Liraglutide 3.0 mg in the treatment of adults with obesity and prediabetes using real-world UK data: A clinical evaluation of a multi-ethnic population

UK guidelines recommend liraglutide 3.0 mg in adults treated within specialist weight management services with BMI ≥35 kg/m2, prediabetes and high cardiovascular disease risk. We aimed to clinically evaluate liraglutide 3.0 mg in specialist weight management services. We evaluated liraglutide 3.0 mg in weight management services at Guys and St Thomas' NHS Foundation Trust. Objective body weight (BW) was measured at baseline and 4 months, allowing classification as 'responders' (≥5% BW reduction) and 'non-responders' (<5% BW reduction). One hundred and twenty-one patients were evaluated. At 4 months, 76.0% attended follow-up (82.6% responders, 17.4% non-responders); BW (-8.6 kg, 95%CI:-9.8, -7.4 kg), BMI (-3.2 kg/m2, 95%CI: -3.6, -2.8) and %-BW (-6.6%, IQR: -8.8%, -5.2%) significantly reduced. In responders, HbA1c reduced by -5.0 mmol/mol (IQR: -7.0. -4.0 mmol/mol). In responders BW continued to reduce up to 12 months (4 m: -10.2 kg, p < .0001; 6 m: -15.6 kg, p < .0001; 9 m: -16.5 kg, p < .0001; 12 m: -16.7 kg, p < .01). Those of Black African and Caribbean ethnicity experienced less BW loss than those of white ethnicity (4.12 kg, p = .017) and had a greater attrition rate. In adults with obesity and prediabetes who are treated within specialist weight management services, liraglutide 3.0 mg reduces BW and HbA1c. Those of Black African and Caribbean ethnicity experienced less BW reduction and greater attrition at 4 months. Further evaluation of the ethnic differences in response to obesity pharmacotherapy is required.

Suspected intoxication by Kikuyu grass (Cenchrus clandestinus) of dairy cattle in the Azores, Portugal

CASE HISTORY

An outbreak of suspected Kikuyu grass (Cenchrus clandestinus) intoxication among dairy cattle occurred on the island of Terceira in the Azores (Portugal), in October 2022. The animals affected were non-lactating dairy cows and heifers from five small farms grazing (free or tethered) a Kikuyu-dominant pasture. Of the 29 animals exposed, 17 were affected, and eight (five heifers and three adult cows) died, resulting in a morbidity rate of 58%, a mortality rate of 28% and a case mortality rate of 47%.

CLINICAL FINDINGS AND TREATMENT

The clinical signs were non-specific and inconsistent, and included dry faeces, some with dark red blood; apathy and prostration; abdominal dilatation; tachycardia; tachypnoea; pale or jaundiced mucous membranes; sham drinking; sialorrhoea; and moderate to severe dehydration. Symptomatic treatment was provided but was ineffective. Haematology and serum biochemistry revealed an acute inflammatory leukogram, increased alkaline phosphatase (ALP) activity, decreased gamma-glutamyl transferase (GGT) activity, and azotaemia.The most consistent necropsy findings were haemorrhages in the epicardium and endocardium, an enlarged liver with rounded edges, non-perforated abomasal ulcers, and haemorrhagic lesions in the small and large intestines. Histopathology indicated myocarditis, hepatitis, interstitial nephritis, enteritis and colitis.Several fungal species were isolated from grass samples taken from affected pastures including several Fusarium spp., the genus implicated in Kikuyu toxicosis. Immediate removal of the animals from the pasture with Kikuyu was the only measure that prevented new cases and resulted in the recovery of some of the less affected animals.

DIAGNOSIS

The epidemiological features of this outbreak and the clinical signs and micro- and macroscopic lesions observed were highly suggestive of Kikuyu grass poisoning.

CLINICAL RELEVANCE

Although the weather conditions varied from other published cases, the grazing conditions (almost exclusive Kikuyu grass) and the post-mortem findings were very similar to those described in the literature, particularly the haemorrhages in the epicardium and endocardium. Kikuyu grass is very invasive and presents many desirable characteristics as cattle feed. Thus, an increase in cases of intoxication may be expected. Practitioners and farmers in areas where Kikuyu grass is abundant should be aware of the potential risks of grazing cattle exclusively on these pastures. They should also be aware of the early and subtle signs of Kikuyu intoxication to allow for timely removal of the animals from pasture.

Laparoscopic adjustable gastric banding with liraglutide in adults with obesity and type 2 diabetes (GLIDE): a pilot randomised placebo controlled trial

INTRODUCTION

Obesity drives type 2 diabetes (T2DM) development. Laparoscopic adjustable gastric banding (LAGB) has lower weight reduction than other bariatric procedures. Liraglutide, a GLP-1 receptor agonist, improves weight and glycaemic control in patients with T2DM. This study aimed to determine the efficacy and safety of liraglutide 1.8 mg in participants undergoing LAGB.

METHODS

GLIDE, a pilot randomised, double-blind, placebo-controlled trial, evaluated LAGB with either liraglutide 1.8 mg or placebo in participants with T2DM and obesity. Participants were randomised (1:1) to 6-months therapy post-LAGB, with further 6 months off-treatment follow-up. The primary outcome was change in HbA1c from randomisation to the end of treatment, secondary outcomes included body weight change. A sample size of 58 (29 per group) had 80% power to detect a 0.6% difference in HbA1c between groups.

