Development of the Italian Clinical Practice Guidelines on Bariatric and Metabolic Surgery: Design and Methodological Aspects.

Development of the Italian clinical practice guidelines on bariatric and metabolic surgery, as well as design and methodological aspects. BACKGROUND: Obesity and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) developed the first Italian guidelines for the treatment of obesity. METHODS: The creation of SICOB Guidelines is based on an extended work made by a panel of 24 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions used the two-step web-based Delphi method, made by repeated rounds of questionnaires and a consensus opinion from the panel. RESULTS: The panel proposed 37 questions. A consensus was immediately reached for 33 (89.2%), with 31 approved, two rejected and three which did not reach an immediate consensus. The further discussion allowed a consensus with one approved and two rejected. CONCLUSIONS: The areas covered by the clinical questions included indications of metabolic/bariatric surgery, types of surgery, and surgical management. The choice of a surgical or a non-surgical approach has been debated for the determination of the therapeutic strategy and the correct indications.

Obesity and COVID-19: An Italian Snapshot.

OBJECTIVE: The clinical manifestations of coronavirus disease (COVID-19) run from asymptomatic disease to severe acute respiratory syndrome. Older age and comorbidities are associated to more severe disease. A role of obesity is suspected. METHODS: Patients hospitalized in the medical COVID-19 ward with severe acute respiratory syndrome coronavirus 2-related pneumonia were enrolled. The primary outcome of the study was to assess the relationship between the severity of COVID-19 and obesity classes according to BMI. RESULTS: A total of 92 patients (61.9% males; age 70.5 [13.3] years) were enrolled. Patients with overweight and obesity were younger than patients with normal weight (68.0 [12.6] and 67.0 [12.6] years vs. 76.1 [13.0] years, P < 0.01). A higher need for assisted ventilation beyond pure oxygen support (invasive mechanical ventilation or noninvasive ventilation) and a higher admission to intensive or semi-intensive care units were observed in patients with overweight and obesity (P < 0.01 and P < 0.05, respectively) even after adjusting for sex, age, and comorbidities (P < 0.05 and P < 0.001, respectively) or when patients with dementia or advanced cancer were removed from the analysis (P < 0.05). CONCLUSIONS: Patients with overweight and obesity admitted in a medical ward for severe acute respiratory syndrome coronavirus 2-related pneumonia, despite their younger age, required more frequently assisted ventilation and access to intensive or semi-intensive care units than normal weight patients.

SCCA-IgM as a Potential Biomarker of Non-Alcoholic Fatty Liver Disease in Patients with Obesity, Prediabetes and Diabetes Undergoing Sleeve Gastrectomy.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has a high prevalence in obesity and its presence should be screened. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for obesity, but its effects on NAFLD are still to be firmly established. The diagnosis of non-alcoholic steatohepatitis (NASH) is currently performed by liver biopsy, a costly and invasive procedure. Squamous cell carcinoma antigen-IgM (SCCA-IgM) is a biomarker of viral hepatitis to hepatocellular carcinoma development and its role in NAFLD to NASH progression has not yet been investigated. OBJECTIVE: The aim of this study was to evaluate SCCA-IgM as a non-invasive biomarker of NAFLD/NASH in patients with different degrees of metabolic-complicated obesity before and after LSG. METHOD: Fifty-six patients with obesity were studied before and 12 months after LSG; anthropometric, biochemical, clinical, and imaging data were collected. RESULTS: At baseline steatosis was strongly associated with the glycaemic profile (p = 0.016) and was already present in prediabetic patients with obesity (82%). Only 3 patients had an SCCA-IgM level above the normal cut-off. SCCA-IgM titre did not change according to glycaemic profile or steatosis. Metabolic and inflammatory factors and transaminases significantly reduced after LSG-induced weight loss, except for SCCA-IgM. The ALT/AST ratio decreased post-LSG correlated with BMI (r = 0.297, p = 0.031), insulin (r = 0.354, p = 0.014), and triglycerides (r = 0.355, p = 0.009) reduction. CONCLUSIONS: Our results confirm the tight link between NAFLD and metabolic complications, suggesting prediabetes as a new risk factor of steatosis. SCCA-IgM does not seem to have a role in the identification and prognosis of NAFLD.

