Mycotoxins are toxic secondary metabolites that globally contaminate an estimated 25 % of cereal crops and thus exposure is frequent in many populations. Aflatoxins, fumonisins and deoxynivalenol are amongst those mycotoxins of particular concern from a human health perspective. A number of risks to health are suggested including cancer, growth faltering, immune suppression and neural tube defects; though only the demonstrated role for aflatoxin in the aetiology of liver cancer is widely recognised. The heterogeneous distribution of mycotoxins in food restricts the usefulness of food sampling and intake estimates; instead biomarkers provide better tools for informing epidemiological investigations. Validated exposure biomarkers for aflatoxin (urinary aflatoxin M 1 , aflatoxin -N7-guaunine, serum aflatoxin -albumin) were established almost 20 years ago and were critical in confirming aflatoxins as potent liver carcinogens. Validation has included demonstration of assay robustness, intake v. biomarker level, and stability of stored samples. More recently, aflatoxin exposure biomarkers are revealing concerns of growth faltering and immune suppression; importantly, they are being used to assess the effectiveness of intervention strategies. For fumonisins and deoxynivalenol these steps of development and validation have significantly advanced in recent years. Such biomarkers should better inform epidemiological studies and thus improve our understanding of their potential risk to human health.

Meningococcal disease remains one of the most feared infectious diseases worldwide because of its sudden onset, rapid progression and high case fatality rates, while survivors are often left with severe long-term sequelae. Young children have the highest incidence of invasive meningococcal disease (IMD), and nearly all cases in the UK, as in most of Europe and many other industrialised countries, are due to group B meningococci (MenB). The licensure of a broad-coverage, recombinant protein-based MenB vaccine (4CMenB) in 2013 was, therefore, heralded a major breakthrough in the fight against IMD. This vaccine was, however, licensed on immunogenicity and reactogenicity studies only, raising uncertainties about field effectiveness, long-term safety and antibody persistence. In 2015, the UK became the first country to implement 4CMenB into the national infant immunisation schedule and, since then, several countries have followed suit. Seven years after licensure, a wealth of real-world data has emerged to confirm 4CMenB effectiveness, along with large-scale safety data, duration of protection in different age groups, successful strategies to reduce vaccine reactogenicity, impact on carriage in adolescents and the potential for 4CMenB to protect against other meningococcal serogroups and against gonorrhoea. A number of questions, however, remain unanswered, including the investigation and management of vaccine-associated fever in infants, as well as disease severity and assessment of breakthrough cases in immunised children. Increasing use of 4CMenB will provide answers in due course. We now have vaccines against all the major serogroups causing IMD worldwide. Next-generation and combination vaccines against multiple serogroups look very promising.

Objectives:Skin graft failure is a recognised complication in the treatment of major burns. Little research to date has analysed the impact of the complex physiological management of burns patients on the success of skin grafting. We analysed surgical and anaesthetic variables to identify factors contributing to graft failure.Methods:Inclusion criteria were admission to our Burns Intensive Care Unit (BICU) between January 2009 and October 2013 with a major burn. After exclusion for death before hospital discharge or prior skin graft at a different hospital, 35 patients remained and were divided into those with successful autografts (n=16) and those with a failed autograft (n=19). For the purposes of this study, we defined poor autograft viability as requiring at least one additional skin graft to the same site. Logistic regression of variables was performed using SPSS (Version 22.0 IBMTM).Results:Age, Sex, %Total Burn Surface Area or Belgian Outcome Burns Injury score did not significantly differ between groups. No differences were found in any surgical factor at logistic regression (graft site, harvest site, infection etc.). When all operations were analysed, the use of colloids was found to be significantly associated with graft failure (p=0.035, CI 95%) and this remained significant when only split thickness skin grafts (STSGs) and debridement operations were included (p=0.034, CI 95%). No differences were found in crystalloid use, intraoperative temperature, pre-operative haemoglobin and blood products or vasopressor use.Conclusions:This analysis highlights an independent association between colloids and graft failure which has not been previously documented.

