Interventions for Managing Late Gastrointestinal Symptoms Following Pelvic Radiotherapy: a Systematic Review and Meta-analysis

AIMS

Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms.

MATERIALS AND METHODS

A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals.

RESULTS

Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed.

CONCLUSIONS

Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted.

Time Patterns in Internal Human Exposure Data to Bisphenols, Phthalates, DINCH, Organophosphate Flame Retardants, Cadmium and Polyaromatic Hydrocarbons in Europe

Human biomonitoring (HBM) data in Europe are often fragmented and collected in different EU countries and sampling periods. Exposure levels for children and adult women in Europe were evaluated over time. For the period 2000-2010, literature and aggregated data were collected in a harmonized way across studies. Between 2011-2012, biobanked samples from the DEMOCOPHES project were used. For 2014-2021, HBM data were generated within the HBM4EU Aligned Studies. Time patterns on internal exposure were evaluated visually and statistically using the 50th and 90th percentiles (P50/P90) for phthalates/DINCH and organophosphorus flame retardants (OPFRs) in children (5-12 years), and cadmium, bisphenols and polycyclic aromatic hydrocarbons (PAHs) in women (24-52 years). Restricted phthalate metabolites show decreasing patterns for children. Phthalate substitute, DINCH, shows a non-significant increasing pattern. For OPFRs, no trends were statistically significant. For women, BPA shows a clear decreasing pattern, while substitutes BPF and BPS show an increasing pattern coinciding with the BPA restrictions introduced. No clear patterns are observed for PAHs or cadmium. Although the causal relations were not studied as such, exposure levels to chemicals restricted at EU level visually decreased, while the levels for some of their substitutes increased. The results support policy efficacy monitoring and the policy-supportive role played by HBM.

Application of human biomonitoring data to support policy development, raise awareness and environmental public health protection among countries within the HBM4EU project

Most countries have acknowledged the importance of assessing and quantifying their population's internal exposure from chemicals in air, water, soil, food and other consumer products due to the potential health and economic impact. Human biomonitoring (HBM) is a valuable tool which can be used to quantify such exposures and effects. Results from HBM studies can also contribute to improving public health by providing evidence of individuals' internal chemical exposure as well as data to understand the burden of disease and associated costs thereby stimulating the development and implementation of evidence-based policy. To have a holistic view on HBM data utilisation, a multi-case research approach was used to explore the use of HBM data to support national chemical regulations, protect public health and raise awareness among countries participating in the HBM4EU project. The Human Biomonitoring for Europe (HBM4EU) Initiative (https://www.hbm4eu.eu/) is a collaborative effort involving 30 countries, the European Environment Agency (EEA) and the European Commission (contracting authority) to harmonise procedures across Europe and advance research into the understanding of the health impacts of environmental chemical exposure. One of the aims of the project was to use HBM data to support evidence based chemical policy and make this information timely and directly available for policy makers and all partners. The main data source for this article was the narratives collected from 27 countries within the HBM4EU project. The countries (self-selection) were grouped into 3 categories in terms of HBM data usage either for public awareness, policy support or for the establishment HBM programme. Narratives were analysed/summarised using guidelines and templates that focused on ministries involved in or advocating for HBM; steps required to engage policy makers; barriers, drivers and opportunities in developing a HBM programme. The narratives reported the use of HBM data either for raising awareness or addressing environmental/public health issues and policy development. The ministries of Health and Environment were reported to be the most prominent entities advocating for HBM, the involvement of several authorities/institutions in the national hubs was also cited to create an avenue to interact, discuss and gain the attention of policy makers. Participating in European projects and the general population interest in HBM studies were seen as drivers and opportunities in developing HBM programmes. A key barrier that was cited by countries for establishing and sustaining national HBM programmes was funding which is mainly due to the high costs associated with the collection and chemical analysis of human samples. Although challenges and barriers still exist, most countries within Europe were already conversant with the benefits and opportunities of HBM. This article offers important insights into factors associated with the utilisation of HBM data for policy support and public awareness.

