Antibiotic resistance has become a major concern for not only human health, but also for animal health. To preserve the efficacy of antibiotics, it has become essential to establish measures to regulate the prescription of antibiotics to ensure their prudent use. In France, these measures have been translated into regulations for animal health since 2015, with the publication of three important regulatory texts. The results obtained on a national scale in terms of reducing the use of antibiotics have been satisfactory. The aim of our study was to evaluate the differences related to the prescription of antimicrobials at the veterinary teaching hospital of the Veterinary School of Lyon (CHUV) before and after the implementation of French regulations. Prescriptions and consumption of antimicrobials were examined, along with bacteriological analyses, for the period of 2014–2020, for companion animals and horses. The most frequently prescribed compounds were broad-spectrum antimicrobials, including penicillins with β-lactamase inhibitors, as well as first-generation cephalosporins tetracyclines and sulfamides. The prescription and consumption of critically important antibiotics (CIA) strongly decreased during the study period, with an increase of bacteriological analyses. This study shows the interest of having computerized tools to monitor the use of antimicrobials to implement corrective measures if needed. Antimicrobial use (AMU) and antimicrobial resistance (AMR) in humans and animals are increasingly becoming health concerns, and public awareness of AMR has grown. Addressing AMR can only be achieved through a One Health approach ,2. Use aStaphylococcus aureus (MRSA) [Veterinarians and physicians have become very involved in the management of risk related to inappropriate antibiotic use or administration of antimicrobials at inappropriate dosages and administration rate. The use of antibiotics in animal husbandry is often considered responsible for the transmission of resistant germs to humans, especially through foodstuffs ,7,8. Hows (MRSA) ,16,17.In human medicine, a variety of strategies for controlling or changing patterns of antimicrobial use have been attempted to control resistance while taking in account that once bacteria become resistant, redeveloping susceptibility to antimicrobial therapy is not guaranteed and is a lengthy process, even if selection pressure is decreased . In FranIn 2016, an interministerial roadmap was established to address AMR . This roThe animal health sector took up the subject later with the Ecoantibio Plans (EcoAntibio 2007–2012 and Ecoantibio 2017–2021), which involve public policy set up by the Ministry of Agriculture, Agro-Food, and Forestry to reduce the risks of antibiotic resistance used in veterinary medicine and to safeguard the efficacy of antibiotics used in human medicine ,25. ThisBased on the regulations, veterinarians can write prescriptions or dispense antibiotic drugs under certain conditions, of which the main ones are: (1) prescribing after clinical examination (2) preventive use of antimicrobials should be avoided or restricted to certain conditions, and (3) avoiding off-label use and, if it is not possible, adapting the dosage regimen based on scientific considerations. In 2005, the World Health Organization (WHO) established a classification of critically important antimicrobials for human medicine due to non-human use. This list is regularly revised until 2018 . The WorThese regulations, which include financial and penal sanctions , are at the origin of a modification of practices and teaching. The aim of this study was to evaluate the impact of antimicrobial use legislation on antimicrobial prescription, delivery, and animal level of exposure to antimicrobials (ALEA) at the teaching veterinary school of Lyon (CHUV) in France from 2014 to 2020. This study focused only on companion animals and horses.From 2014 to 2020, 14,370 antimicrobial prescriptions were written for 9979 animals . There was a small decrease in hospital activity in 2020 due to the COVID-19 crisis. The number of prescriptions has gradually increased since 2014, particularly in the equine sector. In 2012, the software used was updated to allow clinicians to write prescriptions, and the use of this add-on has gradually become more widespread in this clinical sector. Farm animals were excluded from this analysis because this clinical sector did not use the software to write prescriptions.In the years of the study period, the average antimicrobial prescriptions represented 24.0 ± 3.3% of total prescriptions . There wMost antimicrobial prescriptions contain only one antibiotic (83.9 ± 2.9%), but this proportion significantly decreased between 2014 and 2015. In addition, the frequency of prescriptions containing several antibiotics significantly increased from 2015, despite a stable frequency of prescriptions containing only one antibiotic. Generally, prescriptions containing several antibiotics include different routes of administration.Finally, the number of prescriptions containing a CIA decreased significantly between 2014 and 2016 to a level that was relatively stable through 2020.Dogs were the most-prescribed-to species, with a higher average frequency of antibiotic prescription than cats, but lower than horses . ConcernThe oral route was the main route of administration of prescribed antibiotics regardless of the year and species . A trendRegarding the class of antibiotics, the most frequently prescribed was the combination of amoxicillin and clavulanic acid, followed by cephalosporins, until 2020. In 2020, there was an increase of cotrimoxazole prescriptions . TetracyThe critically important antibiotics authorized in veterinary medicine are cephalosporins  and the latest-generation fluoroquinolones . CefovecEnrofloxacin and marbofloxacin were mostly used in carnivores, in accordance with market authorization. Some prescriptions of enrofloxacin have been made for horses. Globally, the prescriptions of these two molecules have clearly decreased during the analysis period. In 2015, there was a great decrease in enrofloxacin prescriptions, which was compensated by prescriptions of marbofloxacin.Concerning ciprofloxacin and ofloxacin, these molecules are used in human medicine and authorized for animals only by ocular route. Prescriptions of these two molecules were essentially by ocular route in horses for ciprofloxacin and by auricular route for ofloxacin in dogs, especially in the context of otitis. Only ciprofloxacin prescriptions tended to decrease during the analyzed period.Prescription of CIAs must be justified, particularly by susceptibility test results. For each CIA prescription, we looked for the presence or absence of antibiogram results. The results are reported in Pseudomonas aeruginosa in ear-swab samples of dogs. Secondarily, Staphylococcus spp. were isolated in otitis in the majority of cases. The most frequently prescribed antibiotics against these bacteria are fluoroquinolones.Veterinarians were asked to fill a questionnaire for each prescription of CIAs. The questionnaires only checked several proposals related to the reason for the prescription and the availability of sensibility test results. The results showed a gradual increase in the number of completed questionnaires from 2016 to 2019, with a decrease in 2020, but the number of prescriptions did not decrease overall . In abouSales of antimicrobials by the pharmacy of the CHUV were monitored during the period of 2014–2020 . Over thALEAs were calculated for oral drugs used for dogs and cats . OverallThe present study involved an analysis of data regarding antimicrobial prescription in a veterinary teaching hospital during a 6-year period. Similar studies have been conducted in other countries. Quantitative analyses of antimicrobial prescriptions were realized in veterinary hospitals in Ontario  and NigeChirollo et al. (2021)  have colThe data collected in these studies are less numerous than our study, which may explain why the information extracted from them is qualitatively different. The observations remain close, especially regarding the class of antibiotics most prescribed in companion animal, except for Nigeria . Indeed,In France, the context of the use of antibiotics in veterinary medicine has changed in the past few years in connection with the implementation of the Ecoantibio Plans and regulatory texts. The aim of the first Ecoantibio Plan was to reduce the risks of antibiotic resistance in veterinary medicine and to safeguard the efficacy of antibiotics. For this purpose, two objectives were established: reduce exposure to antibiotics by 25% in 5 years (measured by the ALEA indicator) and preserve the therapeutic arsenal.To achieve these objectives, legislative and regulatory action has been taken, including control of the prescription and dispensing of CIAs and publication of a guide for good practice in the use of antibiotics in veterinary medicine. After the success of this first plan, particularly in antibiotics exposure, the Ecoantibio 2 plan was set up, which focused on incentivization by education and communication, promotion of alternatives to antibiotics, and preventive measures for infectious disease.A report on sales of veterinary medicinal products containing antimicrobials is published every year by the French National Agency for the Health and Safety of Food and the Environment, as well as the National Agency for Veterinary Medicine. This report includes national quantitative data on antibiotic sales and animal exposure to antibiotics by years and species. However, there are no data at the prescription level or on owner dispensation.Although national monitoring of antibiotic consumption is in place, there is no monitoring of actual antibiotic use at the veterinarian level in France. This is not the case in Switzerland, where prescription data on cats for 2016 and 2018 from 14 private veterinary practices and two university hospitals were collected to evaluate compliance with guidelines . CompliaVeterinary hospitals are structures in which the use of antibiotics is important due to the number of animals that are treated. At the CHUV of the veterinary school of Lyon, the animals received are numerous and are often referred cases. Thus, it is necessary to set an example to ensure that future veterinarians adopt good practice in antibiotic use in connection with the basic education that is carried out. This study provides information on the situation to improve antibiotic prescription and to inform clinicians.The increase of overall prescriptions during the study period (2014–2020) is due to the systematization of the use of software to write prescriptions . This tool was implemented in 2012–2013 in the CHUV and it is only dedicated to French veterinary schools. The number of caseloads in 2020 is probably correlated with the COVID-19 crisis and containment measures. Those measures have also had repercussions on the possibility of performing antibiograms, as shown in A decrease in the frequency of CIA prescriptions was observed one year later, in 2016, following the publication of regulatory text establishing the list of CIAs and the conditions for their prescription. Efforts to reduce the use of CIAs were maintained until 2019, but a return to a level of prescriptions equivalent to 2014 was observed in 2020. Factors involved in this increase are difficult to find, but it could be associated with the increase of complex referral cases with previous therapeutic failure and antimicrobial resistance development in containment measures. Indeed, these complex cases are frequent in CHUV.The impacts on patient illness and death were not assessed. Moreover, this study focused only