Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement

IntroductionLoss of skeletal muscle mass and function (sarcopenia) is common in individuals with obesity due to metabolic changes associated with a sedentary lifestyle, adipose tissue derangements, comorbidities (acute and chronic diseases) and during the ageing process. Co-existence of excess adiposity and low muscle mass/function is referred to as sarcopenic obesity (SO), a condition increasingly recognized for its clinical and functional features that negatively influence important patient-centred outcomes. Effective prevention and treatment strategies for SO are urgently needed, but efforts are hampered by the lack of a universally established SO definition and diagnostic criteria. Resulting inconsistencies in the literature also negatively affect the ability to define prevalence as well as clinical relevance of SO for negative health outcomes.Aims and MethodsThe European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) launched an initiative to reach expert consensus on a definition and diagnostic criteria for SO. The jointly appointed international expert panel proposes that SO is defined as the co-existence of excess adiposity and low muscle mass/function. The diagnosis of SO should be considered in at-risk individuals who screen positive for a co-occurring elevated body mass index or waist circumference, and markers of low skeletal muscle mass and function (risk factors, clinical symptoms, or validated questionnaires). Diagnostic procedures should initially include assessment of skeletal muscle function, followed by assessment of body composition where presence of excess adiposity and low skeletal muscle mass or related body compartments confirm the diagnosis of SO. Individuals with SO should be further stratified into stage I in the absence of clinical complications or stage II if cases are associated with complications linked to altered body composition or skeletal muscle dysfunction.ConclusionsESPEN and EASO, as well as the expert international panel, advocate that the proposed SO definition and diagnostic criteria be implemented into routine clinical practice. The panel also encourages prospective studies in addition to secondary analysis of existing data sets, to study the predictive value, treatment efficacy and clinical impact of this SO definition.     

Standardprozeduren für Erwachsene in akkreditierten Schlafmedizinischen Zentren in Europa

The present paper describes standardised operating procedures (SOP) within clinical sleep medicine. As such, it is a continuation of the previously published European Guidelines for the Accreditation of Sleep Medicine Centres (SMC) and European Guidelines for the Certification of Professionals in Sleep Medicine, aimed at creating standards of practice in European sleep medicine. It is also part of a broader action plan of the European Sleep Research Society (ESRS). In an updated section, the cost-effectiveness of sleep medicine and its relevance for resource allocation of general health care is emphasized. The following section of this paper is the translation of the guideline of the ESRS into German language: Fischer J, Dogas Z, Bassetti CL et al. (2012) Standard procedures for adults in accredited sleep medicine centres in Europe. J Sleep Res 2012; 21:357–368. In the current paper, the SOPs in sleep medicine centres regarding the diagnostic and therapeutic management of patients evaluated at SMC, accredited according to the European Guidelines, are primarily based on prevailing evidence-based medicine principles. In addition, parts of the SOPs are based on a formalized consensus procedure applied by a group of Sleep Medicine Experts from the European National Sleep Societies (ANSS). For the workload of the professionals in different SOPs, consensus was also achieved. The final recommendations for SOPs are categorized either as “standard practice”, “procedure that could be useful”, “procedure that is not useful” or “procedure with insufficient information available”. The SOPs described here include both subjective and objective testing, as well as recommendations for follow-up visits and for ensuring patient-safety in sleep medicine. The overall goal of the current SOPs is the further development of excellence in practice and quality assurance of sleep medicine in Europe.     