PFAS levels and determinants of variability in exposure in European teenagers - Results from the HBM4EU aligned studies (2014-2021)

BACKGROUND

Perfluoroalkyl substances (PFAS) are man-made fluorinated chemicals, widely used in various types of consumer products, resulting in their omnipresence in human populations. The aim of this study was to describe current PFAS levels in European teenagers and to investigate the determinants of serum/plasma concentrations in this specific age group.

METHODS

PFAS concentrations were determined in serum or plasma samples from 1957 teenagers (12-18 years) from 9 European countries as part of the HBM4EU aligned studies (2014-2021). Questionnaire data were post-harmonized by each study and quality checked centrally. Only PFAS with an overall quantification frequency of at least 60% (PFOS, PFOA, PFHxS and PFNA) were included in the analyses. Sociodemographic and lifestyle factors were analysed together with food consumption frequencies to identify determinants of PFAS exposure. The variables study, sex and the highest educational level of household were included as fixed factors in the multivariable linear regression models for all PFAS and each dietary variable was added to the fixed model one by one and for each PFAS separately.

RESULTS

The European exposure values for PFAS were reported as geometric means with 95% confidence intervals (CI): PFOS [2.13 μg/L (1.63-2.78)], PFOA ([0.97 μg/L (0.75-1.26)]), PFNA [0.30 μg/L (0.19-0.45)] and PFHxS [0.41 μg/L (0.33-0.52)]. The estimated geometric mean exposure levels were significantly higher in the North and West versus the South and East of Europe. Boys had significantly higher concentrations of the four PFAS compared to girls and significantly higher PFASs concentrations were found in teenagers from households with a higher education level. Consumption of seafood and fish at least 2 times per week was significantly associated with 21% (95% CI: 12-31%) increase in PFOS concentrations and 20% (95% CI: 10-31%) increase in PFNA concentrations as compared to less frequent consumption of seafood and fish. The same trend was observed for PFOA and PFHxS but not statistically significant. Consumption of eggs at least 2 times per week was associated with 11% (95% CI: 2-22%) and 14% (95% CI: 2-27%) increase in PFOS and PFNA concentrations, respectively, as compared to less frequent consumption of eggs. Significantly higher PFOS concentrations were observed for participants consuming offal (14% (95% CI: 3-26%)), the same trend was observed for the other PFAS but not statistically significant. Local food consumption at least 2 times per week was associated with 40% (95% CI: 19-64%) increase in PFOS levels as compared to those consuming local food less frequently.

CONCLUSION

This work provides information about current levels of PFAS in European teenagers and potential dietary sources of exposure to PFAS in European teenagers. These results can be of use for targeted monitoring of PFAS in food.

HBM4EU feasibility studies: Lessons learned in combining health and human biomonitoring studies

Background

The European Human Biomonitoring Initiative (HBM4EU) is a program protecting humans from the health effects of chemicals. The goal of HBM4EU is to make use of human biomonitoring (HBM) to assess human exposure to chemicals in Europe to better understand the associated health effects for citizens and to improve chemical risk assessment. Harmonisation and sustainable implementation of the HBM programme across Europe are important aims. In parallel to HBM studies, health examination surveys (HESs), dietary surveys, and disease specific health surveys are conducted in many European countries. In HESs, information collected by questionnaire(s) is supplemented with physical examinations and analysis of biomarkers from biological samples. HBM and HES use similar sample and data collection methods and infrastructures hence combining the two is being explored.

Methods

Within HBM4EU, three feasibility studies (Finland, Germany, and UK/England) were conducted to evaluate opportunities and obstacles in combining HBM and health studies. We describe the contents and differences of these feasibility studies, and discuss the matters of shared benefits, obstacles, and lessons learned.

