Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block Combined with Port-Site Infiltration (PSI) for Laparoscopic Sleeve Gastrectomy in an ERABS Pathway: A Randomized, Prospective, Double-Blind, Placebo-Controlled Trial.

PURPOSE: Patients undergoing laparoscopic sleeve gastrectomy (LSG) commonly experience moderate to severe postoperative pain. We conducted a randomized, prospective double-blind placebo-controlled study to evaluate the analgesic effect of laparoscopic-guided TAP (LG-TAP) block after LSG in a high-volume bariatric center, applying an enhanced recovery after bariatric surgery (ERABS) pathway. MATERIAL AND METHODS: One hundred ten patients were randomly allocated to receive LG-TAP block with local anesthetic (LA) or saline solution (placebo), both combined with port-site infiltration with LA (LA-PSI). Primary outcome was pain score measured in post-anesthesia care unit (PACU) and at 6, 12, and 24 h after surgery. Secondary outcomes included postoperative nausea and/or vomiting (PONV), analgesic requirement, time to walking, time to flatus, length of hospital stay (LOS), and surgical complications. RESULTS: No significant differences were observed between LG-TAP and placebo groups in postoperative analgesia, with a median (IQR) NRS of 2 (4.75-0) vs. 2 (5.25-0) in PACU, 5.5 (7-3) vs. 6 (7-4) at 6 h, 2 (6-0) vs. 3 (5.25-1.75) at 12 h, and 2 (3.75-0) vs. 1 (2-0) at 24 h; all p > 0.05. A significant difference was found in PONV in PACU (LG-TAP, 46%; placebo, 25%, p-value, 0.019) and at 6 h postoperatively (LG-TAP, 69%, placebo, 41%, p-value, 0.003). No differences were observed as regards other secondary outcomes. CONCLUSION: Our results suggest that LG-TAP block is not related to more effective postoperative analgesia compared to placebo when LA-PSI is performed.

Liver abscess after endoscopic sleeve gastroplasty: A case report.

Endoscopic sleeve gastroplasty is a minimally invasive procedure for the treatment of obesity. The procedure is generally safe and well-tolerated, but major adverse events occur in up to 3% of patients. Perigastric abscess is a potential complication caused by postprocedural gastric leak. To the best of our knowledge, no cases of hepatic abscess (HA) following endoscopic sleeve gastroplasty have been reported, while HA is a well-known complication of laparoscopic sleeve gastrectomy. We report the case of a patient who developed a liver abscess 2 weeks after endoscopic sleeve gastroplasty. The patient improved with administration of intravenous antibiotics and endoscopic drainage.

Brain functional connectivity differences between responders and non-responders to sleeve gastrectomy.

PURPOSE: To compare resting-state functional connectivity (RSFC) of obese patients responders or non-responders to sleeve gastrectomy (SG) with a group of obese patients with no past medical history of metabolic or bariatric surgery. METHODS: MR images were acquired at 1.5 Tesla. Resting-state fMRI data were analyzed with statistical significance threshold set at p < 0.05, family-wise error (FWE) corrected. RESULTS: Sixty-two subjects were enrolled: 20 controls (age range 25-64; 14 females), 24 responders (excess weight loss > 50%; age range 23-68; 17 females), and 18 non-responders to sleeve gastrectomy (SG) (excess weight loss < 50%; age range 23-67; 13 females). About within-network RSFC, responders showed significantly lower RSFC with respect to both controls and non-responders in the default mode and frontoparietal networks, positively correlating with psychological scores. Non-responders showed significantly higher (p < 0.05, family-wise error (few) corrected) RSFC in regions of the lateral visual network as compared to controls. Regarding between-network RSFC, responders showed significantly higher anti-correlation between executive control and salience networks (p < 0.05, FWE corrected) with respect to both controls and non-responders. Significant positive correlation (Spearman rho = 0.48, p = 0.0012) was found between % of excess weight loss and executive control-salience network RSFC. CONCLUSION: There are differences in brain functional connectivity in either responders or non-responders patients to SG. The present results offer new insights into the neural correlates of outcome in patients who undergo SG and expand knowledge about neural mechanisms which may be related to surgical response.

Advice of General Practitioner, of Surgeon, of Endocrinologist, and Self-determination: the Italian Road to Bariatric Surgery.

PURPOSE: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. METHODS: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. RESULTS: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30-59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. CONCLUSIONS: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story.

Accuracy of controlled attenuation parameter for assessing liver steatosis in individuals with morbid obesity before bariatric surgery.

