The adhesin SCF1 mediates Candida auris colonization

Candida auris is an emerging human fungal pathogen that can rapidly spread and cause outbreaks of invasive infections. Santana et al. discovered that a novel surface colonization factor (SCF1), and a conserved adhesin, Iff4109, mediates C. auris colonization on abiotic surfaces, skin, and virulence in vivo.

Tools and techniques to identify, study, and control Candida auris

Candida auris, is an emerging fungal pathogen that can cause life-threatening infections in humans. Unlike many other Candida species that colonize the intestine, C. auris most efficiently colonizes the skin. Such colonization contaminates the patient's environment and can result in rapid nosocomial transmission. In addition, this transmission can lead to outbreaks of systemic infections that have mortality rates between 40% and 60%. C. auris isolates resistant to all known classes of antifungals have been identified and as such, understanding the underlying biochemical mechanisms of how skin colonization initiates and progresses is critical to developing better therapeutic options. With this review, we briefly summarize what is known about horizontal transmission and current tools used to identify, understand, and control C. auris infections.

C. albicans UME7 deletion does not have major impacts on white opaque switching, filamentation, or virulence

C. albicans is the most prevalent human fungal pathogen, and can be especially dangerous to immunocompromised individuals. One key aspect of C. albicans virulence is morphological plasticity. C. albicans can undergo a number of distinct morphological changes and these changes are controlled by complex transcriptional networks. The transcription factor Ume6 is an important member of these networks, playing an essential role mediating filamentation. C. albicans , however encodes a second UME6 homolog, UME7 . UME7 is highly conserved in the CTG fungal clade, but the role of UME7 in C. albicans biology is unknown. Here we truncate and delete C. albicans UME7 . We find Ume7 is dispensable for growth and filamentation. We also find that deletion does not have major consequences on virulence or white opaque switching. Our results suggest that under standard laboratory conditions deletion of UME7 does not have large effects on C. albicans phenotype leaving its role in C. albicans biology undefined.

Characterization of the role of Ume6 C-terminal tail in C. albicans morphological plasticity

C. albicans is an important human fungal pathogen and filamentation is essential for its virulence. Ume6 is a transcription factor critical for filamentation. Ume6 is composed of three domains, a long N terminal domain, Zn-finger domain, and a C-terminal domain. Previously, it was shown that the Zn-finger domain is essential for filamentation, as removal of this domain led to a lack of filamentation. However, the role for the C-terminal domain has not been defined. We find deletion of the C-terminal domain leads to a filamentation defect and the defect is not as severe as removal of the Zn-finger or ume6 deletion. We mutated a number of residues in the C-terminal domain to try to identify specific residues important for filamentation, but all of our mutants displayed wild type filamentation. Alpha fold predictions suggest the C-terminal domain forms a single alpha helix that is predicted to interact with the Zn-finger domain via hydrogen bond. Our data suggests the C-terminal domain binds the Zn-finger domain and through this interaction is important for filamentation.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

A Review of the Metrics Used to Assess Auto-Contouring Systems in Radiotherapy

Auto-contouring could revolutionise future planning of radiotherapy treatment. The lack of consensus on how to assess and validate auto-contouring systems currently limits clinical use. This review formally quantifies the assessment metrics used in studies published during one calendar year and assesses the need for standardised practice. A PubMed literature search was undertaken for papers evaluating radiotherapy auto-contouring published during 2021. Papers were assessed for types of metric and the methodology used to generate ground-truth comparators. Our PubMed search identified 212 studies, of which 117 met the criteria for clinical review. Geometric assessment metrics were used in 116 of 117 studies (99.1%). This includes the Dice Similarity Coefficient used in 113 (96.6%) studies. Clinically relevant metrics, such as qualitative, dosimetric and time-saving metrics, were less frequently used in 22 (18.8%), 27 (23.1%) and 18 (15.4%) of 117 studies, respectively. There was heterogeneity within each category of metric. Over 90 different names for geometric measures were used. Methods for qualitative assessment were different in all but two papers. Variation existed in the methods used to generate radiotherapy plans for dosimetric assessment. Consideration of editing time was only given in 11 (9.4%) papers. A single manual contour as a ground-truth comparator was used in 65 (55.6%) studies. Only 31 (26.5%) studies compared auto-contours to usual inter- and/or intra-observer variation. In conclusion, significant variation exists in how research papers currently assess the accuracy of automatically generated contours. Geometric measures are the most popular, however their clinical utility is unknown. There is heterogeneity in the methods used to perform clinical assessment. Considering the different stages of system implementation may provide a framework to decide the most appropriate metrics. This analysis supports the need for a consensus on the clinical implementation of auto-contouring.