Results

Benefits of combining HBM and HESs include the use of shared infrastructures, participants receiving additional health information from HES, and higher participation rates. Obstacles can be encountered when obtaining ethical approval and during time-consuming and complicated preparatory phases. Recruitment of participants and low participation rates are common concerns and designing participant-friendly questionnaires is important. Unexpected events such as the COVID-19 pandemic can cause challenges to studies. Furthermore, experiences from several countries demonstrated that long-term funding for combined studies can be difficult to obtain.

Conclusions

In the future, incorporating HBM modules into HESs can provide a feasible and cost-effective method to conduct HBM studies.

Key messages

• The European Human Biomonitoring Initiative (HBM4EU) protects humans from the health effects of chemicals in Europe. HBM4EU uses human biomonitoring (HBM) to evaluate human exposure to chemicals.

• In addition to HBM studies, health examination surveys (HESs) are conducted. In the future, incorporating HBM modules into HESs can provide a feasible and cost-effective method to conduct HBM studies.

Search for Dark Matter Axions with CAST-CAPP

The CAST-CAPP axion haloscope, operating at CERN inside the CAST dipole magnet, has searched for axions in the 19.74 μeV to 22.47 μeV mass range. The detection concept follows the Sikivie haloscope principle, where Dark Matter axions convert into photons within a resonator immersed in a magnetic field. The CAST-CAPP resonator is an array of four individual rectangular cavities inserted in a strong dipole magnet, phase-matched to maximize the detection sensitivity. Here we report on the data acquired for 4124 h from 2019 to 2021. Each cavity is equipped with a fast frequency tuning mechanism of 10 MHz/ min between 4.774 GHz and 5.434 GHz. In the present work, we exclude axion-photon couplings for virialized galactic axions down to gaγγ = 8 × 10-14 GeV-1 at the 90% confidence level. The here implemented phase-matching technique also allows for future large-scale upgrades.

Harmonization of Human Biomonitoring Studies in Europe: Characteristics of the HBM4EU-Aligned Studies Participants

Human biomonitoring has become a pivotal tool for supporting chemicals' policies. It provides information on real-life human exposures and is increasingly used to prioritize chemicals of health concern and to evaluate the success of chemical policies. Europe has launched the ambitious REACH program in 2007 to improve the protection of human health and the environment. In October 2020 the EU commission published its new chemicals strategy for sustainability towards a toxic-free environment. The European Parliament called upon the commission to collect human biomonitoring data to support chemical's risk assessment and risk management. This manuscript describes the organization of the first HBM4EU-aligned studies that obtain comparable human biomonitoring (HBM) data of European citizens to monitor their internal exposure to environmental chemicals. The HBM4EU-aligned studies build on existing HBM capacity in Europe by aligning national or regional HBM studies. The HBM4EU-aligned studies focus on three age groups: children, teenagers, and adults. The participants are recruited between 2014 and 2021 in 11 to 12 primary sampling units that are geographically distributed across Europe. Urine samples are collected in all age groups, and blood samples are collected in children and teenagers. Auxiliary information on socio-demographics, lifestyle, health status, environment, and diet is collected using questionnaires. In total, biological samples from 3137 children aged 6-12 years are collected for the analysis of biomarkers for phthalates, HEXAMOLL® DINCH, and flame retardants. Samples from 2950 teenagers aged 12-18 years are collected for the analysis of biomarkers for phthalates, Hexamoll® DINCH, and per- and polyfluoroalkyl substances (PFASs), and samples from 3522 adults aged 20-39 years are collected for the analysis of cadmium, bisphenols, and metabolites of polyaromatic hydrocarbons (PAHs). The children's group consists of 50.4% boys and 49.5% girls, of which 44.1% live in cities, 29.0% live in towns/suburbs, and 26.8% live in rural areas. The teenagers' group includes 50.6% girls and 49.4% boys, with 37.7% of residents in cities, 31.2% in towns/suburbs, and 30.2% in rural areas. The adult group consists of 52.6% women and 47.4% men, 71.9% live in cities, 14.2% in towns/suburbs, and only 13.4% live in rural areas. The study population approaches the characteristics of the general European population based on age-matched EUROSTAT EU-28, 2017 data; however, individuals who obtained no to lower educational level (ISCED 0-2) are underrepresented. The data on internal human exposure to priority chemicals from this unique cohort will provide a baseline for Europe's strategy towards a non-toxic environment and challenges and recommendations to improve the sampling frame for future EU-wide HBM surveys are discussed.

