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.

Functional MRI study in a case of Charles Bonnet syndrome related to LHON.

INTRODUCTION: Charles Bonnet syndrome is characterized by simple or complex visual hallucinations (VH) due to damage along the visual pathways. We report a functional MRI study of brain correlates of VH in the context of a severe optic atrophy in a patient with Leber's Hereditary Optic Neuropathy (LHON). CASE REPORT: A 62-year-old man was diagnosed with LHON (11778/ND4 mtDNA mutation) after subacute visual loss in left eye (right eye was amblyopic). One month later, he experienced VH of a few seconds consisting in "moving red and blue miniature cartoons". One year later VH content changed in colored mosaic (10-15 s duration), usually stress-related, and blue and white flashes (2-5 s), triggered by unexpected auditory stimuli. Audiometry revealed mild sensorineural hearing loss. Three block design functional MRI paradigms were administrated: 1) random "clap", 2) "checkerboard" and 3) non-random "beep". After random "claps" simple flashes were evoked with bilateral activation of primary and secondary visual cortex, cuneus, precuneus and insula. Neither hallucinations nor cortex activation were registered after "checkerboard" stimulation, due to the severe visual impairment. Primary and secondary auditory cortices were "beep"-activated, without eliciting VH by non-random "beep". CONCLUSIONS: The peculiarity of our case is that VH were triggered by random auditory stimuli, possibly due to a cross-modal plasticity between visual and auditory networks, likely influenced by the sensorineural deafness. Functional alterations of both networks in resting conditions have been demonstrated in LHON patients, even without an auditory deficit. Finally, the absence of VH triggered by expected stimuli is consistent with the "expectation suppression theory", based on increased neural activations after unexpected but not by predicted events.

Loss of temporal retinal nerve fibers in Parkinson disease: a mitochondrial pattern?

BACKGROUND AND PURPOSE: Optic nerve involvement is frequent in mitochondrial disease, and retinal abnormalities are described in Parkinson's disease (PD). METHODS: We evaluated retinal nerve fiber layer (RNFL) thickness by optical coherence tomography in 43 patients with PD and in 86 age-matched controls. We considered separately the eyes ipsilateral and contralateral to the most affected body side in patients with PD. ancova analysis, Pearson test, and multiple regression analysis were used (P < 0.05). RESULTS: Patients with PD showed significantly thinner temporal RNFL thickness compared to controls (P = 0.004), more evident in the eye contralateral to the most affected body side. Average RNFL thickness significantly correlated with age in both controls and patients with PD (P-values ranging from 0.001 to 0.019), whereas in patients with PD RNFL thickness did not correlate with clinical variables. CONCLUSIONS: Our study reveals a loss of retinal nerve fibers in the temporal quadrant in PD, which is typically susceptible in mitochondrial optic neuropathies.

Body composition changes after laparoscopic adjustable gastric banding: what is the role of -174G>C interleukin-6 promoter gene polymorphism in the therapeutic strategy?

BACKGROUND: There is growing evidence that interleukin-6 (IL-6) is linked to the regulation of fat mass (FM). Our previous data define the common -174G>C IL-6 polymorphism as a marker for 'vulnerable' individuals at risk of age- and obesity-related diseases. An association between -174G>C IL-6 polymorphism and weight loss after bariatric surgery has been demonstrated. OBJECTIVE: We investigated the impact of -174G>C IL-6 polymorphism on weight loss, body composition, fluid distribution and cardiometabolic changes in obese subjects, after laparoscopic adjustable gastric banding (LAGB) surgery. DESIGN AND OUTCOME MEASURES: A total of 40 obese subjects were studied at baseline and at 6 months follow-up after LAGB surgery. Cardiometabolic and genetic assessment of -174G>C IL-6 polymorphism, anthropometric, body composition and fluid distribution analysis were performed. RESULTS: After LAGB surgery, significant reductions in weight (Δ%=-11.66 ± 7.78, P<0.001), body mass index (P<0.001), total and trunk FM (kg, %) (Δ% of total FM=-22.22 ± 12.15, P<0.01), bone mineral density (T-score) (P<0.001), resting metabolic rate (RMR) (P<0.01), and total body water and intracellular water (TBW, ICW) (P<0.05) were observed. At baseline, C(-) carriers of IL-6 polymorphism had a significantly higher RMR (P<0.05), free FM (kg), but less total and trunk FM (%), higher body cell mass (BCM), content of TBW (L) and ECW (extracellular water)/ICW ratio compared with C(+) carriers (P<0.001). After LAGB, C(+) carriers had a significantly stronger reduction of total FM (kg), but lower bone density, compared with C(-) carriers (P<0.05). CONCLUSIONS: Beyond the relationship between -174G>C IL-6 polymorphism and body composition, this study provides first evidence about the association of IL-6 variant with fluid distribution, at baseline, and FM and bone density loss in obese subjects at 6 months follow-up after LAGB surgery. LAGB was less effective if the subjects were carrying risk genotypes, C(-) carriers, for obesity, suggesting a role of genetic variations on bariatric surgery outcomes.