European Guidelines for Obesity Management in Adults

Obesity is a chronic metabolic disease characterised by an increase of body fat stores. It is a gateway to ill health, and it has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. In clinical practice, the body fatness is estimated by BMI, and the accumulation of intra-abdominal fat (marker for higher metabolic and cardiovascular disease risk) can be assessed by waist circumference. Complex interactions between biological, behavioural, social and environmental factors are involved in regulation of energy balance and fat stores. A comprehensive history, physical examination and laboratory assessment relevant to the patient''s obesity should be obtained. Appropriate goals of weight management emphasise realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims. Balanced hypocaloric diets result in clinically meaningful weight loss regardless of which macronutrients they emphasise. Aerobic training is the optimal mode of exercise for reducing fat mass while a programme including resistance training is needed for increasing lean mass in middle-aged and overweight/obese individuals. Cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss and weight loss maintenance. Pharmacotherapy can help patients to maintain compliance and ameliorate obesity-related health risks. Surgery is the most effective treatment for morbid obesity in terms of long-term weight loss. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment. Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management.Key Words: European guidelines, Obesity management, Multidisciplinary, Primary care, OMTF, COMs     

ESCMID generic competencies in antimicrobial prescribing and stewardship: towards a European consensus

Objective

To develop a consensus-based set of generic competencies in antimicrobial prescribing and stewardship for European prescribers through a structured consensus procedure.

European guidelines for the accreditation of Sleep Medicine Centres

This document describes guidelines for accreditation of Sleep Medicine Centres in Europe. These guidelines are the result of a consensus procedure, in which representatives of the European Sleep Research Society (ESRS) and representatives of different European National Sleep Societies (ENSS) were involved. The information obtained during different rounds of consultation was gathered and processed by the members of the Steering Committee of the ESRS. The scope of the guidelines is to define the characteristics of multidisciplinary Sleep Medicine Centres (SMCs), in terms of requirements regarding staff, operational procedures and logistic facilities. Accreditation of SMCs is proposed to be the responsibility of the individual ENSS. The Accreditation Guidelines may thus be considered an instrument for the national societies to develop new or standardize existing accreditation questionnaires, as well as procedures for visiting the site, drafting the accreditation report, and finally, granting the accreditation. The Accreditation Guidelines are meant to be a line of action, that ideally should be followed as close as possible, but that may be subject to certain exceptions, depending on local customs or regulations.     

Metabolic Mechanisms in Obesity and Type 2 Diabetes: Insights from Bariatric/Metabolic Surgery

Obesity and the related diabetes epidemics represent a real concern worldwide. Bariatric/metabolic surgery emerged in last years as a valuable therapeutic option for obesity and related diseases, including type 2 diabetes mellitus (T2DM). The complicated network of mechanisms involved in obesity and T2DM have not completely defined yet. There is still a debate on which would be the first metabolic defect leading to metabolic deterioration: insulin resistance or hyperinsulinemia? Insight into the metabolic effects of bariatric/metabolic surgery has revealed that, beyond weight loss and food restriction, other mechanisms can be activated by the rearrangements of the gastrointestinal tract, such as the incretinic/anti-incretinic system, changes in bile acid composition and flow, and modifications of gut microbiota; all of them possibly involved in the remission of T2DM. The complete elucidation of these mechanisms will lead to a better understanding of the pathogenesis of this disease. Our aim was to review some of the metabolic mechanisms involved in the development of T2DM in obese patients as well as in the remission of this condition in patients submitted to bariatric/metabolic surgery.Key Words: Obesity, Type 2 diabetes, Metabolic surgery, Hyperinsulinemia, Insulin resistance, Surgical food restriction, Incretins     

The Assessment of Eating Behaviour in Children Who Are Obese: A Psychological Approach. A Position Paper from the European Childhood Obesity Group

ObjectiveThis paper introduces health professionals to the different psychological models thought to influence eating behaviour in the absence of hunger in children who are obese and to propose a method of assessing these behaviours in practice.MethodsClinical researchers from the European Childhood Obesity Group (ECOG) adopted an evidence-based approach to examine the literature concerning the assessment of eating behaviour in children who are obese. Studies published in English were filtered out of the medical and psychological literature from 1960 to the present, and the resulting bibliography was searched for relevant articles. Key themes from the current evidence were compiled and classified according to the underpinning psychological models. Based on the current evidence and the authors'' combined clinical experience, a three-staged approach to assessment was agreed by consensus.ResultsValid and reliable tools for assessing and monitoring each of the three identified models (Dietary Restraint Theory, Emotional Eating and the Diathesis-Stress Model) are suggested for use in clinical practice, and the ECOG three-staged approach to assessing eating behaviours in the absence of hunger is described.ConclusionsThis paper presents practical guidance on how to assess eating behaviour in the absence of hunger in children who are clinically obese and suggests a focus for future research.Key Words: Children, Obesity, Psychological assessment, Eating behaviour     

