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Rhinogenic headache (RH) is a headache or facial pain syndrome secondary to mucosal contact points in the sino-nasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sino-nasal polyps or masses. It may result from pressure on the nasal mucosa due to anatomical variations among which the pneumatization of the middle turbinate, concha bullosa, a variant of the development of ethmoidal cells, is the most commonly observed. Clinical practice suggests a close correlation between concha bullosa, mucosal contacts and rhinogenic headache, with high impact on the QoL. However diagnostic and therapeutic difficulties still remain. Aim of the present study is to evaluate the impact of medical or surgical care on the QoL of patients suffering from concha bullosa related headache from the patients' perspective.One-hundred-two subjects with concha bullosa and headache anamnesis were randomized into two groups and given medical or surgical treatment. To assess the Quality of life (QoL) we used visual analogue scale and for the first time, the migraine disability score before and after treatment.After treatment the severity of the headache decreased as well as the discomfort in the surgical group compared with medical group.The improvement of symptoms and QoL suggests that the endoscopic surgical plastic may promote the rapid resolution of concha bullosa related headache improving the and reducing health care costs.

Background and aims: Evaluation of incidence and correlates of severe hypoglycemia (SH) and diabetes ketoacidosis (DKA) in children and adolescents with T1DM. Methods and results: Retrospective study conducted in 29 diabetes centers from November 2011 to April 2012. The incidence of SH and DKA episodes and their correlates were assessed through a questionnaire administered to parents of patients aged 0e18 years. Incidence rates and incident rate ratios (IRRs) were estimated through multivariate Poisson regression analysis and multilevel analysis. Overall, 2025 patients were included (age 12.4 � 3.8 years; 53% males; diabetes dura- tion 5.6 � 3.5 years; HbA1c 7.9 � 1.1%). The incidence of SH and DKA were of 7.7 and 2.4 events/ 100 py, respectively. The risk of SH was higher in females (IRR Z 1.44; 95%CI 1.04e1.99), in pa- tients using rapid acting analogues as compared to regular insulin (IRR Z 1.48; 95%CI 0.97e2.26) and lower for patients using long acting analogues as compared to NPH insulin (IRR Z 0.40; 95% CI 0.19e0.85). No correlations were found between SH and HbA1c levels. The risk of DKA was higher in patients using rapid acting analogues (IRR Z 4.25; 95%CI 1.01e17.86) and increased with insulin units needed (IRR Z 7.66; 95%CI 2.83e20.74) and HbA1c levels (IRR Z 1.63; 95% CI 1.36e1.95). Mother' sa ge was inversely associated with the risk of both SH (IRRZ 0.95; 95%CI 0.92e0.98) and DKA (IRR Z 0.94; 95%CI 0.88e0.99). When accounting for center effect, the risk of SH associated with the use of rapid acting insulin analogues was attenuated (IRR Z 1.48; 95%CI 0.97e2.26); 33% and 16% of the residual variance in SH and DKA risk was ex- plained by center effect. Conclusion: The risk of SH and DKA is mainly associated with treatment modalities and strongly depends on the practice of specialist centers.

MODY2 is the most prevalent monogenic form of diabetes in Italy with an estimated prevalence of about 0.5-1.5%. MODY2 is potentially indistinguishable from other forms of diabetes, however, its identification impacts on patients' quality of life and healthcare resources. Unfortunately, DNA direct sequencing as diagnostic test is not readily accessible and expensive. In addition current guidelines, aiming to establish when the test should be performed, proved a poor detection rate. Aim of this study is to propose a reliable and easy-to-use tool to identify candidate patients for MODY2 genetic testing. We designed and validated a diagnostic flowchart in the attempt to improve the detection rate and to increase the number of properly requested tests. The flowchart, called 7-iF, consists of 7 binary "yes or no" questions and its unequivocal output is an indication for whether testing or not. We tested the 7-iF to estimate its clinical utility in comparison to the clinical suspicion alone. The 7-iF, in a prospective 2-year study (921 diabetic children) showed a precision of about the 76%. Using retrospective data, the 7-iF showed a precision in identifying MODY2 patients of about 80% compared to the 40% of the clinical suspicion. On the other hand, despite a relatively high number of missing MODY2 patients, the 7-iF would not suggest the test for 90% of the non-MODY2 patients, demonstrating that a wide application of this method might 1) help less experienced clinicians in suspecting MODY2 patients and 2) reducing the number of unnecessary tests. With the 7-iF, a clinician can feel confident of identifying a potential case of MODY2 and suggest the molecular test without fear of wasting time and money. A Qaly-type analysis estimated an increase in the patients' quality of life and savings for the health care system of about 9 million euros per year.