HBM4EU combines and harmonises human biomonitoring data across the EU, building on existing capacity - The HBM4EU survey

As part of the Human Biomonitoring for Europe (HBM4EU) initiative a human biomonitoring (HBM) survey is conducted in 21 countries. This survey builds on existing HBM capacity in Europe by aligning national or regional HBM studies. The survey targets 3 age groups (i) children aged 6-11 years, (ii) teenagers aged 12-19 years and (iii) young adults aged 20-39 years and includes a total of 9493 participants (3151 children, 2953 teenagers and 3389 young adults). Depending on the age group, internal exposure to phthalates and substitute Hexamoll® DINCH, brominated and organophosphorus flame retardants, per-/poly-fluorinated compounds, cadmium, bisphenols and/or polycyclic aromatic hydrocarbons are assessed. The main goal of the programme is to obtain quality controlled and comparable HBM data of exposure to chemicals, prioritized under HBM4EU, with European wide coverage to inform the development of environment and health policies. This paper describes the framework of the HBM4EU survey and the approach that has been applied to align European HBM initiatives across Europe.

British Dietetic Association's Obesity Specialist Group dietetic obesity management interventions in children and young people: review & clinical application

BACKGROUND

Dietitians play a vital role in the management of childhood obesity. To support that role the Obesity Specialist Group of the British Dietetic Association commissioned a review and clinical application paper. This current paper is a summary of that review document, which is available on the BDA's website.

METHODS

The initial sources of evidence were guidelines, published reviews and government guidance. Best practice advice was sought from networks including the BDA's Obesity and Paediatric Specialists groups. The original document was reviewed by a review group and members of the Obesity and Paediatric Specialist group's committees.

RESULTS

The overall aim of dietetic interventions in childhood weight management should be to deliver evidence based dietetic weight management care, which helps maintain positive lifestyle changes. To support this aim the review recommends the UK BMI cut off points in setting service referral and triaging criteria. Ensuring the whole child's world is taken into account when undertaking assessment and throughout the programme process is essential. Dietitians working in this field require behavioural change skills, motivational techniques and the ability to communicate to children of differing ages and their parents. Knowledge of local child safe guarding procedures are necessary for all working in this field. Recommendations on basic and advanced skills required are specified.

CONCLUSIONS

This paper was written to compliment a full review document. The complexities around case management, child protection issues and competing family motivations require dietitians trained at undergraduate and postgraduate level to deliver high quality weight management and behavioural change.

From 'OPAT' to 'COpAT': implications of the OVIVA study for ambulatory management of bone and joint infection

Bone and joint infection contributes significantly to clinical activity within outpatient parenteral antimicrobial therapy (OPAT) services. The OVIVA (oral versus intravenous antibiotics for bone and joint infection) randomized study has challenged the practice of prolonged intravenous therapy, because non-inferiority of oral antibiotic therapy was demonstrated, thereby implying that early transition to oral therapy is an appropriate alternative to prolonged intravenous therapy. We examine the caveats to the study and discuss the implications for OPAT practice, highlighting the importance of careful oral antibiotic selection with attention to bioavailability, bone penetration, drug interactions, compliance and toxicity monitoring. We emphasize that ambulatory antibiotic therapy (whether intravenous or oral) in this patient group requires expert multidisciplinary management, monitoring and follow-up, and ideally should be undertaken within existing OPAT or, more accurately, complex outpatient antibiotic therapy (COpAT) services.

