In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association ...for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.
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.
Paracetamol for low back pain Saragiotto, Bruno T; Machado, Gustavo C; Ferreira, Manuela L ...
Cochrane database of systematic reviews,
2016-Jun-07
6
Journal Article
Peer reviewed
Open access
Analgesic medication is the most frequently prescribed treatment for low back pain (LBP), of which paracetamol (acetaminophen) is recommended as the first choice medication. However, there is ...uncertainty about the efficacy of paracetamol for LBP.
To investigate the efficacy and safety of paracetamol for non-specific LBP.
We conducted searches on the Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back and Neck Review Group trials register), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, LILACS, and IPA from their inception to 7 August 2015. We also searched the reference lists of eligible papers and trial registry websites (WHO ICTRP and ClinicalTrials.gov).
We only considered randomised trials comparing the efficacy of paracetamol with placebo for non-specific LBP. The primary outcomes were pain and disability. We also investigated quality of life, function, adverse effects, global impression of recovery, sleep quality, patient adherence, and use of rescue medication as secondary outcomes.
Two review authors independently performed the data extraction and assessed risk of bias in the included studies. We also evaluated the quality of evidence using the GRADE approach. We converted scales for pain intensity to a common 0 to 100 scale. We quantified treatment effects using mean difference for continuous outcomes and risk ratios for dichotomous outcomes. We used effect sizes and 95% confidence intervals as a measure of treatment effect for the primary outcomes. When the treatment effects were smaller than 9 points on a 0 to 100 scale, we considered the effect as small and not clinically important.
Our searches retrieved 4449 records, of which three trials were included in the review (n = 1825 participants), and two trials were included in the meta-analysis. For acute LBP, there is high-quality evidence for no difference between paracetamol (4 g per day) and placebo at 1 week (immediate term), 2 weeks, 4 weeks, and 12 weeks (short term) for the primary outcomes. There is high-quality evidence that paracetamol has no effect on quality of life, function, global impression of recovery, and sleep quality for all included time periods. There were also no significant differences between paracetamol and placebo for adverse events, patient adherence, or use of rescue medication. For chronic LBP, there is very low-quality evidence (based on a trial that has been retracted) for no effect of paracetamol (1 g single intravenous dose) on immediate pain reduction. Finally, no trials were identified evaluating patients with subacute LBP.
We found that paracetamol does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP.
Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity ...in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.
The Breast Surgery theoretical and practical knowledge curriculum comprehensively describes the knowledge and skills expected of a fully trained breast surgeon practicing in the European Union and ...European Economic Area (EEA). It forms part of a range of factors that contribute to the delivery of high quality cancer care. It has been developed by a panel of experts from across Europe and has been validated by professional breast surgery societies in Europe. The curriculum maps closely to the syllabus of the Union of European Medical Specialists (UEMS) Breast Surgery Exam, the UK FRCS (breast specialist interest) curriculum and other professional standards across Europe and globally (USA Society of Surgical Oncology, SSO). It is envisioned that this will serve as the basis for breast surgery training, examination and accreditation across Europe to harmonise and raise standards as breast surgery develops as a separate discipline from its parent specialties (general surgery, gynaecology, surgical oncology and plastic surgery).
The curriculum is not static but will be revised and updated by the curriculum development group of the European Breast Surgical Oncology Certification group (BRESO) every 2 years.
1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or ...myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).
2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).
3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).
4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).
5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in
Table 1
, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).
6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).
Bariatric patients may face specific clinical problems after surgery, and multidisciplinary long-term follow-up is usually provided in specialized centers. However, physicians, obstetricians, ...dieticians, nurses, clinical pharmacists, midwives, and physical therapists not specifically trained in bariatric medicine may encounter post-bariatric patients with specific problems in their professional activity. This creates a growing need for dissemination of first level knowledge in the management of bariatric patients. Therefore, the Obesity Management Task Force (OMTF) of the European Association for the Study of Obesity (EASO) decided to produce and disseminate a document containing practical recommendations for the management of post-bariatric patients. The list of practical recommendations included in the EASO/OMTF document is reported in this brief communication.
Summary
Background
Daylight photodynamic therapy (DL‐PDT) with methyl‐5‐aminolaevulinate (MAL) is an effective treatment for mild and moderate actinic keratosis (AK).
Objectives
To assess the ...clinical efficacy, tolerability and cost‐effectiveness of 5‐aminolaevulinic acid nanoemulsion (BF‐200 ALA) compared with MAL in DL‐PDT for grade I–II AKs.
Methods
This nonsponsored, prospective randomized double‐blind multicentre trial included 69 patients with 767 grade I–II AKs located symmetrically on the face or scalp. A single DL‐PDT was given in a randomized split‐face design. The primary outcome was clearance of the AKs at 12 months as assessed by a blinded observer. The secondary outcomes were pain, treatment reactions, cosmetic outcome and the cost‐effectiveness of the therapy.