[Obesity and Eating Disorders. Indications for the different levels of care. An Italian Expert Consensus Document]. / Documento di Consensus. Obesità e Disturbi dell'Alimentazione Indicazioni per i diversi livelli di trattamento.

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

Effect of pupil dilation on retinal nerve fibre layer thickness measurements and their repeatability with Cirrus HD-OCT.

PURPOSE: To assess whether pupil dilation influences retinal nerve fibre layer (RNFL) thickness measurements provided by spectral-domain optical coherence tomography (SD-OCT) in healthy individuals. PATIENTS AND METHODS: In this observational case series, carried out in a private clinical practice, 32 eyes of 32 participants were investigated. Using Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA, USA) three individual 200 × 200 cube optic disc scans were obtained before and after pupil dilation. The RNFL thickness was the outcome measure. Coefficient of variation (COV) and test-retest variability were calculated. RESULTS: Pupil size did not influence RNFL thickness measurements: mean values did not change in any sector (except the 9 o'clock hour) after dilation. Excellent repeatability was achieved both before and after mydriasis. In the former condition, COV ranged between 1.37% (for average RNFL) and 4.46% (for clock hour 2 RNFL) and test-retest variability between 2.17 (for temporal quadrant RNFL) and 9.18 microm (for clock hour 6 RNFL). In the latter condition, COV ranged between 1.36% (for average RNFL) and 4.48% (for clock hour 2 RNFL) and test-retest variability between 2.41 (for average RNFL) and 9.29 microm (for clock hour 6 RNFL). The repeatability was higher than that previously reported for time-domain OCT. CONCLUSION: In eyes with clear media highly repeatable measurements of the RNFL thickness can be obtained by SD-OCT both before and after mydriasis.

Alpha-lipoic acid supplementation: a tool for obesity therapy?

Lipid peroxidation has supposed as the major biochemical alteration underling oxidant-induced cell injury in stress including numerous diseases. One of the natural molecules know to prevent or retard oxidation is alpha-lipoic acid (LA) and, therefore, the lipoic acid/dihydrolipoic acid (LA/DHLA) redox couple has received considerable attention. Recent studies have highlighted the potential of free LA and DHLA as powerful metabolic antioxidants that are able to scavenge the reactive oxygen species, to recycle other antioxidants. Our aim was to investigate the beneficial effects of LA in the treatment of Italian pre-obese and obese subjects. We screened 1612 subjects for enrollment; of these, 1127 subjects (445 men and 682 women, 18-60 age) met enrolment criteria and were enrolled in the study. According to body mass index (BMI) the 53% was obese and the 43% was pre-obese. The subjects were treated for 4 month with 800 mg/day of LA. In pre-obese subject significant reduction (p<0.001) of weight (8%, both gender), BMI (2 points), blood pressure, and abdominal circumference (female 6 cm, male 7 cm) were observed. In obese subjects significant reductions (p<0.001) of weight (9%, both gender), BMI (female 3 point, male 4 point), blood pressure and abdominal circumference (female 9 cm, male 11 cm) were observed. Our study indicated that LA is an ideal antioxidant candidate for the therapy of obesity related diseases. Further clinical studies should be considered to highlight the role and efficacy of LA treatment.

Optical coherence tomography, frequency-doubling technology, and colour Doppler imaging in ocular hypertension.