JCL roundtable: South Asian atherosclerotic risk

South Asian risk for atherosclerotic cardiovascular disease (ASCVD) has received special emphasis in the 2018 US AHA/ACC/Multisociety Cholesterol Guidelines. The term “South Asian” refers specifically to the countries of India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives and to the worldwide diaspora of families from these countries. With this definition, approximately 25% of the world's population is South Asian, but about 50% of ASCVD occurs in this group. In this JCL Roundtable, we discuss the roles of visceral adiposity, diabetes, and features of the metabolic syndrome; lipoprotein(a); and diet and lifestyle, including the transition of both diet and lifestyle over the past 40 to 50 years. Genetic and/or hidden risk is an area of ongoing research. Individual patient assessment and intervention should recognize the earlier onset of ASCVD and the value of screening for traditional risk factors as well as waist circumference, coronary artery calcium scoring, and lipoprotein(a) assay. Culturally acceptable dietary strategies are available, although not widely implemented or evaluated as yet. In very-high-risk cases of secondary prevention, one should consider combining medications to drive low-density lipoprotein cholesterol much lower than 70 mg/dL. Our discussion concludes by insisting that the signal of alarm must be accompanied by decisive action.     

Criteria for EASO-collaborating centres for obesity management

Obesity is recognised as a global epidemic and the most prevalent metabolic disease world-wide. Specialised obesity services, however, are not widely available in Europe, and obesity care can vary enormously across European regions. The European Association for the Study of Obesity (EASO, www.easo.org) has developed these criteria to form a pan-European network of accredited EASO-Collaborating Centres for Obesity Management (EASO-COMs) in accordance with accepted European and academic guidelines. This network will include university, public and private clinics and will ensure that the obese and overweight patient is managed by a holistic team of specialists and receives comprehensive state-ofthe-art clinical care. Furthermore, the participating centres, under the umbrella of EASO, will work closely for quality control, data collection, and analysis as well as for education and research for the advancement of obesity care and obesity science.     

Standard procedures for adults in accredited sleep medicine centres in Europe

The present paper describes standardized procedures within clinical sleep medicine. As such, it is a continuation of the previously published European guidelines for the accreditation of sleep medicine centres and European guidelines for the certification of professionals in sleep medicine, aimed at creating standards of practice in European sleep medicine. It is also part of a broader action plan of the European Sleep Research Society, including the process of accreditation of sleep medicine centres and certification of sleep medicine experts, as well as publishing the Catalogue of Knowledge and Skills for sleep medicine experts (physicians, non-medical health care providers, nurses and technologists), which will be a basis for the development of relevant educational curricula. In the current paper, the standard operational procedures sleep medicine centres regarding the diagnostic and therapeutic management of patients evaluated at sleep medicine centres, accredited according to the European Guidelines, are based primarily on prevailing evidence-based medicine principles. In addition, parts of the standard operational procedures are based on a formalized consensus procedure applied by a group of Sleep Medicine Experts from the European National Sleep Societies. The final recommendations for standard operational procedures are categorized either as 'standard practice', 'procedure that could be useful', 'procedure that is not useful' or 'procedure with insufficient information available'. Standard operational procedures described here include both subjective and objective testing, as well as recommendations for follow-up visits and for ensuring patients' safety in sleep medicine. The overall goal of the actual standard operational procedures is to further develop excellence in the practice and quality assurance of sleep medicine in Europe.     

