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.

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.

Metrics of HIV Pre-exposure Prophylaxis (PrEP) Implementation Before and After a Multidisciplinary Task Force at an Academic Institution

BACKGROUND AND OBJECTIVES

There is a paucity of guidance on HIV pre-exposure prophylaxis (PrEP) implementation in an academic medical center. The objectives of this study were to describe interventions by a multidisciplinary PrEP task force at an academic medical center and compare metrics of PrEP implementation pre- and post-creation of this entity.

METHODS

The interventions of the task force are described within the rubric of the PrEP care continuum. Participants were adults prescribed PrEP for greater than or equal to 30 days at 9 clinical sites across a university health system. Metrics of PrEP implementation were compared over 12-month intervals before and after the creation of the task force.

RESULTS

An increased proportion of participants had HIV testing within 7 days of new PrEP prescriptions (92% vs 63%, P < .001) and were prescribed PrEP in increments of 90 days or shorter (74% vs 56%, P < .001) after the creation of the task force. There were higher rates of testing for bacterial sexually transmitted infections in men who had sex with men and transgender women in the post-intervention compared with pre-intervention period.

CONCLUSIONS

A multidisciplinary team that focuses on optimizing PrEP delivery along each step of the care continuum may facilitate PrEP scale-up and best practices in an academic setting.

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.

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.

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.

Developing and piloting an electronic telephone triage application

e21680

Background: With the shift of cancer care to the outpatient setting, telephone triage is a vital part of today’s oncology practice. UPMC CancerCenter (UPMC) desires to streamline the current telephone triage process across its 31 outpatient clinics. UPMC and Via Oncology collaborated to develop and pilot a prototype of an electronic telephone triage application. The key components of the prototype were defined as decision support, EHR integration, reporting, and workflow management. Methods: A prototype application, Symptom Manager (SM), was developed and piloted with 4 nurses at 3 outpatient clinics. Front office staff registered inbound calls in SM, which populated a phone triage queue. The nurse was prompted to enter information about the call. Decision support materials were displayed for reference, including algorithms for symptom assessment, adjudication, and treatment. The output was a structured summary of the encounter that was copied to the patient’s chart. From the queue, the nurse was also prompted to make outbound calls for symptom reassessment. A feedback session with the nurse users and institution leadership was held following the pilot. Results: A total of 235 inbound calls were captured in the application, of which 74 (31.5%) were symptom-related. Additional data fields collected during the pilot included symptom, adjudication, time elapsed for callback, and symptom status at follow up. The ability to extract and report on data of this type was viewed as valuable for quality and process improvement. The nurse users praised SM’s ease of use, but prototype performance issues shortened the pilot. They indicated that the standardized documentation increased efficiency. Requests for future enhancements included deeper EHR integration and additional fields for data capture. Conclusions: This pilot provided the feedback necessary to develop the latest version of SM which begins roll out across UPMC in November 2016 and includes EMR integration. An update on the software and additional data captured during the pilot will be provided at presentation.

Developing and piloting an electronic telephone triage application

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Background: With the shift of cancer care to the outpatient setting, telephone triage is a vital part of today’s oncology practice. UPMC CancerCenter (UPMC) desires to streamline the current telephone triage process across its 31 outpatient clinics. UPMC and Via Oncology collaborated to develop and pilot a prototype of an electronic telephone triage application. The key components of the prototype were defined as decision support, EHR integration, reporting, and workflow management. Methods: A prototype application, Symptom Manager (SM), was developed and piloted with 4 nurses at 3 outpatient clinics. Front office staff registered inbound calls in SM, which populated a phone triage queue. The nurse was prompted to enter information about the call. Decision support materials were displayed for reference, including algorithms for symptom assessment, adjudication, and treatment. The output was a structured summary of the encounter that was copied to the patient’s chart. From the queue, the nurse was also prompted to make outbound calls for symptom reassessment. A feedback session with the nurse users and institution leadership was held following the pilot. Results: A total of 235 inbound calls were captured in the application, of which 74 (31.5%) were symptom-related. Additional data fields collected during the pilot included symptom, adjudication, time elapsed for callback, and symptom status at follow up. The ability to extract and report on data of this type was viewed as valuable for quality and process improvement. The nurse users praised SM’s ease of use, but prototype performance issues shortened the pilot. They indicated that the standardized documentation increased efficiency. Requests for future enhancements included deeper EHR integration and additional fields for data capture. Conclusions: This pilot provided the feedback necessary to develop the latest version of SM which begins roll out across UPMC in November 2016 and includes EMR integration. An update on the software and additional data captured during the pilot will be provided at presentation.

