonization with Fusarium spp. and for the content of Fusarium mycotoxins. Fungal biomass was determined using species-specific qPCR and mycotoxins were quantified by HPLC-MS/MS. Fusarium graminearum and Fusarium culmorum were dominating Fusarium species, followed by Fusarium poae, Fusarium tricinctum, and Fusarium proliferatum. No Fusarium verticillioides DNA was found. Toxicologically relevant levels of deoxynivalenol and nivalenol but no trichothecenes A were detected. Enniatins, fumonisin B1 and beauvericin were present in grain in all three years. Based on these results and on the evaluation of previous published reports, we hypothesize that low levels of fumonisins commonly occur in wheat grains produced in warm climate; they may remain undetected as long as mycotoxin monitoring programs for wheat do not include fumonisins. The only relevant source of fumonisins in wheat grain appears to be Fusarium proliferatum.

Fusarium isolates obtained from Iran and Italy were identified by morphological characters and confirmed by using species-specific PCR assays. The genetic chemotyping for each strain, as a preliminary assessment for trichothecene production, was defined using PCR. Subsequently, artificial infection on durum wheat (cv. Normanno) was carried out in the greenhouse to study the pathogenicity and aggressiveness of Iranian, Italian and Syrian F. culmorum strains, the causal agent of crown and root rot of wheat. All F. culmorum strains from Iran and Italy belonged to the 3-acetyl-deoxynivalenol (3Ac-DON) chemotype, while F. culmorum strains from Syria, previously characterized, belonged to the 3Ac-DON and nivalenol (NIV) chemotypes. All of the strains were pathogenic and caused typical Fusarium crown rot (FCR) symptoms. Italian and Iranian strains showed similar mean aggressiveness levels (19.1 and 18.7% respectively), while the mean aggressiveness level for Syrian strains was 11.8%. There were statistically significant differences among the strains. Two Italian strains, F383 and F1126, had the greatest level of aggressiveness while FC9 (Italian) and F961 (Syrian) were the least aggressive strains. No significant differences relating to agro-ecological origin were detected among Iranian, Italian and Syrian strains. This is the first genetic chemotyping characterization and comparison of F. culmorum strains, isolated from different agro-ecological countries, Iran, Syria (Middle East) and Italy (Europe), which has estimated their potential for producing mycotoxins, and the aggressiveness levels of F. culmorum for development of FCR. These results support the increasing concerns about the risk of FCR in many wheat producing countries, particularly in Iran and Syria.

PURPOSE: To assess the functional results of surgical treatment of traumatic cloaca by a technique including reconstructive plastic surgery of the perineal body and of the rectovaginal septum using the puborectal and external sphincter muscles. METHODS: Six female patients were submitted to surgical treatment for correction of the cloaca over a period of 5 years (2002 to 2007). Loop sigmoidostomy was parformed in two patients. The mean duration of symptoms before surgical treatment was 97.5 months (4 months to 36 years), mean patient age was 36 years (17 to 58 years) and the follow-up period was 14.6 months (6 months to 2 years). RESULTS: Five patients (83.3%) regained fecal and flatus continence and one patient had flatus incontinence. DISCUSSION: Surgical treatment yields good results, is safe and involves low rates of complications.INTRODUÇÃO: A causa mais comum da cloaca é o trauma obstétrico. O objetivo desse trabalho é avaliar os resultados do tratamento cirúrgico empregando-se plástica reconstrutiva do corpo perineal e do septo reto vaginal. MÉTODOS: Foram operadas seis mulheres, num período de 5 anos (2002-2007). Sigmoidostomia em alça foi realizada em duas pacientes. O tempo médio de duração dos sintomas no pré-operatório foi de 97,5 meses (4 meses a 36 anos), a faixa etária média foi de 36 anos (17-58) e o período de seguimento foi de 14,6 meses (6 meses - 2 anos). RESULTADOS: Cinco pacientes (83,3%) recuperaram a continência anal para fezes e flatos e uma paciente permaneceu com incontinência para gases. DISCUSSÃO: O tratamento cirúrgico da cloaca pós-trauma apresentou bons resultados, sendo considerado um procedimento seguro, com baixo índice de complicação.

Widespread flooding in June 2013 caused damage costs of €6 to 8 billion in Germany, and awoke many memories of the floods in August 2002, which resulted in total damage of €11.6 billion and hence was the most expensive natural hazard event in Germany up to now. The event of 2002 does, however, also mark a reorientation toward an integrated flood risk management system in Germany. Therefore, the flood of 2013 offered the opportunity to review how the measures that politics, administration, and civil society have implemented since 2002 helped to cope with the flood and what still needs to be done to achieve effective and more integrated flood risk management. The review highlights considerable improvements on many levels, in particular (1) an increased consideration of flood hazards in spatial planning and urban development, (2) comprehensive property-level mitigation and preparedness measures, (3) more effective flood warnings and improved coordination of disaster response, and (4) a more targeted maintenance of flood defense systems. In 2013, this led to more effective flood management and to a reduction of damage. Nevertheless, important aspects remain unclear and need to be clarified. This particularly holds for balanced and coordinated strategies for reducing and overcoming the impacts of flooding in large catchments, cross-border and interdisciplinary cooperation, the role of the general public in the different phases of flood risk management, as well as a transparent risk transfer system. Recurring flood events reveal that flood risk management is a continuous task. Hence, risk drivers, such as climate change, land-use changes, economic developments, or demographic change and the resultant risks must be investigated at regular intervals, and risk reduction strategies and processes must be reassessed as well as adapted and implemented in a dialogue with all stakeholders.