RESULTS

Twenty-seven participants were randomised to liraglutide (n = 13) or placebo (n = 14). Multivariate analysis showed no difference between placebo and liraglutide arms in HbA1c at 6 months (HbA1c:0.2 mmol/mol, -11.3, 11.6, p = 0.98) however, at 12 months HbA1c was significantly higher in the liraglutide arm (HbA1c:10.9 mmol/mol, 1.1, 20.6, p = 0.032). There was no difference between arms in weight at 6 months (BW:2.0 kg, -4.2, 8.1, p = 0.50), however, at 12 months weight was significantly higher in the liraglutide arm (BW:8.2 kg, 1.6, 14.9, p = 0.02). There were no significant differences in adverse events between groups.

CONCLUSIONS

Our pilot data suggest no additional improvement in glycaemic control or BW with LAGB and liraglutide therapy. However, this trial was significantly underpowered to detect a significant change in the primary or secondary outcomes. Further trials are needed to investigate whether GLP-1 agonists, and particularly with more effective weekly agents (i.e. semaglutide or tirzepatide), are of benefit following metabolic surgery.

CLINICAL TRIAL REGISTRATION

EudraCT number 2015-005402-11.

Clinical evaluation of patients living with obesity

Obesity is a significant public health concern which is implicated in cardiometabolic disease, mechanical complications and psychiatric sequelae. BMI is currently used for diagnosis; however, it has limited sensitivity for adiposity in certain circumstances. This has led to the development of risk stratification tools like the Edmonton Staging criteria and the Kings Obesity Staging Criteria: these facilitate and guide comprehensive obesity-related complication assessment. Healthcare professionals working within obesity clinics should adopt evidence-based communication strategies, including shared decision-making, motivational interviewing, and realistic goal setting. It is also vital to avoid weight-stigmatising terminology in all aspects of care, as this can negatively impact patients. Primary care plays an essential part in obesity care and should work to promptly identify cases, initiate treatment and forward on to specialist services where appropriate. Clinical evaluation of the patient living with obesity should take a holistic approach and involve input from bariatric physicians, dietitians, psychologists, and bariatric surgeons, wider members of the multi-disciplinary team should be involved where needed. Clinicians should take a detailed history, examination and order laboratory tests to investigate for complications. Overall, with appropriate evaluation, these assessments can guide patient management and facilitate long-term improvement in health.

Diagnosis and management of parathyroid carcinoma: a state-of-the-art review

Parathyroid carcinoma is one of the least common endocrine malignancies and accounts for approximately 1% of all patients with primary hyperparathyroidism. A systematic review of peer-reviewed literature published between January 2000 and March 2022 via Medline, Embase, Cochrane Central Register of Controlled Trials, EudraCT, ClinicalTrials.gov, CINAHL and SCOPUS was conducted. Manuscripts were eligible if they included data on adult non-pregnant populations with parathyroid carcinoma. No restrictions regarding interventions, comparators or duration of follow-up were imposed. Single case reports, reviews or meta-analyses were excluded. Outcomes of interest were molecular pathogenesis, clinical presentation, differential diagnosis, treatment, follow-up and overall survival. Study quality was evaluated using the Newcastle-Ottawa Scale for observational studies. This review included 75 studies from 17 countries, reporting on more than 3000 patients with parathyroid carcinoma. CDC73 mutation has been recognised as playing a pivotal role in molecular pathogenesis. Parathyroid carcinoma typically presents with markedly increased calcium and parathyroid hormone levels. The most frequently described symptoms were bone and muscle pain or weakness. En bloc resection remains the gold standard for the surgical approach. The 5-year overall survival ranged from 60 to 93%, with resistant hypercalcaemia a significant cause of mortality. Emerging evidence indicating that targeted therapy, based on molecular biomarkers, presents a novel treatment option. The rarity of PC and need for personalised treatment warrant multidisciplinary management in a 'centre of excellence' with a track record in PC management.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

The Bariatric-Metabolic Physician's Role in Managing Clinically Severe Obesity

PURPOSE OF REVIEW

The aim of this review is to outline the obesity physician's role in managing patients with severe obesity with a particular emphasis on bariatric surgery candidates.

RECENT FINDINGS

Obesity is a chronic, relapsing and progressive disease. Scoring systems that evaluate the severity of obesity based on the clinical assessment, rather than the Body Mass Index, are a valuable tool. The clinical assessment should explore the underlying contributors for weight gain and screen for obesity-related complications. Bariatric surgery remains the most effective management approach for severe and complex obesity. Nevertheless, pharmacotherapy and other non-surgical approaches play an important role. The bariatric-metabolic physician's role is paramount in delivering effective care to patients with obesity. The multiple complications of patients with clinically severe obesity highlight the complexity of their management and reinforce the need for adequate assessment and long-term follow-up to ensure optimal clinical outcomes.

Early standardized clinical judgement for syncope diagnosis in the emergency department

BACKGROUND

The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).

OBJECTIVE

Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.

METHODS

In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.

RESULTS

Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy.

