RationaleCustom-made mandibular advancement devices (MADs) are reported as providing higher efficacy rates compared with thermoplastic heat-moulded MADs but at the price of higher costs and treatment delays.ObjectiveTo determine whether a thermoplastic heat-moulded titratable MAD (ONIRIS; ONIRIS SAS, Rueil Malmaison, France) is non-inferior to a custom-made acrylic titratable MAD (TALI; ONIRIS SAS, Rueil Malmaison, France) for obstructive sleep apnoea (OSA).MethodsWe conducted a multicentre, open, randomised controlled trial of patients with OSA refusing or not tolerating continuous positive airway pressure (CPAP). Participants were randomly assigned to a thermoplastic heat-moulded titratable device or a custom-made acrylic device for 2 months with stratification by centre and OSA severity. The non-inferiority primary outcome was a ≥50% reduction in apnoea–hypopnoea index (AHI) or achieving AHI <10 events/hour at 2 months. The non-inferiority margin was preset as a difference between groups of 20% for the primary outcome in the per-protocol analysis.Main resultsOf 198 patients (mean age 51 [SD, 12] years; 138 [72.6%] men; mean body mass index 26 [SD, 2.7] kg/m2; mean AHI 26.6/hour [SD, 10.4]), 100 received TALI and 98 ONIRIS. In per-protocol analysis, the response rate was 51.7% in the TALI group versus 53.6% in the ONIRIS group (absolute difference 1.9%; 90% CI: 11% to 15%, within the non-inferiority margin). Effectiveness was the same for severity, symptoms, quality of life and blood pressure reduction. Patients in ONIRIS group reported more side effects and adherence was slightly better with TALI.ConclusionIn patients with OSA refusing or not tolerating CPAP, the thermoplastic heat-moulded titratable MAD was non-inferior in the short-term to the custom-made acrylic MAD.Trial registration number NCT02348970.

The Arga River is an interesting system in which to study the impact of urban effluent pollution because it receives a single effluent in the form of wastewater discharge from the city of Pamplona. To analyze the extent of this discharge, total bacteria, culturable heterotrophic bacteria, and Gram-negative heterotrophic bacteria were enumerated and 409 isolates of the latter were identified. One sampling station was located upstream from the inflow, while five were located up to 30 km downstream. Bacterial counts increased drastically downstream from the wastewater inflow. Total bacterial numbers decreased along the 30 km downstream, the last station attaining similar values to those recorded upstream from the discharge. However, culturable heterotrophic and Gram-negative heterotrophic bacteria levels generally remained significantly higher within the 30 km zone investigated. Among the 409 isolates identified, Aeromonas spp. were the most frequent both upstream and downstream from the discharge. In contrast, although strains belonging to different genera of Enterobacteriaceae were found in all stations, their occurrence was significantly higher just downstream from the polluted discharge. Acinetobacter spp., which were never found upstream, were detected in all stations below the discharge. Our results clearly show that the bacterial community structure changes definitively downstream from the discharge and that Aeromonas were common throughout the sampling zone. Thus they cannot be considered good indicators of pollution in this setting compared to some genera of Enterobacteriaceae or some species of Acinetobacter, the distribution of which correlated better with the distance from the wastewater discharge.

Las observaciones de campo realizadas desde 1995 en distintos países de América Latina acerca del turismo, han venido alimentando una reflexión personal iniciada hace aproximadamente diez años en torno de la naturaleza del fenómeno turístico, sus raíces, sus formas, sus lógicas evolutivas, sus lugares. Esta reflexión se ha inspirado, y paralelamente enriquecido, con los estudios elaborados en Francia sobre el tema del turismo, en particular los trabajos pioneros de G. Cazes sobre los países en vías de desarrollo, los de J.-D. Urbain (antropología), los de los historiadores A. Corbin y M. Boyer, así como los trabajos del equipo MIT dirigido por Rémy Knafou, cuyas recientes publicaciones son estimulantes. El marco brindado por el presente número de Trace constituye el pretexto para una confrontación entre mis propias observaciones y reflexiones, y las ajenas quie se han echo sobre la base de otros campos de estudio. Al mismo tiempo, se trata de mostrar que tipos de reflexión pueden elaborarse en torno del tema del turismo con el fin de suscitar vocaciones entre los investigadores latinoamericanos, quienes frecuentemente tienden a menospreciar este tema porque lo juzgan demasiado superficial, siendo que resulta extremadamente rico tan pronto como se le aborda de manera más profunda y sin prejuicios.

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These are both convincing case reports that emphasise the need for clinicians to be aware of this side effect of ticagrelor and search for central apnoeas in patients complaining from dyspnoea and fatigue during treatment. | Nomenclature of targets and ligandsKey protein targets and ligands in this article are hyperlinked to corresponding entries in http://www.guidetopharmacology.org, 10 the common portal for data from the IUPHAR/BPS Guide to PHARMACOLOGY.

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