Decreasing albumin within normal range is associated with increased likelihood of ischemic heart disease

Background

Albumin (ALB) is a known biomarker of frailty, and cardiovascular disease and frailty are interdependent. Epidemiological evidence demonstrates that low serum albumin levels are linked to events of ischemic heart disease (IHD), venous thromboembolism, heart failure, atrial fibrillation, and stroke.

Purpose

We aimed to investigate the association of variations in ALB levels that are within normal range with IHD events among apparently healthy adults.

Methods

A case-control retrospective study of self-referred adults participating in an executive screening program between 2002 and 2017. All subjects were free of IHD and diabetes at baseline and had their ALB documented in each visit. Only subjects with at least two ALB measurements and whose ALB levels were within the normal range at all visits were included. Relationships between ALB trend and occurrence of IHD (acute coronary syndrome or percutaneous coronary intervention) within 2 years from the last visit were investigated.

Results

The final study cohort included 16,386 subjects. Median age was 53 (IQR 45–60), 11,461 (70%) were men. Analysis included a total of 99,127 visits. Median number of visits per subject was 5 (IQR 3–9, median inter-visit time 1.02 years) and median ALB level was 4.4 (IQR 4.2–4.6). IHD within 2 years was diagnosed in 545 (3%) subjects. Of those, only 36 were female and they tended to have lower variations in ALB throughout the years. Hence, we conducted an analysis of the 509 males only, and created an equal-size age-matched cohort of IHD-free subjects. Our analysis demonstrated a progressive and significant decrease in ALB levels among IHD cases, but not among controls (mean decrease of 0.021 g/DL vs. 0.004 g/DL per year, p<0.01; OR [CI] = 0.82 [0.72–0.93]; Figure 1). Similar results were found among subjects with at least 3 or 4 visits (0.015 g/DL vs. 0.006 g/DL per year, p=0.027, and 0.009 g/DL vs. 0.003 g/DL per year, p=0.045, respectively).

Conclusions

Kinetics of ALB within the normal range can identify men at risk for IHD in preventive healthcare screening programs.

Funding Acknowledgement

Type of funding sources: None.

1473 Urology Consent Forms at a District General Hospital – a Quality Improvement Project

Aim

Consent is a core component of interaction between patients and healthcare professionals. Prior to surgery, forms are completed to record patient consent. As well as containing risks and benefits of the procedure, the consent form, as per guidelines1,2, must be legible and suitable to a patient’s capacity. To evaluate compliance with local and national guidelines, a quality improvement project was undertaken at a district general hospital.

Method

Over a three-week period 30 urology consent forms were selected to assess adherence to local and national guidelines. The appropriateness of consent form, patient signature, legibility, acronym use and whether the patient was offered a carbon copy were assessed. After initial data collection, all urology staff consenting patients were notified of the findings and how best to improve guideline adherence. A further three-week data collection was undertaken, though the sample set was small due to Coronavirus and Christmas.

Results

The results confirmed that patients had appropriate consent forms filled out and were signed appropriately. After intervention, there was clear improvement in legibility, with no low legibility consent forms, and 100% vs 83% high or moderate legibility between data sets. Intervention also resulted in significant reduction of acronym use; 33% vs 60%. More patients were also offered to retain a carbon copy; 89% vs 40%.

Conclusions

Through this intervention of highlighting local and national guidance as compared to current practice, compliance drastically improved. As the pandemic subsides, we hope regular emails to surgical teams will improve consent form completion to better patient care.

An Inter-observer Study to Determine Radiotherapy Planning Target Volumes for Recurrent Gynaecological Cancer Comparing Magnetic Resonance Imaging Only With Computed Tomography-Magnetic Resonance Imaging

AIMS

Target delineation uncertainty is arguably the largest source of geometric uncertainty in radiotherapy. Several factors can affect it, including the imaging modality used for delineation. It is accounted for by applying safety margins to the target to produce a planning target volume (PTV), to which treatments are designed. To determine the margin, the delineation uncertainty is measured as the delineation error, and then a margin recipe used. However, there is no published evidence of such analysis for recurrent gynaecological cancers (RGC). The aims of this study were first to quantify the delineation uncertainty for RGC gross tumour volumes (GTVs) and to calculate the associated PTV margins and then to quantify the difference in GTV, delineation uncertainty and PTV margin, between a computed tomography-magnetic resonance imaging (CT-MRI) and MRI workflow.

MATERIALS AND METHODS

Seven clinicians delineated the GTV for 20 RGC tumours on co-registered CT and MRI datasets (CT-MRI) and on MRI alone. The delineation error, the standard deviation of distances from each clinician's outline to a reference, was measured and the required PTV margin determined. Differences between using CT-MRI and MRI alone were assessed.

