Need for effective detection and early warnings for epidemic and pandemic preparedness planning in the context of multi-hazards: Lessons from the COVID-19 pandemic

The need for effective early detection and timely surveillance for a robust pandemic and epidemic early warning and preparedness has been widely discussed amidst the Covid-19 pandemic, which suddenly erupted worldwide. This need is further established by various other hazards reported in many countries amidst the COVID-19 pandemic. In addition, the failure of early detection of pathogens and their source of origin has been largely connected with global transmission and severe outbreaks in many contexts. Therefore, effective early detection , timely surveillance and early warning are key aspects of a successful response to an epidemic or pandemic. . Hence, this paper aims to identify key elements and stages of an effective epidemic and pandemic early warning (EW) and response system. Further, the paper analyses inter-connections of the elements of the early warning system, focusing on the COVID-19 and multi-hazard context. The systematic literature review method was used to collect data from electronic databases. Results suggest that epidemiological surveillance & detection, primary screening of raw data & information, risk and vulnerability assessments, prediction and decision-making, alerts & early warnings are critical components of epidemic and pandemic EW. In addition, response-control & mitigation, preparedness-preventive strategies, and reducing transmission , elimination and eradication of the disease are integrated components of the early warning and response ecosystem that largely depend on effective early warnings. The significance of integrating epidemic and pandemic EW with other EWs to operate as multi-hazard early warning systems is also analysed.

Activity of a Bacteriophage Cocktail to Control Salmonella Growth Ex Vivo in Avian, Porcine, and Human Epithelial Cell Cultures

We examined the activity of phages to control the growth of chicken and swine Salmonella strains in avian (CHIC-8E11), porcine (IPEC-1), and human (HT-29) cell cultures. We optimized a six-phage cocktail by selecting the five most effective myoviruses and a siphovirus that have optimal lysis on prevalent serovars. We observed ∼20% of 7 log10 PFU/well phage and 3-6 log10 CFU bacterial adhesions, and 3-5 log10 CFU bacterial invasion per 2 cm2 of the cultured cells at 2 h post-treatment. The invasive bacteria when plated had a variable reduced susceptibility to the phages. After phage application at an MOI of 10, the prophylaxis regimen had better efficacy at controlling bacterial growth with an up to 6 log10 CFU/well reduction as compared with the 1-2 log10 CFU/well bacterial reduction observed in the remedial and coinfection regimens. Our data support the development of these phages to control salmonellosis in chickens, pigs, and humans.

Exhaled SARS-CoV-2 RNA viral load kinetics measured by facemask sampling associates with household transmission

OBJECTIVES

No studies have examined longitudinal patterns of naturally exhaled SARS-CoV-2 RNA viral load (VL) during acute infection. We report this using facemask sampling (FMS) and assessed the relationship between emitted RNA VL and household transmission.

METHODS

Between December 2020 and February 2021, we recruited participants within 24 hours of a positive RT-qPCR on upper respiratory tract sampling (URTS) (day 0). Participants gave FMS (for 1 hour) and URTS (self-taken) on seven occasions up to day 21. Samples were analysed by RT-qPCR (from sampling matrix strips within the mask) and symptom diaries were recorded. Household transmission was assessed through reporting of positive URTS RT-qPCR in household contacts.

RESULTS

Analysis of 203 FMS and 190 URTS from 34 participants showed that RNA VL peaked within the first 5 days following sampling. Concomitant URTS, FMS RNA VL, and symptom scores, however, were poorly correlated, but a higher severity of reported symptoms was associated with FMS positivity up to day 5. Of 28 participants who had household contacts, 12 (43%) reported transmission. Frequency of household transmission was associated with the highest (peak) FMS RNA VL obtained (negative genome copies/strip: 0% household transmission; 1 to 1000 copies/strip: 20%; 1001 to 10 000 copies/strip: 57%; >10 000 copies/strip: 75%; p = 0.048; age adjusted OR of household transmission per log increase in copies/strip: 4.97; 95% CI, 1.20-20.55; p = 0.02) but not observed with peak URTS RNA VL.

DISCUSSION

Exhaled RNA VL measured by FMS is highest in early infection, can be positive in symptomatic patients with concomitantly negative URTS, and is strongly associated with household transmission.