Developing and piloting an electronic telephone triage application

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Background: Telephone triage is a vital part of today’s oncology practice and is often not standardized and measured to allow for quality improvement. UPMC CancerCenter (UPMC) has 31 outpatient clinics and is in need of a tool to streamline the current telephone triage process. UPMC and Via Oncology collaborated to develop and pilot a prototype of an electronic telephone triage application. The key components of the prototype were defined as decision support, EHR integration, reporting and workflow management. Methods: A prototype application, Symptom Manager (SM), was developed and piloted with 4 nurses at 3 outpatient clinics. Front office staff registered inbound calls in SM, which populated a phone triage queue. The nurse was prompted to enter information about the call. Decision support materials were displayed for reference, including algorithms for symptom assessment, adjudication and treatment. The output was a structured summary of the encounter that was copied to the patient’s chart. From the queue, the nurse was prompted to make outbound calls for symptom reassessment. A feedback session with nurse users and institution leadership was held following the pilot. Results: A total of 235 inbound calls were captured in the application, of which 74 (31.5%) were symptom-related. Additional data fields collected during the pilot included symptom, adjudication, time elapsed for callback, and symptom status at follow up. The ability to extract and report on data of this type was viewed as valuable for quality and process improvement. The nurse users praised SM’s ease of use, but prototype performance issues shortened the pilot. When referencing the decision support materials, nurses felt more confident consulting providers and during independent decision-making. They indicated that the standardized documentation increased efficiency. Requests for future enhancements included deeper EHR integration and additional fields for data capture. Conclusions: This prototype fulfilled the defined key components of a tool of this type. SM is currently being refined and incorporated into the Via Portal, Via Oncology’s decision support software. An update on the software and additional data captured during the pilot will be provided at presentation.

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.

Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: "In the Closet" in Medical School: MEDSCAPE 2/18/2015

OVERVIEW

Of sexual minority respondents, 29.5% said they concealed their sexual identify in medical school. Although most (67.5%) were "out" about their identity, the authors note that this is not all that much better than the estimate of 44% 2 decades ago. (Some respondents declined to answer this question).Sexual identity concealment was lowest among gay and lesbian (14.7%) and queer (22.2%) respondents. Most bisexuals (53.9%) and questioning (92.0%) respondents reported concealing their sexual identify in medical school.

PURPOSE

To assess identity disclosure among sexual and gender minority (SGM) students pursuing undergraduate medical training in the United States and Canada.

METHOD

From 2009 to 2010, a survey was made available to all medical students enrolled in the 176 MD-and DO-granting medical schools in the United States and Canada. Respondents were asked about their sexual and gender identity, whether they were "out" (i.e., had publicly disclosed their identity), and, if they were not, their reasons for concealing their identity. The authors used a mixed-methods approach and analyzed quantitative and qualitative survey data.