Results
In the per‐patient (half‐face) analysis, clearance was better for the BF‐200 ALA sides than for those treated with MAL (P = 0·008). In total, BF‐200 ALA cleared 299/375 AKs (79·7%) and MAL 288/392 (73·5%) (P = 0·041). The treatment was practically painless with both photosensitizers, the mean pain visual analogue scale being 1·51 for BF‐200 ALA and 1·35 for MAL (P = 0·061). Twenty‐six patients had a stronger skin reaction on the BF‐200 ALA side, seven on the MAL side and 23 displayed no difference (P = 0·001). The cosmetic outcome was excellent or good in > 90% of cases with both photosensitizers (P = 1·000). The cost‐effectiveness plane showed that the costs of DL‐PDT were similar for both photosensitizers, but the effectiveness was slightly higher for BF‐200 ALA.
Conclusions
Our results indicate that BF‐200 ALA is more effective than MAL in DL‐PDT for grade I–II AKs. BF‐200 ALA provides slightly better value for money than MAL.
What's already known about this topic?
Daylight photodynamic therapy (DL‐PDT) with methylaminolaevulinate (MAL) is effective and practically painless for mild or moderate actinic keratosis (AK). Its long‐term efficacy or cost‐effectiveness is rarely reported.
What does this study add?
A single treatment with 5‐aminolaevulinic acid nanoemulsion (BF‐200 ALA) was shown in a 12‐month follow‐up to be more effective than MAL for use in DL‐PDT given in a split‐face design for grade I‐II AKs. BF‐200 ALA provides slightly better value for money than MAL.
Linked Comment: Dawe. Br J Dermatol 2019; 181:246–247.
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Coastal dunes are among habitats with the worst conservation status on a global, European and national scale. Monitoring and reporting are of strategic importance to determine the effectiveness of ...the implementation of Habitats Directive and to preserve the unique biodiversity heritage of the Italian dunes. In this study we show main results of the 4th National Report with specific reference to the macro-habitat “Coastal Sand Dunes and Inland Dunes”, highlighting its updated current conservation status at the national and Biogeographical level. A comprehensive Working Group of territorial experts collected, updated, validated and integrated the data available for 11 Annex I Habitats, distributed in the Alpine, Continental and Mediterranean Biogeographical Regions. The conservation status was evaluated through the following criteria: geographic range, surface area, structure, functions, pressures, threats, conservation measures and prospects. Results highlighted the dramatically bad conservation status of Italian dune Habitats: the overall assessment reported 88% of habitats in bad conservation status and the remaining 12% is in inadequate conditions. Results showed a generalised threat and a worrying conservation status both on herbaceous and wooded communities, in particular in some relevant habitats, such as the shifting dunes. Main pressures and threats were linked to residential, commercial and industrial activities, as well as alien species. Although some of the changes in distribution and trends are probably deriving from more accurate and updated data, the alarming conservation status of Italian sand dunes requires a better knowledge of pressures and threats for further management actions and monitoring plans, inside and outside protected areas.
European Regulation (EC) No. 2073/2005 lays down the microbiological criteria for certain microorganisms in foods and the implementing rules to be complied with by food business operators (FBOs) in ...Europe when implementing general and specific hygiene measures. In relation to Listeria monocytogenes, this regulation covers primarily ready-to-eat (RTE) food products, and requires different microbiological criteria depending on the ability of the food product to support growth of L. monocytogenes. In addition, this regulation establishes that food safety is the responsibility of the FBO. The FBO can conduct studies to evaluate the growth of L. monocytogenes that may be present in the product during the shelf-life under reasonably foreseeable storage conditions of distribution, storage and use in order to investigate compliance with the criteria throughout the shelf-life of the product. The European Union Community Reference Laboratory for L. monocytogenes published a revised technical guidance document in June 2014 for conducting shelf-life studies on L. monocytogenes in RTE foods. This review article describes the recently published European guidance document, with special focus on the design of challenge studies to determine the growth potential of L. monocytogenes on foods. Information is given particularly on what a challenge test is and when one is advisable. The factors to be considered and the laboratory methodology to be applied when performing a challenge test to determine the growth potential of L. monocytogenes in a defined food matrix are also described. Results of recent research articles applying challenge tests to determine the growth of L. monocytogenes in a range of foodstuffs are summarized and discussed. Finally, recommendations for obtaining data that can contribute to any further revision of the guidance document and for addressing the main challenges of challenge testing for FBOs are presented.
•The European Technical Guidance document for conducting L. monocytogenes challenge tests in RTE foods is discussed.•The laboratory methodology to be applied when performing L. monocytogenes challenge tests is described.•Results of recent research articles applying L. monocytogenes challenge tests in a range of foodstuffs are summarized.•Recommendations for obtaining data that can contribute to further revisions of the guidance document are presented.
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