A O03 Ex vivo perfusion of isolated human liver segments: the development of a novel model for ethical, translational research

Background

Ex vivo perfusion techniques for human organs, in particular for the human liver, have been extensively studied for decades. Although ex vivo perfusion of human organs has been widely studied in the context of organ preservation and transplantation, it has also proven to be an invaluable tool in the development of novel models for translational pre-clinical research. Not only do these models allow more accurate study of human organ response to noxious external stimuli, but they also represent a far more ethical alternative to live animal experimentation.Although split-liver perfusion of the left or right hepatic lobe is well described in literature, ex vivo perfusion of isolated liver segments has not been previously attempted. A successful hepatic segmental perfusion model would provide a unique opportunity to study inflammation, response to infection and novel therapeutic approaches.The overall aim of this study was to establish an experimental ex vivo hepatic perfusion model on surgically resected human liver segments as a platform to evaluate and study organ preservation and function. The development of an ex vivo perfusion model of human liver segments would produce the ideal platform to study treatment effects without needing to sacrifice animals.

Methods

Patients were recruited as part of the TIMOLD (Tissue Models for Liver Disease) clinical trial (ClinicalTrials.gov Identifier: NCT05255042; 8/9/2021). Patients recruited were those aged eighteen or over undergoing elective liver resections at a single hepatobiliary unit. Nine human liver segments were retrieved following hemi-hepatectomy for colorectal liver metastases or hepatocellular carcinoma. A healthy segment was resected from the diseased specimen in theatre and a segmental hepatic artery and portal vein was cannulated immediately and flushed with ice cold heparinised preservation solution.

Four segments were perfused with 600ml O negative expired red blood cells (HL-RBC) and five segments were perfused with 250ml Oxyglobin diluted with 250ml Volplex (HL-OXY). All segments were administered several drugs to provide metabolic support and optimise perfusion owing to their anticoagulant, antioxidant, and anti-inflammatory properties. Segments were perfused on a bespoke normothermic machine perfusion circuit for 4–6 hours.

Perfusion parameters were monitored throughout perfusion and hourly hepatic venous blood gases were taken to monitor glucose and lactate levels. Hourly core biopsies were also taken for H&E staining and interpreted by a consultant histopathologist. Data is reported as the median (range) and statistical analysis has been performed using the Mann-Whitney U test on Graphpad Prism.

Results

HL-RBC (n=4) had a median pre-perfusion weight of 216 (146–1330) grams whilst HL-OXY (n=5) had a median weight of 269(128–367) grams (p>0.05). HL-RBC segments had a median warm ischaemic (WI) time of 76.5(68–81) minutes and a median cold ischaemic (CI) time of 97 (35–119) minutes. HL-OXY segments had a median WI time of 5 (3–80) minutes and a median CI time of 38 (28–63) minutes (p>0.05). Median portal venous resistance was lower for the HL-OXY group (0.076mmHg/ml/min) in comparison to the HL-RBC group (0.62mmHg/ml/min); p<0.05. There was no significant difference in hepatic arterial resistance between the two groups (HL-RBC 3 mmHg/ml/min; HL-OXY 2.38 mmHg/ml/min; p>0.05). HL-OXY had a lower median lactate of 4.54mmol/L in comparison to HL-RBC (14.7mmol/L) throughout perfusion (p<0.05). HL-OXY segments also had a lower median glucose of 5.9mmol/L compared to 9.65mmol/L for HL-RBC (p<0.05). 1/4 HL-RBC segments had normal histology after 6 hours of perfusion. 2/4 segments showed evidence of necrosis after 2 hours (one with established cirrhosis), and 1/4 segment demonstrated necrosis after 3 hours of perfusion. 4/5 HL-OXY segments demonstrated normal histology after 6 hours of perfusion. One segment, with known cirrhosis, demonstrated necrosis after two hours of perfusion.

Conclusions

We present here, for the first time, the development of a successful ex vivo isolated hepatic segmental perfusion model. We demonstrate, in the development of this model, that bovine haemoglobin glutamer-200 (Oxyglobin) is a superior oxygen carrier to expired O negative red blood cells in the ex vivo perfusion of isolated human hepatic segments.

The HL-OXY group demonstrated a significantly lower portal venous resistance in comparison to HL-RBC, although there was no difference in arterial resistance. Furthermore, HL-OXY segments had lower median glucose and lactate levels during perfusion compared to HL-RBC segments.