Context:The incidence of type 1 diabetes has been increasing over time.Objective:We estimated the genetic and environmental components of type 1 diabetes susceptibility in a twin cohort of recent-onset cases to explore the sources of changing disease epidemiology.Design:We linked the population-based Italian Twin Registry with 14803 type 1 diabetes records from 36 pediatric diabetes care centers throughout Italy, except Sardinia, and identified 173 diabetic twins. Patients were positive for at least one autoantibody to islet cell, glutamate decarboxylase, tyrosine phosphatase, insulin, or zinc transporter 8 and were insulin dependent since their diagnosis. Zygosity was determined by DNA genotyping or by questionnaire.Outcome Measures:We estimated proband-wise concordance, cotwin recurrence risk with Kaplan-Meier method, and genetic and environmental proportions of susceptibility variance by structural equation models.Results:We recruited 104 diabetic twins (53 males) from 88 pairs (34 monozygotic, 54 dizygotic) and one triplet. The mean age at diagnosis was 8.1 yr (range 1.1-20.5 yr), and the median year of diagnosis was 2002. Proband-wise concordances were 45.5 and 16.4% in monozygotic and dizygotic pairs (P = 0.01). Recurrence risks in monozygotic and dizygotic cotwins were 37 and 12% after 10 yr from the proband's diagnosis (P = 0.005). Genetic contribution to type 1 diabetes susceptibility was 40% (95% confidence interval 8-78), and the shared and individual-specific environmental components were 51% (14-77) and 9% (4-19), respectively.Conclusions:In addition to the moderate genetic effects on type 1 diabetes susceptibility, our results draw attention to the substantial shared environmental effects, suggesting that exposures in fetal or early postnatal life may contribute to the increasing incidence of the disease.

Background: Efficacy and feasibility of sensor-augmented pump (SAP) therapy were evaluated in very young children with type 1 diabetes (T1D). Subjects and Methods: SAP (Dexcom [San Diego, CA] Seven Plus™ usage combined with insulin pump) therapy was retrospectively evaluated in 28 children (15 boys) younger than 7 years (mean age, 5.8±1.2 years; range, 3–7 years), with T1D. Glycosylated hemoglobin (HbA1c) was evaluated at baseline and at the end of the study, as were efficacy and feasibility of the system, using a rating scale (with 3 being the most positive). Results: SAP has been used for at least 6 months by 85% of patients, with an overall good satisfaction (92%). The greatest perceived benefit was the reduced fear of hypoglycemia (score of 3, 81%). HbA1c significantly improved only in patients with baseline HbA1c >7.5% (P=0.026). Conclusions: SAP therapy is effective and feasible in preschool children with T1D. In patients with high HbA1c at baseline it provide a 0.9% decrease, sustained for...

Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome, is characterized by telangiectasic vascular malformations of the skin and of the digestive and respiratory mucosa. Epistaxis is the most common otorhinolaryngologic manifestation, with potential complications as septal perforations and, in cases of serious bleeding, anemia. Given that some therapeutic approaches are burdened by failure, whereas others are invasive and painful, the possibility of using simple and effective approaches to manage recurrent epistaxis, especially in outpatients, is needed and useful. Recently, the use of Surgiflo, (OMRIX biopharmaceuticals Ltd.MDA Blood Bank, Ramar-GanPOB, Kiryat Ono, Israel) a gelatin-thrombin matrix, currently used as an alternative to the nasal packing, has been proposed. We evaluated the effectiveness of Surgiflo in the treatment of recurrent epistaxis in outpatients with HHT. The present investigation reports the case of 3 patients with recurrent HHT-related epistaxis treated with Surgiflo. We also review the literature discussing available treatment options. Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a rare systemic fibrovascular dysplasia with autosomal-dominant inheritance. It is characterized by a spectrum of telangiectasic vascular malformations occurring in the skin and in the digestive and respiratory mucosa. Other manifestations of HHT occur in the lungs, liver, or central nervous system [1] and [2]. Otorhinolaryngologic manifestations are frequent, and epistaxis caused by spontaneous bleeding of nasal mucosa telangiectasis is the most common. The potential complications of epistaxis are septal perforations and, in cases of serious bleeding, anemia [3]. Treatment of HHT is aimed at controlling symptoms. For instance, it is possible to stop nose bleeding by applying direct pressure to the nose or performing anterior and/or posterior packing [4] and [5]. If these measures are insufficient and the frequency and duration of episodes impair the patient's quality of life, surgical cauterization, photocoagulation laser, or septal mucosal dermoplasty may be recommended [1] and [6]. To prevent the onset of chronic anemia resulting from severe epistaxis, the endovascular treatment with microembolization could be performed. Chemical cauterization should always be avoided because it may harm nasal structures [1]. Although brachytherapy and fibrin glue injection in the nasal septum and inferior turbinates submucosa are efficacious, they bring about only temporary symptom improvement [3]. Given that some therapeutic approaches are burdened by failure and some others are invasive and painful, the possibility of using simple and effective approaches to manage recurrent epistaxis, especially in hematology units and in outpatients, is needed and useful. Recently, the use of Surgiflo, a gelatin-thrombin matrix, currently used in neurosurgery and in thoracic and vascular surgery, has been proposed as an alternative to the nasal packing after functional endoscopic sinus surgery. In addition, some authors have evaluated the use of Surgiflo in the management of recurrent epistaxis [4] and [7]. Therefore, we evaluated the effectiveness of Surgiflo in the treatment of recurrent epistaxis in patients with HHT. The present investigation reports 3 cases of outpatients with recurrent HHT-related epistaxis treated with Surgiflo. We also review the literature discussing available treatment options. Surgiflo is a dehydrated gelatin-thrombin matrix in a syringe. For intranasal use, its gelatinous consistency must be maintained to remain in the nasal cavity (reconstitution with up to 3.5 to 4 mL of sterile water). A 16-cm-long applicator is put through the nasal vestibule to the rhinopharynx. The rhinopharynx and the nasal cavity are filled in with Surgiflo from back to front. A.V., female, 63 years old, had been complaining of mild recurrent epistaxis for 20 years, with worsening in the 6 months before treatment. She did not use salicylate-based drugs. The patient underwent cauterization of varices of the base of the tongue 7 years before and of the nasal septum 1 year before, with many anterior packings, followed by immediate epistaxis after each packing removal. The patient was transferred to ENT consultation in April 2011; nasal endoscopy showed crusts and hematic points spread throughout nasal septal mucosa. Blood test showed hemoglobin (Hb) levels of 10.50 g/dL and iron levels of 29 μg/dL. Surgiflo was applied inside both nasal cavities through nasal endoscopy without anesthesia, and the patient left the hospital after 2 hours of monitoring without recurrence of bleeding. No epistaxis has recurred until now. G.C., male, 49 years old with HHT, had been complaining of a right anterior epistaxis for 5 years. He underwent repeated right anterior packings that