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Syphilis infection in pregnancy is known to cause a number of severe adverse pregnancy outcomes, including second-trimester miscarriage, stillbirth, very pre-term delivery and neonatal death, in addition to congenital syphilis. A retrospective review of women with positive syphilis serology and a pregnancy outcome between 2005 and 2012 in Leeds, UK, was performed. In all, 57 cases of positive syphilis serology in pregnancy were identified: 24 with untreated syphilis treated in the current pregnancy (Group 1); seven with reported but unconfirmed prior treatment who were retreated (Group 2); and 26 adequately treated prior to pregnancy (Group 3). The rate of severe adverse pregnancy outcomes in Group 1 at 21% was significantly higher than the 0% outcome of Group 3 (p = 0.02). The severe adverse pregnancy outcomes were two second-trimester miscarriages, two pre-term births at 25 and 28 weeks and one stillbirth at 32 weeks. There were no cases of term congenital syphilis or term neonatal death, but we observed high rates of other adverse pregnancy outcomes despite treatment during pregnancy. Rapid referral for treatment is needed before 18 weeks in order to minimise adverse pregnancy outcomes.

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BackgroundPeople living with HIV have been shown to have an increased risk of invasive meningococcal disease. In some countries, meningococcal vaccines are now routinely recommended to all people living with HIV, but no study has yet assessed the immunogenicity and safety of a meningococcal serogroup B vaccine or the co‐administration of a MenB and MenACWY vaccine in people living with HIV.MethodsThis phase IV open‐label clinical trial investigated the immunogenicity and safety of two doses of a four‐component recombinant protein‐based MenB vaccine (4CMenB) and a quadrivalent conjugate polysaccharide MenACWY vaccine (MenACWY‐CRM197) given 1 month apart in a population of people living with HIV. Immunogenicity analysis was performed before vaccination and 1 month after the second doses of 4CMenB and MenACWY. Primary outcome measures were serum bactericidal assay geometric mean titres against three MenB reference strains at baseline and 1 month post vaccination, the proportion of participants achieving a putative protective titre of ≥4, and the proportion of participants with a ≥4‐fold rise in titre from baseline. Secondary outcome measures were serum bactericidal assay geometric mean titres against MenA, C, W, and Y reference strains at baseline and 1 month post vaccination, the proportion achieving a putative protective titre of ≥8, and the proportion with a ≥4‐fold rise in titre from baseline. Safety outcomes were solicited and unsolicited adverse events in the 7 days following vaccination. The trial was registered with clinicaltrials.gov (NCT03682939).FindingsIn total, 55 participants aged 20–45 years were enrolled. All participants (100%; 95% confidence interval [CI] 93–100) achieved putative protective titres for two of the three MenB strains and for MenA, W, and Y. A total of 98% (95% CI 89–100) achieved a protective titre for the third MenB strain and 94% (95% CI 83–99) for MenC. No serious adverse events were reported.Interpretation4CMenB and MenACWY were immunogenic and well‐tolerated in a population of people living with HIV 1 month after two doses.

The 2008 UK syphilis guideline recommends infants born to women with any positive syphilis serology be followed up until both treponemal and nontreponemal tests are negative to exclude congenital syphilis, whereas Centers for Disease Control and Prevention guidelines recommend using only nontreponemal tests. Historically, we had low infant follow-up rates with no coherent pathways. We initiated a change in multidisciplinary team practice of infant testing for syphilis in 2011 and evaluated the results before and after by retrospective review of testing of infants born to women with positive syphilis serology between 2005 and 2012. A total of 28 infants' mothers were treated in pregnancy (termed 'high risk'); 26 had adequate treatment prior to pregnancy (termed 'low risk'). There was a significant increase in serological testing after 2011 compared with before (83% versus 48%; OR 5.07 [95% CI 1.22-22.77] p = 0.01) but mainly in low risk infants with no significant improvement in high risk infants who are the priority group. Using nontreponemal tests only in the infants would have reduced the tests required by at least 50%, allowing health resources to be concentrated on achieving adequate follow-up for those infants most at risk.