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.

332 THE PATIENT EXPERIENCE OF THE OLDER PERSONS REHAB AT HOME (OPRAH) SERVICE

Background

The Older Persons Rehab at Home (OPRAH) team is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. This provides rehabilitation in the patients’ own home and accelerates discharge from the acute care sector. In this study patient and carer experiences of the service were explored.

Methods

Patients were sent a postal questionnaire after discharge from the service to collect information on the patient experience of the OPRAH service. The following measures were collected: satisfaction with the service, experience of interacting with therapy staff, involvement in shared goal setting and achievement of rehabilitation goals. Data from participants who responded to feedback questionnaires from the first 12 months of the service were analysed using descriptive statistics.

Results

Ninety-five participants were sent feedback questionnaires with 31 responses received (33%). 96% of participants reported that they were satisfied with the service, with the same proportion expressing that they both felt they were treated with respect and dignity and that they had confidence and trust in the staff. All respondents felt that they could understand the answers to any questions they had while receiving rehabilitation and 92% of participants understood their rehabilitation goals, with 88% of participants feeling they achieved their rehabilitation goals. 88% of participants felt they were adequately involved in their care planning with 83% of participants feeling their family members had ample opportunity to ask questions during their rehabilitation experience. Results did not different by age group of patient or by time with the service.

Conclusion

In this structured evaluation of the OPRAH team participants highly rated the service. Our results highlight that this integrated approach to care allowed patients to be involved in shared goal setting with the majority of patients satisfied that they achieved their goals.

225 OLDER PERSONS REHAB AT HOME (OPRAH) INDICATES AN EFFECTIVE ALTERNATIVE PATHWAY TO INPATIENT REHABILITATION

Background

Older adults have longer hospital stays, higher incidence of nosocomial complications and higher readmissions rates. Older persons rehabilitation at home (OPRaH) is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. OPRaH offers a comprehensive geriatric and interdisciplinary approach. The model enables a safe and accelerated discharge from acute care to home.

Methods

Patients are identified and screened by a team coordinator. On Discharge to OPRaH the following measures were collected; basic demographics, referral source, clinical frailty score and Functional Independence Measures (FIM). Outcomes evaluated are the FIM change, readmission rates, length of inpatient stay savings and time on the service. Data from the first year of operation was analysed using descriptive statistics.

Results

109 patients have undergone rehabilitation with the service with a median age of 82 years (63-103 range). Over two thirds (68%) were classified as frail, with 44% living alone. An injurious fall was the most common reason for index hospitalisation (50%). Referral source was inpatient acute medical team in 50% of cases, with 21% from acute geriatrics , 13 % ortho geriatrics, 13% surgical. Average functional independence measure scores improved from 89 to 102 (p = 0.007). There was no difference in the magnitude of improvement by frailty status (13 vs 14, p = 0.85). The average length of stay saving was 7 days per case, with a total of 757 days saved in one year. Readmission rate within 30 days was 9.3 %. Participants highly rated the service through structured evaluation.

Conclusion

This novel service provides a valuable intervention to a wide case-mix of older adults with evidence of improvements in formal markers of functional impairment after intervention. Referral was based on definable rehabilitation goals and not just on frailty status, age, or gender.

POS0999 HIGHER CARDIOVASCULAR MORBIDITY SEEN IN MEN WITH LONGER DELAY TO THE DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS

Background

Diagnostic delay in axial spondyloarthritis (axSpA) is a well-defined feature of the disease, despite increased awareness. Morbidity and mortality are higher in axSpA than the general population1. Much of this excess burden is due to increased comorbidity. However, the association between delayed diagnosis and increased comorbidity in this population is unknown.

Objectives

(1)Examine the relationship between delayed diagnosis and comorbidity in a large cohort of well characterised individuals with axSpA

(2)Assess the impact of sex on the relationship between diagnostic delay and comorbidity.