RESULTS

The overall delineation error and the resulting margin were 3.1 mm and 8.5 mm, respectively, for CT-MRI, reducing to 2.5 mm and 7.1 mm, respectively, for MRI alone. Delineation errors and therefore the theoretical margins, varied widely between patients. MRI tumour volumes were on average 15% smaller than CT-MRI tumour volumes.

DISCUSSION

This study is the first to quantify delineation error for RGC tumours and to calculate the corresponding PTV margin. The determined margins were larger than those reported in the literature for similar patients, bringing into question both current margins and margin calculation methods. The wide variation in delineation error between these patients suggests that applying a single population-based margin may result in PTVs that are suboptimal for many. Finally, the reduced tumour volumes and safety margins suggest that patients with RGC may benefit from an MRI-only treatment workflow.

In-vivo EPID dosimetry for IMRT and VMAT based on through-air predicted portal dose algorithm

We have adapted the methodology of Berry et al. (2012) for Intensity Modulated Radiotherapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) treatments at a fixed source to imager distance (SID) based on the manufacturer's through-air portal dose image prediction algorithm. In order to fix the SID a correction factor was introduced to account for the change in air gap between patient and imager. Commissioning data, collected with multiple field sizes, solid water thicknesses and air gaps, were acquired at 150 cm SID on the Varian aS1200 EPID. The method was verified using six IMRT and seven VMAT plans on up to three different phantoms. The method's sensitivity and accuracy were investigated by introducing errors. A global 3%/3 mm gamma was used to assess the differences between the predicted and measured portal dose images. The effect of a varying air gap on EPID signal was found to be significant - varying by up to 30% with field size, phantom thickness, and air gap. All IMRT plans passed the 3%/3 mm gamma criteria by more than 95% on the three phantoms. 23 of 24 arcs from the VMAT plans passed the 3%/3 mm gamma criteria by more than 95%. This method was found to be sensitive to a range of potential errors. The presented approach provides fast and accurate in-vivo EPID dosimetry for IMRT and VMAT treatments and can potentially replace many pre-treatment verifications.

The Influence of Race and Common Genetic Variations on Outcomes After Pediatric Heart Transplantation

Significant racial disparity remains in the incidence of unfavorable outcomes following heart transplantation. We sought to determine which pediatric posttransplantation outcomes differ by race and whether these can be explained by recipient demographic, clinical, and genetic attributes. Data were collected for 80 black and 450 nonblack pediatric recipients transplanted at 1 of 6 centers between 1993 and 2008. Genotyping was performed for 20 candidate genes. Average follow-up was 6.25 years. Unadjusted 5-year rates for death (p = 0.001), graft loss (p = 0.015), acute rejection with severe hemodynamic compromise (p = 0.001), late rejection (p = 0.005), and late rejection with hemodynamic compromise (p = 0.004) were significantly higher among blacks compared with nonblacks. Black recipients were more likely to be older at the time of transplantation (p < 0.001), suffer from cardiomyopathy (p = 0.004), and have public insurance (p < 0.001), and were less likely to undergo induction therapy (p = 0.0039). In multivariate regression models adjusting for age, sex, cardiac diagnosis, insurance status, and genetic variations, black race remained a significant risk factor for all the above outcomes. These clinical and genetic variables explained only 8-19% of the excess risk observed for black recipients. We have confirmed racial differences in survival, graft loss, and several rejection outcomes following heart transplantation in children, which could not be fully explained by differences in recipient attributes.

Safety of sublingual immunotherapy Timothy grass tablet in subjects with allergic rhinitis with or without conjunctivitis and history of asthma

BACKGROUND

Patients with asthma may be more susceptible to adverse events (AEs) with sublingual immunotherapy tablet (SLIT-tablet) treatment, such as severe systemic reactions and asthma-related events. Using data from eight trials of grass SLIT-tablet in subjects with allergic rhinitis with/without conjunctivitis (AR/C), AE frequencies were determined in adults and children with and without reported asthma.

METHODS

Data from randomized, double-blind, placebo-controlled trials of Timothy grass SLIT-tablet MK-7243 (2800 BAU/75 000 SQ-T, Merck/ALK-Abelló) were pooled for post hoc analyses. Subjects with uncontrolled and severe asthma were excluded from the trials. Frequencies for treatment-emergent AEs (TEAEs), local allergic swelling (mouth or throat), systemic allergic reactions, and asthma-related treatment-related AEs (TRAEs) were calculated.

RESULTS

Among adults (n = 3314) and children (n = 881), 24% and 31%, respectively, had reported asthma. No serious local allergic swellings or serious systemic allergic reactions occurred in subjects with asthma treated with SLIT-tablet. There was no evidence of increased TEAEs, systemic allergic reactions, or severe local allergic swellings in adults or children with asthma treated with grass SLIT-tablet versus subjects without asthma in or outside of pollen season. There were 6/120 asthma-related TRAEs assessed as severe with grass SLIT-tablet and 2/60 with placebo, without a consistent trend among subjects with and without asthma (5 and 3 events, respectively).