on prescriptions given to owners. Antibiotics administration in the hospital was not include in the analysis. This explains why the oral route is the main route of administration. Parenteral presentations tend to be more prescribed, but there are prescribed for off-label use; for example, fluoroquinolones are administered by auricular route for local otitis treatment to improve antibiotic concentration.Regarding molecules, β-lactamin was the main group prescribed to companion animals, which is correlated with the availability of these drugs, as well as cotrimoxazole, tetracyclines, and macrolides for many presentations. These results are consistent with those described by Italian universities ,38, whicFrench regulations require that CIA prescriptions be justified by the results of sensitivity tests. The absence of these results can only be justified by the impossibility of taking a sample. Prescription in an emergency situation without sensitivity data is tolerated provided that the treatment is re-evaluated after 4 days following analysis of the bacteriological sensitivity results and the clinical context. Thus, all CIA prescriptions are checked to verify the availability of antibiograms.The results showed a rapid increase of sensibility results from 2015 to 2019. The number of CIA prescriptions that are not associated with sensitivity outcomes decreased over this period. In 2020, data showed fewer antibiogram requests, probably due to the COVID-19 pandemic situation and difficulties in maintaining laboratory and clinical activities. Surprisingly, among the responses to the questionnaire on the rationale for the use of CIAs, the absence of non-CIA adapted antibiotics is very often cited (70.0% in 2019). The interpretation of these data was difficult, and might be done case by case to appreciate this fact, even if it is mentioned in the regulatory text as a possible justification.P. aeruginosa was isolated very often, mostly in the context of canine ear infections. This bacterium’s many natural resistances to non-critical antibiotics and its location are two arguments in favor of prescribing CIAs by a general route of administration. Staphylococcus spp. were also frequently isolated, but the frequency of MRSA was not evaluated.However, when the bacteriological results were analyzed, we found that Regarding the sales of antimicrobials in tonnage of active ingredients, the results are very satisfactory, with a decrease of 58.6% in 2020. The percentage decrease in 2016 of 34.9% was higher than expected by the first National Eco Antibio plan for 2012–2016 (25%) and higher than that achieved by France between 2014 and 2016 for all species (18.16%) . The tonDespite the level of fluoroquinolone prescriptions in 2020 being comparable to 2014, sales have fallen sharply. This is probably linked to regulations that limit the duration of fluoroquinolone prescriptions to 1 month, with the need to repeat a clinical examination to extend the treatment, thus increasing the number of prescriptions. As fluoroquinolones are often prescribed in association with complex dermatological pathologies, the duration of treatment often exceeds one month. This interpretation confirms the need to analyze all available drug-related data  to understand antibiotic use. However, a more in-depth analysis of prescriptions in terms of dosage and duration of treatment remains complex and challenging.Sales of antibiotics to animal owners provide an indirect indicator of their final use. Detailed analysis of the data tends to show a change in the distribution of antibiotics sold in relation to prescriptions. Sales of tetracyclines have decreased significantly since 2014, probably in favor of sulfamides due to their very broad spectrum. Sales of cephalosporins have also fallen very rapidly, with a consequent slight increase in the sales of penicillins . The increase in sales of aminosides is probably related to their primarily local use. Indeed, regulations call for limiting the use of the oral route in favor of local routes.Finally, animal exposure to antibiotics was evaluated by calculating the ALEA index. This index was established by the French Agency for Veterinary Medicinal Products and is considered the best indicator. In order to obtain a good representation of animal exposure, we collected all data on animal weight and not a standard weight per individual . The resAs already discussed regarding prescription and antibiotic sales, fluoroquinolones were not a concern, due to a decrease in animal exposure. Again, the increase in complex cases admitted to the hospital may be an explanation for this exception. This study focused on the use of antibiotics in a specific context of a teaching veterinary hospital regarding national data. Globally, the data obtained were very satisfactory and correlated with the consideration of the regulation from its inception.This is the first time that such a study has been conducted in a hospital while taking into account prescription data, sales data, and the availability of bacteriological results. The interpretation of the results was specific to the type of establishment and cannot be transposed to other activities in medical practice. National reports did not distinguish use regarding the context or analyze it in detail. These data could have been analyzed according to medical sectors, but for reasons of respect for the clinicians, it was preferrable to carry out an overall analysis at the hospital level. Moreover, as in other studies ,38, it wThe analysis of the data is complex because it is based on a manual analysis using Excel files, as the prescription software tools do not allow this type of study to be carried out. The implementation of simpler tools that are easy for clinicians to use could improve knowledge of antibiotic use. Moreover, this would allow us to better meet the expectations of the authorities.The CHUV is the veterinary teaching hospital of Vetagro Sup, one of the four French veterinary schools. Veterinary schools are under the Ministry of Agriculture, Agri-food, and Forestry. The veterinary teaching hospital is organized into three separate clinical departments according to the target species: one for companion animals and its emergency facility, one for horses and its emergency facility, and a hospital for cattle and small ruminants. In 2019, 92% of the teaching staff were qualified veterinarians, and 42% of them were recognized specialists (EBVS or DESV).This study was conducted from 2014 to 2020, and data were obtained via export from our management software. Extracted data were provided in Microsoft Excel format. Pharmacy records at the CHUV were searched for drug-dispensing data and drug prescriptions, which were evaluated in terms of antimicrobial class or the individual antimicrobial when only one particular class was used. Combinations of antimicrobials were also analyzed.In each prescription, the following data were considered: class of antibiotic prescribed, dosage regimen, route of administration, species, and weight of the animal. If an animal was prescribed the same antibiotic multiples times, the prescription was kept to evaluate animal exposition, but the individual was counted only once. The combinations of amoxicillin with clavulanic acid and of sulfamides with trimethoprim were specifically analyzed under the names “co-amoxiclav” and “cotrimoxazole”, respectively (independently of the sulfamide derivative). All routes of administration were considered, and antibiotic administrations within the hospital were not registered.All prescriptions entered in the software were exported in Excel format. Each prescription is identified by a unique number and includes species, weight, presentation, and dosage regimen. Once all the prescriptions were exported, a manual analysis was performed to extract the prescriptions containing antibiotics for any route of administration. As CIAs prescription needs to be justified, clinicians should answer a questionnaire before prescribing them; however, it was possible to skip this step.Calculations were based on the methodology proposed by the French Agency for Veterinary Medicinal Products.-Antibiotics dispensed by the pharmacyData on the sale of medicinal products was extracted in Excel format for each year, and then the antimicrobials were extracted manually. The sales data included presentation, number of units dispensed, species, date of dispensation, and the weight and unique identification number of the animal. The antimicrobial group and molecule contained in each presentation were affected. The weight of antimicrobials dispensed was calculated by multiplying quantitative composition of the active ingredient for each presentation by the number of units sold. For active ingredients expressed in international units, a conversion coefficient from OIE recommendations was used. The quantities of antimicrobials sold expressed in milligrams were presented by class of antimicrobials or by species, based on data extracted.-Animal level of exposure to antimicrobials (ALEA)ALEAs were calculated according to the method proposed by the French Agency for Veterinary Medicinal Products, based on the recommendations of the European Surveillance of Veterinary Antimicrobial Consumption. Sales data from the pharmacy of CHUV were used. This indicator is calculated by dividing the body weight of treated animals  by the total weight of animals that come to the hospital and are likely to be exposed to antibiotics. The ALEA indicator has no units and is based on the assumption that all the antimicrobials sold during the year are administered to animals in the hospital during this year.The body weight treated for a given drug was calculated by dividing the weight of antimicrobials dispensed in milligrams of active substance by the dose required to treat one kilogram of typical animal over the entire duration of treatment. It was subtracted from the total mass of the antibiotic dispensed by the drug as follows:For each drug and each species, the dosage selected is the one defined in the marketed authorization for the considered species in mg of antimicrobials per kg of body weight treated. When multiple doses were possible, the highest dose was chosen for the drug’s main indication. When multiple treatment durations were possible, the longest treatment duration was chosen.The weight of animals that came to the hospital was extracted for each animal by year. If an animal came several times, it was counted only once, on the basis of the average weight.Data were analyzed with Excel software for MacOS (version 16.48). Descriptive statistics (frequencies and proportions) were used to summarize the data. The frequencies of prescription across the years were compared using Fisher’s exact test, with Prism 9 software.To the author’s knowledge, this is the first time such a study has been conducted in a teaching veterinary hospital in France. This study tend to assess this study tends to show that clinicians take into account the recommendations and regulatory texts in antimicrobial prescriptions. It would be interesting to develop a collaboration between clinical practice and teachers in pharmacy, pharmacology, and bacteriology in veterinary teaching hospitals, which already exists in human hospitals. This could be done by creating an internal antibiotic use committee with an antibiotic manager. This would allow for continued vigilance regarding the proper use of antibiotics and surveillance of antibiotic resistance in this particular context. Indeed, bacterial resistance has not been studied sufficiently, and it would be interesting to explore the evolution of the resistance of bacteria present at the CHUV with regard to the use of antibiotics.