Methods

The Ankylosing Spondylitis Registry of Ireland (ASRI), a descriptive epidemiological study of the Irish axSpA population, provided the cohort for this study. A standardised clinical assessment was performed on each patient. Delay to diagnosis was calculated as age at diagnosis minus age at symptom onset. Comorbidities were considered as any condition present in addition to axial SpA, excluding extra-musculoskeletal manifestations (EMM). SPSS was used for statistical analysis, with appropriate tests used for normally and non-normally distributed data.

Results

Of the 913 included patients, 659 (72%) were male and mean age was 46 years (SD 13). Detailed baseline clinical and demographic characteristics are outlined in Table 1. Median delay to diagnosis was 5 (2, 12) years. Comorbidity was present in 37% (n=341) of the cohort, with hypertension the most prevalent (see Figure 1).

Table 1.

Baseline demographic and clinical characteristics

VariableAge, mean (SD)45.8 (12.6)Female, n (%)254 (27.8)Caucasian, n (%)819 (96.5)Ever Smoker, n (%)*527 (57.7)HLA-B27 positive, n (%)631 (89.9)Disease duration, median (25th,75th)17.1 (9.5, 27.8)Delay to diagnosis, median (25th, 75th)5.0 (2.0, 12.0)AAU, n (%)308 (34.4)PsO, n (%)150 (16.7)IBD, n (%)96 (10.7)Biologic use, n (%)628 (68.5)BASMI, mean (SD)3.6 (2.1)BASFI, mean (SD)3.4 (2.9)BASDAI, mean (SD)3.9 (2.4)HAQ, median (25th, 75th)0.38 (0.0, 0.9)

The median delay to diagnosis was significantly longer in those with ≥1 comorbidity compared to those with none (7 v 5 years, p<0.01). Hypertension (6 v 5 years, p=0.1) and cerebrovascular disease (10 v 5 years, p=0.03) were associated with a significantly longer delay to diagnosis, with a similar trend seen in those with hyperlipidaemia (7 v 5 years, p=0.09) and ischaemic heart disease (10 v 5 years, p=0.07). The delay to diagnosis was also longer in those that currently (7 v 5 years, p=0.03) or ever smoked (6 v 5 years, p<0.01). The delay to diagnosis was significantly longer in those with depression (9 v 5, p<0.05). The presence of EMM did not contribute to a delay to diagnosis, and there was no association with any categories of medication.

There was no significant difference in the median delay to diagnosis between females (5 v 6 years) for males. However, there were differences in the relationship between delay to diagnosis and the pattern of comorbidities between sexes. There was a significantly (p<0.05) longer delay to diagnosis in men with cerebrovascular disease (12 v 6 years), ischaemic heart disease (10 v 6 years) and diabetes (10 v 6 years), which wasn’t evident in females. Depression was associated with a longer delay to diagnosis in males (10 v 6 years, p<0.05), but not females (6 v 5 years, p=0.5).

Conclusion

Delay to diagnosis of axSpA was associated with a higher prevalence of comorbidities. This was particularly evident in men, with higher cardiovascular morbidity in those with a longer delay to diagnosis. Further research is needed to determine if shortening the delay to diagnosis would reduce the burden of cardiovascular morbidity.

References

[1]Chaudhary et al. All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Arthritis Care Res. 2021 Nov 17 (online).

Disclosure of Interests

None declared

POS1001 CURRENT SMOKING IS ASSOCIATED WITH LOWER RISK OF UVEITIS AND PERIPHERAL ARTHRITIS IN MALES WITH AXIAL SPONDYLOARTHRITIS

Background

The associations between smoking and extra-axial manifestations of axial spondyloarthritis (axSpA) are inadequately described. Previous observational studies have demonstrated smoking as protective against some but not other manifestations. However, the impact of sex on these associations is unknown.

Objectives

Using a large descriptive epidemiological dataset, we performed a sex-stratified analysis of the association between smoking status and extra-axial manifestations in axSpA.