CONCLUSION

ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

Pharmacotherapy for weight loss in adults with type 2 diabetes: a systematic review of randomised controlled trials

Background: Clinically significant weight loss improves glycaemic control and cardiovascular disease risk in patients with type 2 diabetes (T2DM).Aim: To identify and assess the efficacy of medical treatments for weight loss in adults with T2DM.Methods: A systematic review was conducted of peer- reviewed literature between July 2004 and July 2020 via PubMed, Embase, Web of Science, medRxiv and Cochrane Central Register of Controlled Trials. Randomised controlled trials (RCTs) in English investigating medical treatments for weight loss in patients with T2DM were included. RCTs of pharmacotherapy withdrawn from the market were excluded. No minimum length of follow-up time was established. Outcomes of interest were changes from baseline in body weight (%), changes from baseline in HbA1c (%, mmol/mol) and proportion of patients who achieved ≥5% weight loss. Quality assessment was evaluated using the Jadad score.Results: Fifteen RCTs were included with a total of 4,207 participants with T2DM. Interventions included medications approved for obesity management (orlistat, liraglutide, naltrexone-bupropion and phentermine-topiramate) and other agents investigated for the primary purpose of weight loss (topiramate, metreleptin, dapagliflozin and exenatide) compared with placebo. The duration of the intervention varied from 12 to 56 weeks. Placebo-adjusted body weight loss ranged from 2.2% to 7.3%. Furthermore, 30.5–77.0% of patients achieved ≥5% weight loss. Placebo-adjusted change in glycated haemoglobin was 0.3–1.5% (3.3–16.4 mmol/mol).Conclusion: Current evidence demonstrates that pharmacotherapy for weight loss, except for leptin, is associated with weight loss and glycaemic improvement in patients with T2DM.

Associations between social anxiety and avoidance, attachment styles and parental marital status, in late adolescence

Introduction

The relation between insecure general attachment and social anxiety has long been established.

Objectives

To explore the associations between social interaction and performance anxiety and avoidance, attachment styles, and parental marital status.

Methods

146 Portuguese adolescents, with a mean age of 18.99 years old (SD = .848; range: 18-20), filled in the Social Interaction and Performance Anxiety and Avoidance Scale and the Experiences in Close Relationships-Relationship Structures Questionnaire.

Results

Distress/Anxiety was correlated with avoidance attachment to mother and father (rs = .17*, p = .04; rs = .18*, p = .03), to anxious attachment to romantic partner (rs = .21*, p = .01), and to anxious and avoidance attachment to best friend (rs = .25**, p = .00; (rs = .17*, p = .035). Avoidance was significantly correlated with avoidance to father and to romantic partner (rs = .18*, p = .03), and to anxious and avoidance attachment to best friend (rs = .21**, p = .009; rs = .18*, p = .03). A significant difference was found in avoidance attachment to father X2 = 10.246 (4, n = 146), p = .036, by parental marital status, with the adolescents with single/divorced parents presenting a higher mean score (Md = 111.10; Md = 82.93) than the other groups.

Conclusions

Distress/anxiety seems to be associated with more close relationships, and a single/divorced status with Avoidance. Longitudinal studies are needed to explore if insecure attachment to parents predicts insecure extra-familiar attachment, and to explore the long-term effects of parental marital status.

New insights about the monomer and homodimer structures of the human AOX1

We conducted MD simulations to provide a comprehensive study on the human aldehyde oxidase and on the impact that the allosteric inhibitor thioridazine and malonate ions have on its structure, particularly on the catalytic tunnel.

Bioavailability and bioaccumulation of heavy metals of several soils and sediments (from industrialized urban areas) for Eisenia fetida

Soils and sediments are susceptible to anthropogenic contamination with Metallic Trace Elements (MTEs) and it can present some risks to ecosystems and human health. The levels of Cd, Cu, Fe, Ni, Pb and Zn were assessed in soils (C, G, K, L) from Estarreja (Portugal) and sediments from a stormwater basin in Lyon (DJG), a harbour (LDB) and a Rhône river site (TRS) (France). An ecotoxicological study was performed with Eisenia fetida (E. fetida) to infer about potential transfer risks to the soil invertebrates. To assess risks associated with MTEs contamination, it is important to know their total concentrations, fractionation and the potential available fractions. CaCl₂, DTPA and NaOAc extractions were performed to assess the extractable and available MTEs fractions. The studied sediments were much more contaminated than the soils for all the MTEs analysed. The trace elements fraction linked with DTPA extraction shows higher values when compared with the NaOAc and the CaCl₂ pools. Low mortality effects were recorded in the tests with E. fetida. The MTEs levels in soils and sediments and the concentrations bioaccumulated in adult earthworms contributed to a reduction in the number of juveniles produced. E. fetida adults and juveniles accumulated ETMs as follows: Cd > Cu = Zn > Ni > Pb > Fe. Determined BAFs were mostly lower than 1 with some higher values for Cd, Cu and Zn. Calculated SET and ERITME indexes allowed to classify the samples from the most to the less toxic for E. fetida as: LDB > DJG > L > G > C > K > TRS. Despite this order of toxicity, the earthworms exposed to the sediment TRS presented the lowest reproduction rate. The combination of "chemical" measurements with the calculation of BAFs, but especially SET and ERITME indexes can be a useful tool in risk assessment.

Using patients as educators for communication skills: Exploring dental students' and patients' views

TITLE

A qualitative study to explore the issues for patients and students when giving feedback on the communication of dental students.

OBJECTIVES

The Department of Health and National Institute for Health Research are committed to involving patients in improving clinical education, research and service delivery. Yet, there is a limited body of evidence on the perceptions of patients when asked to be involved in this way, and specifically when asked to provide feedback on the communication skills of dental students. This study seeks to address this gap and heighten the understanding of the issues faced by patients when asked to be involved in clinical education.

