Italian guidelines for the management of adult individuals with overweight and obesity and metabolic comorbidities that are resistant to behavioral treatment.

AIM: This guideline (GL) is aimed at providing a clinical practice reference for the management of adult patients with overweight or obesity associated with metabolic complications who are resistant to lifestyle modification. METHODS: Surgeons, endocrinologists, gastroenterologists, psychologists, pharmacologists, a general practitioner, a nutritionist, a nurse and a patients' representative acted as multi-disciplinary panel. This GL has been developed following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A systematic review and network meta-analysis was performed by a methodologic group. For each question, the panel identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for clinical practice recommendations. Consensus on the direction (for or against) and strength (strong or conditional) of recommendations was reached through a majority vote. RESULTS: The present GL provides recommendations about the role of both pharmacological and surgical treatment for the clinical management of the adult patient population with BMI > 27 kg/m2 and < 40 kg/m2 associated with weight-related metabolic comorbidities, resistant to lifestyle changes. The panel: suggests the timely implementation of therapeutic interventions in addition to diet and physical activity; recommends the use of semaglutide 2.4 mg/week and suggests liraglutide 3 mg/day in patients with obesity or overweight also affected by diabetes or pre-diabetes; recommends semaglutide 2.4 mg/week in patients with obesity or overweight also affected by non-alcoholic fatty liver disease; recommends semaglutide 2.4 mg/week as first-line drug in patients with obesity or overweight that require a larger weight loss to reduce comorbidities; suggests the use of orlistat in patients with obesity or overweight also affected by hypertriglyceridemia that assume high-calorie and high-fat diet; suggests the use of naltrexone/bupropion combination in patients with obesity or overweight, with emotional eating; recommends surgical intervention (sleeve gastrectomy, Roux-en-Y gastric bypass, or metabolic gastric bypass/gastric bypass with single anastomosis/gastric mini bypass in patients with BMI ≥ 35 kg/m2 who are suitable for metabolic surgery; and suggests gastric banding as a possible, though less effective, surgical alternative. CONCLUSION: The present GL is directed to all physicians addressing people with obesity-working in hospitals, territorial services or private practice-and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.

Zenker diverticulum in the right side of the neck resembling a thyroid mass at ultrasound.

Zenker’s diverticulum represents the most common form of pharyngo-oesophageal diverticula usually occurring on the left side of the neck. Due to its anatomical proximity to the thyroid, it can mimic a thyroid mass. Here we describe the case of an asymptomatic 49-year-old man referred to the Thyroid Clinic of the Policlinico Umberto I Hospital-“Sapienza” University of Rome for thyroid sonography due to a family history of autoimmune thyroid disease. The patient’s thyroid blood tests did not reveal any abnormalities. The sonographic examination showed a dishomogeneus and hypoechoic thyroid gland. In addition, in the third middle of the right lobe, a mass (with a diameter greater than 26 mm), with heterogeneous internal echogenicity, hypoechoic margins and internal hyperechoic spots was recorded, with no appreciable flow at the Doppler evaluation. The TI-RADS score was 4c. Hence, the patient underwent ultrasound-guided fine-needle aspiration cytology that revealed the presence of squamous cells without cytological atypia, erythrocytes, muscular and vegetable fibres, colonies of bacteria in the absence of inflammatory infiltrate. This was consistent with the diagnostic hypothesis of oesophagus diverticulum, which was confirmed by means of a barium-swallow oesophagography. This case report underlines the possibility that a suspicious thyroid mass may result from a Zenker’s diverticulum, even if located on the right side, especially if the lesion has a heterogeneous echo-texture, a hypoechoic rim and internal hyperechoic spots.

Urinary hydroxypyrene and estradiol in an occupationally exposed "outdoor" population.