Methods

This study was carried out within the framework of ASRI (Ankylosing Spondylitis Registry of Ireland), a descriptive epidemiological study of the axSpA population of Ireland. A standardised clinical assessment was performed on each patient, collecting demographic and clinical data. Smoking status was characterised as current, previous or never. The number of cigarettes per day, plus number of years smoking was also collected. Data on the following extra-axial manifestations was collected: arthritis, enthesitis, dactylitis, acute anterior uveitis (AAU), psoriasis (PsO), inflammatory bowel disease (IBD). Standardised measures of disease severity were also collected. Separate logistic regression models were used to define the association between extra-axial manifestations and smoking, controlling for potential confounders. SPSS was used for statistical analysis.

Results

Smoking data was available for 913 out of the 917 axSpA individuals with data in ASRI (mean age 46 (SD 13) years, disease duration 19 (SD 12) years, 72% male, 97% Caucasian). Twenty eight percent (n=259) were current smokers, 29% (n=268) were past smokers and 42% (n=386) were never smokers. Of the current smokers, the mean number of cigarettes per day was 12 (SD 7) and number of years smoking was 22 (SD 12). Thirty one percent had peripheral arthritis, 7% had dactylitis, 18% had enthesitis, 34% had AAU, 17% had psoriasis and 11% had IBD.

Current smokers had a significantly lower prevalence of arthritis and uveitis than past or non-smokers (see Table 1). A sex-stratified analysis was performed. There was no association between smoking status and any extra-axial manifestation in females. However, current smoking was associated with lower prevalence of arthritis in males compared to past or non-smokers (22% v 36% v 42%, p=0.002). A similar pattern was seen for uveitis, where male current smokers had a lower prevalence than non-smokers (24% v 38%, p=0.01). In contrast, psoriasis was more prevalent in men who were current smokers compared to non-smokers (18% v 12%, p=0.01), with no difference seen in females. There was no association with number of cigarettes smoked or number of years smoking.

Table 1.

Association between smoking status and extra-axial manifestations in axSpA.

AxSpA cohortCurrent smokerPast smokerNon-smokerArthritis30.9%22.4%a35.5%b33.3%bDactylitis6.7%5.5%a6.7% a7.4% aEnthesitis18.1%17.4% a16.2% a19.9% aUveitis34.3%27.4%a35.0%b38.6%bPsoriasis16.7%18.5% a19.3% a13.8% aInflammatory bowel disease10.7%9.9% a13.2% a9.5% a

Different subscript letters denote significant (p<0.05) differences between groups. Significant values highlighted in bold.

There was no association between smoking status and disease severity by subjective or objective measures, either for the cohort as a whole or by sex.

When compared to non- or ex-smokers and controlled for potential confounders including sex, age, biologic use, the association remained only between current smokers and lower risk of uveitis (OR 0.68, 95% CI 0.49 to 0.96) and arthritis (OR 0.62, 95% CI 0.43 to 0.88), in separate logistic regression models. The association between current smoking and increased prevalence of psoriasis in males did not remain significant once controlled for confounders (OR 1.10, 96% CI 0.73 to 1.65).

Conclusion

We demonstrated that current smoking is independently associated with a lower risk of uveitis and arthritis in males with axSpA, but not females. More research is needed to further investigate this paradoxical finding.

Disclosure of Interests

None declared

Chromatic visual phenomenon caused by a subluxed intraocular lens

A 74-year-old man developed an unusual chromatic aberration as a complication of cataract extraction surgery with posterior chamber intraocular lens implantation. The patient could see the location and color of one of the haptics of the dislocated lens. His symptoms resolved with miotic therapy.