Modifications of Resting Energy Expenditure After Sleeve Gastrectomy.

OBJECTIVES: Resting energy expenditure (REE) declines more than what is expected according to body composition changes after caloric restriction. This metabolic adaptation is considered one of the factors favoring weight regain. The aim of this study is to evaluate the changes of REE and calculate the degree of metabolic adaptation occurring after laparoscopic sleeve gastrectomy (LSG). METHODS: REE (by indirect calorimetry) and body composition (fat-free mass or FFM, fat mass or FM by bioelectrical impedance analysis) were determined before and after 12 months in 154 patients with obesity treated with laparoscopic sleeve gastrectomy (LSG). RESULTS: Weight loss was 29.8 ± 10.6%, with corresponding relative reductions in FM (44.5 ± 22.8%), FFM (13.7 ± 9.9%), and REE (27.3 ± 12.9%). A predictive equation for REE was computed by using the baseline FFM and FM values to account for body composition changes. A predicted post-weight loss REE was calculated by using this equation and entering post-weight loss body composition values. Observed post-surgery REE was significantly lower than predicted one (1410 ± 312 vs 1611 ± 340 kcal/day, P < 0.001) and metabolic adaptation, calculated as the difference between observed and predicted post-weight loss REE, was - 199 ± 238 kcal/day. The post-surgery level of metabolic adaptation was inversely related to postoperative percent weight loss (r = - 0.170; P < 0.05) and FM loss (r = - 0.245; P < 0.01). CONCLUSIONS: A significant reduction of resting energy expenditure and a significant degree of metabolic adaptation both occur after sleeve gastrectomy. A greater metabolic adaptation could be partly responsible for a lower weight loss after surgery.

Incidence and Predictors of Hypoglycemia 1 Year After Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: Hypoglycemia is a known adverse event following gastric bypass. The incidence of hypoglycemia after laparoscopic sleeve gastrectomy (LSG) is still under investigation. The aim of our study was to verify the presence of oral glucose tolerance test (OGTT)-related hypoglycemia after LSG and to identify any baseline predictors of its occurrence. METHODS: We analyzed 197 consecutive non-diabetic morbid obese patients that underwent LSG. All patients were studied before and 12 months after LSG. Evaluation included anthropometric parameters, 3-h OGTT for blood glucose (BG), insulin and c-peptide, lipid profile, interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), highly sensitive C-reactive protein (hsCRP), and leptin. Hypoglycemia was defined as BG ≤ 2.7 mmol/l. RESULTS: After surgery, 180 patients completed the OGTT. Eleven patients did not complete the test for gastric intolerance, and in six patients, the test was stopped earlier for the onset of severe symptomatic hypoglycemia. Of the patients, 61/186 (32.8%) had at least one OGTT-related hypoglycemia. The highest frequency of hypoglycemic events occurred 150' after glucose load (20.2%). At baseline, patients with hypoglycemic events after surgery (Hypo) were younger (40 ± 11 vs 46 ± 10 years; p < 0.001), less obese (BMI 46 ± 5.7 vs 48.4 ± 7.9 kg/m2; p < 0.05), and had a worse lipid profile as compared to patients without hypoglycemic events (N-Hypo). Moreover, after LSG, Hypo patients compared with N-Hypo presented a higher weight loss (%EBMIL 80 ± 20 vs 62 ± 21%; p < 0.001). Low age, low fasting glucose, and high triglyceride levels before LSG were independent predictors of hypoglycemia development after surgery (r 2 = 0.131). CONCLUSION: These findings confirm the high incidence of post-prandial hypoglycemia 1 year after LSG. Hypoglycemia is more frequent in younger patients with lower fasting glucose and higher triglyceride levels before surgery.