were effective, but bleeding recurrences were immediate after each packing removal. Nasal endoscopy showed hematic points throughout the right nasal cavity. Blood tests showed Hb levels of 10.90 g/dL and iron levels 33 μg/dL. In September 2011, he was treated with Surgiflo without anesthesia. The patient left the hospital after 2 hours of monitoring without bleeding. No epistaxis has recurred until now. G.E., male, 62 years old, was affected by HHT; he had been complaining of epistaxis for 7 years, treated by repeated anterior packings followed by immediate bleeding recurrences. During his physical examination at ENT Unit, we noticed hematic points spread throughout nasal septum. Blood tests showed Hb levels of 10.30 g/dL and iron levels 30 μg/dL. We applied Surgiflo in July 2012 inside his nasal mucosa through nasal endoscopy without anesthesia. The patient left the hospital after 2 hours of monitoring without bleeding. No epistaxis has recurred until now. Epistaxis is the earliest and the most common symptom of HHT. Ninety-five percent of individuals with HHT experience recurrent epistaxis, with a mean frequency of 18 episodes per month [1]. Although the nasal packing allows stopping most of bleedings, the disadvantages of local infections, septic complications, pain, mucosal traumatism, and bleeding recurrence still remain. An alternative to the traditional packing could be the use of absorbable packing such as Surgicel (ETHICON, LLC San Lorenzo, Puerto Rico) (oxidized cellulose polymer) or Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) (absorbable gelatin sponge), whose placement is, anyhow, painful in outpatients and less effective for posterior bleeding [4]. For instance, some authors have evaluated the use of the gelatin-thrombin matrix after functional endoscopic sinus surgery with encouraging outcomes, reporting the prevention of bleeding after surgery in 96.7% of cases [7]. Furthermore, Buiret et al [4] report the cases of 2 patients, one with thrombocytopenia and the other with thrombopathy, hospitalized for recurrent epistaxis and, after repeated failed treatments, successfully treated with local application of Surgiflo. In the present study, we report 3 cases of patients with recurrent HHT-related epistaxis treated with Surgiflo. Our preliminary encouraging findings suggest that the use of local application of gelatin-thrombin matrix could be an effective alternative to the traditional anterior/posterior nasal packing, especially in outpatients at higher risk for bleeding, in which often the bleeding occurs again after the removal of nasal packing. Moreover, this technique is not invasive or potentially dangerous for outpatients. Surgiflo is effective, repeatable over time, and easy to apply, even without anesthesia. In addition, it could avoid the use of surgical procedures such as cauterization. In our opinion, Surgiflo can represent a valid tool for the management recurrent epistaxis in HHT, particularly in outpatients, because it is free of disadvantages related to the anterior packing or surgical procedures, effective, and reabsorbable. Furthermore, the cost of this device is widely offset by the reduction of hospitalization [4].

Obiettivo di questo lavoro (all'interno del volume dal titolo: "Nessuno escluso. Formazione, inclusione sociale e cittadinanza attiva, a cura di P. Valerio, M. Striano, S. Oliverio) è di dimostrare come sia possibile ridurre le distanze tra ciò che si studia e ciò che sarà vissuto, dopo la laurea, a confronto con la disciplina del mondo del lavoro e dei sistemi professionali nelle organizzazioni aziendali attraverso l’inclusione attiva e la partecipazione. La riduzione delle distanze avverrà facendo ricorso ad alcuni strumenti e linguaggi proprî di certa teoria delle organizzazioni di matrice critical, orientata ad un approccio non dogmatico di stampo antipositivista. Strumenti idonei, come si vedrà, a favorire la messa in azione di saperi astratti, nei contesti imperfetti del mondo reale. Messa in azione dei saperi che è, appunto, esperienza di inclusione attiva e partecipata. Pertanto le categorie prese in esame saranno: (1) simbolismo culturale: il concetto di interpretazione simbolico culturale fornisce l’immagine di “noi come organizzazione”, premessa per un apprendimento adulto; (2) costruttivismo radicale: concepire l’organizzazione come prodotto delle conoscenze che gli individui hanno della realtà, focalizza l’attenzione sul concetto di competenze e sui processi di apprendimento individuale e organizzativo nella duplice dimensione formale/informale; (3) modello Tavistock: considerare le organizzazioni come dispositivi di controllo delle “ansie” evidenzia la necessità di logiche di inclusione e partecipazione per la gestione dei processi di cambiamento e apprendimento individuale/organizzativo.