Effects of cytokines on the production of lipoprotein lipase in cultured human macrophages

Macrophages are important cells in the pathogenesis of atherosclerosis because of their tendency to accumulate lipid and become transformed into foam cells. Cultured human monocyte-derived macrophages spontaneously secrete lipoprotein lipase (LPL), and LPL has been linked to increased lipid uptake by these cells. Because secretion of various macrophage products depends on activation by lymphokines, we studied the effects of immunoregulatory lymphokines on LPL secretion by cultured human macrophages. After culturing cells in RPMI 1640 medium with 20% fetal calf serum, recombinant human gamma-interferon (gamma-INF), interleukin-1 (IL-1), and interleukin-2 (IL-2) were added to the medium and LPL secretion was assessed by measuring LPL activity and/or LPL mass in the medium. Gamma-INF suppressed LPL production both when added to freshly plated cultures of human blood monocytes, as well as when added to monocyte/macrophages from mature cultures (day 6) that were producing large amounts of LPL. IL-1 inhibited medium LPL when added to freshly plated cultures, but not when added to mature cultures. On the other hand, IL-2 did not inhibit LPL in freshly plated cultures, but produced a dose-dependent suppression of LPL from mature cultures. None of the cytokines were cytotoxic to macrophages, and cells that were cultured in gamma-INF demonstrated partial recovery from LPL-suppressive doses of the cytokine. After exposure of cells to 50 U/ml of gamma-INF and 50 U/ml of IL-2 for 3 days, LPL mRNA levels, when expressed as LPL/gamma-actin ratios, were 42% and 53% of controls, respectively. Thus, activation of human macrophages in vitro by gamma-INF resulted in a suppression of LPL production.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of weight loss on the activity and expression of adipose-tissue lipoprotein lipase in very obese humans

Lipoprotein lipase is an enzyme in adipose tissue that hydrolyzes circulating triglycerides and thereby generates the fatty acids used in the synthesis of triglyceride in fat cells. To determine whether the activity and expression of lipoprotein lipase are affected by weight loss, we studied lipoprotein lipase in the adipose tissue of nine very obese subjects before and after a program of weight reduction. The subjects' mean (+/- SEM) initial weight was 136 +/- 7.3 kg, and the body-mass index (weight in kilograms divided by the square of the height in meters) ranged from 33.3 to 52.8 (mean, 43.0 +/- 2.5). Biopsies of adipose tissue were performed before weight loss and after it, when weight had been stable for three months. The weight reduction was achieved by a very-low-calorie diet (mean weight loss, 42.5 +/- 6.8 kg). After weight loss, the level of heparin-releasable lipoprotein lipase activity increased in all patients, from 3.8 +/- 1.1 to 7.1 +/- 1.6 neq of free fatty acid released per minute per 10(6) cells (P less than 0.05). In addition, the amount of lipoprotein lipase immunoreactive protein increased from 6.3 +/- 1.7 to 24.4 +/- 6.9 ng per 10(6) cells (P less than 0.05), and there was also an increase in the level of lipoprotein lipase messenger RNA as measured by Northern blotting. There was a strongly positive correlation between the initial body-mass index and the magnitude of the increase in lipoprotein lipase activity (r = 0.80, P less than 0.01) and immunoreactive protein (r = 0.92, P less than 0.01). We conclude that weight loss in very obese subjects leads to the increased activity and expression of lipoprotein lipase, thereby potentially enhancing lipid storage and making further weight loss more difficult.

Identification of lipoprotein lipase immunoreactive protein in pre- and postheparin plasma from normal subjects and patients with type I hyperlipoproteinemia