PURPOSE: To study in ocular hypertension (OH) the retinal nerve fibre layer (RNFL) with optical coherence tomography (OCT) and the neuronal function with frequency-doubling technology (FDT) to assess which of the two methods was more sensitive in detecting early glaucomatous damage. Furthermore, a colour Doppler imaging (CDI) of the optic nerve was carried out to highlight any correlation with RNFL thickness and FDT abnormality. MATERIALS AND METHODS: We enrolled 28 ocular hypertensive patients who underwent OCT of the RNFL and FDT. Moreover, we performed a CDI of the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary arteries (PCAs). RESULTS: The patients with OH following OCT revealed a significant thinning in the RNFL as compared to the control group only in the inferior quadrant: 122.250+/-14.091 vs131.750+/-10.729 mum (P<0.045). As regards FDT, there was a significant difference between the two groups only for pattern standard deviation (PSD): 3.873+/-1.488 vs1.938+/-0.704 dB (P<0.044). In OH and in the control group, CDI resistance index (RI) in the OA was 0.768+/-0.012 vs0.745+/-0.019 (P<0.022), in the CRA was 0.66+/-0.012 vs0.645+/-0.019 (P<0.032), and in PCAs was 0.673+/-0.039 vs0.622+/-0.012 (P<0.037). The OCT had a sensitivity of 83% but only in the inferior RNFL quadrant. The FDT-PSD revealed a sensitivity of 85%. CONCLUSIONS: Both FDT and OCT detect early glaucomatous damage with a slightly superior sensitivity of FDT vsOCT. The CDI measurements suggest that circulatory abnormalities may have a role in the development of OCT and FDT damage.

Resting metabolic rate incremented by pulsating electrostatic field (PESF) therapy.

Pulsating electrostatic field (PESF) therapy was investigated to assess the possibility of increasing the resting metabolic rate (RMR) in 14 adult females. The pumping effect of positive calcium and hydrogen ions was obtained by 30 min daily exposure to negative PESF, adjusted individually between 2 and 9 kV. This treatment could result in a buffering effect on blood pH and reduction of the rouleaux formation of erythrocytes, thus ameliorating the oxygen exchange potential and the red cell circulation in the capillary system. After PESF therapy, the average RMR (measured by indirect calorimetry) of 1255 kcal was increased on average by 323 kilocalories, indicating a possible role of PESF in the obesity treatment.

Body composition and respiratory function.

Although the effects of sex, ageing, height, race, and current and past health on pulmonary function tests have been described, only non-significant associations have been observed between body weight and lung function among healthy persons after having accounted for the effects of age and height. However, few studies have considered the influence of body compartments (e. g. lean and fat masses and their distribution) on lung function and respiratory gas exchange. The present work consists of a review of the literature on the effects of body weight components and body composition measurements on lung function. One of the important findings of this review was that the central (or upper body) pattern of fat distribution is negatively associated with airway function and that increases in body muscular mass result in linear increases for all spirometric variables in healthy persons. Nonetheless, the role that body composition plays in lung function still needs to be clarified.

Predicting fat-free mass in children using bioimpedance analysis.

Body composition assessment is a useful procedure for the study of nutritional status and water distribution. In adults, it is a predictor of morbidity and mortality, since body fatness is associated with risk factors for cardiovascular disease. Bioelectric impedance analysis (BIA) is a simple, safe, and inexpensive method for assessment of body composition both in pediatric and adult subjects. The aim of our study was to validate the impedance index, ZI (H(2)/Z, height in cm(2)/impedance), as a predictor factor of fatfree mass (FFM) and fat mass (FM) in a sample ( n=75) of normal children. Dual-energy X-ray absorptiometry (DXA) was chosen as reference method. Despite some minor bias, DXAis considerably less expensive and easier to administer in pediatric subjects than other established gold standard reference methods for assessing body composition. ZI values were highly correlated with FFM measured with DXA. The following equations were obtained from the regression analysis: (a). male subjects, FFM(DXA)=0.6375 (ZI)+5.9913, r(2)=0.897, p<0.0001; (b). female subjects, FFM(DXA)=0.7597 (ZI)+ 3.5853, r(2)=0.903, p<0.0001. These data support the notion that BIA alone can be used as a surrogate to measure FFM in a pediatric sample.

Body composition modification in obese patients treated with intragastric balloon.

At the Centre for the Therapy of Morbid Obesity, a multidisciplinary team attends severely obese patients in a day-care hospital setting. The patients' psychological and nutritional profiles are studied and their body composition investigated with bioelectrical impedance. After the diagnosis, several approaches are proposed; among them, the insertion of a Bioenterics Intragastric Balloon (BIB). For 6 months after insertion, patients were periodically examined and followed a strict personal regimen, behaviour schedule and physical activity programme compatible with the BIB. The results obtained from the first 20 subjects are encouraging. No severe complications have been reported, and after the BIB removal, subjects are maintaining the obtained results with some of them continuing to lose weight.

Effects of weight loss on body composition and pulmonary function.