METHODS

Data were collected using focus groups with dental students (n=10) and patients (n=8) being treated by these students. Both groups were asked about their thoughts, feelings and beliefs about patients being asked to provide feedback on the communication skills of dental students. Data analysis involved inductive thematic analysis of transcribed audio recordings.

RESULTS

Four themes emerged from the data: "legitimacy," "co-educators," "maintaining the equilibrium of the patient-student relationship" and the "timing of patient feedback." Support for involving patients in giving feedback on students' communication skills was established, with patients considering they were best placed to comment on the communication skills of dental students. Patients and students do not want to provide feedback alone and want support to assist them, especially if feedback was negative. Issues of anonymity, confidentiality and ownership of the feedback process were worrisome, and the positioning of patient feedback in the programme was seen as critical.

CONCLUSIONS

Patients and students are willing to engage in patient feedback on students' communication skills, and with support and training, the concerns around this are not insurmountable and the benefits could potentially profit both groups. These findings have resonance with other healthcare educators when using patients as educators in the development of communication skills.

Manganese and Lipoflavonoid Plus(®) to Treat Tinnitus: A Randomized Controlled Trial

BACKGROUND

Several tinnitus sufferers suggest that manganese has been helpful with their tinnitus.

PURPOSE

We tested this in a controlled experiment where participants were committed to taking manganese and Lipoflavonoid Plus(®) to treat their tinnitus.

RESEARCH DESIGN

Randomized controlled trial.

STUDY SAMPLE

40 participants were randomized to receive both manganese and Lipoflavonoid Plus(®) for 6 months, or Lipoflavonoid Plus(®) only (as the control).

DATA COLLECTION AND ANALYSIS

Pre- and postmeasures were obtained with the Tinnitus Handicap Questionnaire, Tinnitus Primary Functions Questionnaire, and tinnitus loudness and annoyance ratings. An audiologist performed the audiogram, the tinnitus loudness match, and minimal masking level.

RESULTS

Twelve participants were dropped out of the study because of the side effects or were lost to follow-up. In the manganese group, 1 participant (out of 12) showed a decrease in the questionnaires, and another showed a decrease in the loudness and annoyance ratings. No participants from the control group (total 16) showed a decrease in the questionnaires ratings. Two participants in the control group reported a loudness decrement and one reported an annoyance decrement.

CONCLUSIONS

We were not able to conclude that either manganese or Lipoflavonoid Plus(®) is an effective treatment for tinnitus.

Availability of polycyclic aromatic hydrocarbons to earthworms in urban soils and its implications for risk assessment

Polycyclic aromatic hydrocarbons (PAHs) are a global problem, and in urban soils they can be found at potentially hazard levels. Nevertheless, the real risks that these contaminants pose to the environment are not well known, since the bioavailability of PAHs in urban soils has been poorly studied. Therefore, the bioavailability of PAHs in some selected urban soils from Lisbon (Portugal) was evaluated. Moreover, the applicability of a first screening phase based on total contents of PAHs was assessed. Results show that bioavailability of PAHs is reduced (low levels in earthworms, low accumulation percentages, and low biota-to-soil accumulation factors values), especially in more contaminated soils. The aging of these compounds explains this low availability, and confirms the generally accepted assumption that accumulation of PAHs in urban areas is mostly related with a long-term deposition of contaminated particles. The comparison of measured PAHs concentrations in earthworm tissues with the ones predicted based on theoretical models, reinforce that risks based on total levels are overestimated, but it can be a good initial approach for urban soils. This study also highlights the need of more reliable ecotoxicological data.

Academic performance of undergraduate dental students with learning disabilities

Aims To compare the academic performance of undergraduate dental students with known learning disabilities (LDs) to their peers.Methods This study analysed the results of students in applied dental knowledge (ADK) progress tests across four cohorts of dental students. A mixed model analysis of variance (ANOVA) was conducted to compare the performance of students with known disability to their peers. ADK test sitting was treated as a repeated measures variable, and the outcome variable of interest was percentage score on the ADK.Results Students' performance data on five ADK test sittings (ADK15, ADK16, ADK17, ADK18, and ADK19) by disability showed a significant main effect of test but no significant effect of disability or any interaction between disability and test.Conclusions This is the first study that explores the academic performance of dental students with a diagnosis of disability. The findings give reassurance to all stakeholders that, within the study population, students with LDs are not disadvantaged in knowledge-based assessments, demonstrating compliance with the legal obligations. Further research is required to explore how generalisable these findings are, as well as assess academic, clinical, and behavioural attributes of students with learning disabilities.

Frequent occurrence of trimethoprim-sulfamethoxazole hetero-resistant Staphylococcus aureus isolates in different African countries

High rates of trimethoprim/sulfamethoxazole (SXT) resistance, a combination of two antifolate antibiotics trimethoprim (TMP) and sulfamethoxazole (SMZ), have been reported among Staphylococcus aureus isolates in Portuguese-speaking African countries. Our study aimed to evaluate the occurrence of TMP resistance markers in major SXT^R methicillin-resistant S. aureus (MRSA) clones from these countries. We accessed also different fitness traits that could explain the success of these isolates over the Brazilian MRSA (the most successful SXT^R MRSA clone worldwide but never identified in these countries). Minimum inhibitory concentrations for SXT, TMP and SMZ were determined, and genes encoding TMP resistance (dfrG, dfrA, dfrK and dfrB) were searched. Representatives of the Brazilian clone and of the major MRSA African clones were evaluated for their fitness by individual growth curves, competition assays, survival under desiccation, autolytic activity, resistance to oxidative stress, and also growth at high osmolarity and in acid and alkaline environments. Although all African isolates showed high-level resistance to TMP, the majority presented hetero-resistance to SXT. TMP resistance was linked to the presence of dfrG (78%), dfrA (19%) or both (3%) genes. Compared to the Brazilian clone, the African isolates showed higher growth rates and autolytic activity, and better survival to desiccation and alkaline conditions. Since isolates exhibiting SXT hetero-resistance are frequent in Africa, the implementation of standardized guidelines to detect this phenomenon is of major interest. The predominant MRSA clones in Portuguese-speaking African countries likely possess significant advantages over other clones, such as the Brazilian MRSA, that may explain their epidemiological success.