The Mediterranean diet (MD) has become a dietary pattern of reference due to its preventive effects against chronic diseases, especially relevant in cardiovascular diseases (CVD). Establishing an objective tool to determine the degree of adherence to the MD is a pending task and deserves consideration. The central axis that distinguishes the MD from other dietary patterns is the choice and modality of food consumption. Identification of intake biomarkers of commonly consumed foods is a key strategy for estimating the degree of adherence to the MD and understanding the protective mechanisms that lead to a positive impact on health. Throughout this review we propose potential candidates to be validated as MD adherence biomarkers, with particular focus on the metabolites derived from the phenolic compounds that are associated with the consumption of typical Mediterranean plant foods. Certain phenolic metabolites are good indicators of the intake of specific foods, but others denote the intake of a wide-range of foods. For this, it is important to emphasise the need to increase the number of dietary interventions with specific foods in order to validate the biomarkers of MD adherence. Moreover, the identification and quantification of food phenolic intake biomarkers encouraging scientific research focuses on the study of the biological mechanisms in which polyphenols are involved. Molecular, histologic, radiographic, or physiologic characteristics are types of biomarkers”. The choice of a particular biomarker will be determined according to the aim of the study and its suitability will be reflected in its susceptibility to change. In this review we describe a selective group of food polyphenols and their biological metabolites identified in biofluids  for the purpose of considering them as potential biomarkers of adherence to the Mediterranean diet (MD). For this purpose, the study is restricted to the most representative plant foods of the MD considering their frequency of consumption and seasonality.The term “biomarker” is understood by the Food and Drug Administration   and its occurrence in biofluids is a direct indicator of the degree of exposition (intake) to a particular food ,3. Food Most food components are essential for life. Others, although dispensable, accomplish body functions related with protective effects on health. Due to this property, these types of substances are called “bioactive compounds”. Among them, polyphenols have gained special scientific interest. Polyphenols are secondary metabolites of plants that are classified into flavonoids and non-flavonoids. In turn, flavonoids are subdivided into flavan-3-ols, anthocyanins, flavonols, flavanones and isoflavones. The non-flavonoids include phenolic structures with diverse chemical characteristics such as phenolic acids (hydroxycinnamic and hydroxybenzoic acids), stilbenes, phenolic alcohols, and non-hydrolysable and hydrolysable tannins .More than 500 different polyphenols with a heterogeneous pattern of distribution have been described in food .,78.77,78Wine is consumed throughout the year in the Mediterranean countries where this is not constricted by religion. The phenolic composition of red wine has a particular combination of resveratrol, flavan-3-ols, procyanidins, anthocyanidins, ellagic acid related compounds and a broad spectrum of phenolic acids ,80,81. Btrans- and cis-resveratrol with different patterns of glucuronidation and sulphation as well as conjugated forms of the microbial metabolite dihydroresveratrol were observed in urine [Other phenolic compounds also proposed as biomarkers of wine consumption are anthocyanins, particularly malvidin-3-glucoside, which has been detected in both urine and plasma after an acute intake of red wine  Table 6Table 6. in urine  . These colonic metabolites are common to most MD foods and are represented by such simple phenolic acids as phenylacetic, phenylpropionic, benzoic acids and similar phenolic structures . Their cMetabolites of mixed origin: indicates metabolites form endogenous (phase II metabolites) and those generated by gut microbiota. However, there are important challenges to be addressed. A major one is the need to find discriminated phenolic metabolites directly associated with the intake of a particular food or group of foods in order to offer solid candidates to be used as biomarkers of adherence to the MD. However, the intake of some foods is sporadic, normally because they are markedly seasonal, as is the case of some fruits or vegetables. Therefore, it should be adequate to consider a range biomarkers of food intake according to the period of the year when biofluids are analysed. It is evident that the same phenolic metabolite can be considered as intake biomarker of more than one MD food. On the other hand, other phenolic metabolites are exclusive to a one particular or a reduced number of foods. In this sense, short-term phenolic metabolites indicate recent consumption and can be used to validate some dietary assessment methods, such as 24 h recall of FFQ. Another challenge to highlight is the importance of unifying analytical methods and laboratory procedures to allow more consistence in the comparisons and data collected by different studies. So, a standardization of laboratory procedures including analytical instruments and protocols, sample collection and treatment, quantification and identification of phenolic compounds and their metabolites and homogeneity in the expression of results is necessary. One of the weak points is the lack of available commercial standards for identifying and quantifying phenolic biological metabolites. This is of special importance in the quantification of phase-II metabolites and specific colonic metabolites, such as urolithins or phenyl-γ-valerolactones.Overall, three main groups of phenol biological metabolites can be proposed as good candidates for MD intake biomarkers. Firstly, there are the most food-specific phase-II metabolites with the limitation of their fast body clearance and the lack of standards for precise quantification in biofluids. Secondly, there are the colonic phenol metabolites represented by the simple phenolic acids  and which are common to different plant-foods in the MD, together with the specific urolithins and phenyl-γ-valerolactones. Third are the native forms of polyphenols, for example anthocyanins or hydroxytyrosol, resulting from the sustained intake of certain foods over the year. However, an unmanageable aspect for the selection of phenol colonic metabolites as biomarkers of MD intake is the inter-individual variability observed in most human studies. These qualitative and mainly quantitative differences are mainly related to the variability in the microbiota composition defined as “metabotype” that result in differences in the phenol colonic catabolism.The data presented in this review indicates that, instead of a single intake biomarker, a good proposal could be the study of the phenol metabolome in different populations of the Mediterranean area in order to link the concentration of specific phenol metabolites in biofluids, preferably in fasting urine, with the level of adherence to the MD (from low to high) based on 24 h recall of Food Frequency Questioners (FFQ).