BACKGROUND: Polycyclic aromatic hydrocarbons (PAHs) are widely present in the air pollution. The urinary hydroxypyrene (1-HOPu) is considered the main biological biomarker currently available to measure the exposure to PAH. It is supposed responsible of an increase of estradiol levels in males. Aim of this study is to verify whether there is a relation between 1-HOPu and plasmatic estradiol in non-smoker male workers. METHODS: The study was conducted on a sample of 122 non-smoker policemen in a large Italian city; we monitored their levels of 1-HOPu and the values of estradiol. The sample was divided into three groups according to the levels of urinary hydroxypyrene. The indices of correlation (r) and multiple linear regression (ß), between levels of 1-HOPu and estradiol were calculated. It was also calculated the student's t-test among the groups to check the differences. RESULTS: We found statistically significant correlations and multivariate linear regressions between 1-HOPu and estradiol in the total sample and in group III (levels of 1-HOPu above the 75th percentile). The average levels of estradiol in group III was statistically and significantly higher than in the group I (levels of 1-HOPu below the 25th percentile) and group II (levels 1-HOPu between 25th and the 75th percentile). CONCLUSIONS: 1-HOPu in non-smoker male workers is related with an increase of plasmatic estradiol. We believe that PAHs, of which 1-HOPu is the main biomarker, can interact with the hypothalamic-pituitary axis. The preliminary results suggest that the topic needs further research on male and female as well.

Correlation between urinary nickel and testosterone plasma values in workers occupationally exposed to urban stressors.

BACKGROUND: The purpose of this study is to assess whether occupational exposure to low doses of nickel (Ni) present in urban air can cause alterations in the concentration of plasma testosterone in workers of the Municipal Police of a large Italian city assigned to different types of outdoor tasks. METHODS: 359 male subjects were included in the study and divided on the basis of job, age, length of service and smoking habits. The dosage of the atmospheric Ni was performed by personal dosimetries on a sample of the workers included in the study. For each worker included in the study the dosage of whole blood Ni and of the plasma testosterone was carried out. The total sample was subjected to the independent-samples T-test and the Mann-Whitney U test for variables with 2 modes (smoking cigarette) and the ANOVA test and the Kruskal Wallis test for variables with more than 2 modes (age, length of service and job function). The correlation of Pearson with p at 2 wings between the variables was evaluated in the total sample and after subdivision on the basis of smoking and on the basis of the job. After taking into account the major confounding factors the multiple linear regression was performed on the total sample and after breakdown by tasks. RESULTS: The correlation between the values of urinary Ni and the values of plasma testosterone on the total sample and for all classes of subdivision was found constantly negative. These results were confirmed by multiple linear regression, which indicated the Ni as the only significant variable that can contribute to the alterations of the testosterone. CONCLUSIONS: Based on the results, the Authors suggest that occupational exposure to low doses of Ni present in the urban environment is able to influence some lines of the hypothalamic-pituitary-gonadal axis in exposed workers.

Thyroid hormones in male workers exposed to urban stressors.

BACKGROUND: The occupational exposure to urban pollution may induce adverse effects on the human health. METHODS: Plasma levels of thyrotropin stimulating hormone (TSH), free thyroxine (FT4) and free triiodothyronine (FT3) of 50 outdoor workers and 50 indoor workers were compared. RESULTS: In the outdoor workers the TSH levels were significantly higher than in the control subjects (p =0.02) while the average of FT3 and FT4 values, was not significantly different compared to the controls (p > 0.05). CONCLUSIONS: The differences found for TSH levels between outdoor and indoor workers, though not high, suggest that, due to greater exposure to environmental pollutants, the outdoor workers are more susceptible to the development of function abnormalities of the thyroid gland compared to indoor workers.

[Meta analysis blood and urinary values in urban pollution exposed workers]. / Meta-analisi di indicatori di effetto in lavoratori esposti ad inquinamento urbano.

INTRODUCTION: Aim of this study is evaluating alteration of neuro-immune-endocrine parameters in exposed workers and estimating whether urban pollution can modify them. METHODS: Literature research. Different categories of exposed workers were included in the study (7287) and compared with controls (8054). To calculate results Effect Size (ES) and confidence interval were used. RESULTS: A correlation between urban pollution exposition and some neurogenic mediators and metabolites alterations was demonstrated; blood values can be alterated by toxicity of benzene and by xenobiotic metabolites' mechanism; follicle stimulating hormone is significantly increased in exposed versus controls. CONCLUSIONS: High heterogeneity and literature limitations, together with results of this meta analysis, induce to believe that is necessary to deepen the research about urban pollution effects on these parameters.