4 of 5 segments perfused with Oxyglobin demonstrated viable hepatocytes on histopathological analysis after 6 hours of perfusion. The segment demonstrating early necrosis was one with established cirrhosis on pre-perfusion histology.

We describe a protocol for the successful ex vivo perfusion of non-cirrhotic human hepatic segments. Human liver is routinely resected in tertiary hepatobiliary units and much of the specimen discarded. The paradigm presented here identifies a readily available ethical source of human liver with minimal warm ischaemia. This facilitates optimal conditions for translational research, is cost-effective and avoids animal experimentation.

Epigenetic Modification Impacts on Gene Regulation in Streptococcus pneumoniae

Methylation by the type I restriction modification system (RMS) SpnIII in Streptococcus pneumoniae is hypothesised to regulate gene expression via epigenetic changes (Manos). The phase variable SpnIII generates six host specificity determinants (hsdS) alleles through site-specific recombination (DeSteCroix), each allele correspond with different methylation pattern.

In addition to known functions of the RMS in restricting phage infection (Furi) and transformation (Kwun), we have now tested impact on gene expression. RNAseq was used to analyse S. pneumoniae strains expressing a single spnIII allele (spnIIIA, spnIIIB or spnIIIE) to determine differences in gene expression profiles. The data have identified six genes which show differential expression and have a methylation site mapping to their predicted promoter region. Three synthetic promoters with the wild type and altered methylation target site were cloned in front of a luciferase gene in strains expressing a single spnIII alleles. For the first three sets of constructs analysed, data indicate that the methylated promoters show a three- to twenty-fold higher activity compared to non-methylated promoters. Results obtained were further confirmed by qPCR analysis. Preliminary data using drugs targeting DNA topoisomerases indicate that the mechanism by which methylation impact gene expression could be related to DNA topology. These data demonstrate for the first-time RMS dependent variations in gene expression and propose an alternative mechanism for this epigenetic regulation.

References:

* Manso, Nature Communication, 2014; 5:5055.

* De Ste Croix, J. Bacteriol. 2019; 201(15). pii: e00233-19.

* Furi, J. Bacteriol. 2019; 201(19). pii: e00370-19.

* Kwun, Nucleic Acids Res. 2018; 46(21):11438-11453.

Development of a colorimetric assay for the detection of SARS-CoV-2 3CLpro activity

Diagnostic testing continues to be an integral component of the strategy to contain the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) global pandemic, the causative agent of Coronavirus Disease 2019 (COVID-19). The SARS-CoV-2 genome encodes the 3C-like protease (3CLpro) which is essential for coronavirus replication. This study adapts an in vitro colorimetric gold nanoparticle (AuNP) based protease assay to specifically detect the activity of SARS-CoV-2 3CLpro as a purified recombinant protein and as a cellular protein exogenously expressed in HEK293T human cells. We also demonstrate that the specific sensitivity of the assay for SARS-CoV-2 3CLpro can be improved by use of an optimised peptide substrate and through hybrid dimerisation with inactive 3CLpro mutant monomers. These findings highlight the potential for further development of the AuNP protease assay to detect SARS-CoV-2 3CLpro activity as a novel, accessible and cost-effective diagnostic test for SARS-CoV-2 infection at the point-of-care. Importantly, this versatile assay could also be easily adapted to detect specific protease activity associated with other viruses or diseases conditions.

Evaluating the network of stakeholders in Multi-Hazard Early Warning Systems for multiple hazards amidst biological outbreaks: Sri Lanka as a case in point

Synergized impacts of simultaneous hazards amidst COVID-19 have called for the need for highly collaborative multi-sectoral approaches for disaster preparedness planning. In such a context, this study aims at evaluating the network of stakeholders in the National Early Warning System of Sri Lanka during preparedness planning. Social Network Analysis was used to visualise the network of stakeholders for selected hazard scenarios. Furthermore, a series of key informant interviews were conducted focusing on disaster preparedness planning during the recent multiple hazard scenarios. The findings highlight the need for a framework to guide the stakeholder coordination in preparedness planning for multiple hazards.

Exhaled SARS-CoV-2 quantified by face-mask sampling in hospitalised patients with COVID-19

BACKGROUND

Human to human transmission of SARS-CoV-2 is driven by the respiratory route but little is known about the pattern and quantity of virus output from exhaled breath. We have previously shown that face-mask sampling (FMS) can detect exhaled tubercle bacilli and have adapted its use to quantify exhaled SARS-CoV-2 RNA in patients admitted to hospital with Coronavirus Disease-2019 (COVID-19).