BACKGROUND & AIMS: The ultrasound-based controlled attenuation parameter (CAP) is a non-invasive tool widely validated for assessing liver steatosis across different etiologies. However, few studies, with liver biopsy available, have investigated its performance in individuals with morbid obesity. Herein, we aimed to evaluate the diagnostic accuracy of CAP in participants with morbid obesity from the MAFALDA study before bariatric surgery. METHODS: A total of 120 individuals with valid examinations within three months from bariatric surgery were included. Clinical, laboratory, FibroScan® (XL probe), and liver biopsy data were collected using standardized procedures. The overall accuracy of CAP for detecting liver steatosis was estimated by the area under the receiver-operating characteristics curve (AUROC). Optimal cut-offs were chosen at points with the highest Youden index. RESULTS: The AUROCs of CAP for detecting S ≥ S1, S ≥ S2, and S = S3 were 0.91 (95% CI 0.86-0.97), 0.83 (95% CI 0.76-0.90), and 0.86 (95% CI 0.79-0.94), respectively. The best CAP cut-offs for S ≥ S1, S ≥ S2, and S = S3 were 300 dB/m (95% CI 275-316), 328 dB/m (95% CI 296-345), and 344 dB/m (95% CI 343-352), respectively. CAP values were independently influenced by steatosis grade (estimate 20.60, 95% CI 12.70-28.40, P = 1.05 × 10-6 ). The AUROC of FibroScan-AST (FAST) score for detecting progressive non-alcoholic steatohepatitis was 0.76 (95% CI 0.66-0.86). CONCLUSIONS: In individuals with morbid obesity, CAP measured by XL probe is an accurate non-invasive tool for grading liver steatosis. Measurement of liver fat content by CAP may help identify those eligible for bariatric procedures and estimate the effect of bariatric surgery on hepatic steatosis. LAY SUMMARY: The ultrasound-based controlled attenuation parameter (CAP) by using the XL probe has an excellent performance for grading liver steatosis among individuals with morbid obesity. CAP may represent an accurate tool for the non-invasive assessment of liver steatosis among individuals with morbid obesity before and after bariatric surgery.

The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study.

INTRODUCTION: Cigarette smoking is the most important risk factor for Crohn's disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood. METHODS: This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months. RESULTS: Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22-32; vs 25 and 22-28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9-13; vs 14 and 12-15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD. CONCLUSIONS: The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.

Underwater Optical Wireless Communications: Overview.

Underwater Optical Wireless Communication (UOWC) is not a new idea, but it has recently attracted renewed interest since seawater presents a reduced absorption window for blue-green light. Due to its higher bandwidth, underwater optical wireless communications can support higher data rates at low latency levels compared to acoustic and RF counterparts. The paper is aimed at those who want to undertake studies on UOWC. It offers an overview on the current technologies and those potentially available soon. Particular attention has been given to offering a recent bibliography, especially on the use of single-photon receivers.

Delayed surgery after radio-chemotherapy for rectal adenocarcinoma is protective for anastomotic dehiscence: a single-center observational retrospective cohort study.

Ideal time interval between end of neoadjuvant radio-chemotherapy (NRCT) and surgery for rectal cancer is debated. Effect that different time intervals have on postoperative complications with particular regard to anastomotic dehiscence (AD) was evaluated on 167 patients who underwent surgery after long-course NRCT. Three different time intervals were considered: (0-42; 43-56; > 57 days). A time interval > 57 days was significantly protective for AD (p = 0.04, Odds ratio = 0.35; 95% CI 0.1254-0.9585) without influence on early oncological outcomes. Optimal time interval after end of NRCT and surgery may help achieving the best pathological response with lowest postoperative morbidity.Trial registration number: Clinical Trial. Gov NCT04013347. https://clinicaltrials.gov/ct2/results?cond=&term=NCT04013347&cntry=&state=&city=&dist= ).

Aripiprazole causing false positive urine amphetamine drug screen in an adult patient with bipolar disorder.

There has been only a few reports regarding aripiprazole causing false positive urine amphetamine drug screens, exclusively on children accidently ingesting aripiprazole. Herein, we present the first reported case of a 40 year old woman affected by Bipolar I Disorder, treated with aripirazole at therapeutic oral dose ranging from 15 mg/day to 30 mg/day, in the context of a depressive episode with mixed and psychotic features, showing a false positive urine amphetamine drug screen. We document the relationship between aripiprazole-dose, plasma concentration and amphetamines values in toxicologic urine examinations over time. Awareness of potential false positive urine amphetamine drug screens during aripiprazole treatment can condition therapeutic choices and prevent legal implications.