[Cardiovascular diseases in workers at risk]. / Cardiovasculopatie in lavoratori a rischio.

Our research group has conducted several studies to investigate the effects of occupational risks on the cardiovascular system of exposed workers. In these studies, groups of workers exposed to possible professional cardiovascular risk factors were compared with controls with respect to some parameters (blood pressure, ECG, etc.). The groups were made comparable by age, length of service, traditional cardiovascular risk factors and possible confounding factors outside work. Four studies investigated the effects of noise exposure, three studies the effects of exposure to urban stressors, other studies the presence of other cardiovascular risk factors in various occupational categories (manual workers, agricultural workers, workers exposed to ionizing radiation, workers in rotogravure factory). The results of our studies confirm the presence of cardiovascular risk factors in various professions and the consequent need to take develop preventive strategies in workplaces to prevent the onset of cardiovascular diseases associated with these risk factors.

[Meta-analysis: cardiovascular effects in workers occupationally exposed to urban pollution]. / Metanalisi: effetti sull'apparato cardiovascolare in lavoratori esposti a inquinamento urbano.

BACKGROUND: Many studies showed a connection between exposition to high levels of urban pollution (especially to particulate and traffic noise) and the onset of even deadly cardiovascular diseases. DESIGN: Meta-analysis of case-control design. OBJECTIVES: The aim of this study is to estimate the association between cardiovascular effects and occupational exposition to atmospheric pollution in urban environment. DATA SOURCES: Biomedcentral, MEDLINE/ PubMed, MEDLINE/ National Library of Medicine (NLM), MEDLINE Plus, Nioshtic-2, Scopus, TOXNET/Toxline, unpublished studies known by the authors and acts of national and international conferences between 1988 and May 2010 included. There has not been any kind of language or typological restriction. CRITERIA OF ELEGIBILITY: The research on cardiovascular effects includes control cases of workers exposed to urban pollution, compared with non-exposed subjects. PARTICIPANTS AND INTERVENTIONS: The selected studies present outdoor workers exposed to urban pollution (drivers and petrol pump attendants) and a control group of indoor workers (managers, university students and other selected subjects). STUDY APPRAISAL AND SYNTHESIS METHODS: The evidences (independently token from two different authors) have been grouped in two classes, the first one formed by continuous variables (systolic blood pressure, diastolic blood pressure, heart rate, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) and the second one by discontinuous variables (electrocardiographic abnormalities prevalence, hypertension prevalence, hypercholesterolemia prevalence). The studies related to both classes and presenting more than one variable for each class have been included and used, in order to elaborate the results. We calculated heterogeneity in each variable (ES calculation for continuous variables and OR calculation for discontinuous variables). RESULTS: On 378 publications, we have selected and included 16 articles. The variables show statistically irrelevant differences between exposed group and control group, except regarding the triglycerides. LIMITATIONS: The controlled studies are limited and characterized by a non-homogeneous evaluation of both expositional times of workers to urban pollution and of professional expositional values. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Considering the heterogeneity and the lack of studies, it is impossible at the moment to document effects on the cardiovascular system in workers exposed to urban pollution. The results of this meta-analysis only suggest the association of urban pollution with alteration of triglycerides blood levels (referring to just three studies). As reported in scientific literature on this subject, it is necessary to conduct a future professional investigation on this subject with more qualified and homogeneous studies.

[Cardiovascular parameters in workers exposed to urban pollutions]. / Parametri cardiovascolari in lavoratori esposti ad inquinamento urbano.

