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Summary Severe obesity is an increasingly prevalent condition and is often associated with long-term comorbidities, reduced survival and higher healthcare costs. Non-surgical methods avoid the side effects, complications and costs of surgery, but it is unclear which non-surgical method is most effective. The objective of this article was to systematically review the effectiveness of lifestyle interventions compared to standard or minimal care for weight loss in adults with severe obesity. MEDLINE, EMBASE, CENTRAL, databases of on-going studies, reference lists of any relevant systematic reviews and the Cochrane Library database were searched from inception to February 2016 for relevant randomized controlled trials (RCTs). Inclusion criteria were participants with severe obesity (body mass index [BMI] > 40 kg/m2 or BMI > 35 kg/m2 with comorbidity) and interventions with a minimal duration of 12 weeks that were multi-component combinations of diet, exercise and behavioural therapy. Risk of bias was evaluated using the Cochrane risk of bias criteria. Meta-analysis was not possible because of methodological heterogeneity. Seventeen RCTs met the inclusion criteria. Weight change in kilograms of participants from baseline to follow-up was reported for 14 studies. Participants receiving the lifestyle intervention had a greater decrease in weight than participants in the control group for all studies (1.0–11.5 kg). Lifestyle interventions varied greatly between the studies. Overall lifestyle interventions with combined diet and exercise components achieved the greatest weight loss. Lifestyle interventions for weight loss in adults with severe obesity were found to result in increased weight loss when compared to minimal or standard care, especially those with combined diet and exercise components.

Organophosphate esters (OPEs) are commonly used as flame retardants (FRs) and plasticizers. The usage of OPEs has increased recently due to the ban of several brominated flame retardants, but information on levels in the environment, including the indoor environment is still limited. We investigated the occurrence and distribution of 12 OPEs in urban house dust from Vancouver, Canada; Istanbul, Turkey; and Cairo, Egypt. The medianSOPE concentration was 41.4 mu g/g in the Vancouver samples while median levels in Istanbul and Cairo were significantly lower. The median composition profiles of OPEs in Vancouver and Cairo were dominated by tris (2-butoxyethyl) phosphate (TBOEP), accounting for 56 and 92% of total OPEs respectively while it showed a detection frequency of only 14% in Istanbul. Tris (2-chloropropyl) phosphate (TCPP) was the most abundant chlorinated OPE representing 20 and 36% of the total OPEs in Vancouver and Istanbul respectively, but was below the detection limit in the Cairo dust samples. Consistent with other studies, SOPE concentrations were similar to 1 to 2 orders of magnitude higher than PBDEs and currently used flame retardants in the same dust samples. The mean estimated daily intakes (EDI) of SOPE from dust were 115, 38 and 9 ng/kg/bw/day in Vancouver, Cairo and Istanbul respectively for toddlers where adults were similar to 10 times lower. The total toddler OPE intake ranged from 115 to 2900, 38 to 845 and from9 to 240 ng/kg bw/day across the three cities. TBOEP had the largest contribution to the EDI in both toddler and adults, where toddler TBOEP exposures via dust represented 4% to 80%, 2% to 44% and 0.1% to 6% of the Reference Doses (RfD) in the mean and high intake scenarios for toddlers in Vancouver, Cairo and Istanbul respectively. Crown Copyright (C) 2018 Published by Elsevier B.V. All rights reserved.

There are very few studies reporting concentrations of polybrominated diphenyl ethers (PBDEs) and novel flame retardants (FRs) or non-PBDEs in Africa and the Middle East. The present work reported concentrations of fourteen PBDE congeners and eleven non-PBDE flame retardants in dust samples collected from homes (n=17), workplaces (n=9) and cars (n=5) in the greater Cairo region. The median ∑PBDE concentrations were 57, 425 and 1608 ng g(-1) in homes, workplaces and cars respectively. The highest PBDE levels were observed for BDE 209, with a median concentration of 40.2, 366 and 1540 ng g(-1) representing 70% to 95% of the total PBDEs in homes, workplaces and cars respectively. This is about 8 to 46 times greater than the median concentration of the pentaBDE (represented by the most abundant compounds in this formulation, ∑BDE 47, 99 and 100). In the case of non-PBDE flame retardants, a detection frequency between 52% and 100% was observed for several compounds including: hexabromocyclododecane (HBCD), hexabromobenzene (HBB), 2-ethylhexyl-2,3,4,5-tetrabromobenzoate (EH-TBB), bis (2-ethyl-1-hexyl) tetrabromophthalate (TBPH), 1,2-bis (2,4,6-tribromophenoxy) ethane (TBPE), ally-2,4,6-tribromophenyl ether (ATE) and Dechlorane Plus (DP). The ∑non-PBDE median concentrations were 8.30, 28.9 and 49.9 ng g(-1) in homes, workplaces and cars respectively with the highest level observed for HBCD in the three microenvironments. The detection of novel flame retardants in indoor environments may be due to their wide usage after the ban of the penta and octa BDE formulation. Results show the levels of PBDEs and non-PBDEs in Egyptian dust to be among the lowest levels reported from other countries. Different dust exposure scenarios using 5th percentile, median, 95th percentile and maximum levels were estimated for adult and children. The estimated dust intake results were several orders of magnitude lower than the oral reference dose values.