METHODS

Between May and December 2020, we took two concomitant FMS and nasopharyngeal samples (NPS) over two days, starting within 24 h of a routine virus positive NPS in patients hospitalised with COVID-19, at University Hospitals of Leicester NHS Trust, UK. Participants were asked to wear a modified duckbilled facemask for 30 min, followed by a nasopharyngeal swab. Demographic, clinical, and radiological data, as well as International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) mortality and deterioration scores were obtained. Exposed masks were processed by removal, dissolution and analysis of sampling matrix strips fixed within the mask by RT-qPCR. Viral genome copy numbers were determined and results classified as Negative; Low: ≤999 copies; Medium: 1000-99,999 copies and High ≥ 100,000 copies per strip for FMS or per 100 µl for NPS.

RESULTS

102 FMS and NPS were collected from 66 routinely positive patients; median age: 61 (IQR 49 - 77), of which FMS was positive in 38% of individuals and concomitant NPS was positive in 50%. Positive FMS viral loads varied over five orders of magnitude (<10-3.3 x 106 genome copies/strip); 21 (32%) patients were asymptomatic at the time of sampling. High FMS viral load was associated with respiratory symptoms at time of sampling and shorter interval between sampling and symptom onset (FMS High: median (IQR) 2 days (2-3) vs FMS Negative: 7 days (7-10), p = 0.002). On multivariable linear regression analysis, higher FMS viral loads were associated with higher ISARIC mortality (Medium FMS vs Negative FMS gave an adjusted coefficient of 15.7, 95% CI 3.7-27.7, p = 0.01) and deterioration scores (High FMS vs Negative FMS gave an adjusted coefficient of 37.6, 95% CI 14.0 to 61.3, p = 0.002), while NPS viral loads showed no significant association.

CONCLUSION

We demonstrate a simple and effective method for detecting and quantifying exhaled SARS-CoV-2 in hospitalised patients with COVID-19. Higher FMS viral loads were more likely to be associated with developing severe disease compared to NPS viral loads. Similar to NPS, FMS viral load was highest in early disease and in those with active respiratory symptoms, highlighting the potential role of FMS in understanding infectivity.

A biobank analysis of prognostic biomarkers of the systemic inflammatory response in patients presenting with malignancy of undefined primary origin

BACKGROUND

Survival prediction in patients presenting with malignancy of undefined primary origin (MUO) is challenging, with a lack of validated prognostic tools. Biomarkers of the systemic inflammatory response independently predict survival in other cancer types, but their role in MUO is unclear. The aim of this study was to assess biomarkers of the systemic inflammatory response in patients presenting with MUO.

PATIENTS AND METHODS

A biobank of 1049 patients presenting with MUO referred to a regional oncology service in Scotland was analysed. Key inflammatory biomarkers (white cell count, neutrophil count and C-reactive protein combined with albumin [to give the modified Glasgow Prognostic Score {mGPS}]) were examined. The relationship between these and survival was examined using Kaplan-Meier and Cox regression methods.

RESULTS

Data were available for 1049 patients. Median survival was 4.3 months (interquartile range: 1.7-16.0 months). On multivariate analysis mGPS was independently associated with survival and stratified survival from 13.6 months (mGPS: 0) to 2.3 months (mGPS: 2) (p < 0.001). The mGPS was predictive of survival on multivariate analysis in patients found to have a non-cancer diagnosis (p = 0.034), an identified primary cancer (0.002), cancer of unknown primary (CUP) (p = 0.011), those for whom biopsy was not done (MUO) (p = 0.036), those found to have an identified primary cancer (0.002) and even those found to have a non-cancer diagnosis (p = 0.034) after further detailed investigations. In patients with CUP mGPS predicted survival regardless of the recognised clinicopathological prognostic subgroup (p < 0.001).

CONCLUSIONS

The results of the present study demonstrate that biomarkers of the systemic inflammatory response are reliable prognostic factors in patients presenting with MUO. These simple, objective, routine clinical tests may inform clinical management.