An owner's ability to detect changes in the behavior of a dog afflicted with osteoarthritis (OA) may be a barrier to presentation, clinical diagnosis and initiation of treatment. Management of OA also relies upon an owner's ability to accurately monitor improvement following a trial period of pain relief. The changes in behavior that are associated with the onset and relief of pain from OA can be assessed to determine the dog's health-related quality of life (HRQOL). HRQOL assessments are widely used in human medicine and if developed correctly can be used in the monitoring of disease and in clinical trials. This study followed established guidelines to construct a conceptual framework of indicators of HRQOL in dogs with OA. This generated items that can be used to develop a HRQOL assessment tool specific to dogs with OA. A systematic review was conducted using Web of Science, PubMed and Scopus with search terms related to indicators of HRQOL in dogs with osteoarthritis. Eligibility and quality assessment criteria were applied. Data were extracted from eligible studies using a comprehensive data charting table. Resulting domains and items were assessed at a half-day workshop attended by experts in canine osteoarthritis and quality of life. Domains and their interactions were finalized and a visual representation of the conceptual framework was produced. A total of 1,264 unique articles were generated in the database searches and assessed for inclusion. Of these, 21 progressed to data extraction. After combining synonyms, 47 unique items were categorized across six domains. Review of the six domains by the expert panel resulted in their reduction to four: physical appearance, capability, behavior, and mood. All four categories were deemed to be influenced by pain from osteoarthritis. Capability, mood, and behavior were all hypothesized to impact on each other while physical appearance was impacted by, but did not impact upon, the other domains. The framework has potential application to inform the development of valid and reliable instruments to operationalize measurement of HRQOL in canine OA for use in general veterinary practice to guide OA management decisions and in clinical studies to evaluate treatment outcomes. Osteoarthritis (OA), also known as degenerative joint disease, refers to the irreversible degeneration of cartilage and other tissues within joints. Prevalence estimates in the late 1990s have been as high as 20–30% of dogs over the age of 1 year . Pain asOwners may not recognize signs of OA that are presented by their dogs and this can be a major barrier to initiation of treatment . Case maHumans are generally able to assess their own quality of life. This may be performed using a patient-reported outcome measure (PROM), an instrument that allows the patient to report on aspects of their own health, such as pain and QOL , 18. NonHRQOL assessments are widely used in human medicine. The Food and Drug Administration (FDA) patient-reported outcome (PRO) guidance outlines methods for the development and validation of human PROs and HRQOL measures that can be used to support claims in medical product labelling . This guThe current study aimed to construct a conceptual framework of indicators of HRQOL in dogs with OA, focusing on the subjective experience of the dog. The CF was based upon a systematic literature review that was reviewed by an expert panel. The framework has potential application to inform the development of valid and reliable instruments to operationalize measurement of HRQOL in canine OA for use in general veterinary practice to guide OA management decisions and in clinical studies to evaluate treatment outcomes.A systematic literature review was performed in August 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines . Three sQuality assessment was performed using a modified version of the STROBE  guidelines . This coIndicators of osteoarthritis and/or its impact on quality of life were extracted to generate “items” from each study. Only indicators listed within the body of the manuscript were included. Data were initially extracted by one of four authors , with the process repeated independently by a single author (CR) for all studies. A comprehensive data charting table based on a previous review for HRQOL in cats with osteoarthritis  and refiThe resulting domains and items were assessed at a workshop attended by members of the research team, a specialist in small animal internal medicine with a PhD in decision making in dogs with osteoarthritis and a veterinary surgeon who founded an initiative to provide advice and education on canine arthritis to owners and veterinary professionals. Prior to the meeting, panel attendees were provided with a PowerPoint file covering the methodology and results including a table of key domains/items  and a brThe workshop took place in November 2020 online and lasted 2 1/2 h. Domains were discussed and final titles decided, with each item assessed for designation to the correct domain. Additionally, any potential missing items were discussed. Hypothesized directional interactions between the domains were identified and a visual representation of the conceptual framework was produced.A total of 1,264 unique articles were generated in the database searches and assessed for inclusion using the title and abstract . Of thesn = 11), translation (n = 2), or use (n = 3) of pain or HRQOL assessment instrument[s]. There were five instruments: the Liverpool Osteoarthritis in Dogs (LOAD) score, (The eligible studies dated from 2003 to August 2020 inclusive. Study characteristics are shown in ) score, , 46, Can) score, , 44, 46,) score, , 42, 46,) score, , 36, 37 ) score, , 45, 48.Data extraction produced 134 unique items  categoriThe expert workshop resulted in four remaining categories: physical appearance, capability, behavior, and mood . The oriThe four domains were incorporated into a visual conceptual framework model . All fouThe current study aimed to construct a conceptual framework of indicators of HRQOL in dogs with OA, through a systematic literature review and expert panel, focusing on the subjective experience of the dog. This approach is consistent with FDA guidance  for the Over half of the studies described the development of one of five existing instruments or their translation into other languages. These instruments are varied in their relation to HRQOL in dogs with osteoarthritis. The LOAD  and HCPIMore relevant to HRQOL was the Glasgow University health-related dog behavior questionnaire (GUVQuest) which was specifically developed to assess the impact of pain, including from OA, on HRQOL , 45, 48.Three studies used one of these instruments, with one performing a welfare assessment of a population of dogs . A furthOf the remaining six studies, two reported clinical-based methods to OA assessment: mechanical joint threshold  and therMore than half of the items were unique to a single manuscript. This was especially the case in the original domains of “energy” and “temperament” and perhaps reflects the subjectivity of these domains. There was scope for different semantic interpretations for several items because their exact meaning within the context of their respective source articles was not always clearly characterized. Combination of synonyms reduced the number of items from 134 to 47. The mobility domain had fewer unique items and contained most of the most commonly reported items. There are several potential reasons for this. It could indeed be that these are the most common issues in OA in dogs, either as the most important to owners, or the most obvious signs. This is reflected in the clinical signs reported to be useful in a presumptive OA diagnosis . HoweverThe final conceptual framework comprised four domains representing HRQOL of dogs with osteoarthritis. The final domains were mobility, behavior, mood, and physical appearance which were all deemed to be affected by pain. A negative impact of pain on QOL has been reported in humans –52. It iThe resulting CF is consistent with a non-peer reviewed model produced by Canine Arthritis Management (CAM) representing the impact of chronic pain on capability, behavior, muscular changes and posture . AlthougThere were some limitations to this study, perhaps the main one being that the multiple references to existing pain and HRQOL instruments in the screened papers, which limited the usefulness of quantification of item frequency in this review. This may have resulted in an overestimation of the importance of mobility and exercise-based items. However, the discussion from the expert panel allowed the review of these items and mobility and exercise (termed “capability”) were deemed to be important. There may also have been bias at the review level by searching publications only in the English language. Again, the use of an expert panel allowed for the addition of any items that may have been missed in the review and no items were added.The conceptual framework developed by this study has highlighted the complexity of HRQOL in dogs with osteoarthritis, and the impact of pain on all other HRQOL domains. It can be used as a first step in the development of a disease-specific instrument to measure HRQOL in dogs with osteoarthritis, in order to encourage and better monitor treatment. A future qualitative concept elicitation study with key informants including veterinarians and dog owners would provide additional evidence to validate whether the HRQOL domains and their interrelations in our model reflect real-world experiences.RRID:SCR_005901Europe PubMed Central, The original contributions presented in the study are included in the article/AC, DB, and IO contributed to conception and design of the study. BA performed the literature search. BA, GC, SM, and LG performed sifting, data extraction, and quality assessment. Data extraction was audited by CR. AC, BA, CR, and DB planned and attended the expert workshop. ZB and HC provided expert advice at the workshop. CR wrote the first draft of the manuscript. BA wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that this study received funding from Zoetis under the auspices of a wider collaboration: the Veterinary Health Innovation Engine (vHive). In addition to the funding described above (Conflicts of Interest), the funder had the following involvement in the study: compensation to expert panel.DB and IO are employees of company Zoetis. GC, BA, and CR's positions are funded by Zoetis, LG has a PhD scholarship which is partially funded by Zoetis. AC is an academic Principal Investigator for other projects funded or co-funded by Zoetis. The attendance of ZB and HC at the expert panel was compensated by Zoetis. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pancreatic cancer has a dismal prognosis and only a few treatment options are available. In the European Union, pancreatic cancer classifies as a rare disease, allowing drug developers to apply for orphan medicinal product (OMP) designation. The aim of this study was to provide more detail on OMPs for pancreatic cancer. All applications for OMP designation submitted to the EMA between 2000 and 2019 were identified. For each medicinal product that received an OMP designation, the mode of drug action, use of protocol assistance, and current life cycle status was determined. Fifty-two medicinal products received an OMP designation. At the time of submission, eighteen OMPs were at the non-clinical and 34 OMPs were at the clinical stage of development. At least fourteen kinds of mode of action were explored in the condition. For eighteen out of 52 OMPs protocol assistance was sought. At the time of data analysis, one OMP received marketing authorisation and 24 OMPs were ongoing in development. Many medicinal products for pancreatic cancer received an OMP designation and the majority of these products was already in the clinical stage of development. Nonetheless, the success rate of OMPs for pancreatic cancer that reach the market is low, and increasing this rate is something to aspire. Fortunately, development is still ongoing for a part of the OMPs, and a few developers are planning to submit a marketing authorisation application in the near future. This however does not guarantee success, as pancreatic cancer remains a difficult disease to treat. Developers are advised to make optimal use of incentives such as protocol assistance, establishing (early) dialogue between regulators and drug developers and to agree on important topics such as clinical trial design. Pancreatic cancer has a poor prognosis and is currently the seventh leading cause of cancer-related deaths worldwide . The mosA few treatment options exist for patients with pancreatic cancer. Curative treatment is only optional in those that have a resectable tumour at the time of diagnosis; the minority of patients. Palliative treatment can be considered for patients with advanced or metastatic disease. Dependent on the performance status (PS) of the patient, FOLFIRINOX (PS 0 or 1), albumin-bound paclitaxel in combination with gemcitabine (PS 0 or 1) or gemcitabine monotherapy  can be considered as a first-line treatment option, according to clinical practice guidelines . The onlAccording to the European Union Orphan Regulation, pancreatic cancer is classified as a rare disease , allowinTo date, the COMP has approximately 20 years of experience with applications for OMP designation for pancreatic cancer. Through the years, many applications have been submitted to the EMA, and we are of the opinion that this orphan condition deserves further attention. The aim of this study was to provide a detailed overview on OMPs for pancreatic cancer, which can be of value for various stakeholders, including regulators and drug developers. Of special interest were the use of PA incentive and the current life cycle status.www.ema.europa.eu.Internal and publicly available documents from the EMA were used in this study. Internal data was derived from EMA/COMP summary reports on applications for OMP designation, PA letters, and annual reports on designated OMPs. Publicly available data was retrieved from public summaries of positive opinion for orphan designation and European public assessment reports (EPARs); both available at All applications for OMP designation for medicinal products for the treatment of pancreatic cancer submitted to the COMP between 17 April 2000 and 31 December 2019 were included in this study.via PubMed.From the summary reports the following information was obtained: date of submission, final COMP opinion, MoA, and stage of development at time of submission. In addition to the summary reports, information on MoAs was also obtained from public summaries. If the MoA was not clearly described in the summary report and/or public summary, literature describing the MoA was sought PA letters were used to determine how many developers made use of this incentive and if advice on clinical development was sought.From the annual reports the (development) status and the planned submission date was subtracted.EPARs provided insight in the number of marketing authorisation applications (MAAs) submitted to the EMA. The time from OMP designation to Committee for Medicinal Products for Human Use (CHMP) opinion or withdrawal was determined by calculating the days between the date of the OMP designation and the date of final CHMP opinion or withdrawal of the MAA. Public summaries enabled the identification of OMPs that were withdrawn from the Community Register of designated Orphan Medicinal Products (access date: 12 March 2021).Descriptive statistics were used.Between 2000 and 2019, a total of 80 applications for OMP designation for pancreatic cancer were evaluated by the COMP. Of the 80 applications, 52 received a positive opinion on OMP designation, two received a negative opinion on OMP designation and 26 were withdrawn by the applicant prior to final COMP opinion. Seven applications were resubmitted to the agency after the first application was withdrawn; six applications were resubmitted once and one application was resubmitted twice. Of these, six were granted positive opinion on OMP designation; these positive opinions were already included in the total number of positive opinions mentioned above. The other application resulted in a second withdrawal and eventually a negative opinion; this negative opinion was already included in the total number of negative opinions mentioned above. All medicinal products that received positive opinion by the COMP were granted OMP designation by the EC  were already in the clinical stage of development when the developers applied for an OMP designation. This finding is however not solely confined to OMPs for the treatment of pancreatic cancer. Pauwels and colleagues revealed that the majority of anti-cancer medicinal products were in the clinical stage of development at the time of submission for OMP designation . AdditioOur results show that OMPs for pancreatic cancer had distinct MoAs. The most commonly investigated OMPs included those that stimulate an immune response, block signalling pathways, infect tumour cells and replicate therein, and inhibit DNA synthesis. These OMPs can be classified as immunotherapy, targeted therapy, oncolytic virus therapy and chemotherapy, respectively. Chemotherapy continues to play an important role in the treatment of pancreatic cancer. However, other types of therapy have unfortunately not yet demonstrated definitive efficacy in pancreatic cancer, which concerns both OMPs as well as medicinal products without an OMP designation. Targeted therapy could be considered an exception, as a phase III clinical trial showed a statistically significant improvement in overall survival for erlotinib plus gemcitabine compared to gemcitabine monotherapy . HoweverTo stimulate the development of medicinal products for rare diseases, incentives have been implemented in the EU Orphan Drug legislation . We founEven though the majority of medicinal products was already in the clinical stage of development when the developers applied for OMP designation, to date, only one OMP for pancreatic cancer received MA, namely irinotecan hydrochloride trihydrate . IrrespeA positive finding in our results is that development is still ongoing for almost half of the OMPs (46%), and a couple of developers are even planning to submit an application for MA in the near future. Of all these, a few developers indicated their plans to submit a MAA in previous years, but this did not happen so far. The reasons for this might be delayed of failed development. For the remaining OMPs it could not be determined whether development is still ongoing, as the annual reports were absent or OMPs were withdrawn from the Community Register. It remains difficult to speculate on the reasons behind this, but plausible reasons could be either failure in development or financial considerations. At least for those products that have received an OMP designation a while ago.This study has a few limitations, one of which is the lack of correction for time. For example, some medicinal products have received an OMP designation recently, while others have received OMP designation years ago. Therefore, products that have recently been granted OMP designation might still face potential developmental challenges in the future. Another limitation is the incompleteness of our overview on status of drug development, which is due to the lack of (recent) annual reports for a part of the OMPs. Determining whether the OMP is still in the drug pipeline of the developer would provide a more definitive answer on the life cycle status than is currently provided in our study.The success rate of medical products for pancreatic cancer that reach the market as OMPs is lower than for OMPs in general and increasing this success rate is something to aspire. Despite that pancreatic cancer is such a difficult disease to treat, a substantial number of applications has been submitted to the EMA for this condition, which indicates interest among drug developers. Development is still ongoing for a part of the OMPs, and for a few of these OMPs a submission for MAA in planned in the near future. It should be reminded that an OMP designation is supported by promising non-clinical and/or preliminary clinical data, but efficacy and safety still needs to be determined and the late stages of development are often the most challenging. Therefore an OMP designation is not a guarantee for a successful MA. In this respect, developers are advised to make optimal use of incentives inherent with an OMP designation, such as PA, establishing (early) dialogue between regulators and drug developers to agree on important topics such as clinical trial design. In addition, developers are strongly encouraged to provide yearly updates on advancements in development. Close monitoring of the drug development through the annual reports and transparency regarding the reason(s) for stopping development are crucial for saving human and financial resources and redirecting efforts in promising concepts.science@cbg-meb.nl.The data analyzed in this study is subject to the following licenses/restrictions, the data that support the findings of this study are only available from the EMA through a confidentiality agreement which the authors signed. Requests to access these datasets should be directed to JM, AP, and VS-B designed the study. JM and TV performed the research. JM, AP, and VS-B analysed the data. JM, TV, SM, AM, AD, AP, and VS-B wrote the manuscript. All authors contributed to the article and approved the submitted version.The views expressed in this article are the personal views of the authors and may not be understood or quoted as being made on behalf of, or reflecting the position of the EMA or one of its committees, working parties, or any of the national agencies.