A rare case of multiple secondary endotracheal metastasis from early stage small cell cancer

Introduction

Small Cell Lung Cancer (SCLC) is an aggressive malignancy with poor prognosis that accounts for 10% of all clinical lung cancer. SCLC commonly metastasizes to the mediastinum, liver, bone, adrenals, and the brain but secondary endotracheal metastasis is an especially rare occurrence. We discuss the case of a 74-year-old male with principal complaint of cough, wheezing and hemoptysis found to have secondary endotracheal lesions on bronchoscopy.

Case report

A 74-year-old male, former smoker with a past medical history of pulmonary embolism, bullous emphysema, and limited stage small cell lung cancer with wedge resection and chemotherapy 3 years ago presented with cough, wheezing, weight loss and intermittent hemoptysis ongoing for few weeks. CT scan of the chest showed multiple polypoid masses arising in the anterior wall of the trachea. He underwent bronchoscopy with biopsy. Pathology was consistent with small-cell lung cancer.

Conclusion

Secondary tracheal metastasis from early stage small cell cancer is a rare occurrence. The likelihood of tracheal metastasis of lung cancer is amplified when an endotracheal nodule or eccentric thickening of the tracheal wall is seen on CT of patients with high suspicion. It is important for clinicians to suspect endotracheal lesions when a patient presents with recurrent respiratory complaints despite stable surveillance CT scan of chest in patients with history of lung cancer.

Heat Mitigation Strategies for Finishing Beef Cattle During the Summer in the Southeastern United States Reduces Heat Load and Improves Weight Gain, but does not Influence Meat Quality

ObjectivesThe objective of this research was to determine the effect of heat mitigation strategies on meat quality when finishing cattle under heat stress conditions.Materials and MethodsForty-five Angus crossbred steers (446 ± 23 kg) were blocked by weight and randomly assigned to 1 of 3 finishing environments: shaded with fan (CWF), shaded without fan (CNF), or outside no shade (OUT). For 92 d steers were individually fed a corn-based total mixed ration and were weighed every 3 wk. Environmental monitors (Kestrel Instruments) were used to quantify heat load index (HLI) and accumulated heat load units (AHLU). When the first treatment group averaged 613 kg all steers were harvested. Carcass quality and yield data were collected 24 h postmortem. Strip loins were removed from the right side of each carcass at 24 h postmortem, vacuum packaged, and aged (2 ± 1°C) for 5 d. Strip loins were then fabricated into 2.54-cm steaks anterior to posterior. The first steak was designated for proximate analysis, followed by two steaks for slice shear force (14 and 21 d aging), two steaks for other analyses, and the remaining 7 steaks were randomly assigned to shelf life (SL) for 6 d following 28 d of wet aging. Steaks were vacuum packaged and held (2 ± 1°C) for their respective days of aging. After 28 d, shelf life steaks were opened, placed in Styrofoam trays with PVC overwrap, and placed in retail display cases (1 ± 2°C). Steaks were frozen (–20°C) once they reached their assigned day of wet aging or simulated shelf life. Objective color L* (lightness), a* (redness), b* (yellowness), and isobestic wavelengths were recorded daily (± 2 h). Hue, chroma, DE, and deoxymyoglobin (%Dmb), oxymyoglobin (%Omb), and metmyoglobin (%Mmb) were calculated. Data were analyzed using a mixed model (JMP v.13; SAS) and means were separated using LSmeans at a = 0.05.ResultsEnvironmental monitors showed that CWF and CNF had lower HLI and AHLU (P < 0.01) than OUT. Final weights were greater for CWF than OUT (P = 0.02) while CNF was similar (P ≥ 0.17) to both. Similar results were observed for hot carcass weights where CWF > OUT (P = 0.03), and CNF was similar to both (P ≥ 0.23). Treatment differences were not observed for USDA yield grade (P = 0.38), dressing percent (P = 0.93), kidney pelvic heart fat (P = 0.89), ribeye area (P = 0.47), backfat thickness (P = 0.49), marbling score (P = 0.71), overall maturity (P = 0.92), or subjective lean color (P = 0.16). No differences in fat color scores were observed between CNF and OUT (P = 0.95) while CWF were whiter (P ≤ 0.04) than both. Protein analysis showed CWF had more protein than OUT (P = 0.01) while CNF was similar to both (P ≥ 0.90). No differences were observed for lipid content (P = 0.99), ash (P = 0.39), or moisture (P = 0.92). Treatment nor day of aging effected slice shear force (P = 0.45 and P = 0.53, respectively). While treatment differences were not observed for a*, b*, hue, chroma and DE (P = 0.51, P = 0.65, P = 0.18 P = 0.57, and P = 0.57, respectively). Treatment values for L* were lighter for CNF than CWF (P = 0.04), while OUT was similar to both (P ≥ 0.14). There were no differences for %Dmb, %Omb, and %Mmb (P = 0.24, P = 0.32, and P = 0.39, respectively) among the treatments.ConclusionResults indicate that heat stress mitigation is a viable method to improve weight, however, does not impact the quality of the meat.