Diffuse large B-cell lymphoma genotyping on the liquid biopsy.

Accessible and real-time genotyping for diagnostic, prognostic, or treatment purposes is increasingly impelling in diffuse large B-cell lymphoma (DLBCL). Cell-free DNA (cfDNA) is shed into the blood by tumor cells undergoing apoptosis and can be used as source of tumor DNA for the identification of DLBCL mutations, clonal evolution, and genetic mechanisms of resistance. In this study, we aimed at tracking the basal DLBCL genetic profile and its modification upon treatment using plasma cfDNA. Ultra-deep targeted next generation sequencing of pretreatment plasma cfDNA from DLBCL patients correctly discovered DLBCL-associated mutations that were represented in >20% of the alleles of the tumor biopsy with >90% sensitivity and ∼100% specificity. Plasma cfDNA genotyping also allowed for the recovery of mutations that were undetectable in the tissue biopsy, conceivably because, due to spatial tumor heterogeneity, they were restricted to clones that were anatomically distant from the biopsy site. Longitudinal analysis of plasma samples collected under rituximab-cyclophosphamide-doxorubicin-vincristine-prednisone (R-CHOP) chemotherapy showed a rapid clearance of DLBCL mutations from cfDNA among responding patients. Conversely, among patients who were resistant to R-CHOP, basal DLBCL mutations did not disappear from cfDNA. In addition, among treatment-resistant patients, new mutations were acquired in cfDNA that marked resistant clones selected during the clonal evolution. These results demonstrate that cfDNA genotyping of DLBCL is as accurate as genotyping of the diagnostic biopsy to detect clonally represented somatic tumor mutations and is a real-time and noninvasive approach to tracking clonal evolution and the emergence of treatment-resistant clones.

Association between molecular lesions and specific B-cell receptor subsets in chronic lymphocytic leukemia.

Genetic lesions and B-cell receptor (BCR) signaling are both oncogenic drivers in chronic lymphocytic leukemia (CLL). However, scant data are available on preferential associations between specific genetic alterations and stereotyped BCR subsets. By analyzing 1419 cases, 2 CLL subsets (2 and 8) harboring stereotyped BCR are enriched in specific molecular alterations influencing disease course. SF3B1 mutations are the genetic hallmark of IGHV3-21-CLL belonging to subset 2 (52%) but are evenly represented in nonstereotyped IGHV3-21-CLL. Trisomy 12 (87%) and NOTCH1 mutations (62%) characterize IGHV4-39-CLL belonging to subset 8 but occur with the expected frequency in IGHV4-39-CLL with heterogeneous BCR. Clinically, co-occurrence of SF3B1 mutations and subset 2 BCR configuration prompts disease progression in IGHV3-21-CLL, whereas cooperation between NOTCH1 mutations, +12, and subset 8 BCR configuration invariably primes CLL transformation into Richter syndrome. These findings provide a proof of concept that specific stereotyped BCR may promote or select molecular lesions influencing outcome.

Integrated mutational and cytogenetic analysis identifies new prognostic subgroups in chronic lymphocytic leukemia.

The identification of new genetic lesions in chronic lymphocytic leukemia (CLL) prompts a comprehensive and dynamic prognostic algorithm including gene mutations and chromosomal abnormalities and their changes during clonal evolution. By integrating mutational and cytogenetic analysis in 1274 CLL samples and using both a training-validation and a time-dependent design, 4 CLL subgroups were hierarchically classified: (1) high-risk, harboring TP53 and/or BIRC3 abnormalities (10-year survival: 29%); (2) intermediate-risk, harboring NOTCH1 and/or SF3B1 mutations and/or del11q22-q23 (10-year survival: 37%); (3) low-risk, harboring +12 or a normal genetics (10-year survival: 57%); and (4) very low-risk, harboring del13q14 only, whose 10-year survival (69.3%) did not significantly differ from a matched general population. This integrated mutational and cytogenetic model independently predicted survival, improved CLL prognostication accuracy compared with FISH karyotype (P < .0001), and was externally validated in an independent CLL cohort. Clonal evolution from lower to higher risk implicated the emergence of NOTCH1, SF3B1, and BIRC3 abnormalities in addition to TP53 and 11q22-q23 lesions. By taking into account clonal evolution through time-dependent analysis, the genetic model maintained its prognostic relevance at any time from diagnosis. These findings may have relevant implications for the design of clinical trials aimed at assessing the use of mutational profiling to inform therapeutic decisions.