GPs have been debating the pros and cons of statins for different patients since the 4S trial back in 1994 first showed that statins could reduce mortality from strokes and heart attacks in those with existing cardiovascular disease.1 The whole country seemed to be debating them in September 2016, with Rory Collins explaining on BBC Radio 4’s Today programme that the benefits were ‘100 times the harms’ . Collins had led a new review of the statins trials which concluded that the evidence strongly supported the benefits of statins and showed very modest risks. The review argued that ‘exaggerated claims about side effects’ , often based on observational data, may have contributed to lower than recommended levels of statin use in individuals at increased risk of cardiovascular disease.2 Primary care data show that statin prescriptions are lower than recommended for high-risk groups.3 The arguments about the evidence have been well rehearsed, and it is hard to come to any other conclusion than that statin therapy has prevented a great many heart attacks and strokes in those with pre-existing cardiovascular disease. Important gaps remain, however, such as uncertainties over the long-term harms of statin therapy; the greater incidence of side effects such as muscle pain seen in clinical practice than reported in trials; the lack of trial data on the elderly (at least until the results of the STAREE study in the over-70s become available after 2020);4 and, importantly, the difficulty of comparing risk in trial populations with the output of risk calculators such as QRISK2, which is routinely used in UK general practice. It is also premature to dismiss large observational datasets that, despite the problem …

OBJECTIVE To explore the rationale for investigating patients presenting with globus symptoms. In this regard, we also assess the efficacy and safety of transnasal flexible laryngo-oesophagoscopy (TNFLO). METHODS A prospective study in a head and neck cancer centre of patients with persistent globus symptoms with normal flexible nasoendoscopy/indirect mirror laryngoscopy and failure of first-line medical treatment. The role of TNFLO in investigating these patients was assessed. RESULTS A total of 218 patients were recruited in this study. Positive findings included upper aerodigestive cancers in two patients, other pathologies included reflux (four patients), cricopharyngeus-related pathologies (19 patients), candida (five patients). There were only five re-referrals of patients who were discharged following normal examination with TNFLO. In nine patients, TNFLO could not be completed and they went on to have other diagnostic procedures CONCLUSION: This article is the largest to date in the UK to assess the role of TNFLO in investigating patients with globus symptoms. TNFLO is equal to rigid endoscopy as a diagnostic tool. However, it is superior in terms of image clarity, ability to record video images and safety.

Cardiovascular disease (CVD) is a major cause of mortality accounting for 27% of deaths in the UK in 2014 and is a great cost to the UK economy, estimated to be £15.2 billion in 2015.1 Lipid modification is important as there is a positive correlation between the incidence of CVD and cholesterol levels.2 There is substantial evidence of benefit in prescribing statins to all patients for secondary prevention of CVD and for primary prevention in many of those patients with higher CVD risk.3 A Cochrane review in 2013 included 18 randomised controlled trials of statin prescribing for primary prevention and reported a reduction in all-cause mortality (odds ratio [OR] 0.86, 95% confidence interval [CI] = 0.79 to 0.94), with the number needed to treat to prevent one death over 5 years being 96 and an acceptable cost-effectiveness.3 The Cholesterol Treatment Trialists’ Collaboration (CTTC) trial performed a meta-analysis of individual patient data from 27 randomised controlled trials and reported in 2012 that statin therapy reduces the risk of major vascular events even in patients with 5-year CVD risks of 10% 10-year risk of developing CVD. This guidance was revised from a >20% risk in 2014 and a >30% risk in 2010.4 …

PFASs concentrations in dust samples collected from three microenvironments in Cairo ranged from 1.3 to 69 ng g(-1) with FTOHs being dominant. The 8:2 FTOH was detected in all samples. Among the FOSAs and FOSEs the MeFOSE was dominant while among ionic PFASs, PFOS and PFOA were most prominent. The concentrations of PFASs were among the lowest worldwide. Correlations between worldwide concentrations of PFOS + PFOA and country development indexes highlight higher usage and human exposure in more developed countries. Food packaging was analyzed for PFSAs, PFCAs and PAPs. The 6:2 and 8:2 monoPAPs were found to be above the MDL in 18% of the samples. PFOA was detected in 79% of the samples with median concentration of 2.40 ng g(-1). PFOS was detected in 58% of the samples with median concentration of 0.29 ng g(-1) while PFHxS and PFDS were below detection limit. Different human exposure scenarios were estimated.