P57 IGG4-related disease causing sudden cardiac death

Background

IgG4-related disease (IgG4-RD) is a chronic systemic inflammatory disorder presenting with mass lesions in various organs and showing plasma cell infiltration, storiform fibrosis and obliterative phlebitis on histology. IgG4-RD has previously been identified as a rare cause of sudden cardiac death (SCD) in case reports, but in settings where pathology has been unexpectedly found on post-mortem examination. To our knowledge, there are no published case reports of SCD in patients during treatment for IgG4-RD.

Methods

A 43-year old chef with a 15 pack-year smoking history presented with portal vein thrombosis, widespread lymphadenopathy, proptosis and inflammatory lung changes. He was found to have IgG4-RD on submandibular lymph node biopsy with storiform fibrosis and abundance of IgG4-positive plasma cells. Test showed a high IgG and low complement levels and a persistent eosinophilia. He was anticoagulated with warfarin for the HPV thrombosis. Treatment with steroids (initially prednisolone 40mg/day) was initially successful and he continued at work and kept fit in the gym. There was also a good biochemical and radiological response to steroids, with normalisation of eosinophil count, IgG level, complements and CRP along with regression of imaging changes. After a period of 12 months steroid weaning (prednisolone 5mg) and having been well at OPD review, he was unexpectedly found dead at home. Post-mortem examination identified IgG4-RD coronary pan-arteritis as the cause of death. The finding of this unanticipated severe complication raises new questions about surveillance and prevention.

Results

Coronary involvement in IgG4-RD is thought to be rare but may reflect difficulty obtaining coronary artery tissue and clinically silent disease remaining undiagnosed. A systematic review of IgG4-RD outcomes (7 studies comprising 294 patients, follow-up mean of 29 months) identified 26 deaths (8.8%). One was from an aneurysm and four from other cardiovascular disease, while most deaths were from disease progression or cancer. Case reports describe IgG4-RD coronary artery disease pathologies, including inflammatory pseudotumour, periarterial thickening, coronary artery aneurysm and coronary artery stenosis.

Conclusion

This case raises important questions about identifying and monitoring for asymptomatic cardiovascular involvement in IgG4-RD. Steroid treatment may be less effective for coronary involvement, and in theory, could precipitate rupture or dilatation of the arteries. Recent IgG4-RD management guidelines have not addressed surveillance for cardiovascular disease. ECG and echocardiography are reasonable initial surveillance options, but we suggest clinicians have a low threshold for CT coronary angiography and/or cardiac MR. Invasive coronary angiography and CT-PET can then be used to provide additional information if required. We noted a normal CRP despite active coronary inflammation in our patient and therefore look forward to improved biomarkers for disease activity in IgG4-RD.

Disclosures

R. Haigh None. L. Smyth None. A. Ludman None.

EP27 The Exeter Biologics Management Plan

Background

The introduction of biologic drugs has been life-changing for our patients, but these drugs are very expensive. Moreover, they are immunosuppressive and are associated with an increased infection risk. Conventional practice is to maintain the same dose long term. An internal audit identified significant drug wastage; £40,000 drug 'wasted' per year by repeat prescription requests, hoarding of supplies and missed doses. Dose reduction could result in cost savings and reduced complications, but this strategy also risks loss of disease control & requires enhanced monitoring.

Methods

We set up a new 'Biologics Managment Plan' Service (BMP) with the following aims: 1. Reduce costs from wastage, 2. Enable patients to confidently reduce dose by introducing a part time nurse and biologics administrator, 3. Assess efficacy, 4. Receive patient feedback. We formulated criteria to ensure eligibility for dose reduction and a dose reduction protocol for each biologic drug. We organised an intensification of follow up, monitoring and support. We maintained close liaison with pharmacy regarding prescription management and vial sharing on Day Case Unit. We fully counselled our BMP patients and subsequently obtained detailed patient feedback using a patient experience measure (PREM), plus free text comments. We examined clinical outcomes including disease activity assessments, occurrence of flares and, where possible, radiological outcomes, in patients with inflammatory arthritis undergoing biologic dose reduction.

