Bruno Scarpa

Cervical mucus symptom and daily fecundability: first results from a new database

With the collaboration of Italian centres providing services on natural family planning, a prospective study collected data on 2755 menstrual cycles of 193 women. A database was constructed using information on the daily characteristics of cervical mucus and episodes of intercourse. Taking the day of peak mucus as a conventional marker of ovulation, the database identified the length (12 days) and location of a ‘window’ of potential fertility, the highest level of conception probability being confined to the central five to six days. Univariate analysis provided evidence of the impact on fecundability of the woman’s age and the basic infertile pattern of a cycle. Several analytical approaches highlighted the relationship between daily mucus characteristics and levels of fecundability.

Multivariate measures of skewness for the skew-normal distribution

Our main objective is the calculation and the comparative study of some general measures of multivariate skewness, namely Mardias measure (1970), Malkovic and Afifi (1973), the Balakrishnan, Brito and Quiroz (2007) and Songs measure of shape (2001). In this context, exact formulas for the first three measures are derived for the family of skew normal distribution, while the Songs measure of shape is obtained by approximation via delta-method. The behaviour of the obtained measures, their similarities and differences, possible interpretations and uses in practice are investigated by comparing them in specific members of the skew-normal family of multivariate distributions.

Dynamic monitors of brain function: a new target in neurointensive care unit.

IntroductionSomatosensory evoked potential (SEP) recordings and continuous electroencephalography (EEG) are important tools with which to predict Glasgow Outcome Scale (GOS) scores. Their combined use may potentially allow for early detection of neurological impairment and more effective treatment of clinical deterioration.MethodsWe followed up 68 selected comatose patients between 2007 and 2009 who had been admitted to the Neurosurgical Intensive Care Unit of Treviso Hospital after being diagnosed with subarachnoid haemorrhage (51 cases) or intracerebral haemorrhage (17 cases). Quantitative brain function monitoring was carried out using a remote EEG-SEP recording system connected to a small amplification head box with 28 channels and a multimodal stimulator (NEMO; EBNeuro, Italy NeMus 2; EBNeuro S.p.A., Via P. Fanfani 97/A - 50127 Firenze, Italy). For statistical analysis, we fit a binary logistic regression model to estimate the effect of brain function monitoring on the probability of GOS scores equal to 1. We also designed a proportional odds model for GOS scores, depending on amplitude and changes in both SEPs and EEG as well as on the joint effect of other related variables. Both families of models, logistic regression analysis and proportional odds ratios, were fit by using a maximum likelihood test and the partial effect of each variable was assessed by using a likelihood ratio test.ResultsUsing the logistic regression model, we observed that progressive deterioration on the basis of EEG was associated with an increased risk of dying by almost 24% compared to patients whose condition did not worsen according to EEG. SEP decreases were also significant; for patients with worsening SEPs, the odds of dying increased to approximately 32%. In the proportional odds model, only modifications of Modified Glasgow Coma Scale scores and SEPs during hospitalisation statistically significantly predicted GOS scores. Patients whose SEPs worsened during the last time interval had an approximately 17 times greater probability of a poor GOS score compared to the other patients.ConclusionsThe combined use of SEPs and continuous EEG monitoring is a unique example of dynamic brain monitoring. The temporal variation of these two parameters evaluated by continuous monitoring can establish whether the treatments used for patients receiving neurocritical care are properly tailored to the neurological changes induced by the lesions responsible for secondary damage.

Bayesian hierarchical functional data analysis via contaminated informative priors.

A variety of flexible approaches have been proposed for functional data analysis, allowing both the mean curve and the distribution about the mean to be unknown. Such methods are most useful when there is limited prior information. Motivated by applications to modeling of temperature curves in the menstrual cycle, this article proposes a flexible approach for incorporating prior information in semiparametric Bayesian analyses of hierarchical functional data. The proposed approach is based on specifying the distribution of functions as a mixture of a parametric hierarchical model and a nonparametric contamination. The parametric component is chosen based on prior knowledge, while the contamination is characterized as a functional Dirichlet process. In the motivating application, the contamination component allows unanticipated curve shapes in unhealthy menstrual cycles. Methods are developed for posterior computation, and the approach is applied to data from a European fecundability study.

