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 g_aγγ = 8 × 10⁻¹⁴ GeV⁻¹ at the 90% confidence level. The here implemented phase-matching technique also allows for future large-scale upgrades.

Haloscopes aim at detecting axions by converting them into photons using high-quality resonant cavities, where the cavity resonance should be tuned with the unknown axion mass. Here, the authors improve exclusion limits using four phase-matched resonant cavities and a fast frequency scanning technique.

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.

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.

An anti–glypican 3/CD3 bispecific T cell–redirecting antibody for treatment of solid tumors

Cancer care is being revolutionized by immunotherapies such as immune checkpoint inhibitors, engineered T cell transfer, and cell vaccines. The bispecific T cell–redirecting antibody (TRAB) is one such promising immunotherapy, which can redirect T cells to tumor cells by engaging CD3 on a T cell and an antigen on a tumor cell. Because T cells can be redirected to tumor cells regardless of the specificity of T cell receptors, TRAB is considered efficacious for less immunogenic tumors lacking enough neoantigens. Its clinical efficacy has been exemplified by blinatumomab, a bispecific T cell engager targeting CD19 and CD3, which has shown marked clinical responses against hematological malignancies. However, the success of TRAB in solid tumors has been hampered by the lack of a target molecule with sufficient tumor selectivity to avoid “on-target off-tumor” toxicity. Glypican 3 (GPC3) is a highly tumor-specific antigen that is expressed during fetal development but is strictly suppressed in normal adult tissues. We developed ERY974, a whole humanized immunoglobulin G–structured TRAB harboring a common light chain, which bispecifically binds to GPC3 and CD3. Using a mouse model with reconstituted human immune cells, we revealed that ERY974 is highly effective in killing various types of tumors that have GPC3 expression comparable to that in clinical tumors. ERY974 also induced a robust antitumor efficacy even against tumors with nonimmunogenic features, which are difficult to treat by inhibiting immune checkpoints such as PD-1 (programmed cell death protein–1) and CTLA-4 (cytotoxic T lymphocyte–associated protein–4). Immune monitoring revealed that ERY974 converted the poorly inflamed tumor microenvironment to a highly inflamed microenvironment. Toxicology studies in cynomolgus monkeys showed transient cytokine elevation, but this was manageable and reversible. No organ toxicity was evident. These data provide a rationale for clinical testing of ERY974 for the treatment of patients with GPC3-positive solid tumors.

Per-protocol investigation of a best practice exercise referral scheme

OBJECTIVES

To investigate the effects of an exercise referral scheme (ERS) aligned to the UK best practice guidelines on a range of outcomes including those associated with key health concerns of the Scottish population.

STUDY DESIGN

A longitudinal design with data collection at three time points (baseline, midway and post) during a 12-week ERS intervention was employed.

METHODS

Health-related physical fitness was assessed through measurement of resting heart rate, blood pressure, FEV1:FEV6 (ratio of forced expiratory volume over one [FEV1] and six [FEV6] seconds), body mass and peak oxygen uptake (VO₂ peak), whilst functional capacity was assessed through the five times sit to stand test. Psychosocial well-being and quality of life were measured using the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) and the Profile of Mood State questionnaires. Growth curve analyses were used to model each outcome variable across the three time periods.

RESULTS

A range of effects were obtained with significant linear improvements in physical performance tests (P < 0.001) and psychosocial assessments (P ≤ 0.002). Additionally, significant quadratic effects of time were obtained for body composition variables and physical activity levels (P < 0.001) with the greatest improvements obtained between baseline and midway assessments.

CONCLUSIONS

An ERS aligned to the UK best practice guidelines can positively influence a range of health outcomes including those associated with lung function and cardiovascular fitness which are prevalent medical conditions in Scotland. In addition, results indicate that ERS can positively affect outcomes related to functional capacity as well as mental well-being and perceptions of health. The findings of the study identify the need for further investigation including consideration of the initial health status of referred clients.

Tranexamic acid in life-threatening military injury and the associated risk of infective complications

BACKGROUND

Tranexamic acid (TXA) has been shown to reduce mortality from severe haemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in injured patients. The aim was to examine the association between TXA administration and infection risk among injured military personnel.

METHODS

Patients who received TXA were matched by Injury Severity Score with patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first-infection model.

RESULTS

A total of 335 TXA recipients were matched with 626 patients who did not receive TXA. A greater proportion of TXA recipients had an infection compared with the comparator group (P < 0·001). Univariable analysis estimated an unadjusted odds ratio (OR) of 2·47 (95 per cent c.i. 1·81 to 3·36) for the association between TXA and infection risk; however, TXA administration was not significant in multivariable analysis (OR 1·27, 0·85 to 1·91). Blast injuries, intensive care unit (ICU) admission, and receipt of 10 units or more of blood within 24 h after injury were independently associated with infection risk. The Cox proportional model confirmed the association with ICU admission and blood transfusion. Traumatic amputations were also significantly associated with a reduced time to first infection.

CONCLUSION

In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk of having infections nor was the time to develop infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations and ICU stay were associated with infection.