Survey on the Effectiveness of Dietary Supplements to Treat Tinnitus

PURPOSE

We surveyed the benefit of dietary supplements to treat tinnitus and reported adverse effects.

METHOD

A website was created for people with tinnitus to complete a variety of questions.

RESULTS

The 1,788 subjects who responded to questionnaires came from 53 different countries; 413 (23.1%) reported taking supplements. No effect on tinnitus was reported in 70.7%, improvement in 19.0%, and worsening in 10.3%. Adverse effects were reported in 6% (n = 36), including bleeding, diarrhea, headache, and others. Supplements were reported to be helpful for sleep: melatonin (effect size, d = 1.228) and lipoflavonoid (d = 0.5244); emotional reactions: melatonin (d = 0.6138) and lipoflavonoid (d = 0.457); hearing: Ginkgo biloba (d = 0.3758); and concentration Ginkgo biloba (d = 0.3611). The positive, subjective reports should be interpreted cautiously; many might have reported a positive effect because they were committed to treatment and expected a benefit. Users of supplements were more likely to have loudness hyperacusis and to have a louder tinnitus.

CONCLUSIONS

The use of dietary supplements to treat tinnitus is common, particularly with Ginkgo biloba, lipoflavonoids, magnesium, melatonin, vitamin B12, and zinc. It is likely that some supplements will help with sleep for some patients. However, they are generally not effective, and many produced adverse effects. We concluded that dietary supplements should not be recommended to treat tinnitus but could have a positive outcome on tinnitus reactions in some people.

Differences Among Patients That Make Their Tinnitus Worse or Better

PURPOSE

Our objective was to identify activities that influence tinnitus and to determine if conditional probabilities exist among such variables.

METHOD

Two hundred fifty-eight patients were asked the following two questions: "When you have your tinnitus, which of the following makes it worse?" and "Which of the following reduces your tinnitus?"

RESULTS

Things that made tinnitus better included noise (31%) and relaxation (15%). Things that made tinnitus worse included being in a quiet place (48%), stress (36%), being in a noisy place (32%), and lack of sleep (27%). Almost 6% of patients suggested coffee/tea and 4% said certain foods made their tinnitus worse. Conditional probabilities indicated that for those whose tinnitus is not worse in quiet, it is usually not reduced by noise. For those whose tinnitus is not worse in noise, it is usually not reduced in quiet.

CONCLUSION

There are dramatic differences among patients. Such differences need to be considered in planning treatments.

Staphylococcus aureus in former Portuguese colonies from Africa and the Far East: missing data to help fill the world map

The aim of the present study was to determine the prevalence and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage among patients and healthcare workers in Angola (ANG), São Tomé and Príncipe (STP), Cape Verde (CV) and East Timor (ET), and to characterize the antimicrobial susceptibility, virulence content and population structure of all S. aureus. Despite the importance of MRSA as a major human pathogen, data from these former Portuguese colonies in Africa and Asia are scarce. A total of 2065 nasal swabs recovered between 2010-14 were included in the study. Antimicrobial susceptibility testing and molecular characterization of S. aureus showed: (i) a very high MRSA prevalence in ANG (61.6%), moderate in STP (25.5%), low in CV (5.6%) and null in ET; (ii) a high prevalence of Panton-Valentine leukocidin in STP (36.8%), ET (29.2%) and CV (28.3%) contrasting with ANG (7.9%); (iii) ST5-SCCmecIVa, ST8-IV/V and ST5-VI were the major MRSA clones in ANG (65.2%), STP (44.8%) and CV (50%), respectively; (iv) a high resistance to trimethoprim-sulfamethoxazole in ANG (66.5%) and STP (50.9%), to rifampin in ANG (77.3%), and to tetracycline in STP (26.3%) and ET (20.8%); (v) three major methicillin-susceptible S. aureus clones (ST15, ST508, ST152) were present in all four countries. Age <18 years (OR 2.03, 95% CI 1.24-3.31), previous surgery (OR 2.45, 95% CI 1.24-4.83), no smoking (OR 4.04, 95% CI 1.05-15.50), and longer hospitalization (OR 2.53, 95% CI 1.49-4.28) were risk factors for MRSA carriage. This study provided the first comprehensive overview on MRSA in former Portuguese colonies in Africa and Asia, missing data in the world map.