Postheparin plasma is a convenient source for the measurement of lipoprotein lipase (LPL) in humans. Previous studies have focused on the measurement of LPL catalytic activity, and have been unable to conveniently measure the LPL protein or identify possibly different plasma forms of the enzyme. Pre- and postheparin plasma was treated with a highly specific antibody raised against bovine milk LPL and the immunoprecipitate was analyzed by Western blotting. In normal subjects there were several species of LPL in plasma. A 56 kD protein increased after heparin injection, and likely represented active LPL. The anti-LPL antibody reacted specifically with this 56 kD protein, and also reacted specifically with proteins at 52 kD, 69 kD, as well as a 20 kD breakdown product. In addition, using peptide mapping, the 56 kD protein was structurally similar to the 52 and 69 kD LPL proteins. The antibodies were affinity purified, biotinylated, and used to quantitate LPL immunoreactive mass using an enzyme-linked immunosorbent assay (ELISA). LPL immunoreactive mass was present in all subjects in preheparin plasma. In postheparin plasma, five patients with type I hyperlipoproteinemia displayed decreased LPL immunoreactive mass when compared to normal subjects, although there was a wide range of specific activity of the small amount of enzyme present. When the LPL from the plasma of the patients was immunoprecipitated and Western blotted, there was considerable heterogeneity in the appearance of the LPL forms, and an overall decrease in LPL protein. Thus, several different immunoreactive LPL proteins were present in pre- and postheparin plasma. In preheparin plasma, as well as in patients with type I hyperlipoproteinemia, there was decreased immunoreactive LPL protein, and the LPL protein that was present was of low specific activity.

A mouse T cell product that preferentially enhances IgA production. I. Biologic characterization

Supernatants from a subset of helper T cell clones can enhance IgA, IgE, and IgG1 production in cultures of lipopolysaccharide-stimulated, T cell-depleted spleen cells. The lymphokine interleukin (IL)-4 has been shown to cause the IgE and IgG1 enhancement produced by these supernatants. IgA enhancement, however, is mediated by a factor distinct from IL-4, although IL-4 can potentiate the effect of the IgA-enhancing factor. IgA-enhancing factor is also distinct from IL-1, IL-2, IL-3, granulocyte-macrophage colony-stimulating factor, and interferon-gamma and acts directly on B cells. Purified IgA-enhancing factor enhances IgA production three- to sixfold yet causes less than a twofold increase in other isotypes. The IgA enhancing activity is not inhibited by concentrations of interferon-gamma that inhibit IL-4 activities. In the accompanying article, we show that this IgA enhancing activity is a novel property of the lymphokine IL-5.

A mouse T cell product that preferentially enhances IgA production. I. Biologic characterization

Supernatants from a subset of helper T cell clones can enhance IgA, IgE, and IgG1 production in cultures of lipopolysaccharide-stimulated, T cell-depleted spleen cells. The lymphokine interleukin (IL)-4 has been shown to cause the IgE and IgG1 enhancement produced by these supernatants. IgA enhancement, however, is mediated by a factor distinct from IL-4, although IL-4 can potentiate the effect of the IgA-enhancing factor. IgA-enhancing factor is also distinct from IL-1, IL-2, IL-3, granulocyte-macrophage colony-stimulating factor, and interferon-gamma and acts directly on B cells. Purified IgA-enhancing factor enhances IgA production three- to sixfold yet causes less than a twofold increase in other isotypes. The IgA enhancing activity is not inhibited by concentrations of interferon-gamma that inhibit IL-4 activities. In the accompanying article, we show that this IgA enhancing activity is a novel property of the lymphokine IL-5.

B cell stimulatory factor-1 enhances the IgE response of lipopolysaccharide-activated B cells

Supernatants from some mouse helper T cell (TH) lines contain an activity that can enhance IgE production by lipopolysaccharide (LPS)-stimulated B cells by at least two orders of magnitude. During purification, this activity could not be resolved from B cell stimulatory factor-1 (BSF-1). Highly purified BSF-1 from a different source, the T lymphoma cell line EL-4, enhanced IgE production to the same extent as TH supernatants, which suggests that BSF-1 is responsible for this increase in IgE production. Monoclonal antibody to BSF-1 totally inhibits the IgE-enhancing activity of a TH supernatant, lending further support to this conclusion. The effects of BSF-1 on LPS-stimulated B cells are specific for IgE and, as previously reported, IgG1 and IgG3, because the levels of IgM, IgG2a, IgG2b, and IgA in the cultures change relatively little when BSF-1 is added.