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Epigallocatechin gallate (EGCG) (particularly present in green tea) and ketone bodies (in particular beta-hydroxybutyrate (BHB)), whose main source is coconut oil, have shown emotional benefits and body fat loss. The aim of this study was to assess the impact of EGCG and coconut oil on cortisol activity related to fat loss and depression in MS patients. (2) Methods: The study involved 51 MS patients who were randomly divided into an intervention group or a control group. The intervention group received 800 mg of EGCG and 60 mL of coconut oil, which were included in their daily diet for four months. The control group received placebo and all patients followed an isocaloric diet. A blood sample was collected before and after the four-month period, and levels of cortisol, albumin and BHB were measured in serum. In addition, immediately before and after the intervention, anthropometric variables were measured: waist-to-hip ratio (WHR), body fat mass percentage, fat weight, total weight, and muscle mass percentage. Depression was assessed with the Beck Depression Inventory II (BDI-II). (3) Results: No significant changes were obtained in cortisol levels in any of the groups, and there was a significant increase in albumin in the blood of the intervention group only that could lead to a decrease in serum free cortisol. In addition, it was observed a significant decrease in levels of depression and abdominal fat. (4) Conclusions: EGCG combined with coconut oil increase the concentration of albumin in blood and produce less depression in MS patients. Multiple sclerosis (MS) is an autoimmune disease of an inflammatory nature characterized by the progressive loss of myelin that covers the axon of neurons . One of Depression is present in most MS patients , playingIn order to treat depression, which is on the rise in these types of patients, usually antidepressants are being given . HoweverTaking all the aforementioned into account, the aim of this study was to establish the impact of the administration of EGCG, supplemented with coconut oil in cortisol activity, and its relations with possible improvements in the perception of depression associated with abdominal fat loss.A prospective, mixed, and experimental pilot study was conducted. The clinical trial ID for this study is NCT03740295.The population sample was obtained by contacting the main MS associations in Spain, which informed their members on the nature of the research. The following selection criteria were applied to the 67 people interested in participating in the study: patients over 18 years of age diagnosed with MS at least 6 months ago and treated with glatiramer acetate and interferon beta (a common treatment for the disease). Moreover, the exclusion criteria included: pregnant or breastfeeding women; patients with tracheotomy; stoma or with short bowel syndrome; patients with dementia; evidence of alcohol or drug abuse; patients with myocardial infarction; heart failure; cardiac dysrhythmia; symptoms of angina or other heart conditions; patients with kidney conditions with creatinine levels two times higher than normal; patients with elevated liver markers three times higher than normal or with chronic liver disease; patients with hyperthyroidism; patients with acromegaly; patients with polycystic ovary syndrome; or MS patients who were included in other studies with experimental drugs or treatment. A CONSORT diagram is attached that describes the flow of participants, from joining the study to analyzing statistical data , where ip-value below 0.05 was considered significant. Data are presented as mean ± standard deviation, or the number of patients and the percentage representing this number for each group (control and intervention groups).The SPSS v.23  tool was used for the statistical analysis. The first step involved estimating the distribution of the variables investigated through statistical methods in order to assess normality; this also included the use of the Kolmogorov–Smirnov Test. A non-normal distribution of all the scale variables studied in this analysis was demonstrated. Therefore, a Mann–Whitney U test and Wilcoxon signed-rank test were used to assess the inter-group and pre–post differences, respectively. A chi-square test was used to analyze categorical data. A All participants received specific information on the nature and aim of the study. After the final sample was selected, they were provided with instructions indicating not to change the established diet for each case (depending on which group they were assigned to), as well as to take the capsules every day at the agreed times over the 4-month duration of the intervention. Weekly telephone calls were made to all patients to verify whether they were complying with the treatment. They were also asked about any doubts and issues about following the intervention.A final sample of 51 MS patients was obtained after the selection criteria had been applied. Participants were randomly divided into the intervention and control groups. Randomization of patients to either group was performed without stratification by drawing consecutively numbered sealed envelopes. The intervention group received an isocaloric diet for 4 months , enriched with 60 mL of extra virgin coconut oil divided into 2 equal intakes (30 mL for breakfast and 30 mL for lunch), and supplemented with 800 mg of EGCG, administered in 2 capsules of 400 mg to be taken twice a day (one capsule in the morning and another in the afternoon). On the other hand, the same isocaloric diet was also followed by the control group for 4 months, with the exception of the coconut oil that was replaced with other lipids, such as olive oil, sunflower oil, fish and nuts. This ensured that a state of ketosis did not occur in the control group, as the percentages and the amounts of macronutrients were not characteristic of a ketogenic diet . PlaceboThe following measurements were taken before and after the 4-month intervention, in the same conditions and at the same time. In terms of the specific case of the questionnaire establishing levels of depression, it was carried out by the same neurologist assigned to each patient before the study. Body composition: Each subject received detailed information on the procedure that was to be followed in the assessment in terms of how the anthropometric variables were measured. Informed verbal and written consent were requested. The measurements were taken by an ISAK  level 3 certified anthropometrist, in line with the protocol established by the Society . The valIn order to measure body weight (kg), we requested participants to wear light clothes, take their shoes off, and stand up straight in the center of the scale, looking forward, with upper limbs resting on both sides of the body and trying to distribute weight equally on both feet. Height (cm) was measured without them wearing shoes, with the subject standing on both feet and with feet together, with heels forming a 45° angle, ensuring that the head was in a Frankfort plane position. Waist circumference (cm) was taken at the point between the bottom part of the last rib and the highest part of the hip, at the end of a normal exhalation and with arms relaxed on either side of the body. Hip circumference was taken with the subject standing up, with legs and knees together and relaxed glutes. The anthropometrist placed the anthropometric tape at the maximum circumference of the glutes, perpendicular to the longitudinal axis of the torso. The necessary anatomical points were marked with a dermographic pencil before taking skinfold measurements. All skinfolds (mm) were taken from the participant’s right side. The waist-to-hip ratio (WHR), which is an anthropometric measurement to measure intra-abdominal fat levels, was determined using the ratio of waist circumference to that of the hip . Beck Depression Inventory II (BDI-II): BDI-II was validated in the general population in 2003, showing greater internal consistency and factorial validity than its predecessor, BDI-IA. BDI-II has undergone some modifications compared to previous versions in order to better represent the criteria to diagnose depressive disorders included in DSM5. The test is preferably intended to be used as a clinical tool as a means of assessing the severity of depression in adults and teenagers over 13 years of age .This was a questionnaire that assessed symptoms of depression in patients, mainly of a cognitive type, although physiological, emotional or motivational types were also evaluated. This version also included symptoms such as agitation, feelings of worthlessness, difficulty in concentrating and loss of energy. Each item on the questionnaire reflected a symptom of depression, and each one offered four alternative statements, ordered from least to most serious. The assessed person had to choose the phrase from each of the 21 sets of four options that best reflected how they had felt over the last week, including the day they fill out the questionnaire. Each item was assessed from 0 to 3 points, according to the chosen option and, after directly adding the score for each item, a total score was obtained, ranging from 0 to 63, that quantified the presence and severity of symptoms of depression .Blood analysis: A blood sample was taken at 9 a.m. on an empty stomach. After the test, the serum was then separated from the plasma after centrifuging the samples. Cortisol was measured by means of a chemiluminescent immunoassay using commercial kits (Immulite). Concentrations of BHB and albumin were measured with commercial kits  in an automatic clinical biochemical analyzer (Olympus A 400).This study was carried out in accordance with the Helsinki Declaration , with prOnce the selection criteria were applied, the population sample of 51 patients with MS was divided into the intervention group and the control group. The sociodemographic and clinical characteristics of both groups are shown in After 4 months of treatment,significant increases in BHB and albumin, and a decrease in depression, were observed in the intervention group . There wp > 0.05); solely, a difference between sexes was observed in pre-treatment in the control group in the variable RCT (p = 0.03)  .These results, together with the significant increase in albumin protein already indicated above, could determine a decrease in the concentrations of free cortisol in the intervention group.Finally, it should be noted that, throughout the 4-month intervention, no relapses of the disease were registered in any study participant.MS is characterized by a mitochondrial alteration of the neurons as a result of high levels of oxidative stress and, at the same time, is related to the presence of depression . It is aThere are few studies that have researched possible emotional improvement after non-pharmacological interventions in MS patients. This is mainly due to the complexity of the etiopathogenesis of depression involving several factors . Among these factors, the hyperactivation of the HHA axis with high levels of cortisol, related to the presence of depression in certain pathological situations, stands out . In thisThe high concentrations of albumin and decrease in body fat mass could be related to a decrease in inflammation. Albumin is a negative acute phase protein that decreases in inflammation , and whoIn our study, ketone bodies were significantly increased) in the intervention group after administering 60 mL daily. Ketogenic diets, and especially the consumption of coconut oil, due to its high percentages in medium-chain fatty acids that exceed 50%  , are theThe side effects of the drugs used to treat these types of patient can produce negative effects. Therefore, we suggest that the development of non-pharmacologic treatments based on alternative therapies, such as the administration of antioxidants, effective for practical effects in MS patients, as our results show, is essential. Being able to know the beneficial impact of these possible treatments and understanding how they achieve these improvements, as we have tried to do in our work, will allow us to advance knowledge in the area, improving the quality of life of these patients. All the aforementioned information makes our results promising for understanding and treating MS.Despite these findings, our study has limitations that should be taken into account for future projects. For example studies should be performed about the possible correlation betweenthe anthropometric changes and biomarkesr or imaging test that can indicate the probable energy improvements on a mitochondrial level. It would also be of interest the evaluation of the concentrations of albumin, cortisol and even BHB, not only before and after 4 months of intervention, but also throughout the intervention. Furthermore, studies regarding changes in ACTH and their relation with depression should be performed.The combination of EGCG and coconut oil as a source of ketone bodies in the blood is associated with an increase in albumin in blood, a decrease in abdominal fat, and lower depression.


