Upcoming Italian clinical practice guidelines on endoscopic bariatric treatment of overweight and obesity: design and methodological aspects.

Obesity/overweight 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) decided to develop the first Italian guidelines for the endoscopic bariatric treatment of obesity. The creation of SICOB Guidelines is based on an extended work made by a panel of 44 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. We will perform systematic reviews, formal meta-analyses, and network meta-analyses for each PICO and critical outcomes aimed at assessing and rating the efficacy and safety of endoscopic bariatric procedures in comparison with either no interventions, lifestyle interventions, or approved anti-obesity treatments in trials with a follow-up of at least 52 weeks. For PICO on temporary endoscopic bariatric treatments, we will also consider RCT with a minimum duration of 6 months. The panel proposed 8 questions, organized into four domains: A. Indication for endoscopic bariatric surgery; B. Revisional surgery; C. Temporary gastric and duodenal-jejunal procedures; D. Endoscopic diagnosis/treatment of bariatric and metabolic surgery complications. These guidelines will apply to patients aged ≥ 14 years) with body mass index (BMI) ≥ 27 kg/m2 and requiring endoscopic bariatric surgery or endoscopic diagnostic and/or therapeutic procedures. The areas covered by the clinical questions included indications of endoscopic bariatric surgery, types of surgery, revisional surgery, and management of bariatric and metabolic surgery complications.

The use of pediatric short-stay observation in Italy.

BACKGROUND: In Italy, the State Regions Conference on 1st August 2019 approved the Guidelines for Short-Stay Observation (SSO). At the beginning of 2022, the main Scientific Societies of the pediatric hospital emergency-urgency area launched a national survey to identify the extent to which these national guidelines had been adopted in the emergency rooms and pediatric wards of the Italian Regions. METHODS: A survey has been widespread, among Pediatric Wards and Pediatric Emergency Departments (EDs), using both a paper questionnaire and a link to a database on Google Drive, for those who preferred to fill it directly online. Those who did not spontaneously answer, where directly contacted, via email and/or through a phone call and invited to participate. The data collected have been: age of managed children, presence of triage, presence of Sub-intensive Care Unit and Intensive Care Unit and special questions about Pediatric SSO, availability of training courses for workers, number of ED access in the last 4 years. RESULTS: This survey is still ongoing, without a definite deadline, so we presented the preliminary data. Currently, 8/20 Regions have not yet adopted the Guidelines. Till 02 January 2023, data from 253 hospitals were collected. There are currently 180/253 active Pediatric SSO (71.03% of the Hospitals). There are not active SSO in 33.27% of first level ED, in 19.35% of second level ED and in 33.66% of General Hospitals with Pediatric Wards. Active SSO are located mainly (75.97%) within Pediatric Wards. At the moment, the survey has been completed in 16 Regions: in the 8 Regions which are using guidelines, pediatric SSOs are active in all the second level ED (compared to 60.87% of the other 8 regions), in the 91.66% of first level ED (compared to the 33.3%), and in the 97.1% of General Hospitals (compared to 33.3%), with a statistically significance (p < 0.0001). The territorial analysis of these 16 regions highlighted geographical differences in the percentage of SSOs active: 35.22% are active in hospitals in Southern Italy, 88.64% in Central Italy and 91.67% in those of the North. CONCLUSIONS: The delay in adopting specific guidelines negatively influences activation of pediatric SSOs in hospital system and prevents the adjustment of welfare level to new needs. To facilitate the activation of SSOs in hospitals, it is also necessary to guarantee adequate economic recognition. It is essential to implement public interventions to overcome the current inequalities in the interest of children and their families: the current delay seriously penalizes emergency pediatric hospital care, especially in the southern Italian Regions.

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.

A Longitudinal Study of Assisted Infant Toilet Training During the First Year of Life.