Hepatitis E Virus in Sylvatic and Captive Wild Boar from Portugal

Hepatitis E virus (HEV) is a zoonotic agent today considered a major Public Health issue in industrialized countries. HEV strains belonging to zoonotic genotype 3 are widely present in swine, being today considered important reservoirs for human disease. Unlike in swine, only scarce data are available on the circulation of HEV in wild boar. This study describes the detection and molecular characterization of HEV in livers from sylvatic wild boar hunted in Portugal and destined for consumption. Additionally, the detection of HEV in stools of a confined wild boar population also destined for consumption is also described. A total of 80 liver samples collected during the hunting season of 2011/2012 and 40 stools collected in February 2012 from a wild boar breeding farm in Portugal were tested by a nested broad-spectrum RT-PCR assay targeting open reading frame (ORF) 1. Twenty livers (25.0%) and 4 stools (10%) were positive for HEV. Phylogenetic analysis showed that all strains clustered with sequences classified as HEV genotype 3 subgenotype e. To our knowledge, this is the first report documenting the occurrence and molecular analysis of HEV in sylvatic and captive wild boar destined for human consumption in Portugal. This report demonstrates for the first time the circulation of HEV in wildlife reservoirs of Portugal adding knowledge to the epidemiology of HEV in wild boar populations.

Evaluation and selection of indicators for land degradation and desertification monitoring: types of degradation, causes, and implications for management

Indicator-based approaches are often used to monitor land degradation and desertification from the global to the very local scale. However, there is still little agreement on which indicators may best reflect both status and trends of these phenomena. In this study, various processes of land degradation and desertification have been analyzed in 17 study sites around the world using a wide set of biophysical and socioeconomic indicators. The database described earlier in this issue by Kosmas and others (Environ Manage, 2013) for defining desertification risk was further analyzed to define the most important indicators related to the following degradation processes: water erosion in various land uses, tillage erosion, soil salinization, water stress, forest fires, and overgrazing. A correlation analysis was applied to the selected indicators in order to identify the most important variables contributing to each land degradation process. The analysis indicates that the most important indicators are: (i) rain seasonality affecting water erosion, water stress, and forest fires, (ii) slope gradient affecting water erosion, tillage erosion and water stress, and (iii) water scarcity soil salinization, water stress, and forest fires. Implementation of existing regulations or policies concerned with resources development and environmental sustainability was identified as the most important indicator of land protection.

Evaluation and selection of indicators for land degradation and desertification monitoring: methodological approach

An approach to derive relationships for defining land degradation and desertification risk and developing appropriate tools for assessing the effectiveness of the various land management practices using indicators is presented in the present paper. In order to investigate which indicators are most effective in assessing the level of desertification risk, a total of 70 candidate indicators was selected providing information for the biophysical environment, socio-economic conditions, and land management characteristics. The indicators were defined in 1,672 field sites located in 17 study areas in the Mediterranean region, Eastern Europe, Latin America, Africa, and Asia. Based on an existing geo-referenced database, classes were designated for each indicator and a sensitivity score to desertification was assigned to each class based on existing research. The obtained data were analyzed for the various processes of land degradation at farm level. The derived methodology was assessed using independent indicators, such as the measured soil erosion rate, and the organic matter content of the soil. Based on regression analyses, the collected indicator set can be reduced to a number of effective indicators ranging from 8 to 17 in the various processes of land degradation. Among the most important indicators identified as affecting land degradation and desertification risk were rain seasonality, slope gradient, plant cover, rate of land abandonment, land-use intensity, and the level of policy implementation.

Oral bioaccessibility and human exposure to anthropogenic and geogenic mercury in urban, industrial and mining areas

The objective of this study was to characterize the link between bioaccessibility and fractionation of mercury (Hg) in soils and to provide insight into human exposure to Hg due to inhalation of airborne soil particles and hand-to-mouth ingestion of Hg-bearing soil. Mercury in soils from mining, urban and industrial areas was fractionated in organometallic forms; mobile; semi-mobile; and non-mobile forms as well as HCl-extractable Hg. The in vitro bioaccessibility of Hg was obtained by extracting soils with (1) a simulated human gastric fluid (pH1.5), and (2) a simulated human lung fluid (pH7.4). Total soil Hg concentrations ranged from 0.72 to 1.8 mg kg(-1) (urban areas), 0.28 to 94 mg kg(-1) (industrial area) and 0.92 to 37 mg kg(-1) (mining areas). Both organometallic Hg as well as 0.1M HCl extractable Hg were lower (<0.5% of total Hg) than Hg extracted by gastric fluid (up to 1.8% of total Hg) and lung fluid (up to 12% of total Hg). In addition, Hg extracted by lung fluid was significantly higher in urban and industrial soils (average 5.0-6.6% of total Hg) compared to mining soils. Such differences were related to levels of mobile Hg species in urban and industrial soils compared to mining soils. These results strengthen the need to measure site-specific Hg fractionation when determining Hg bioaccessibility. Results also show that ingestion and/or inhalation of Hg from soil particles can contribute up to 8% of adult total Hg intake when compared to total Hg intake via consumption of contaminated fish and animal products from contaminated areas.

Development and validation of the tinnitus primary function questionnaire

PURPOSE

To create a questionnaire focused on the primary activities impaired by tinnitus and therefore more sensitive to treatments.

METHOD

Questions were developed on (a) emotions, (b) hearing, (c) sleep, and (d) concentration. A 20-item questionnaire was administered to 158 patients. First, confirmatory factor analysis was used to select 3 questions per domain. Second, factor analysis was used to evaluate the appropriateness of the 12-item questionnaire.

RESULTS

The analysis indicated that the selected questions successfully represented 4 independent domains. Scores were correlated with the Tinnitus Handicap Questionnaire ( r = .77, p < .01) and loudness ( r = .40, p < .01). The Sleep subscale correlated with the Pittsburgh Sleep Index ( r = .68, p < .01); the Emotion subscale correlated with the Beck Inventory ( r = .66, p < .01) and the Trait Anxiety questionnaire ( r = .67, p < .01). The average scores went from 51% to 38% following treatment.