A varied and well-planned diet can meet the nutritional needs of an athlete; however, in certain cases, it could be advisable to increase the intake of some vitamins, minerals or other components through the controlled intake of fortified foods or dietary supplements. In the European Union, a high number of sport foods and supplements are marketed; athletes could at times consume them indiscriminately or even choose products that have not been evaluated and approved by scientific evidence. In this sense, it is necessary to know and interpret the specific regulations for these products in order to make adequate use of them. The aim of this manuscript is to describe the current status of the European regulatory framework, focusing on: (1) regulation of the marketing and labelling of both fortified foods and supplements; (2) regulation of the use of substances used as ingredients in fortified foods; and (3) regulation of nutritional claims and/or health properties associated with nutrients, ingredients and other related substances. This review can facilitate knowledgeable decision making by sports nutrition professionals in order to counsel or manage adequate food choices as well as help consumers make better-informed food decisions. Other experts, such as producers who ensure food safety, might also be interested in this review. An adequate diet can provide all the nutrients necessary for the development and maintenance of the organism; however, in specific situations, such as the sport field, it may be necessary to increase the intake of some of these nutrients through the use of fortified foods and/or dietary supplements.Fortified foods are common foods with one or more of their nutritional components increased in relation to their usual composition ; howeverAlthough is supposed that a well-balanced diet could meet the increased energy and nutrient demands of athletes, the use of fortified foods or supplements may be necessary depending on the intensity/duration of the exercise or when food intake is not possible for various reasons . In receAppropriate use of these products can benefit athletes, but indiscriminate use could harm their health and performance . In addiThe present study explores and summarizes the legislative documents that regulate the marketing and labelling of fortified foods and dietary supplements for athletes in the European framework. The evolution of the regulatory framework is described, the mandatory information including in labelling is presented, and the legal use of vitamins, minerals and other chemical constituents in foods and supplements is discussed. This paper also outlines requirements for labelling, notification, and for claims of nutritional and/or health properties associated with a nutrient, ingredient, or any other substance.This review provides knowledge to sport nutrition professionals in order to counsel or manage adequate food choices, and provides a nutritional education approach that will reduce the risk associated with nutritional supplementation and allow for making better-informed food decisions. It includes examples of some labels as an interpretative education approach.Firstly, the topic “foodstuffs for particular nutritional uses” was taken into consideration, in order to understand the possible existence of a particular legal policy for sport foods.Then, a narrative review of legislative documents related to fortified foods and dietary supplements was developed. The information was extracted from legislative documents such as laws, regulations, and/or standards laid down by the competent authorities in the European or in some cases national field.The legislative documents selected for this review were those that included information about the different points established in the objectives of this review: (1) Regulation of the marketing and labelling of both fortified foods and supplements; (2) Use of substances as ingredients for food fortification; (3) Use of nutritional claims and/or claims of health properties associated with a nutrient, ingredient or any other substance.https://ec.europa.eu/food/safety_en: accessed on 5 July 2021). This section compiles the European laws that establish the rights of consumers to safe food and to accurate and up to date information. The section “labelling and nutrition” on the European Commission website was consulted (According to the first objective of this review (marketing and labelling of both fortified foods and supplements) the subsection “food information to consumers” of the section “labelling and nutrition” was examined. In order to describe the correct use of substances as ingredients for food fortification (objective 2), the subsection “addition of vitamins and minerals” was studied. This regulatory section considers a wide range of nutrients such as vitamins, minerals, amino acids, essential fatty acids or fiber added to food in order to enrich or fortify them. In addition, the subsection “food supplements” was examined in order to explorer the harmonized list of vitamins and minerals or other substances that may be added for nutritional purposes in food supplements.Finally, the subsection “nutrition and health claims” was examined to summarize the regulatory framework that controls the use of nutritional claims and/or claims of health properties associated with a nutrient, ingredient or any other substance in sport foods and dietary supplements. This broad group of rules is the legal framework used by food business operators when they want to highlight the particular beneficial effects of a product in relation to health and nutrition on the product label or in its advertising.In 1989, Directive 89/398/EEC of the European Council [For years, many countries were in favor of regulating sport foods in a specific way; however, the European Commission did not consider it necessary to establish specific regulations. In 2009, the Directive of 1989 was derogated by Directive 2009/39/EC of the European Parliament and of the Council , left spFinally, in 2016, The European Commission decided that specific provisions were not necessary, establishing that these foods (including food supplements) should be treated as “ordinary foods” and regulated by horizontal European regulations.As indicated in the previous section, packaged foods for athletes, fortified or not, are regulated by the same horizontal regulations as common foods. In this way, the marketing and labelling of food for athletes is regulated by Regulation 1169/2011 of the European Parliament and of the Council [(a)Name of the food(b)List of ingredients(c)Quantity of certain ingredients or category of ingredients(d)Presence of substances or products causing allergies or intolerances(e)Weight or net volume(f)Minimum durability date, ‘use by’ date and date of freezing(g)Special storage conditions and/or conditions of use(h)Name and address of manufacturer(i)Country of origin or place or provenance(j)Instructions for use where it would be difficult to make an appropriate use(k)Nutritional informationAccording to this Regulation, all the sport foods must include the follow specific information: (a)The names of the categories of nutrients or substances that characterize the product or an indication of the nature of those nutrients or substances(b)The portion of the product recommended for daily consumption(c)A warning not to exceed the stated recommended daily dose(d)A statement about that food supplements should not be used as a substitute for a varied diet(e)A warning about that the products should be stored out of the reach of young childrenIn addition to this information, the labels on dietary supplements should include other information regulated by Directive 2002/46/EC of the European Parliament and of the Council . This re2, the x-height could be equal to or greater than 0.9 mm.All the information expressed in Regarding nutrition information and in order to share the same international approach on nutrition labeling, the European Regulation is in accordance with the Codex Alimentarius Guidelines on nutrition labelling , The CodA wide variety of nutrients and other ingredients such as vitamins and minerals, amino acids, essential fatty acids, fibers or various plants and herbal extracts can be used to manufacture fortified foods and dietary supplements, as long as they have been approved by the European Food Safety Authority.In this sense, a legislative framework that regulates the use of different substances as ingredients has been developed in order to establish requirements to ensure their safe use in foods.For years Member States have developed different national regulations that obstructed the internal market; subsequently, harmonized rules were adopted, but only for the use of vitamins and minerals as ingredients. In 2002, Directive 2002/46/CE of the European Parliament and of the Council  was deveThe list of authorized vitamins and minerals as ingredients included in these regulations has been reviewed, and they have been updated on several occasions. The last positive list of vitamins, minerals and their forms to add to food and supplements was compiled in Regulation 1170/2009 of the Council , amendinIn addition, consumers should know that fortified foods and food supplement labels must include information about how the product contributes to the daily diet. In this sense, they are required to include information about the percentage of the recommended daily amount of each nutrient that is met per 100 g or 100 mL, in a mandatory way. Optionally, information per individual packaged food or per dietary supplement can be added. The daily reference intakes of vitamins and minerals have been set by European legislation about food information to consumers, as mentioned in Ephedra herbs and its preparations from the genus Ephedra and Yohimbe bark and its preparations from Yohimbe , respectively.Although vitamins and minerals have been regulated in a European context, the use of other substances in the manufacture of foods and supplements may be regulated by national rules in each Member State, and the European Commission, on the basis of the information provided by each Member States, may include them in the list of substances whose use in foods is prohibited, restricted or under scrutiny. In this sense, and on the basis of the assessment of a Member State (Germany), there is a harmonized negative list of substances with possible harmful effects. Commission Regulation (EU) 2015/403  and Comm(a)Fatty acids(b)Amino acids  and other nitrogenous compounds(c)Dipeptides and peptides(d)Coenzymes(e)Flavonoids, carotenoids(f)Nucleotides(g)Polysaccharides and oligosaccharides(h)Other substancesWith respect to positive substances different from vitamins and minerals, there are not harmonized lists in a European context; however, several Member States have drawn up lists of substances that can be used in the production of food supplements. For example, Spanish Royal Decree 130/2018 [In this regard, it is usual to send food supplements from other Member States in a Member State with more lax regulations regarding authorized ingredients, by means of the mutual recognition principle. This principle was set out in Regulation (EC) 764/2008, of the European Parliament and of the Council , and estEphedra herbs and its preparations from the genus Ephedra and Yohimbe bark and its preparations from Yohimbe .It is important to emphasize that, the lack of a harmonized European framework in terms of substances allowed in food supplements  makes possible the commercialization of food supplements with ingredients other than those allowed in a Member State, through the principle of mutual recognition. Nevertheless, no Member State may market foods with the following prohibited ingredients: Finally, it should be noted that both, fortified foods and dietary supplements, may contain nutrition and/or health claims associated with a nutrient, ingredient or any other substance on the label. Regulation (EC) No 1924/2006 of the European Parliament and of the Council [A nutritional claim means any claim which states, suggests or implies that a food has particular beneficial nutritional properties due to (a) the energy it provides, or provides at a reduced or increased rate, or does not provide; (b) the nutrients or other substances it contains, or contains in reduced or increased proportions, or does not contain. A health claim means any claim that states, suggests or implies that a relationship exists between a food category, a food or one of its constituents and health.The nutrition or health claims must be authorized and subject to certain conditions of use and could refer to substances of mandatory declaration or others that do not appear on the list of mandatory mentions, in which case, the quantity of that substance must be indicated in the same visual field as the nutritional labelling. The allowed nutritional claims are listed in the annex of the aforementioned Regulation. Consumers should be aware that only the following mentions may appear on the labels; any other are not authorized: low energy, energy-reduced, energy-free, low-fat, fat-free, low-saturated fat, saturated fat-free, low sugar, sugar-free, with no added sugar, low sodium/salt, very low sodium/salt, sodium-free or salt-free, source of fibre, high fibre, source of protein, high protein, source of (name of vitamin/s) and/or , high (name of vitamin/s) and/or , contains (name of the nutrient or other substance), increased (name of the nutrient), reduced (name of the nutrient), light/lite, naturally/natural.The health claims shall only be allowed if they are authorized in accordance with the Regulation and if they are included in later lists of claims. (a)A statement indicating the importance of a varied and balanced diet and a healthy lifestyle.(b)The quantity of the food and pattern of consumption required to obtain the claimed beneficial effect.(c)Where appropriate, a statement addressed to persons who should avoid using the food.(d)An appropriate warning for products that are likely to present a health risk if consumed to excess.Athletes should know that, when a product is associated to a health claim, the label should include the following information: In order to share the same international approach on nutritional claims and health properties, the European Regulation takes into account the Codex Alimentarius guidelines for use of nutritional and health claims . ConsumeIn order to improve the understanding and use of food labelling, some examples labels for sport foods, both fortified and not, and supplements labels are included. In addition to these mandatory requirements, if the sport food is fortified in a permitted substance, the labelling must refer to the added amounts of these substances. Finally, a dietary supplement label is commented. To this end, two interpretive examples about the use of nutritional and health claims associated with a nutrient are included. According to the regulation mentioned above , this prThe health claim shown on this label is authorized for commercial use and is associated with vitamin C intake .Food labelling provides relevant information for making informed purchasing decisions. It has been recognized as a tool to protect consumers by ensuring food safety and nutritional quality.Labels inform consumers about ingredients found in the product, specific nutrients and amounts, storage, cooking or preparation conditions, origin of the products, and the benefits associated with the product due to its nutrient content or contribution to a healthy diet. Also, labels are used to compare products though the purchases.In the field of sport foods, all of the information that food labels contain is regulated by a legislative framework that may result in complex and confusing labeling by producers. It may be necessary to assist producers in understanding the information in order to avoid inappropriate labels in the marketplace. In the same terms, educational initiatives to help consumers make good use of labels may be necessary.This type of manuscript could be a help to producers and consumers of sport foods and supplements because it explains and examines the principles that regulate sport food labelling. In addition, it could be of interest to sport nutrition professionals seeking to counsel appropriate food choices. In addition, readers can find some specific types of labels, such as sport food labels and supplement labels with specific mandatory information, fortified food labels with the mandatory nutritional information, and some practical examples of nutrition and health claims made by both sport foods and dietary supplements.