CONCLUSIONS

In the AR/C subjects with reported well-controlled mild asthma included in these studies, grass SLIT-tablet did not increase TEAE frequency, severe local allergic swelling, or systemic allergic reactions versus subjects without asthma. There was no indication that treatment led to acute asthma worsening.

Bivalirudin use in patients undergoing percutaneous coronary intervention for acute myocardial infarction. Insights from the prospective, multi-centre EUROVISION registry

BACKGROUND

The effectiveness of bivalirudin in patients undergoing percutaneous coronary intervention for acute myocardial infarction has been tested in clinical trials, but its use in a real-world scenario has never been reported.

METHODS

From the total number of patients enrolled in the EUROVISION registry, 678 subjects affected by ST-elevation myocardial infarction were selected and included in the analysis. Posology and usage patterns of bivalirudin, as evaluated by dose and time of drug bolus and infusion administered, were evaluated. The 30-day outcome has been assessed by efficacy and safety endpoints.

RESULTS

All patients received an initial intravenous bolus of bivalirudin (0.70±0.25 mg/kg) followed by an infusion (1.58±0.47 mg/kg/h; duration: 60 [30, 107] min) in 99.3% of cases. An additional bolus (0.49±0.06 mg/kg) was administered in 9.3% of patients. Bivalirudin infusion was prolonged after procedure in 62.2%. Death occurred in 2.1% of patients, non-fatal myocardial reinfarction in 0.3%, unplanned revascularization in 0.6% and non-fatal stroke in 0.4%. Acute stent thrombosis was not observed. Major bleeding occurred in 1.5% of patients.

CONCLUSIONS

Bivalirudin usage in the setting of primary PCI provided excellent results in terms of 30-day outcome even in a real-world population.

Optimized threshold for serum HCV RNA to predict treatment outcomes in hepatitis C patients receiving peginterferon alfa-2a/ribavirin

It is unclear whether the current threshold for 'high' hepatitis C virus (HCV) RNA level (800,000 IU/mL) is optimal for predicting sustained virological response (SVR). We retrospectively analysed pretreatment HCV RNA levels and SVR rates in 1529 mono-infected and 176 HIV-HCV co-infected patients treated with peginterferon alfa-2a (40 kD) plus ribavirin. We improved the threshold for differentiating low and high viral load by fitting semiparametric generalized additive logistic regression models to the data and constructing receiver operating characteristics curves. Among HCV genotype 1 mono-infected patients, the difference in SVR rates between those with low and high baseline HCV RNA levels was 27% (70%vs 43%) when 400,000 IU/mL was used and 16% (59%vs 43%) when 800,000 IU/mL was used. In HIV-HCV genotype 1 co-infected patients, the difference was 51% (71%vs 20%) when 400,000 IU/mL was used and 43% (61%vs 18%) when 800,000 IU/mL was used. A lower threshold (200,000 IU/mL) was identified for genotype 1 mono-infected patients with 'normal' alanine aminotransferase (ALT) levels. No threshold could be identified in HCV genotype 2 or 3 patients. A threshold HCV RNA level of 400,000 IU/mL is optimal for differentiating high and low probability of SVR in genotype 1-infected individuals with elevated ALT.

The effectiveness of schema focused therapy; Indirect, experimental measures of emotional change in forensic patients

According to recent literature, 50 to 90 percent of criminal offenders have personality disorders (PDs), with cluster B PDs being the most prevalent in forensic settings. The latter type of PD is associated with an increased risk of violence and recidivism. Among forensic patients with a cluster B diagnosis, psychopathic offenders are at particularly high risk for re-offending. Psychopaths are believed to be untreatable, but evidence for this view is weak.

The current study aims at determining the effectiveness of Schema Focused Therapy (SFT) versus ‘treatment as usual’ in male forensic patients (including psychopaths) with Antisocial, Borderline, Narcissistic, and Paranoid PDs, within a 3-year multi-center randomized clinical trial. SFT is an integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object relations, and humanistic/existential approaches, and was developed as a treatment for PDs and other longstanding problems. SFT aims at changing early maladaptive schema modes, thereby producing changes on a structural, emotional level.

The goal of a second study that runs within the same project is to objectively determine the nature of the emotional deficiencies that are thought to be central to psychopathy. By administering forensic patients an extensive test battery that assesses various affective capacities (e.g., moral emotion, emotional expressive behavior, cognitive and emotional empathy), we aim at constructing an integrative picture of psychopaths’ emotional functioning. Within the SFT effectiveness study, patients are tested twice (with a one year interval), to see whether these affective capacities are subject to change in the context of therapy.