The aim of the study is to evaluate if "outdoor" workers exposed to chemical, physical and psycho-social urban stressors could have alterations of systolic and diastolic blood pressure at rest and heart disease investigated by electrocardiogram compared with a group of "indoor" workers not exposed. Among non-smoking, the mean values of systolic blood pressure at rest were significantly higher in exposed compared to non exposed (p = 0.002) and frequency of electrocardiographic abnormalities was significantly higher in exposed (20.8%) than not exposed (10.4%, p = 0.02). Among exposed, the values of systolic blood pressure at rest were significantly higher in smokers than non-smokers (p = 0.002). Among non-exposed, the frequency of electrocardiographic abnormalities was significantly higher in smokers than non-smokers (p = 0.002). The study results suggest that chronic exposure to chemical, physical and psycho-social stressors can be a cardiovascular risk factor in addition to cigarette smoking in a manner determined by the categories of outdoor workers.

Can noise cause high blood pressure? Occupational risk in paper industry.

OBJECTIVES: The authors hypothesize cardiovascular effects in paper industry workers exposed to noise. MATERIALS AND METHODS: The study included 72 paper industry workers exposed to noise and two control groups not exposed to noise. The workers completed a questionnaire and underwent a medical examination, measurement of blood pressure, electrocardiogram, blood tests, audiometry and measurement of noise exposure. RESULTS: The workers exposed to noise, all hearing impaired, were compared with not exposed and showed: significant increase of mean systolic and diastolic blood pressure values (p<0.001), higher frequency of hypertension, systolic and diastolic blood pressure (p<0.01 and p<0.001) and electrocardiografic abnormalities (p<0.05), significant reduction of blood pressure response in orthostatism (p<0.005). CONCLUSIONS: Our results suggest that for the workers of the paper industry the noise is an occupational risk factor for cardiovascular effects.

Exposure to antineoplastic drugs in health care and blood chemistry parameters.

OBJECTIVES: The purpose of the research is to evaluate whether the exposure to antineoplastic drugs of health workers may cause alteration of blood chemistry parameters. MATERIALS AND METHODS: Research was conducted on 5800 health workers employed in a hospital in a big Italian city. The final sample is composed of 57 people in charge of cytotoxic drugs compared with 57 subjects not exposed; each worker underwent a general clinical examination and determination of the following values: complete blood count (CBC), white blood cell count (WBC), total protein, BUN, total bilirubin, creatinine, GOT, GPT, alkaline phosphatase, gamma GT. Statistical analysis of data was based on calculation of the mean, standard deviation and the distribution into classes according to the nature of each variable. Differences were considered significant when p was <= 0.05. RESULTS: The mean and the distribution of values of total bilirubin were significantly higher in the workers exposed to antineoplastic drugs than in workers non-exposed; the mean and the distribution of values of monocytes were significantly lower in subjects exposed compared to controls. CONCLUSIONS: According to the results antiblastic drugs, at the doses used in the departments we studied, can induce an increase in the values of total bilirubin for liver toxicity and a reduction in the monocyte line due to myelosuppression.

[Urban stressors and thyroid hormones]. / Stressor urbani e ormoni tiroidei.

OBJECTIVES: The aim of the study is to evaluate whether occupational exposure to urban stressors could cause alterations in thyroid hormones plasma levels (TSH, FT3 and FT4) in female outdoor workers vs. administrative. MATERIALS AND METHODS: The study has been performed on an initial sample of 198 female subjects divided in two groups (occupationally exposed and not exposed to urban stressors). After excluding the subjects with the main confounding factors, female outdoor workers and administrative staff were matched by age, working life and drinking habit. RESULTS: In 40 female outdoor workers mean plasma TSH levels were significantly higher compared to 40 administrative staff. The distribution of TSH values in outdoor workers and in administrative staff was significant. Plasma FT3 and FT4 levels were not significantly different in the two groups. Our results suggest that exposure to urban stressors (chemical, physical and psycho-social), can alter the plasma concentration of TSH. CONCLUSIONS: According to our previous research, plasma TSH levels may be used as an early biological marker of chronic exposure to urban stressors, in occupational set even before the onset of the related disorders.