The coding genome of splenic marginal zone lymphoma: activation of NOTCH2 and other pathways regulating marginal zone development.

Splenic marginal zone lymphoma (SMZL) is a B cell malignancy of unknown pathogenesis, and thus an orphan of targeted therapies. By integrating whole-exome sequencing and copy-number analysis, we show that the SMZL exome carries at least 30 nonsilent gene alterations. Mutations in NOTCH2, a gene required for marginal-zone (MZ) B cell development, represent the most frequent lesion in SMZL, accounting for ∼20% of cases. All NOTCH2 mutations are predicted to cause impaired degradation of the NOTCH2 protein by eliminating the C-terminal PEST domain, which is required for proteasomal recruitment. Among indolent B cell lymphoproliferative disorders, NOTCH2 mutations are restricted to SMZL, thus representing a potential diagnostic marker for this lymphoma type. In addition to NOTCH2, other modulators or members of the NOTCH pathway are recurrently targeted by genetic lesions in SMZL; these include NOTCH1, SPEN, and DTX1. We also noted mutations in other signaling pathways normally involved in MZ B cell development, suggesting that deregulation of MZ B cell development pathways plays a role in the pathogenesis of ∼60% SMZL. These findings have direct implications for the treatment of SMZL patients, given the availability of drugs that can target NOTCH, NF-κB, and other pathways deregulated in this disease.

Surgical debridement with VERSAJET: an analysis of bacteria load of the wound bed pre- and post-treatment and skin graft taken. A preliminary pilot study.

Surgical debridement, which is used for the removal of necrotic tissue from a wound, is becoming more and more important in the treatment of skin injuries. VERSAJET (VERSAJET™, Versajet Hydrosurgery System, Smith and Nephew, Hull, UK) is one of the techniques used for wound debridement. Medical literature does not present either analytical or comparative data correlating the bacterial load with the VERSAJET treatment. For this reason, we have decided to carry out a study to evaluate the level of bacterial contamination before and after the surgical debridement treatment with VERSAJET and, in connection with this, the correlation between the bacterial load and the successful healing of the skin graft. We took a total of 100 bacteriological swabs, 50 before and 50 from 27 selected patients after the treatment with VERSAJET, with which the wound bed was prepared to receive the skin graft or Integra graft in order to acquire data about the level of bacterial contamination. After analysing all those data we can assume that reducing the bacterial load is not the only variable which the successful healing of the skin graft depends on. In conclusion, there is still many data to analyse and study in order to better understand the qualitative and quantitative presence of bacteria and the success of this future surgical procedure. We remind that the performance of this study was not sponsored by any company.

Primer informe en Uruguay de la vitrificación de embriones como alternativa real a la técnica de congelación lenta / First report in Uruguay on vitrification of embryos as a real alternative to slow freezing