Endosomal regulation of contact inhibition through the AMOT:YAP pathway

It was shown previously that endotubin, an integral membrane protein of endosomes, regulates the trafficking of tight junction proteins between endosomes and the tight junctions. Here it is shown that endotubin regulates YAP localization on endosomes through its interaction with AMOT and thus may play a role in contact inhibition.

Contact-mediated inhibition of cell proliferation is an essential part of organ growth control; the transcription coactivator Yes-associated protein (YAP) plays a pivotal role in this process. In addition to phosphorylation-dependent regulation of YAP, the integral membrane protein angiomotin (AMOT) and AMOT family members control YAP through direct binding. Here we report that regulation of YAP activity occurs at the endosomal membrane through a dynamic interaction of AMOT with an endosomal integral membrane protein, endotubin (EDTB). EDTB interacts with both AMOT and occludin and preferentially associates with occludin in confluent cells but with AMOT family members in subconfluent cells. EDTB competes with YAP for binding to AMOT proteins in subconfluent cells. Overexpression of the cytoplasmic domain or full-length EDTB induces translocation of YAP to the nucleus, an overgrowth phenotype, and growth in soft agar. This increase in proliferation is dependent upon YAP activity and is complemented by overexpression of p130-AMOT. Furthermore, overexpression of EDTB inhibits the AMOT:YAP interaction. EDTB and AMOT have a greater association in subconfluent cells compared with confluent cells, and this association is regulated at the endosomal membrane. These data provide a link between the trafficking of tight junction proteins through endosomes and contact-inhibition-regulated cell growth.

Changes in vertebral bone marrow fat and bone mass after gastric bypass surgery: A pilot study

Bone marrow fat may serve a metabolic role distinct from other fat depots, and it may be altered by metabolic conditions including diabetes. Caloric restriction paradoxically increases marrow fat in mice, and women with anorexia nervosa have high marrow fat. The longitudinal effect of weight loss on marrow fat in humans is unknown. We hypothesized that marrow fat increases after Roux-en-Y gastric bypass (RYGB) surgery, as total body fat decreases. In a pilot study of 11 morbidly obese women (6 diabetic, 5 nondiabetic), we measured vertebral marrow fat content (percentage fat fraction) before and 6 months after RYGB using magnetic resonance spectroscopy. Total body fat mass declined in all participants (mean ± SD decline 19.1 ± 6.1 kg or 36.5% ± 10.9%, p<0.001). Areal bone mineral density (BMD) decreased by 5.2% ± 3.5% and 4.1% ± 2.6% at the femoral neck and total hip, respectively, and volumetric BMD decreased at the spine by 7.4% ± 2.8% (p<0.001 for all). Effects of RYGB on marrow fat differed by diabetes status (adjusted p=0.04). There was little mean change in marrow fat in nondiabetic women (mean +0.9%, 95% CI -10.0 to +11.7%, p=0.84). In contrast, marrow fat decreased in diabetic women (-7.5%, 95% CI -15.2 to +0.1%, p=0.05). Changes in total body fat mass and marrow fat were inversely correlated among nondiabetic (r=-0.96, p=0.01) but not diabetic (r=0.52, p=0.29) participants. In conclusion, among those without diabetes, marrow fat is maintained on average after RYGB, despite dramatic declines in overall fat mass. Among those with diabetes, RYGB may reduce marrow fat. Thus, future studies of marrow fat should take diabetes status into account. Marrow fat may have unique metabolic behavior compared with other fat depots.

Scaffolding protein GOPC regulates tight junction structure

GOPC (FIG/PIST/CAL) is a PDZ-domain scaffolding protein that regulates the trafficking of a wide array of proteins, including small GTPases, receptors and cell surface molecules such as cadherin 23 and cystic fibrosis transmembrane regulator. In Madin-Darby canine kidney (MDCK) cells, we find that GOPC localizes to the trans-Golgi network (TGN) but not to the cis- or trans-Golgi cisternae. Colocalization occurs with the early endosome Rab GTPase Rab5 and a TGN/endosome marker Rab14 but not with Rab11, a marker of recycling endosomes. No localization of GOPC was detected to the lateral membranes or tight junctions. Knockdown of GOPC in MDCK cells results in decreased transepithelial resistance and increased paracellular flux. This might be attributable to the compromised trafficking of tight junction components from the TGN, as GOPC-knockdown cells have decreased lateral labeling of the tight junction protein claudin-1 and decreased protein levels of claudin-2. GOPC might mediate the trafficking of newly synthesized tight junction proteins from the TGN to the cell surface or the recycling of these proteins from specialized endosomal compartments.

Parents as the start of the solution: a social marketing approach to understanding triggers and barriers to entering a childhood weight management service

BACKGROUND

Childhood obesity is a sensitive subject and barriers exist with respect to accessing weight management programmes. Social marketing insight gathering provides an opportunity to understand behaviours and address these challenges. This project gained insight into the views of parents/carers on triggers and barriers to entering a childhood weight management service.