Results

82 patients entered our BMP, 48 with rheumatoid arthritis (RA). 70% were able to dose reduce successfully. Mean dose reduction was 43%. For the 48 patients with RA, disease duration, presence of erosive disease nor serological status determined dose reduction outcome. 13 patients lost control of disease with dose reduction, but regained control rapidly with intervention. 2 patients switched biologic drug after a period of poor disease control. There was no progression of erosive disease in 31 RA patients who had follow up X-rays, within 18/12 of dose reduction. Similar outcomes were seen in ankylosing spondylitis (15), psoriatic arthritis (19) and JIA (2) with ∼70% success rate. Our PREM revealed &gt;95% felt involved, had sufficient information, & felt that drug reduction had not caused interference with daily life. All would recommend our project to others. We calculated this project was able to save £269,278.58 in the first 12 months.

Conclusion

It is possible to reduce the dose of biologic drugs in selected patients with inflammatory arthritis in remission. Patients were keen to reduce their drug doses and engaged enthusiastically in the process. Enhanced follow-up and support ensured that patients felt 'looked after' and rapid intervention can manage any loss of control of disease promptly. Significant cost savings can be made. We have begun to determine whether therapeutic drug monitoring can complement this process.

Disclosures

R. Haigh: Honoraria; speaker fees Pfizer. Grants/research support; conference attendance Pfizer, UCB. D. Murphy: None. J. Moran: None.

Oxidative stress in autoimmune rheumatic diseases

The management of patients with autoimmune rheumatic diseases such as rheumatoid arthritis (RA) remains a significant challenge. Often the rheumatologist is restricted to treating and relieving the symptoms and consequences and not the underlying cause of the disease. Oxidative stress occurs in many autoimmune diseases, along with the excess production of reactive oxygen species (ROS) and reactive nitrogen species (RNS). The sources of such reactive species include NADPH oxidases (NOXs), the mitochondrial electron transport chain, nitric oxide synthases, nitrite reductases, and the hydrogen sulfide producing enzymes cystathionine-β synthase and cystathionine-γ lyase. Superoxide undergoes a dismutation reaction to generate hydrogen peroxide which, in the presence of transition metal ions (e.g. ferrous ions), forms the hydroxyl radical. The enzyme myeloperoxidase, present in inflammatory cells, produces hypochlorous acid, and in healthy individuals ROS and RNS production by phagocytic cells is important in microbial killing. Both low molecular weight antioxidant molecules and antioxidant enzymes, such as superoxide dismutase, catalase, glutathione peroxidase, and peroxiredoxin remove ROS. However, when ROS production exceeds the antioxidant protection, oxidative stress occurs. Oxidative post-translational modifications of proteins then occur. Sometimes protein modifications may give rise to neoepitopes that are recognized by the immune system as 'non-self' and result in the formation of autoantibodies. The detection of autoantibodies against specific antigens, might improve both early diagnosis and monitoring of disease activity. Promising diagnostic autoantibodies include anti-carbamylated proteins and anti-oxidized type II collagen antibodies. Some of the most promising future strategies for redox-based therapeutic compounds are the activation of endogenous cellular antioxidant systems (e.g. Nrf2-dependent pathways), inhibition of disease-relevant sources of ROS/RNS (e.g. isoform-specific NOX inhibitors), or perhaps specifically scavenging disease-related ROS/RNS via site-specific antioxidants.

Phase-variable methylation and epigenetic regulation by type I restriction-modification systems

Epigenetic modifications in bacteria, such as DNA methylation, have been shown to affect gene regulation, thereby generating cells that are isogenic but with distinctly different phenotypes. Restriction-modification (RM) systems contain prototypic methylases that are responsible for much of bacterial DNA methylation. This review focuses on a distinctive group of type I RM loci that , through phase variation, can modify their methylation target specificity and can thereby switch bacteria between alternative patterns of DNA methylation. Phase variation occurs at the level of the target recognition domains of the hsdS (specificity) gene via reversible recombination processes acting upon multiple hsdS alleles. We describe the global distribution of such loci throughout the prokaryotic kingdom and highlight the differences in loci structure across the various bacterial species. Although RM systems are often considered simply as an evolutionary response to bacteriophages, these multi-hsdS type I systems have also shown the capacity to change bacterial phenotypes. The ability of these RM systems to allow bacteria to reversibly switch between different physiological states, combined with the existence of such loci across many species of medical and industrial importance, highlights the potential of phase-variable DNA methylation to act as a global regulatory mechanism in bacteria.