B cell stimulatory factor-1 enhances the IgE response of lipopolysaccharide-activated B cells

Supernatants from some mouse helper T cell (TH) lines contain an activity that can enhance IgE production by lipopolysaccharide (LPS)-stimulated B cells by at least two orders of magnitude. During purification, this activity could not be resolved from B cell stimulatory factor-1 (BSF-1). Highly purified BSF-1 from a different source, the T lymphoma cell line EL-4, enhanced IgE production to the same extent as TH supernatants, which suggests that BSF-1 is responsible for this increase in IgE production. Monoclonal antibody to BSF-1 totally inhibits the IgE-enhancing activity of a TH supernatant, lending further support to this conclusion. The effects of BSF-1 on LPS-stimulated B cells are specific for IgE and, as previously reported, IgG1 and IgG3, because the levels of IgM, IgG2a, IgG2b, and IgA in the cultures change relatively little when BSF-1 is added.

A T cell activity that enhances polyclonal IgE production and its inhibition by interferon-gamma

The addition of concanavalin A-stimulated supernatants of the helper T cell clone, D9.1, to cultures of lipopolysaccharide (LPS)-stimulated T-depleted mouse spleen cells caused more than a 100-fold increase in immunoglobulin (Ig) E production. These supernatants cause a 10-fold to 15-fold increase in IgG1, a fivefold to 10-fold increase in IgA, and a fivefold to 10-fold decrease in IgG3. These effects are optimal when the supernatants are added 1 to 2 days after stimulation with LPS. Cells from mouse strains that normally give little or no IgE response in vivo give normal IgE levels in response to LPS plus the supernatant of Concanavalin A-stimulated D9.1 cells in vitro. The enhancement of both IgE and IgG1 can be completely inhibited by relatively low concentrations of interferon-gamma (IFN-gamma). Both the IgE-enhancing activity and IFN-gamma act directly upon purified B cells.

A T cell activity that enhances polyclonal IgE production and its inhibition by interferon-gamma

The addition of concanavalin A-stimulated supernatants of the helper T cell clone, D9.1, to cultures of lipopolysaccharide (LPS)-stimulated T-depleted mouse spleen cells caused more than a 100-fold increase in immunoglobulin (Ig) E production. These supernatants cause a 10-fold to 15-fold increase in IgG1, a fivefold to 10-fold increase in IgA, and a fivefold to 10-fold decrease in IgG3. These effects are optimal when the supernatants are added 1 to 2 days after stimulation with LPS. Cells from mouse strains that normally give little or no IgE response in vivo give normal IgE levels in response to LPS plus the supernatant of Concanavalin A-stimulated D9.1 cells in vitro. The enhancement of both IgE and IgG1 can be completely inhibited by relatively low concentrations of interferon-gamma (IFN-gamma). Both the IgE-enhancing activity and IFN-gamma act directly upon purified B cells.

Bacteriuria and its correlates in old age

Autopsy renal findings were correlated with clinical data during life in 100 aged people. An indwelling catheter in life was associated with raised serum creatinine and also infected renal pathology. Urinary infection itself did not correlate with serum creatinine level, systolic or diastolic blood pressure or infected renal pathology. The presence of any form of renal pathology correlated with elevated serum creatinine and elevated systolic but not diastolic blood pressure.

Coordination complexes of gallium(III) and indium(III) halides. IV. Infrared spectra, Raman spectra, and structures of complexes with dimethylsulfoxide and dimethylsulfoxide-d6

The preparation and characterization by far-infrared and Raman spectroscopy of dimethylsulfoxide (dmso) and dimethylsulfoxide-d6 (dmso-d6) complexes of gallium trihalides are reported. The compounds GaX3(dmso)6 (X = Br, I) have ionic structures containing the hexacoordinate cation Ga(dmso)63+. Reaction of gallium trichloride with dmso gives GaCl3(dmso)1.5. This compound appears to be identical with GaCl3(dmso)2 described by other workers and has been shown to have the structure [Ga(dmso)6][GaCl4]3. Some new vibrational data are presented for InX3(dmso)3 (X = Cl, Br) and InI3(dmso)2.