METHODS

Participants were identified from the public using marketing recruitment. Four focus groups were conducted with parents of school aged children (n = 27) by an experienced interviewer. Twenty two mothers, three fathers and two grandmothers participated, with half describing their child as overweight. Groups discussed health behaviours; attitudes to health messages and weight issues; and motivations, benefits and barriers with respect to accessing weight management services. Discussions were taped and transcribed. Themes were identified using framework analysis of content matrix data analysis.

RESULTS

Participants were aware of healthy lifestyle messages, although the ability to implement these was variable. Triggers to seeking help included bullying, health concerns and inability to participate in school activities. Barriers included feeling a lack of control, desire to avoid conflict and no proven case that weight was a problem. Parents wished to be given information regarding their child's weight by a trusted person. The Internet and word of mouth were identified as methods of recruitment into a weight management service, with a focus on fitness, fun and friendliness and being free-of-charge.

CONCLUSIONS

Insight gathering can be used to establish parental/carer opinion regarding engaging in childhood weight management services. A fun, friendly programme that is free of charge appealed to parents. Local community involvement around normalising child weight issues may boost referrals into child healthy weight interventions.

Rab14 regulation of claudin-2 trafficking modulates epithelial permeability and lumen morphogenesis

Epithelial permeability is regulated by targeted insertion and recycling of tight junction proteins. Rab14 regulates the lysosomal targeting of the leaky claudin, claudin-2, and depletion of Rab14 results in increased transepithelial resistance and aberrant morphogenesis in three-dimensional culture.

Regulation of epithelial barrier function requires targeted insertion of tight junction proteins that have distinct selectively permeable characteristics. The insertion of newly synthesized proteins and recycling of internalized tight junction components control both polarity and junction function. Here we show that the small GTPase Rab14 regulates tight junction structure. In Madin–Darby canine kidney (MDCK) II cells, Rab14 colocalizes with junctional proteins, and knockdown of Rab14 results in increased transepithelial resistance. In cells without Rab14, there are small changes in the trafficking of claudin-1 and occludin. In addition, there is substantial depletion of the leaky claudin, claudin-2, but not other tight junction components. The loss of claudin-2 is complemented by inhibition of lysosomal function, suggesting that Rab14 sorts claudin-2 out of the lysosome-directed pathway. MDCK I cells lack claudin-2 endogenously, and knockdown of Rab14 in these cells does not result in a change in transepithelial resistance, suggesting that the effect is specific to claudin-2 trafficking. Furthermore, leaky claudins have been shown to be required for epithelial morphogenesis, and knockdown of Rab14 results in failure to form normal single-lumen cysts in three-dimensional culture. These results implicate Rab14 in specialized trafficking of claudin-2 from the recycling endosome.

Search for solar axions by the CERN axion solar telescope with 3He buffer gas: closing the hot dark matter gap

The CERN Axion Solar Telescope has finished its search for solar axions with (3)He buffer gas, covering the search range 0.64 eV ≲ ma ≲ 1.17 eV. This closes the gap to the cosmological hot dark matter limit and actually overlaps with it. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of gaγ ≲ 3.3 × 10(-10)  GeV(-1) at 95% C.L., with the exact value depending on the pressure setting. Future direct solar axion searches will focus on increasing the sensitivity to smaller values of gaγ, for example by the currently discussed next generation helioscope International AXion Observatory.

Synthesis of cyclohexapeptides as antimalarial and anti-trypanosomal agents

Azolic and non-azolic cyclohexapeptides were obtained and/or evaluated as promising antimalarial and/or anti-trypanosomal agents.

British Dietetic Association evidence-based guidelines for the protein requirements of adults undergoing maintenance haemodialysis or peritoneal dialysis

BACKGROUND

Existing nutritional guidelines suggest that protein requirements of adults with stage five chronic kidney disease undergoing haemodialysis (HD) or peritoneal dialysis (PD) are increased as a result of protein losses during dialysis. The present review aimed to update previous guidance and develop evidence-based practice guidelines on the protein requirements of adults undergoing maintenance dialysis.

METHODS

Following a PICO approach (Participants or Population, Intervention or Exposure, Comparison and Outcome), four research questions were formulated to investigate the total protein requirement and protein quality required by adults undergoing HD and PD. A comprehensive, systematic review was undertaken using the databases Medline, EMBASE and the Cochrane Library from 2005 to September 2009 for HD studies and from 1997 to September 2009 for PD studies.

RESULTS

The literature search yielded 2931 studies, which were assessed for inclusion. Following appraisal, 19 studies in HD and 18 studies in PD met the inclusion criteria and were systematically reviewed. Limited good quality evidence supports the recommendations that: (i) adults undergoing maintenance HD require a minimum protein intake of 1.1 g kg(-1) ideal body weight (IBW) per day; and (ii) adults undergoing maintenance PD require a minimum protein intake of 1.0-1.2 kg(-1) IBW per day, in conjunction with an adequate energy intake. There were no studies that addressed the quality of protein for either HD or PD.

CONCLUSIONS

Evidence suggests that nutritional status may be maintained with lower protein intakes than previously recommended. However, the evidence base is limited and further randomised controlled trials are required to establish the optimal protein intake for dialysis patients.