CONCLUSION

The Tinnitus Primary Function Questionnaire is valid, reliable, and sensitive and can be used to determine the efficacy of clinical trials.

Cariogenic bacteria and dental health status in adolescents: the role of oral health behaviours

AIM

To evaluate the association between dental health status and levels of cariogenic bacteria in teenagers and the influence of behaviours and socio-demographic background on levels of bacteria.

MATERIALS AND METHODS

Study design: A cross-sectional population-based sample of 13-year-old adolescents (112 females and 78 males, total 190) was examined. The number of decayed, missing and filled surfaces (DMFS), plaque and hygiene index were recorded according to the WHO criteria. The saliva samples were collected in a sterile container and then analysed by culture on Mitis Salivarius Bacitracin (MSB) agar for mutans Streptococci and on Man Rogosa Sharp (MRS) agar for Lactobacilli. The levels of bacteria were expressed as the number of colonies forming units per millilitre of saliva (CFU/ml). Associations between levels of mutans Streptococci and Lactobacilli and dental health were estimated by odds ratio (OR) and 95% confidence interval (95% CI) using unconditional logistic regression.

RESULTS

No mutans Streptococci were detected in 53.2% of the adolescents but 22.6% presented ≥ 10³ CFU/ml. For Lactobacilli, these values were, respectively 43.7% and 34.7%. After adjustment for gender and social class, the OR (95% CI) for DMFS >5 was 8.66 (3.57-21.02) if mutans Streptococci ≥ 10³ CFU and 2.11 (0.96-4.64) if Lactobacilli ≥ 10³ CFU.

CONCLUSION

This data allow us to conclude that hygiene habits and dental visits are not associated with high levels of cariogenic bacteria, but high scores of DMFS were found in adolescents with high levels of mutans Streptococci and lower parents' education.

Helicobacter pylori identification: a diagnostic/confirmatory method for evaluation

The Helicobacter pylori extra gastric reservoir is probably the oral cavity. In order to evaluate the presence of this bacterium in patients with periodontitis and suspicious microbial cultures, saliva was collected from these and non-periodontitis subjects. PCRs targeting 16S rRNA gene and a 860 bp specific region were performed, and digested with the restriction enzyme DdeI. We observed that the PCR-RFLP approach augments the accuracy from 26.2 % (16/61), found in the PCR-based results, to 42.6 % (26/61), which is an excellent indicator for the establishment of this low-cost procedure as a diagnostic/confirmatory method for H. pylori evaluation.

Risk assessment for Cd, Cu, Pb and Zn in urban soils: chemical availability as the central concept

To assess the geochemical reactivity and oral bioaccessibility of Cd, Cu, Pb and Zn in urban soils from the Porto area, four extractions were performed including Aqua Regia (AR; pseudototal), 0.43 M HNO3 (reactive), 0.01 M CaCl2 (available), and 0.4 M glycine at pH = 1.5, SBET method (oral bioaccessible pool). Oral bioaccessibility in urban soils was higher than in samples from rural, industrial and mining areas which is most likely related to sources of metals and parent materials of corresponding soils. The availability and reactivity were described well by non-linear Freundlich-type equations when considering differences in soil properties. The resulting empirical models are able to predict availability and reactivity and can be used to improve the accuracy of risk assessment. Furthermore, a close 1:1 relationship exists between results from the 0.43 M HNO3 method and the SBET method which substantially facilitates risk assessment procedures and reduces analytical costs.

Risks associated with the transfer of toxic organo-metallic mercury from soils into the terrestrial feed chain

Although the transfer of organo-metallic mercury (OrgHg) in aquatic food webs has long been studied, it has only been recently recognized that there is also accumulation in terrestrial systems. There is still however little information about the exposure of grazing animals to OrgHg from soils and feed as well as on risks of exposure to animal and humans. In this study we collected 78 soil samples and 40 plant samples (Lolium perenne and Brassica juncea) from agricultural fields near a contaminated industrial area and evaluated the soil-to-plant transfer of Hg as well as subsequent trophic transfer. Inorganic Hg (IHg) concentrations ranged from 0.080 to 210mgkg(-1) d.w. in soils, from 0.010 to 84mgkg(-1) d.w. in roots and from 0.020 to 6.9mgkg(-1) d.w. in shoots. OrgHg concentrations in soils varied between 0.20 and 130μgkg(-1) d.w. representing on average 0.13% of the total Hg (THg). In root and shoot samples OrgHg comprised on average 0.58% (roots) and 0.66% (shoots) of THg. Average bioaccumulation factors (BAFs) for OrgHg in relation to soil concentrations were 3.3 (for roots) and 1.5 (for shoots). The daily intake (DI) of THg in 33 sampling sites exceeded the acceptable daily intake (ADI) of THg of both cows (ADI=1.4mgd(-1)) and sheep (ADI=0.28mgd(-1)), in view of food safety associated with THg in animal kidneys. Estimated DI of OrgHg for grazing animals were up to 220μgd(-1) (for cows) and up to 33μgd(-1) (for sheep). This study suggested that solely monitoring the levels of THg in soils and feed may not allow to adequately taking into account accumulation of OrgHg in feed crops and properly address risks associated with OrgHg exposure for animals and humans. Hence, the inclusion of limits for OrgHg in feed quality and food safety legislation is advised.