Modern pathology methods for neural investigations

This session at the 2010 joint symposium of the Society of Toxicologic Pathology (STP) and the International Federation of Societies of Toxicologic Pathologists (IFSTP) explored modern neuropathology methods for assessing the neurotoxicologic potential of xenobiotics. Conventional techniques to optimally prepare and evaluate the central and peripheral neural tissues while minimizing artifact were reviewed, and optimal schemes were set forth for evaluation of the nervous system during both routine (i.e., general toxicity) studies and enhanced (i.e., specialized neurotoxicity) studies. Stereology was introduced as the most appropriate means of examining the possible impact of toxicants on neural cell numbers. A focused discussion on brain sampling took place among a panel of expert neuroscientists (anatomists and pathologists) and the audience regarding the proper balance between sufficient sampling and cost- and time-effectiveness of the analysis. No consensus was reached on section orientation (coronal sections of both sides vs. a parasagittal longitudinal section with several unilateral hemisections from the contralateral side), but most panelists favored sampling at least 8 sections (or approximately double to triple the current complement) in routine toxicity studies.     

EAACI consensus statement for investigation of work-related asthma in non-specialized centres

Work-related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work-up of WRA, nor to be a formal evidence-based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in-depth investigations in a specialized centre. No evidence-based system could be used because of the low grade of evidence of published studies in this area, and instead, 'key messages' or 'suggestions' are provided based on consensus of the expert panel members.     

Basal metabolic rate of inuit

Basal metabolic rates (BMR) at the end of the winter of 1981–1982 were determined in both Inuit and subjects of European ancestry resident in Igloolik, N.W.T. (69°40'N, 81°W). Values for the Inuit sample (22 females, 14–53 years, and 30 males, 14–70 years) exceeded published body surface area norms by some 16–18%; they also exceeded the body mass norms of Schofield (1985) by 9–10%. In contrast, readings on the six subjects of European ancestry, obtained by the same observer, using the same Douglas bag technique, agreed closely with both sets of published norms. When data were expressed per unit of lean body mass, values were again 10–12% higher in the Inuit. Concomitant recordings of heart rate did not suggest that the BMRs of the Inuit subjects were increased by anxiety. Contrary to findings in the subjects of European ancestry, BMRs appeared to be higher in the elderly than in young and middle-age Inuit. This could reflect two consequences of a more traditional lifestyle among the older members of the Igloolik population: greater exposure to a very cold external environment, and greater consumption of “country” foods rich in protein and fat. © 1995 Wiley-Liss, Inc.     

Mitochondria as Pharmacological Targets: The Discovery of Novel Anti-Obesity Mitochondrial Uncouplers from Africa's Medicinal Plants

Obesity results from prolonged positive imbalance between energy in take and expenditure. When food intake chronically exceeds the body''s energy need, an efficient metabolism results in the storage of the excess energy as fat. Mitochondria are the main centre for energy production in eukaryotic cells. Mitochondrial proton cycling is responsible for a significant proportion of basal or standard metabolic rate, therefore, further uncoupling of mitochondria may be a good way to increase energy expenditure and hence represent a good pharmacological target for the treatment of obesity. This implies that, any chemical agent or photochemical compound that further uncouples the mitochondria in vivo without having any effect on mitochondria activity could be a potential target in finding treatment for obesity. In the past, uncoupling by 2, 4-dinitrophenol has been used this way with notable success. This paper discusses the mitochondria as targets in the discovery of potential plant natural anti-obesity products from Africa''s rich rainforests.     

Management of adenovirus infection in patients after haematopoietic stem cell transplantation: State‐of‐the‐art and real‐life current approach

The important insights gained over the past years in diagnosis and treatment of invasive adenoviral infections provide new paradigms for the monitoring and clinical management of these life‐threatening complications. A meeting was held to discuss and subsequently disseminate the current advances in our understanding of the aetiology/pathogenesis and future treatment options facilitating effective control or prevention of adenovirus‐related diseases in the allogeneic haematopoietic stem cell transplant setting. Invited experts in the field discussed recent progress with leading members of the Infectious Diseases Working Party of the European Society of Blood and Marrow Transplantation at the “State‐of‐the‐art” Meeting in Poznan, Poland, in October 2017. In this review article, the panel of experts presents a concise summary of the current evidence based on published data from the last 15 years and on recent achievements resulting from real‐life practice. The present position statement reflects an expert opinion on current approaches to clinical management of adenovirus infections in patients undergoing allogeneic haematopoietic stem cell transplant and provides graded recommendations of the panel for diagnostic approaches and preemptive therapy reflecting the present state of knowledge.     