Comparison between unilateral PNIF and rhinomanometry in healthy and obstructed noses

BACKGROUND According to the Federal Institution of Health Insurance, ENT doctors perform more skin prick tests for the diagnosis of allergic rhinitis (AR) than other medical specialties in Belgium. However, immunotherapy (IT) is not practiced by all. This study aims to obtain insight into IT practice by ENT doctors, the type of IT performed and the reasons not to perform IT. METHODOLOGY A questionnaire was sent to all registered ENT doctors of Belgium (n=648), involving questions on type and duration of ENT practice, geography and gender. In addition, the questionnaire informed about diagnosis of AR, indication for IT, type of IT performed, and reasons not to perform IT and referral pattern. RESULTS The response rate among ENT doctors was 54%, with 7% of responders being excluded as they do not diagnose AR. 81% of Belgian ENT doctors make the indication for IT in AR patients, with 19% neglecting the indication for IT in AR patients. The two main reasons for not indicating IT are lack of expertise and the perception of high costs associated with IT. 70% of ENT specialists are practicing IT themselves, with sublingual IT being mostly performed. Interestingly, IT is mostly frequently performed by those ENT doctors with long-standing ENT practice, in private practice and in Wallonia. CONCLUSION Despite the high prevalence of AR in ENT practice, IT is most frequently performed by ENT doctors with longstanding practice, working in private practice and/or in the French speaking part of Belgium. Among the different types of IT, sublingual IT is the most frequently performed means of IT by ENT doctors.OBJECTIVE To investigate the role of inflammation in non-allergic rhinitis (NAR) patients in a large series to establish the prevalence of different NAR-subtypes, clinical features and the role of nasal cytology in the diagnostic algorithm. METHODOLOGY Patients were selected out of 3650 individuals who spontaneously presented at our institution. We consecutively enrolled 519 NAR-patients in an analytical cross-sectional study between November 2007 and June 2013 (level of evidence: 3b). All patients underwent rhinological evaluation including symptoms questionnaire, endoscopy, CT scan, allergy tests and nasal cytology. RESULTS The inflammatory cell infiltrate affects the severity of symptoms differently, allowing for identification of different phenotypes of NAR. We distinguished two groups: “NAR without inflammation”(NAR-) and “NAR with inflammation”(NAR+), in addition to different NAR-subtypes with inflammation. A significant difference was observed in terms of clinical symptoms and association with comorbidities (previously diagnosed asthma and aspirin intolerance) between NAR–, NAR+ and between different NAR+ subtypes. CONCLUSION Our data suggest that NAR- and NAR with neutrophils behave similarly, showing lower symptom score values and a lower risk of association with comorbidities compared to NAR with eosinophils and mast cells (singularly or mixed). In our belief it is very important to establish the presence and type of inflammation in non-allergic rhinitis patients and nasal cytology is a very useful test in correct differential diagnosis.OBJECTIVE To assess the applicability of the Peak Nasal Inspiratory Flow (PNIF) curves in follow-up of children in the treatment of allergic rhinitis. METHODS Prospective study of 40 patients with AR, grouped in corticosteroid spray versus physiological saline solution use. Follow up for 10 weeks through clinical score and PNIF percentages in relation to the reference curves, with was-out at week 8. Statistical assessment of the effect of treatment on variation of PNIF and clinical score was calculated by ANOVA model and Multiple Comparison of Means Test - Least Significant Difference. RESULTS There was a statistically significant influence of the group, time and interaction between time and group on PNIF percentages. Throughout follow up, patients from the treatment group had mean PNIF percentages significantly higher than the placebo group. Clinical score results also demonstrated a statistically significant influence between the groups, time and interaction between time and group. CONCLUSION Increase in PNIF percentage values observed in children treated with intranasal corticosteroids revealed the applicability of PNIF curves in their follow up.OBJECTIVE