Recommendations for a first Core Outcome Measurement set for complex regional PAin syndrome Clinical sTudies (COMPACT)

Complex regional pain syndrome (CRPS) is a persistent pain condition that remains incompletely understood and challenging to treat. Historically, a wide range of different outcome measures have been used to capture the multidimensional nature of CRPS. This has been a significant limiting factor in the advancement of our understanding of the mechanisms and management of CRPS. In 2013, an international consortium of patients, clinicians, researchers, and industry representatives was established, to develop and agree on a minimum core set of standardised outcome measures for use in future CRPS clinical research, including but not limited to clinical trials within adult populations. The development of a core measurement set was informed through workshops and supplementary work, using an iterative consensus process. "What is the clinical presentation and course of CRPS, and what factors influence it?" was agreed as the most pertinent research question that our standardised set of patient-reported outcome measures should be selected to answer. The domains encompassing the key concepts necessary to answer the research question were agreed as follows: pain, disease severity, participation and physical function, emotional and psychological function, self-efficacy, catastrophizing, and patient's global impression of change. The final core measurement set included the optimum generic or condition-specific patient-reported questionnaire outcome measures, which captured the essence of each domain, and 1 clinician-reported outcome measure to capture the degree of severity of CRPS. The next step is to test the feasibility and acceptability of collecting outcome measure data using the core measurement set in the CRPS population internationally.

Salad Leaf Juices Enhance Salmonella Growth, Colonization of Fresh Produce, and Virulence

We show in this report that traces of juices released from salad leaves as they become damaged can significantly enhance colonization of salad leaves by Salmonella enterica Salad juices in water increased Salmonella growth by 110% over the level seen with the unsupplemented control and in host-like serum-based media by more than 2,400-fold over control levels. In serum-based media, salad juices induced growth of Salmonella via provision of Fe from transferrin, and siderophore production was found to be integral to the growth induction process. Other aspects relevant to salad leaf colonization and retention were enhanced, such as motility and biofilm formation, which were increased over control levels by >220% and 250%, respectively; direct attachment to salad leaves increased by >350% when a salad leaf juice was present. In terms of growth and biofilm formation, the endogenous salad leaf microbiota was largely unresponsive to leaf juice, suggesting that Salmonella gains a marked growth advantage from fluids released by salad leaf damage. Salad leaf juices also enhanced pathogen attachment to the salad bag plastic. Over 5 days of refrigeration (a typical storage time for bagged salad leaves), even traces of juice within the salad bag fluids increased Salmonella growth in water by up to 280-fold over control cultures, as well as enhancing salad bag colonization, which could be an unappreciated factor in retention of pathogens in fresh produce. Collectively, the study data show that exposure to salad leaf juice may contribute to the persistence of Salmonella on salad leaves and strongly emphasize the importance of ensuring the microbiological safety of fresh produce.

IMPORTANCE

Salad leaves are an important part of a healthy diet but have been associated in recent years with a growing risk of food poisoning from bacterial pathogens such as Salmonella enterica Although this is considered a significant public health problem, very little is known about the behavior of Salmonella in the actual salad bag. We show that juices released from the cut ends of the salad leaves enabled the Salmonella cells to grow in water, even when it was refrigerated. Salad juice exposure also helped the Salmonella cells to attach to the salad leaves so strongly that washing could not remove them. Collectively, the results presented in this report show that exposure to even traces of salad leaf juice may contribute to the persistence of Salmonella on salad leaves as well as priming it for establishing an infection in the consumer.

Dissemination of Novel Antimicrobial Resistance Mechanisms through the Insertion Sequence Mediated Spread of Metabolic Genes