In vitro susceptibility evaluation of Candida species isolated from removable prosthesis, from three antifungal agents and an essential oil

Short Communication selected from the Oral Presentations of the 56th Congress of the Groupèment International pour la Recherche Scientifique en Stomatologie et Odontologie, Peñafiel (Portugal) May 2012.

[Not Available]

Short Communication selected from the Oral Presentations of the 56th Congress of the Groupèment International pour la Recherche Scientifique en Stomatologie et Odontologie, Peñafiel (Portugal) May 2012.

Methodological aspects of clinical trials in tinnitus: a proposal for an international standard

Chronic tinnitus is a common condition with a high burden of disease. While many different treatments are used in clinical practice, the evidence for the efficacy of these treatments is low and the variance of treatment response between individuals is high. This is most likely due to the great heterogeneity of tinnitus with respect to clinical features as well as underlying pathophysiological mechanisms. There is a clear need to find effective treatment options in tinnitus, however, clinical trials differ substantially with respect to methodological quality and design. Consequently, the conclusions that can be derived from these studies are limited and jeopardize comparison between studies. Here, we discuss our view of the most important aspects of trial design in clinical studies in tinnitus and make suggestions for an international methodological standard in tinnitus trials. We hope that the proposed methodological standard will stimulate scientific discussion and will help to improve the quality of trials in tinnitus.

Tinnitus handicap inventory for evaluating treatment effects: which changes are clinically relevant?

OBJECTIVE

To determine the minimum change of the Tinnitus Handicap Inventory (THI) score that could be considered clinically relevant, the authors compared the absolute change of the THI with the Clinical Global Impression–Improvement (CGI-I) score.

STUDY DESIGN

International studies register with standardized data collection.

SETTING

Tinnitus Research Initiative (TRI).

SUBJECTS AND METHODS

Two hundred ten patients of the TRI database were eligible for this study. In the first analysis, the THI score change and CGI-I ratings were compared with equipercentile linking. In a second analysis, the authors categorized the CGI-I into the 4 groups much better or better, minimally better, no change, and worse and calculated the corresponding differences of the THI score and the effect sizes. An effect size separating the minimally better and the no-change groups was chosen, and the referring THI mean score difference was calculated.

RESULTS

According to the linking method, a CGI-I value of 3 (minimally better) corresponded to a THI score reduction of 6 to 16, whereas the CGI-I value of 4 (no change) corresponded to the range between improvement by 5 points and worsening by 4 points. For separating the no-change and minimally better groups, an effect size d = 0.5 was determined, resulting in a minimal clinically relevant difference of ΔTHI = 7.

CONCLUSION

Two different methods yielded comparable results in identifying a reduction in the THI score of 6 and 7 points, respectively, as the minimal clinically relevant change. This study provides a first orientation for sample size calculations and for planning the design of future studies.

Attitudes to ageing and expectations for filial piety across Chinese and British cultures: a pilot exploratory evaluation

INTRODUCTION

Filial piety (FP) is a central theme in Asian culture and is seen as care for one's parents as part of a traditional concept of Confucianism. Older people may hold strong expectations for FP from their children. Attitudes towards the experience of ageing may be influenced by how far one perceives their expectations to be met.

METHOD

A cross-sectional evaluation of expectation for FP and attitudes to ageing was undertaken in three different cultural groups--elderly Chinese immigrants living in the UK, Chinese older people living in Beijing and Scottish older people living in Scotland.

RESULTS

There were significant differences between the three cultural groups on a standardized measure of attitudes to ageing on psychosocial loss, F(2, 127) = 28.20, p = 0.0005 and physical change, F(2, 127) = 67.60, p = 0.0005 domains of attitudes to ageing. With expectations for FP, the UK-born participants evidenced lower expectations than the two Chinese groups, who were very similar in their levels of expectation, F(2, 127) = 10.92, p = 0.0005.

CONCLUSIONS

The study was the first of its kind to consider attitudes to ageing and expectations for FP across three cultural groups. Overall an interesting pattern of results emerged suggesting that both Chinese groups remain invested in the concept of FP, whereas the UK sample was not. In contrast, however, the Chinese immigrants and the UK participants were more similar in reporting attitudes to ageing than the Chinese participants who were more likely to endorse a loss-deficit view of ageing.

Changes in the tinnitus handicap questionnaire after cochlear implantation

PURPOSE

To determine (a) changes in the Tinnitus Handicap Questionnaire (THQ) for patients using cochlear implants, (b) differences between patients who receive total or partial relief, and (c) identifiable characteristics of those who report tinnitus after implantation.

METHOD

Pre- and postoperatively, 244 adults were administered the THQ when they reported tinnitus.

RESULTS

Of the 153 patients who had tinnitus preoperatively, 94 (61%) patients reported total suppression and 59 (39%) reported a partial reduction. In 91 patients who did not have tinnitus before implantation, 11 (12%) reported tinnitus postimplantation. The THQ score decreased from 41% preimplant to 30% postimplant. The largest reductions involved social handicap and hearing. Patients with a more severe hearing loss might be more likely to experience an exacerbation of their tinnitus. We were not able to clearly identify differences between patients who received total or partial relief and the characteristics of patients who reported tinnitus after implantation. Those who acquired tinnitus had the shortest duration hearing loss (5.6 years) and were the oldest (63 years). The average THQ score of patients getting tinnitus was 29%.

CONCLUSIONS

Most tinnitus patients benefit from receiving a cochlear implant.