This study aims to examine humans ́ abilities to localize odorants within the open field. METHODOLOGY Young participants were tested on a localization task using a relatively selective olfactory stimulus (2-phenylethyl-alcohol, PEA) and cineol, an odorant with a strong trigeminal component. Participants were blindfolded and had to localize an odorant source at 2 m distance (far-field condition) and a 0.4 m distance (near-field condition) with either two nostrils open or only one open nostril. RESULTS For the odorant with trigeminal properties, the number of correct trials did not differ when one or both nostrils were used, while more PEA localization trials were correctly completed with both rather than one nostril. In the near-field condition, correct localization was possible in 72-80% of the trials, irrespective of the odorant and the number of nostrils used. Localization accuracy, measured as spatial deviation from the olfactory source, was significantly higher in the near-field compared to the far-field condition, but independent of the odorant being localized. CONCLUSION Odorant localization within the open field is difficult, but possible. In contrast to the general view, humans seem to be able to exploit the two-nostril advantage with increasing task difficulty.BACKGROUND This study was designed to assess if illness perception, mood state and coping strategies differ according to allergic rhinitis (AR) persistence and severity. METHODS Illness perception, mood profiles, coping behaviors and rhinitis symptoms were assessed by means of validated tools inpatients classified according to the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines. RESULTS Two hundred and thirty-one patients underwent data analysis. No difference in age, sex, socio-economic status, smoking habits was detected comparing patients according to AR severity, duration or 4 ARIA classes. Patients with intermittent AR reported higher scores than those with persistent AR in confusion-bewilderment of Profile of Mood States (POMS); patients with moderate/severe rhinitis had significantly higher scores than those with mild rhinitis in TSSS, Identity and Consequences. No differences were detected in all assessed outcomes in the 4 ARIA classes. CONCLUSIONS The patients perspective about AR is independent of persistence and severity of symptoms. This may explain why AR remains under-diagnosed and under-treated, even in its most severe forms. Self-management plans should consider the patients perspective.The assessment of Chronic Rhinosinusitis, like any other disease, may involve multiple possible disease manifestations, including subjective patient-reported outcomes, objective disease (e.g. endoscopy or radiographic), and physician-driven (e.g. need for systemic medications). Disease control is often used as a global metric of disease burden and represents the extent to which disease manifestations are within an acceptable range. Achieving control is an important treatment goal.The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012(1-3). The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings.BACKGROUND Endoscopic dacryocystorhinostomy (EN-DCR) is a commonly used procedure in the treatment of nasolacrimal duct obstruction (NLDO). However, there is no generally accepted disease-specific questionnaire for assessing outcomes. METHODOLOGY We conducted a prospective study to initially validate a Nasolacrimal Duct Obstruction Symptom Score questionnaire(NLDO-SS) and to evaluate the long-term success of EN-DCR procedures. Seventy-six patients (86 eyes) were evaluated in follow-up visits at 1-8 years after EN-DCR. The patients completed the NLDO-SS questionnaire twice, first, at home and, second,after receiving information from the otorhinolaryngologist, during the visit. The surgical outcome was considered successful if the irrigation succeeded and if the patient symptoms were relieved as assessed with the NLDO-SS. RESULTS The diagnostic accuracy of the NLDO-SS was 84%, sensitivity 82%, specificity 85%, positive predictive value 58%, negative predictive value 95%, odds ratio 26, risk ratio 11 and usefulness index 0.55. Cronbachs alpha was 0.85, and the test-retest reliability coefficient was 0.87. The long-term success rate after EN-DCR was 79%. CONCLUSION The NLDO-SS iss a feasible clinical tool in assessing the success of EN-DCR. The success rate was found to decrease EN-DCR at long-term follow-up.