Evaluation of Pearl Millet With and Without Soybean Hull Supplementation for Forage-Finished Beef Production Systems

ObjectivesThe objective of this research was to evaluate pearl millet, a warm-season annual grass, with and without soybean hull supplementation for forage-finished beef production systems in the Southeast.Materials and MethodsEach year, 32 Angus-crossbred steers (339 ± 40 kg) were randomly assigned to one of four finishing treatments. Treatments were arranged in a 2 × 2 factorial and included two varieties of pearl millet, ‘Tifleaf 3’ (PM) and ‘Exceed’ brown mid-rib (BMR), and two levels of soybean hull supplementation, 0 and 0.75% of body weight d–1. Steers were on treatments for 90 and 84 d during the summers of 2017 and 2018, respectively, at the University of Georgia Department of Animal and Dairy Science Beef Research Unit located near Eatonton, GA. Shrunk weights were taken at initiation and termination of the finishing period and average daily gains (ADG) were calculated. At the end of the finishing period, steers were harvested under USDA inspection and carcass data was collected 24 h postmortem from the right side of each carcass. Striploins were then removed from the right side, vacuum packed, and allowed to age for 21 d prior to fabrication. Striploins were fabricated into 2.54-cm steaks and allocated to meats proximate (n = 1), 0 through 7 d of simulated shelf life (n = 8), trained sensory panel (n = 2), and instrumental tenderness analyses (n = 2). All data were analyzed using PROC GLIMMIX in SAS v. 9.4.ResultsSupplementation increased ADG over forage alone (P < 0.01) however, hot carcass weights were increased by supplementation in the PM steers only (P < 0.05). No treatment differences were observed for marbling score (P = 0.61), overall maturity (P = 0.49), 12th rib fat thickness (P = 0.21), ribeye area (P = 0.1668), and subjective fat color (P = 0.93). Objective carcass lean color values for L* and subjective lean color scores were different (P < 0.05). Treatment effects were also observed for carcass lean maturity scores (P < 0.05). No treatment differences were observed for meats proximate analysis (P > 0.05), instrumental tenderness as measured by Warner-Bratzler shear force (P = 0.94), initial and sustained tenderness (P = 0.66 and P = 0.29, respectively), beef and off-flavor intensities (P = 0.83 and P = 0.36, respectively), or juiciness (P = 0.54) as measured by a trained sensory panel. No treatment differences (P > 0.05) were observed for lipid oxidation or color change (Delta E) within any day of simulated shelf life. Calculated values for hue, chroma, and redness were unaffected (P > 0.05) by treatment within day of simulated shelf life.ConclusionResults indicate pearl millet is a viable forage option for forage-finished beef systems and soybean hull supplementation improves animal performance over forage alone with minimal impacts on carcass characteristics, meat quality, and shelf life.