Introducción: la vitrificación es una técnica de criopreservación de las denominadas "rápidas". En comparación con los tradicionales procesos de congelación lenta, la estrategia de vitrificación permite la eliminación total de la formación de cristales tanto intracelular como extracelularmente. Permite poner las células directamente en el crioprotector y sumergirlas en N2 líquido. Su aplicación en el mundo ha ido creciendo exponencialmente y se puede aplicar tanto a ovocitos como a embriones en cualquier estadio. Objetivos: revisión de la técnica de vitrificación y presentación de la experiencia de dos años en el Centro Iberoamericano de Reproducción Asistida, la primera en Uruguay. Material y método: se incluyeron 17 pacientes de las que se han vitrificado y desvitrificado embriones. Se usó el método comercial Cryotop con las soluciones de vitrificación de Kitazato. Resultados: con una media de embriones vitrificados de 2,71 (±0,69) por paciente, la tasa de supervivencia global de los embriones tras la desvitrificación fue de 93,4%. Con una media deembriones transferidos de 2,41 ±0,62), la tasa final de embarazo fue de 47,1%. La edad de las pacientes en las que se logra embarazo es menor (media 30,0 ±2,51) que las que no lo logran.Conclusiones: la vitrificación como método de criopreservación se muestra prometedor y como buen sustituto de las técnicas de congelación lentas, debido a su alta tasa de éxito, su fiabilidad y la rapidez de ejecución, con resultados reproducibles.

Introduction: vitrification is a cryopreservation technique that forms part of the so called "fast" cryopreservation techniques. Compared to traditional slow freezing processes, vitrification enables the total elimination of both intracellular and extracellular crystal formation. It allows for placing the cells directly on the cryoprotector and submersing them in liquid nitrogen. Its application around the world has exponentially grown and the technique may be applied both to ovocytes and embryos at all stages. Objectives: to carry out a review of the vitrification technique, the first one to be conducted in Uruguay, and to present the two-year experience at the Ibero-American Center for Assisted Reproduction. Method: we included 17 patients in our study, the embryos of which have been vitrified and unvitrified. We used the commercial Cryotop method with the Kitazato vitrification solutions. Results: with an average of 2,71 (±0,69) vitrified embryos per patients, global embryo survival rate after vitrification was 93,4%. With an average of 2,41 (±0,62) embryos transferred , the final pregnancy rate was 47,1%. The average age of patients who succeeded in getting pregnant is lower (average 30,0 ±2,51) than those who fail to get pregnant. Conclusions: vitrification as a cryopreservation method appears to be a promising technique and seems to be a good substitute for show freezing technique, due to its high-success rates, its reliability and execution speed, with replicable results.

Introdução: a vitrificação é uma técnica de criopreservação do grupo das chamadas técnicas "rápidas". Comparada com os processos tradicionais de congelação lenta, a vitrificação permite eliminar totalmente a formação de cristais tanto intra como extracelulares. Permite também colocar as células diretamente no crioprotetor e submergi-las em N2 líquido. Em todo o mundo sua aplicação vem crescendo exponencialmente e pode ser utilizada tanto com ovócitos como a embriões em qualquer estágio. Objetivos: revisão da técnica de vitrificação e apresentação da experiência de dois anos no Centro Iberoamericano de Reprodução Assistida, a primeira no Uruguay. Material e método: foram incluídas 17 pacientes que cujos embriões haviam sido vitrificados e desvitrificados. O método comercial Cryotop com soluções de vitrificação de Kitazato foi utilizado. Resultados: A média de embriões vitrificados foi de 2,71 (±0,69) por paciente com uma taxa de sobrevivência global dos embriões depois da desvitrificação de 93,4%. Com uma média de embriões transferidos de 2,41 (±0,62), a taxa final de gravidez foi de 47,1%. A idade das pacientes que engravidaram (média 30,0 ±2,51) era menor que a das que não engravidaram. Conclusões: a vitrificação se apresenta como um método de criopreservação prometedor e um bom substituto das técnicas de congelação lenta devido às altas taxas de sucesso, sua confiabilidade e rapidez para sua execução, com resultados reproduzíveis.

Gene expression time-series analysis of camptothecin effects in U87-MG and DBTRG-05 glioblastoma cell lines.