OBJECTIVE: Previous retrospective studies have examined elimination signals, stool toileting refusal, and completion age in Assisted Infant Toilet Training (AITT). The aim of this longitudinal cohort study was to describe the practice of AITT and caregiver satisfaction in a primarily Western setting during the first year of life. METHODS: Families who started AITT before 4 months of age were recruited. Standardized interviews of caregivers were conducted at 1- to 2-month intervals. To identify trends over time, data were fitted to a linear mixed-effect model. Data were analyzed according to five 2-month blocks, starting at 3 to 4 months. RESULTS: Of 85 participating families, 87 children started AITT at a mean age of 2.5 months. At all age intervals, 88% to 94% of caregivers could identify elimination signals. Toileting attempts decreased from 10/day at 3 to 4 months to 7/day at 11 to 12 months (p < 0.001). Many families (45%-53%) practiced AITT on a part-time basis. Daytime dryness was noted in 12% to 14% of infants throughout the first year. Although more than 63% of families used cloth or disposable diapers throughout this study, use of trainers and underwear increased significantly by 2- to 3-fold (p < 0.01 for both). Caregiver satisfaction was high overall. Although negatively associated with potty refusal, it was positively associated with daytime and nighttime dryness, perceived elimination signals, and a better understanding of their infant's needs (p < 0.001 for all). CONCLUSION: This study demonstrates that AITT is a worthy viable alternative to the use of diapers even in Western settings. Better understanding of AITT provides a new perspective to properly meet infants' basic needs.

Survival and complications in patients with thalassemia major treated with transfusion and deferoxamine.

BACKGROUND AND OBJECTIVES: Seven Italian centers reported data on survival, causes of death and appearance of complications in patients with thalassemia major. The interactions between gender, birth cohort, complications, and ferritin on survival and complications were analyzed. DESIGN AND METHODS: Survival after the first decade was studied for 977 patients born since 1960 whereas survival since birth and complication appearance was studied for the 720 patients born after 1970. Better survival was demonstrated for patients born in more recent years (p<0.00005) and for females (p=0.0003); 68% of the patients are alive at the age of 35 years. In the entire population 67% of the deaths were due to heart disease. RESULTS: There was a significant association between birth cohort and complication-free survival (p<0.0005). The prevalence of complications was: heart failure 6.8%, arrhythmia 5.7%, hypogonadism 54.7%, hypothyroidism 10.8%, diabetes 6.4%, HIV infection 1.7%, and thrombosis 1.1%. Lower ferritin levels were associated with a lower probability of heart failure (hazard ratio =3.35, p<0.005) and with prolonged survival (hazard ratio = 2.45, p<0.005), using a cut-off as low as 1,000 ng/mL. INTERPRETATION AND CONCLUSIONS: Survival and complication-free survival of patients with thalassemia major continue to improve, especially for female patients born shortly before or after the availability of iron chelation.

Serendipitous diagnosis of infracardiac total anomalous pulmonary venous return by umbilical venous catheter blood gas samples.

Total anomalous pulmonary venous return (TAPVR) is a rare congenital heart defect that occurs when all four pulmonary veins connect to the systemic venous circulation. We describe a full-term male neonate who presented with cyanosis and mild tachypnea shortly after birth. One umbilical artery and the umbilical vein were catheterized, and oxygen treatment was provided. Four echocardiograms indicated severe pulmonary hypertension and were negative for any congenital heart defects. After the umbilical artery catheter was removed, high partial pressure of oxygen was detected in blood samples drawn from the umbilical venous catheter that was positioned below the diaphragm. Based on this finding, TAPVR was suspected and confirmed with angiography through a central venous catheter. The neonate underwent a successful surgical repair to correct the cardiac defect.

Assisted infant toilet training in a Western family setting.

In the Western world, independent toilet training usually starts at age 18 months or later. In Asia and Africa, assisted toilet training traditionally starts between one and three months and is completed within approximately one year. This article reports a male infant who started caregiver-assisted toilet training at age 33 days in a Western family setting. During the first days, the caregiver made observations of the infant's bowel movement schedule and the cues he provided, from which she learned when to assist him to eliminate in the bathroom. During the elimination process, the infant was held in an "in-arms" position, with close contact between the infant's back and the caregiver's chest. Meanwhile, the caregiver gave vocal signals to prompt the infant to eliminate. Successful bowel training was completed at five months. This case report shows that early infant toilet training is possible in a Western family setting if the caregiver properly learns the infant's natural elimination timing and signals.

Automated external defibrillators for children: what is new?

Although automated external defibrillators (AEDs) have been available for adults for more than 20 years, their use in children under 8 years of age has been approved by the International Liaison Committee on Resuscitation (ILCOR) as recently as June 2003. The following concerns about AEDs limited their use in children: amount of delivered energy, effect of biphasic waveforms in children, pad size, and capacity of detecting pediatric shockable and non-shockable rhythms. Lately, a new generation of AEDs addressed these issues and new encouraging data are available. New AEDs safely identify pediatric shockable and non-shockable rhythms and deliver fixed lower energy shocks through pads of appropriate size. This perspective briefly describes the main advances which heralded the new recommendations of ILCOR. Randomized clinical trials are now needed to identify whether these new pediatric devices can improve the outcome of pediatric cardiac arrest.