Bruxism and gastroesophageal reflux (GERD) can lead to wear of the dental tissues. Wear has a mechanical or chemical origin, and it is of extrinsic or intrinsic type. Bruxism and GERD are two etiological factors of dental wear. The intrinsic mechanical wear (abfraction) of Bruxism and intrinsic chemical wear (erosion) of GERD are both involved in sleep disorders; indeed, they could have associations and act in synergy in dental wear. The purpose of this review was to find out the possible associations between bruxism and GERD and their effects on tooth wear. The research was conducted on PubMed and the Cochrane Library using the following Keywords/Mesh Terms: Tooth wear, Bruxism, Sleep Bruxism, Sleep Disorders, or GERD. Only systematic reviews and clinical studies performed exclusively on human subjects were included in the review. Initially, the research gave more than 630 results on dental wear, bruxism and GERD and after application of the inclusion criteria irrelevant studies were excluded, and 5 studies were finally included in this review. It was possible to observe the presence of some associations between the two problems (reflux and GERD) and hypothesize negative effects on tooth wear. This research revealed the presence of an interconnection between these three problems  that can further act in synergy by attacking the hard dental tissues both from a chemical (reflux) and mechanical (bruxism) point of view. The dentist could play a role of “sentinel” in a multidisciplinary team, intercepting these problems early in order to treat them in the most appropriate way. PROSPERO Registration Number: CRD42021234209. Bruxism and gastroesophageal reflux (GERD) can lead to wear of the dental tissues ,2. DentaTooth wear can be divided into two subtypes: mechanical wear  and chemical wear (erosion) . AccordiAccording to the Montreal definition, GERD is a condition of troublesome symptoms and complications that result from the reflux of stomach contents into the esophagus; This causes bothersome symptoms and/or complications ,10. The Regarding bruxism, it is essential to make a distinction between sleep bruxism and awake bruxism. Sleep bruxism is a masticatory muscle activity during sleep characterized as rhythmic (phasic) or non-rhythmic (tonic) movement and is not considered a movement disorder or sleep disorder in otherwise healthy individuals ,16. AwakThe purpose of this systematic review is to analyze the previous studies regarding the possible associations between tooth wear and sleep disorders, in particular GERD and bruxism, as well as the associations between these disorders themselves.The review was performed in accordance with PRISMA and registered on the PROSPERO database with registration number CRD42021234209. For the present systematic review of the literature, a search was carried out on the PubMed , Embase, Scopus and the Cochrane Library databases using the following Keywords/Mesh Terms: Bruxism, Sleep Bruxism, Sleep Disorders, GERD and Tooth wear applying the specific research strategy shown in low: total score ≤ 4;average: score ≤ 5 and ≤ 9;high: >9.Then, all the data relating to the type and construction of the study  were recorded with the aim of evaluating the level of evidence and the quality of the studies that were considered based on these systematic scores that were assigned to the retrieved articles , with a The search yielded 1887 publications in response to the search strategy used including the keywords; 1882 articles were excluded as not relevant, duplicated, or incompatible with the inclusion criteria. The flowchart is represented in Following the selection, five publications that observed the presence of some associations between the two problems and hypothesized their negative effects on oral health were included. The qualitative analysis of the studies is summarized in One study was considered of low level, with a score of 4; two studies were considered medium level with scores of 5 and 6, and two studies were considered high with scores of 9 and 10.The overall level of the studies does not include an adequate number of prospective longitudinal studies that can really clarify the relationship between GERD and bruxism. The study by Yuanyuan Li et al.  demonstrThe second study from the same research group  confirmeSpecifically, by analyzing the correlations presented by Li et al. from the studies of July and November 2018 it was possible to obtain a summary table , in whicThe other three studies included in the review have lower scientific quality levels than the first mentioned, as they are case-reports and overviews. However, they are considered because they hypothesize the mechanisms of correlations between GERD and bruxism ,22,24.Naila Aparecida de Godoi Machado  presentsWetselaar et al.  wrote a Finally, Lavigne et al.  describeThe aim of this study was to review existing scientific literature data on correlations between GERD and bruxism as causes of dental wear and to establish their level of evidence.GERD is widespread in the western world, its prevalence increases with age and BMI, and men are more frequently affected than women ,10. GERDRegarding bruxism, a single definition of bruxism is no longer recommended, but two separate definitions are proposed; sleep bruxism which is a masticatory muscle activity during sleep and is not a movement disorder or sleep disorder in otherwise healthy individuals. Awake bruxism is the activity of the masticatory muscles during wakefulness that is characterized by contact repetitive or prolonged dental work and/or by bracing or pushing the mandible, also it is not considered a movement disorder in otherwise healthy individuals ,17. BruxDental wear, in addition to being related to GERD, is related to bruxism, considered as a muscular activity. Thus, the analysis of existing literature confirms a probable multifactorial model for tooth wear. Moreover, bruxism and GERD seem to be both risk factors associated with tooth wear ,17,22,24Of the five studies analyzed in the present review, two studies have a considerable level of scientific evidence and focus on the relationship of both issues with dental wear. One is a case report focused on bruxism and GERD as coexisting causes of tooth wear. Two other studies are overviews that hypothesize a direct association between GERD and bruxism.From the study from Lavigne et al., it appeared clear that bruxism and GERD are conditions related to sleep, and both can act by attacking the hard tissues of the tooth. Thus, tooth wear is associated (both directly and indirectly) with sleep disorders .This demonstrates what has already been known for some time, i.e., single wear mechanisms can rarely act alone, but they interact with each other, and an association between bruxism and GERD can also be hypothesized .Therefore, more recent publications of 2018 have paid attention to a possible association between GERD and bruxism on tooth wear [The data collected state the existence of an association between GERD and tooth wear, more precisely it can be said that there is an association between GERD and chemical tooth wear and the severity of the wear is related to the severity of the symptoms of GERD. Data also evidence an association between GERD and bruxism. Specifically, as shown in Both bruxism and GERD fall into the category of sleep disorders, as they occur mainly during the night, both lead to wear of the teeth, and in conclusion, it seems that there is an interconnection between these three problems that are indirectly associated; when the onset of a GERD event precedes the onset of a sleep bruxism event there may be increased tooth wear caused by the demineralization of hard dental tissues by stomach acid which can accelerate the loss of superficial dental tissue through the activity of sleep bruxism.From a clinical point of view, the results of this literature review can support dental teams. It is essential to identify in the patient who has already been diagnosed with GERD or bruxism, a patient at risk of presenting or developing the other pathology, and therefore, subsequent severe dental wear. An interdisciplinary clinical team will, therefore, be necessary and essential to managing sleep disorders related to oral health. Only a global approach can lead to a correct diagnostic process, and therefore, to optimal assistance. Limits of this review are represented by the small number of publications identified, by the low level of the scientific quality of some of these studies and by the presence of non-homogeneous variables in the various protocols.The present review is limited to a small number of articles. Although two publications of high scientific evidence were found, both of the publications came from the same scientific group. Thus, the number of studies is limitedThe present systematic review of the existing literature is based on a small number of included articles. With this limit, a probable multifactorial model for tooth wear is confirmed. Bruxism and GERD both seem to be risk factors associated with tooth wear. There is an association between GERD and bruxism, mostly awake bruxism. Long-term GERD seems associated with severe tooth wear  in patients with bruxism. Even if the evidence emerged from the considered studies, with clinical relevance, further studies are requested in order to better understand the biological mechanisms behind the described associations.