Smartphone sensors for stone lithography authentication.

Nowadays mobile phones include quality photo and video cameras, access to wireless networks and the internet, GPS assistance and other innovative systems. These facilities open them to innovative uses, other than the classical telephonic communication one. Smartphones are a more sophisticated version of classic mobile phones, which have advanced computing power, memory and connectivity. Because fake lithographs are flooding the art market, in this work, we propose a smartphone as simple, robust and efficient sensor for lithograph authentication. When we buy an artwork object, the seller issues a certificate of authenticity, which contains specific details about the artwork itself. Unscrupulous sellers can duplicate the classic certificates of authenticity, and then use them to "authenticate" non-genuine works of art. In this way, the buyer will have a copy of an original certificate to attest that the "not original artwork" is an original one. A solution for this problem would be to insert a system that links together the certificate and the related specific artwork. To do this it is necessary, for a single artwork, to find unique, unrepeatable, and unchangeable characteristics. In this article we propose an innovative method for the authentication of stone lithographs. We use the color spots distribution captured by means of a smartphone camera as a non-cloneable texture of the specific artworks and an information management system for verifying it in mobility stone lithography.

Max Frei theory revisitation: does really strokes depth change along time?

A serious problem in questioned document examination is to establish the age of written lines. With respect to paper dating, in the past, Max Frei theory (based only on microscope analysis) claimed that strokes are time-dependent. Therefore, according to this theory, it has been asserted that from the analysis of the strokes depth changes it is possible to try to date the handwritten document (to find out that the document is older than ...). In the present work, we investigate the strokes depth change by a laser profilometer considering not only the time but also microclimatic variations. First, we analyze the stability of stroke characteristics along the time. In particular, we demonstrate that if the document is preserved without change of temperature and humidity, the depth of the strokes has not appreciable changes. In this way, we have the purpose to verify the real possibility of documents dating by means of Max Frei theory. Subsequently, we test how the 3D profile of strokes changes in connection with the microclimatic variations. In particular, we test humidity variations. With this experiment, we show that humidity variations reduce the strokes depth. Moreover, this effect shows a non-linear trend, leaving a hysteresis on the depth. Finally, we show that the analysis of 3D stroke profile is unable to determine the age of documents.

Potentiality of 3D laser profilometry to determine the sequence of homogenous crossing lines on questioned documents.

The determination of the sequence of line crossings is still a current problem in the field of forensic documents examination. Optical examination, lifting technique, ESDA technique, and electron microscopy are the most widely used methods for the determination of the writing order of crossing texts. However, at present many examinations of intersecting lines result in an inconclusive opinion, particularly if the same type and colour of ink is involved. This paper presents the potentiality of the 3D laser profilometry, which has been to determine the chronological sequence of homogenous "crossing lines". The laser profilometry, illustrated in this paper, has been developed on a conoscopic holography based system. It is a non-contact three-dimensional measuring system that allows producing holograms, even with incoherent light, with fringe periods that can be measured precisely to determine the exact distance to the point measured. This technique is suitable to obtain a 3D micro-topography with high resolution also on surfaces with unevenness reflectivity (usual for the paper surface). The proposed technique is able to obtained 3D profile in non-invading way. Therefore, the original draft are not physically or chemically modified, allowing a multi-analysis in different times. The experiments performed with line crossings database show that the proposed method is able of "positive identification" of writing sequence in the majority of the tests. In absence of a positive identification, the result has been "inconclusive" (no false determination did occur in this work).

Low-cost optoelectronic system for three-dimensional artwork texture measurement.

A new optoelectronic system based on a projection unit in which light, coming from a laser diode coupled to an optic fiber impinges on a diffractive optical element (DOE) to produce sinusoidal fringes is proposed for three-dimensional (3-D) texture measurement. If the projected fringe pattern is viewed at an angle different from the projection angle, the fringe profile is phase-modulated by the 3-D object shape. The 3-D map information is obtained with the aid of a fringe analyzer based on phase-shifting synthetic moiré pattern, Fast Fourier Transform (FFT), signal demodulation techniques and a robust and fast phase unwrapping performed by a specially developed software. The proposed system is based on a simple and low cost equipment; furthermore, it is suitable for in situ measurements also by nonskilled operators. Some experimental examples illustrate its performance.