Pediatric obesity: looking into treatment.

Prevalence of pediatric obesity continues to rise worldwide. Increasing the number of health care practitioners as well as pediatricians with expertise in obesity treatment is necessary. Because many obese patients suffer obesity-associated cardiovascular, metabolic and other health complications that could increase the severity of obesity, it is fundamental not only to identify the child prone to obesity as early as possible, but to recognize, treat and monitor obesity-related diseases during adolescence. This short review outlines the treatment of pediatric obesity that may have applications in the primary care setting. It examines current information on eating behavior, sedentary behavior, and details studies of multidisciplinary, behavior-based, obesity treatment programs. We also report the less common and more aggressive forms of treatment, such as medication and bariatric surgery. We emphasize that health care providers have the potential to improve outcomes by performing early identification, helping families create the best possible home environment, and by providing structured guidance to obese children and their families.

Routine coagulation tests in newborn and young infants.

BACKGROUND: The diagnostic approach to haemostatic defects in the newborn is challenging and requires appropriate interpretation of coagulation tests according to reference values dependent on the postnatal age. METHODS: This investigation was designed to study the postnatal development of the human coagulation system in newborn infants and to develop appropriate reference ranges for prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (FBG) according at the day of birth and for the following postnatal period (days 1, 2, 3, 4, 5, 6, from 7 to 10 and from 11 to 44). RESULTS: The mean FBG value was already within the adult reference range in newborns at birth, the mean PT value fell within the adult reference range in infants aged 4 days or more, whereas the mean APTT value was still higher than the upper limit of the adult reference range in infants aged between 11 and 20 days. The prevalence of infants with pathological values according to the actual adult reference ranges was limited for FBG (from 24 to 7%), decreased from 92 to 8% in infants aged 0 and 11-20 days for PT, but remained elevated throughout the observational period for APTT (from 94 to 71%). CONCLUSIONS: The results of the present investigation demonstrate that the actual adult reference ranges for coagulation screening tests, especially PT and APTT, cannot be applied to newborns and young infants.

Familial haemophagocytic lymphohistiocytosis: survival of a premature twin with immuno-chemotherapy and bone marrow transplantation from an HLA-identical unrelated donor.

UNLABELLED: We describe a premature twin born at 30 wk of gestational age, affected with familial haemophagocytic lymphohistiocytosis. Two different mutations were identified in his DNA: one inherited from the mother and one from the father. Haemophagocytosis had been confirmed in his twin brother, who died soon after birth, as well as in the re-evaluation of the autopsy of his older sister, who died 1 y earlier. At 26 d of age, chemotherapy and immune-suppressive treatment were started according to the HLH-94 protocol. At 6 mo of age, a bone marrow transplant from an HLA-identical, unrelated volunteer was performed. Now at 32 mo of age, the infant is healthy and without signs of graft-versus-host disease. CONCLUSION: This case report shows that immuno-chemotherapy and allogenic bone marrow transplant are feasible even in premature infants affected with familial haemophagocytic lymphohistiocytosis, which should be ruled out in unknown bleeding disorders of neonates.

Long-term treatment of Barth syndrome with pantothenic acid: a retrospective study.

We report on three patients (two are brothers) with confirmed Barth syndrome treated with pantothenic acid. This treatment is still controversial and only one study has reported positive results to date. In our patients, long-term treatment has failed to reduce the number of infectious episodes and prevent dilated cardiomyopathy. Our cases show that this treatment is not as effective in Barth syndrome as was previously claimed.

Neonatal screening for glucose-6-phosphate dehydrogenase deficiency fails to detect heterozygote females.

We examined glucose-6-phosphate dehydrogenase (G6PD) deficiency in north-eastern Italian Caucasian neonates detected by neonatal screening, in order to measure the incidence of heterozygote females detected by neonatal screening, and to estimate the near-true total incidence. A total of 85,437 Caucasian neonates, born between January 2000 and December 2001, have been enclosed in the study. The total incidence of the disease, measured by fluorescent method, is 0.9 per thousand; the total incidence, calculated by Hardy-Weinberg law, is 4.8 per thousand. The frequency of missed females is 93% of total females expected with G6PD deficiency; most of them are very likely heterozygous females. The sensitivity of the fluorescent method might be not sufficient to detect all females. Since heterozygote females might develop the symptoms of G6PD deficiency later, these results suggest that the G6PD neonatal screening may not be helpful in preventing disease in females.