BACKGROUND: The clinical efficacy of camptothecin (CPT), a drug specifically targeting topoisomerase I (TopoI), is under evaluation for the treatment of malignant gliomas. Due to the high unresponsiveness of these tumours to chemotherapy, it would be very important to study the signalling network that drives camptothecin outcome in this type of cancer cells. To address this issue, we had previously compared the expression profile of human U87-MG glioblastoma cells with that of a CPT-resistant counterpart, giving evidence that the development of a robust inflammatory response was the main transcriptional effect associated with CPT resistance. Here we report time-related changes and cell line specific patterns of gene expression after CPT treatment by using two p53 wild-type glioblastoma cell lines, U87-MG and DBTRG-05, with different sensitivities to TopoI inhibition. RESULTS: First, we demonstrated that CPT treatment brings the two cell lines to completely different outcomes: accelerated senescence in U87-MG and apoptosis in DBTRG-05 cells. Then, to understand the different susceptibility to CPT, we used oligo-microarray to identify the genes whose expression was regulated during a time-course treatment, ranging from 2 h to 72 h. The statistical analysis of microarray data by MAANOVA (MicroArray ANalysis Of VAriance) showed much less modulated genes in apoptotic DBTRG-05 cells (155) with respect to the senescent U87-MG cells (3168), where the number of down-regulated genes largely exceeded that of the up-regulated ones (80% vs. 20%). Despite this great difference, the two data-sets showed a large overlapping (60% circa) mainly due to the expression of early stress responsive genes. The use of High-Throughput GoMINER and EASE tools, for functional analysis of significantly enriched GO terms, highlighted common cellular processes and showed that U87-MG and DBTRG-05 cells shared many GO terms, which are related to the down-regulation of cell cycle and mitosis and to the up-regulation of cell growth inhibition and DNA damage.Furthermore, the down-regulation of MYC and DP1 genes, which act as key transcription factors in cell growth control, together with the inhibition of BUB1, BUB3 and MAD2 mRNAs, which are known to be involved in the spindle checkpoint pathway, were specifically associated with the execution of senescence in U87-MG cells and addressed as critical factors that could drive the choice between different CPT-inducible effectors programs. In U87-MG cells we also found inflammation response and IL1-beta induction, as late transcriptional effects of Topo I treatment but these changes were only partially involved in the senescence development, as shown by IL1-beta gene silencing. CONCLUSION: By comparing the transcription profile of two glioblastoma cell lines treated with camptothecin, we were able to identify the common cellular pathways activated upon Topo I inhibition. Moreover, our results helped in identifying some key genes whose expression seemed to be associated with the execution of senescence or apoptosis in U87-MG and DBTRG-05 cells, respectively.

Corynebacterium urealyticum urinary tract infection in a cat with urethral obstruction.

Corynebacterium urealyticum is an uncommon cause of urinary tract infections in cats. However, it is difficult to diagnose and if left untreated it may result in irreversible bladder lesions. C urealyticum is a multiantibiotic-resistant bacterium whose culture requires special care. Risk factors for the occurrence of this infection include urological procedures, foreign bodies, bladder mucosa abnormalities, immuno-suppressed states and antibiotic treatment. This report describes an unusual case of C urealyticum urinary infection in a young cat with pre-existing urethral obstruction. C urealyticum was isolated in pure cultures from two urine samples. Clinical and ultrasound features, results of the urinalysis and urine culture are described as well as therapeutic treatment and eventual favourable outcome to treatment with amoxycillin-clavulanic acid.

A cDNA-microarray analysis of camptothecin resistance in glioblastoma cell lines.

Chemotherapy, as generally available, is of a limited value in curing malignant brain tumors (gliomas), which often develop resistance to drugs, becoming completely unresponsive to any standard therapeutic approach. Camptothecins, a family of topoisomerase I inhibitor drugs, represent a new promising treatment strategy and are currently under evaluation for testing the clinical efficacy. We selected a CPT-resistant sub-line (U87CPT-R) from U87-MG grade III-IV astrocytoma cells, and compared the expression profile of the two cell lines by cDNA-microarray, as a preliminary screening of the molecular mechanisms involved in the acquisition of CPT resistance in glioma cells. The relevant role of IL-1 beta overproduction as well as a generalised up-regulation of genes implicated in angiogenesis and inflammatory response are discussed in details.