BACKGROUND: The relationship between obesity, impaired respiratory function and weight loss is established. OBJECTIVE: Some aspects need further elucidation: the different impact of the pathological modifications of body compartments (total and regional fat mass and lean body mass) on respiratory function, the choice of a restricted diet, the relationship between the modifications of body compartments and the variations in respiratory parameters after weight loss. METHODS: The restricted diet was elaborated according to the traditional Mediterranean diet. In a series of 16 obese patients, respiratory function was assessed by spirometry; body composition was assessed by dual-energy X-ray absorptiometry, allowing the direct estimation of total and segmental body fat and lean body mass. RESULTS: Weight loss was sustained mainly by fat mass decrease, mostly upper body fat. Total and truncal lean body mass were not affected. Lung volumes and function were improved. A correlation was observed between lean body mass and respiratory parameters, and was unmodified after weight loss. CONCLUSIONS: Mediterranean-style restricted diet was well accepted and enabled a selective decrease in fat mass, with a good improvement in lung function. Truncal fat (as well as abdominal fat) was decreased, while truncal lean body mass (i.e. respiratory muscles) were not affected, as expected in obese subjects with respiration problems.

Monitoreo ambulatorio de la presión arterial en pacientes diabéticos: detección precoz de la hipertensión y cambios en el ritmo circadiano / Ambulatory monitoring of blood pressure in diabetic patients

El propósito de este trabajo fue establecer el comportamiento de la tensión arterial buscando hipertensión oculta y alteración del ritmo circadiano. Se estudiaron 35 pacientes diabéticos, 20 normotensos y 15 hipertensos,de los cuales 22 eran insulinodependientes y 13 no insulinodependientes, los quefueron comparados con 37 pacientes no diabéticos, 17 normotensos y 20 hipertensos.Se clasificó a los hipertensos según el criterio del Joint National Comittee de los Estados Unidos. A toda la población se le realizó monitoreo ambulatorio depresión arterial de 24 horas, aceptando como hipertensos a los pacientes que presentaban un 30 de las lecturas que excedían los valores 140/85 mm Hg. En la población diabética se evaluó el control metabólico por medio de hemoglobina glicosilada y la presencia de microangiopatía por microalbuminuria y retinofluoresceinografía. De los 35 pacientes diabéticos, 45.7 presentaron alteraciones del ritmo circadiano. Mientras que de los 20 pacientes diabéticos normotensos, al 60 sele diagnosticó hipertensión por medio del monitoreo ambulatorio.Estos resultadosponen en evidencia la necesidad de buscar hipertensión arterial en pacientes diabéticos, mediante el monitoreo ambulatorio de presión arterial de 24 horas, que permitiría el diagnóstico precoz, ofreciendo una posible prevención del daño queproduce en la evolución de las lesiones degenerativas de la diabetes y en el órgano blanco

Monitoreo ambulatorio de la presión arterial en pacientes diabéticos: detección precoz de la hipertensión y cambios en el ritmo circadiano / Ambulatory monitoring of blood pressure in diabetic patients

El propósito de este trabajo fue establecer el comportamiento de la tensión arterial buscando hipertensión oculta y alteración del ritmo circadiano. Se estudiaron 35 pacientes diabéticos, 20 normotensos y 15 hipertensos,de los cuales 22 eran insulinodependientes y 13 no insulinodependientes, los quefueron comparados con 37 pacientes no diabéticos, 17 normotensos y 20 hipertensos.Se clasificó a los hipertensos según el criterio del Joint National Comittee de los Estados Unidos. A toda la población se le realizó monitoreo ambulatorio depresión arterial de 24 horas, aceptando como hipertensos a los pacientes que presentaban un 30 de las lecturas que excedían los valores 140/85 mm Hg. En la población diabética se evaluó el control metabólico por medio de hemoglobina glicosilada y la presencia de microangiopatía por microalbuminuria y retinofluoresceinografía. De los 35 pacientes diabéticos, 45.7 presentaron alteraciones del ritmo circadiano. Mientras que de los 20 pacientes diabéticos normotensos, al 60 sele diagnosticó hipertensión por medio del monitoreo ambulatorio.Estos resultadosponen en evidencia la necesidad de buscar hipertensión arterial en pacientes diabéticos, mediante el monitoreo ambulatorio de presión arterial de 24 horas, que permitiría el diagnóstico precoz, ofreciendo una posible prevención del daño queproduce en la evolución de las lesiones degenerativas de la diabetes y en el órgano blanco (AU)