Dataset for reporting of carcinoma of the urethra (in urethrectomy specimens): recommendations from the International Collaboration on Cancer Reporting (ICCR)

The International Collaboration on Cancer Reporting (ICCR) is a not‐for‐profit organisation sponsored by the Royal Colleges of Pathologists of Australasia and the United Kingdom, the College of American Pathologists, the Canadian Association of Pathologists in association with the Canadian Partnership Against Cancer, the European Society of Pathology, the American Society of Clinical Pathology and the Faculty of Pathology, Royal College of Physicians of Ireland. Its goal is to produce standardised, internationally agreed‐upon, evidence‐based datasets for cancer pathology reporting throughout the world. This paper describes the development of a cancer dataset by the multidisciplinary ICCR expert panel for the reporting of carcinoma of the urethra in urethrectomy specimens. The dataset is composed of ‘required’ (mandatory) and ‘recommended’ (non‐mandatory) elements, which are based on a review of the most recent evidence and supported by explanatory commentary. Fourteen required elements and eight recommended elements were agreed by the international dataset authoring committee to represent the essential/required (core) and recommended (non‐core) information for the reporting of carcinoma of the urethra in urethrectomy specimens. Use of an internationally agreed, structured pathology dataset for reporting carcinoma of the urethra (in urethrectomy specimens) will provide the necessary information for optimal patient management, will facilitate consistent data collection and will provide valuable data for research and international benchmarking. The dataset will be valuable for those countries and institutions that are not in a position to develop their own datasets.     

Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group

BackgroundAntimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations.MethodsAn international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members.ResultsWe propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design.ConclusionsResearchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.     

Metabolic regulation by protein tyrosine phosphatases

Obesity and the metabolic syndrome and their associated morbidities are major public health issues, whose prevalence will continue to increase in the foreseeable future. Aberrant signaling by the receptors for leptin and insulin plays a pivotal role in development of the metabolic syndrome. More complete molecular-level understanding of how both of these key signaling pathways are regulated is essential for full characterization of obesity, the metabolic syndrome, and type II diabetes, and for developing novel treatments for these diseases. Phosphorylation of proteins on tyrosine residues plays a key role in mediating the effects of leptin and insulin on their target cells. Here, we discuss the molecular methods by which protein tyrosine phosphatases, which are key physiological regulators of protein phosphorylation in vivo, affect signaling by the leptin and insulin receptors in their major target tissues.     

Regulations and practices of genetic counselling in 38 European countries: the perspective of national representatives

The aim of this article is to review the national regulations and practices of genetic counselling in 38 European countries, and to examine how well they intersect the ideals of genetic counselling defined in international guidelines. Using an electronic survey, representatives of the National Societies of Human Genetics in 29 countries, and appropriate contact persons for the field of genetic counselling in 9 other countries, were asked about the regulations and practices. The answers showed that consent, confidentiality, genetic counselling in the context of prenatal diagnosis, those professionals who may perform genetic counselling, and non-directiveness were the topics most often either agreed upon among professionals or regulated in those countries. These are also among the key aspects of ideal genetic counselling, based on international guidelines. Counselling in the context of susceptibility testing for multifactorial diseases, counselling people from ethnic minorities and recontacting the counsellees, on the contrary, were topics regulated or guided by generally applied practices in only few countries. Many of the answers expressed a desire for more regulation of genetic counselling, and that more uniform practices of education and organization of genetic counselling would be welcome in Europe.