Olfactory sensitivity and sexual desire in young adult and elderly men: An introductory investigation.

Background It has been suggested that olfaction could influence human sexual behavior. Age is negatively associated with many aspects of sexuality and, with increasing age, people tend to show a declining sexual desire. The present pilot study investigated the relationship between sexual desire and olfactory sensitivity in healthy men of two age groups, young adult and elderly (≥65 years old), to ascertain whether their sense of smell could determine sexual desire and whether an age-related weaker olfactory sensitivity could correlate with the decline in sexual appetite in elderly patients. Methods Sixty-three volunteers were recruited and divided into two groups, one consisting of 48 healthy young adult men, the other of 15 healthy elderly men. All participants were tested to ascertain their odor threshold for n-butanol (Sniffin’ Sticks) and their sexual desire using the International Index of Erectile Function (IIEF), presenting only the questions relating to frequency (IIEF1) and level (IIEF2) of sexual desire. Results Sexual desire and mean olfactory thresholds were higher in the younger adults than in the elderly men (p = 0.001 and p = 0.02, respectively). There was a significant association between butanol threshold and sexual desire for the young adult group (p = 0.02), but not for the elderly group (p = 0.35). Conclusion This study found a preliminary association between olfaction and sexual behavior, in young adults at least. More studies are needed to improve our knowledge in this intriguing field, possibly using electrophysiological olfactory methods.

Sequential predictions of menstrual cycle lengths

Forecasting the length of the menstrual cycle and of its phases is an important problem in infertility management and natural family planning. Using repeated measurements of the length of the entire cycle and of the preovular phase provided by a large English database, we describe a Bayesian hierarchical dynamic approach to the problem. A state-space process is used to model the temporal behavior of the series of lengths for each woman. The individual processes are then embedded into a multivariate system through a Bayesian hierarchy in which model parameters are allowed to vary across subjects according to a specified probability distribution. The most interesting features of the suggested method are (a) it takes into account explicitly the temporal nature of the available data and (b) if combined with a fecundability model, it can be used to forecast the probability of conception in future cycles as a function of any intercourse behavior.

Peak nasal inspiratory flow and peak expiratory flow. Upright and sitting values in an adult population

BACKGROUND Nasal obstruction is correlated with a decreased quality of life . An easy way to evaluate nasal patency is the peak nasal inspiratory flow (PNIF) measurement. Normal PNIF values have been published by many authors. However, some authors evaluated volunteers in a sitting position, while others have measured PNIF values in standing volunteers. Body position has been shown to influence pulmonary function, with differences between sitting and upright positions. As nasal and pulmonary flows are strictly related, the present pilot study tried to establish whether PNIF/PEF changed with body position in adults. METHODOLOGY PNIF and PEF were measured in sitting and standing positions with the order of testing randomized in 76 healthy volunteers, 30 male (40 ± 16 years). RESULTS In the group as a whole between sitting and upright position, PEF was significantly different (p=0.009), while PNIF showed a trend towards a significant difference (p=0.10). CONCLUSIONS The present study, although showing a generally positive effect of the standing position on PEF values, does not show a clear effect on PNIF.

Unilateral peak nasal inspiratory flow, normal values in adult population.

AIMS Measurement of Peak Nasal Inspiratory Flow (PNIF) is a cheap, simple, easily performed method to assess nasal patency and it is suitable for serial measurements and for home use. The purpose of this study was to establish normative unilateral PNIF data for a healthy adult population and provide charts relating unilateral PNIF normal values with various explanatory variables. METHODS AND RESULTS Repeated measurements of PNIF and unilateral PNIF were performed in 109 volunteers. Ninety seven of these fulfilled the study criteria and all of them were non-smokers, non-asthmatic, without nose and paranasal sinus problems, with ages ranging from 13 to 80 years. Data were statistically analysed and tables were produced relating unilateral PNIF to height which was the only studied variable that correlated statistically with unilateral PNIF. CONCLUSIONS The measurement of unilateral PNIF, providing the present data are confirmed in a larger series, could be a useful method to study single nostril patency to aid diagnosis of nasal disease, especially when it is necessary to assess the functional effects of unilateral nasal septal deviations or in all cases where there is a suspicion of a unilateral nasal occlusion. This pilot study provides initial normative unilateral PNIF data.

Sniffin' Sticks and olfactory system imaging in patients with Kallmann syndrome.

The relationship between olfactory function, rhinencephalon and forebrain changes in Kallmann syndrome (KS) have not been adequately investigated. We evaluated a large cohort of male KS patients using Sniffin’ Sticks and MRI in order to study olfactory bulb (OB) volume, olfactory sulcus (OS) depth, cortical thickness close to the OS, and olfactory phenotype.