RESULTS

Of 5,812 completed responses (of 101,473 eligible respondents; response rate 5.7%), 920 (15.8%) students from 152 (of 176; 86.4%) institutions identified as SGMs. Of the 912 sexual minorities, 269 (29.5%) concealed their sexual identity in medical school. Factors associated with sexual identity concealment included sexual minority identity other than lesbian or gay, male gender, East Asian race, and medical school enrollment in the South or Central regions of North America. The most common reasons for concealing one's sexual identity were "nobody's business" (165/269; 61.3%), fear of discrimination in medical school (117/269; 43.5%), and social or cultural norms (110/269; 40.9%). Of the 35 gender minorities, 21 (60.0%) concealed their gender identity, citing fear of discrimination in medical school (9/21; 42.9%) and lack of support (9/21; 42.9%).

CONCLUSIONS

SGM students continue to conceal their identity during undergraduate medical training. Medical institutions should adopt targeted policies and programs to better support these individuals.

Barriers and facilitators to patient retention in HIV care

Background

Retention in HIV care improves survival and reduces the risk of HIV transmission to others. Multiple quantitative studies have described demographic and clinical characteristics associated with retention in HIV care. However, qualitative studies are needed to better understand barriers and facilitators.

Methods

Semi-structured interviews were conducted with 51 HIV-infected individuals, 25 who were retained in care and 26 not retained in care, from 3 urban clinics. Interview data were analyzed for themes using a modified grounded theory approach. Identified themes were compared between the two groups of interest: patients retained in care and those not retained in care.

Results

Overall, participants identified 12 barriers and 5 facilitators to retention in HIV care. On average, retained individuals provided 3 barriers, while persons not retained in care provided 5 barriers. Both groups commonly discussed depression/mental illness, feeling sick, and competing life activities as barriers. In addition, individuals not retained in care commonly reported expensive and unreliable transportation, stigma, and insufficient insurance as barriers. On average, participants in both groups referenced 2 facilitators, including the presence of social support, patient-friendly clinic services (transportation, co-location of services, scheduling/reminders), and positive relationships with providers and clinic staff.

Conclusions

In our study, patients not retained in care faced more barriers, particularly social and structural barriers, than those retained in care. Developing care models where social and financial barriers are addressed, mental health and substance abuse treatment is integrated, and patient-friendly services are offered is important to keeping HIV-infected individuals engaged in care.

Sexual and gender minority identity disclosure during undergraduate medical education: "in the closet" in medical school

PURPOSE

To assess identity disclosure among sexual and gender minority (SGM) students pursuing undergraduate medical training in the United States and Canada.

METHOD

From 2009 to 2010, a survey was made available to all medical students enrolled in the 176 MD- and DO-granting medical schools in the United States and Canada. Respondents were asked about their sexual and gender identity, whether they were "out" (i.e., had publicly disclosed their identity), and, if they were not, their reasons for concealing their identity. The authors used a mixed-methods approach and analyzed quantitative and qualitative survey data.

RESULTS

Of 5,812 completed responses (of 101,473 eligible respondents; response rate 5.7%), 920 (15.8%) students from 152 (of 176; 86.4%) institutions identified as SGMs. Of the 912 sexual minorities, 269 (29.5%) concealed their sexual identity in medical school. Factors associated with sexual identity concealment included sexual minority identity other than lesbian or gay, male gender, East Asian race, and medical school enrollment in the South or Central regions of North America. The most common reasons for concealing one's sexual identity were "nobody's business" (165/269; 61.3%), fear of discrimination in medical school (117/269; 43.5%), and social or cultural norms (110/269; 40.9%). Of the 35 gender minorities, 21 (60.0%) concealed their gender identity, citing fear of discrimination in medical school (9/21; 42.9%) and lack of support (9/21; 42.9%).

CONCLUSIONS

SGM students continue to conceal their identity during undergraduate medical training. Medical institutions should adopt targeted policies and programs to better support these individuals.

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.

Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students' Preparedness and Comfort

Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown.

APPROACH

An online questionnaire (2009-2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients.

FINDINGS

Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as "fair" or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel "more prepared" and 46.3% (1,972/4,262) of students feel "more comfortable" to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.

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.

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.