Risk factors and patterns of household clusters of respiratory viruses in rural Nepal

Viral pneumonia is an important cause of death and morbidity among infants worldwide. Transmission of non-influenza respiratory viruses in households can inform preventative interventions and has not been well-characterised in South Asia. From April 2011 to April 2012, household members of pregnant women enrolled in a randomised trial of influenza vaccine in rural Nepal were surveyed weekly for respiratory illness until 180 days after birth. Nasal swabs were tested by polymerase chain reaction for respiratory viruses in symptomatic individuals. A transmission event was defined as a secondary case of the same virus within 14 days of initial infection within a household. From 555 households, 825 initial viral illness episodes occurred, resulting in 79 transmission events. The overall incidence of transmission was 1.14 events per 100 person-weeks. Risk of transmission incidence was associated with an index case age 1-4 years (incidence rate ratio (IRR) 2.35; 95% confidence interval (CI) 1.40-3.96), coinfection as initial infection (IRR 1.94; 95% CI 1.05-3.61) and no electricity in household (IRR 2.70; 95% CI 1.41-5.00). Preventive interventions targeting preschool-age children in households in resource-limited settings may decrease the risk of transmission to vulnerable household members, such as young infants.

Successful prospective quality improvement programme for the identification and management of patients at risk of sepsis in hospital

Objective

This audit aimed to improve the speed and completeness of delivery of treatment to urology patients at risk of sepsis in the hospital.

Patients and methods

Patients were prospectively included if they developed a new-onset systemic inflammatory response syndrome, were reviewed by a doctor who thought this was due to infection and prescribed antibiotics. We measured median time to antibiotic administration (TTABx) as the primary outcome. Factors associated with delays in management were identified, targeted quality improvement interventions implemented and then reaudited.

Results

There were 74 patients in the baseline cohort and 69 following interventions. Median TTABx fell from 3.6 (1.9–6.9) hours to 1.7 (1.0–3.8) p<0.001 hours after interventions. In the baseline cohort, factors significantly associated with a delay in TTABx were: an Early Warning Score less than the medical review trigger level; a temperature less than 38°C; having had surgery versus not. Interventions included: reduced medical review trigger thresholds, education sessions, communication aids, a department-specific sepsis protocol. There were significant improvements in the speed and completeness of sepsis management. Improvements were most marked in postoperative patients. Improvement longevity was achieved through continued work by permanent ward nurse practitioners.

Conclusion

A period of baseline prospective study, followed by tailored quality improvement initiatives, can significantly improve the speed and quality of sepsis management for inpatients on an acute hospital ward.

Antigenic mimicry of ubiquitin by the gut bacterium Bacteroides fragilis: a potential link with autoimmune disease

Ubiquitin is highly conserved across eukaryotes and is essential for normal eukaryotic cell function. The bacterium Bacteroides fragilis is a member of the normal human gut microbiota, and the only bacterium known to encode a homologue of eukaryotic ubiquitin. The B. fragilis gene sequence indicates a past horizontal gene transfer event from a eukaryotic source. It encodes a protein (BfUbb) with 63% identity to human ubiquitin which is exported from the bacterial cell. The aim of this study was (i) to determine if there was antigenic cross‐reactivity between B. fragilis ubiquitin and human ubiquitin and (ii) to determine if humans produced antibodies to BfUbb. Molecular model comparisons of BfUbb and human ubiquitin predicted a high level (99·8% confidence) of structural similarity. Linear epitope mapping identified epitopes in BfUbb and human ubiquitin that cross‐react. BfUbb also has epitope(s) that do not cross‐react with human ubiquitin. The reaction of human serum (n = 474) to BfUbb and human ubiquitin from the following four groups of subjects was compared by enzyme‐linked immunosorbent assay (ELISA): (1) newly autoantibody‐positive patients, (2) allergen‐specific immunoglobulin (Ig)E‐negative patients, (3) ulcerative colitis patients and (4) healthy volunteers. We show that the immune system of some individuals has been exposed to BfUbb which has resulted in the generation of IgG antibodies. Serum from patients referred for first‐time testing to an immunology laboratory for autoimmune disease are more likely to have a high level of antibodies to BfUbb than healthy volunteers. Molecular mimicry of human ubiquitin by BfUbb could be a trigger for autoimmune disease.