The widely used biocide triclosan selectively targets FabI, the NADH-dependent trans-2-enoyl-acyl carrier protein (ACP) reductase, which is also an important target for the development of narrow spectrum antibiotics. The analysis of triclosan resistant Staphylococcus aureus isolates had previously shown that in about half of the strains, the mechanism of triclosan resistance consists on the heterologous duplication of the triclosan target gene due to the acquisition of an additional fabI allele derived from Staphylococcus haemolyticus (sh-fabI). In the current work, the genomic sequencing of 10 of these strains allowed the characterization of two novel composite transposons TnSha1 and TnSha2 involved in the spread of sh-fabI. TnSha1 harbors one copy of IS1272, whereas TnSha2 is a 11.7 kb plasmid carrying TnSha1 present either as plasmid or in an integrated form generally flanked by two IS1272 elements. The target and mechanism of integration for IS1272 and TnSha1 are novel and include targeting of DNA secondary structures, generation of blunt-end deletions of the stem-loop and absence of target duplication. Database analyses showed widespread occurrence of these two elements in chromosomes and plasmids, with TnSha1 mainly in S. aureus and with TnSha2 mainly in S. haemolyticus and S. epidermidis. The acquisition of resistance by means of an insertion sequence-based mobilization and consequent duplication of drug-target metabolic genes, as observed here for sh-fabI, is highly reminiscent of the situation with the ileS2 gene conferring mupirocin resistance, and the dfrA and dfrG genes conferring trimethoprim resistance both of which are mobilized by IS257. These three examples, which show similar mechanisms and levels of spread of metabolic genes linked to IS elements, highlight the importance of this genetic strategy for recruitment and rapid distribution of novel resistance mechanisms in staphylococci.

Recording occupation in general practice--a second cycle audit

BACKGROUND

An audit of working age patients' records in two Cornish general practices in 2012 found infrequent and inconsistent recording of patients' occupations. A concurrent survey of general practitioners (GPs) in Cornwall found that a majority of them believed it was important to do so.

AIMS

To review occupation recording in the same practices a year later and to audit a third practice, following the introduction of the electronic fit note. To repeat the survey of attitudes to recording occupation in GPs in Cornwall.

METHODS

We manually checked 300 randomly selected patient records in Practice A and electronically searched all records of working age patients (aged 16-65 years) in Practices B and C for recorded occupation. We sent an electronic survey of attitudes to recording occupation to 202 GPs in Cornwall.

RESULTS

Recording of occupation increased from 17 to 30% of records (χ(2) = 15, P < 0.001) in Practice A and from 12 to 14% (χ(2) = 16.5, P < 0.001) in Practice B. In Practice C, 1% of records had occupation recorded and coded. The proportion of GPs in Cornwall who said that it is important to records patients' occupation increased from 70 to 90% (Fisher's exact statistic 0.01, P < 0.05).

CONCLUSIONS

Recording of patients' occupation increased in both practices from 2012 to 2013, but remains infrequent and inconsistent and the very low levels in a third practice not previously audited is of concern.

A random six-phase switch regulates pneumococcal virulence via global epigenetic changes

Streptococcus pneumoniae (the pneumococcus) is the world’s foremost bacterial pathogen in both morbidity and mortality. Switching between phenotypic forms (or ‘phases’) that favour asymptomatic carriage or invasive disease was first reported in 1933. Here, we show that the underlying mechanism for such phase variation consists of genetic rearrangements in a Type I restriction-modification system (SpnD39III). The rearrangements generate six alternative specificities with distinct methylation patterns, as defined by single-molecule, real-time (SMRT) methylomics. The SpnD39III variants have distinct gene expression profiles. We demonstrate distinct virulence in experimental infection and in vivo selection for switching between SpnD39III variants. SpnD39III is ubiquitous in pneumococci, indicating an essential role in its biology. Future studies must recognize the potential for switching between these heretofore undetectable, differentiated pneumococcal subpopulations in vitro and in vivo. Similar systems exist in other bacterial genera, indicating the potential for broad exploitation of epigenetic gene regulation.

Pneumococci can alternate between harmless and highly virulent forms. Here the authors show that such variation may be due to random rearrangements in a genetic locus encoding a restriction-modification system, resulting in epigenetic changes that affect expression of many genes.

Inducible hydrogen sulfide synthesis in chondrocytes and mesenchymal progenitor cells: is H2S a novel cytoprotective mediator in the inflamed joint?

Hydrogen sulfide (H₂S) has recently been proposed as an endogenous mediator of inflammation and is present in human synovial fluid. This study determined whether primary human articular chondrocytes (HACs) and mesenchymal progenitor cells (MPCs) could synthesize H₂S in response to pro-inflammatory cytokines relevant to human arthropathies, and to determine the cellular responses to endogenous and pharmacological H₂S. HACs and MPCs were exposed to IL-1β, IL-6, TNF-α and lipopolysaccharide (LPS). The expression and enzymatic activity of the H₂S synthesizing enzymes cystathionine-β-synthase (CBS) and cystathionine-γ-lyase (CSE) were determined by Western blot and zinc-trap spectrophotometry, respectively. Cellular oxidative stress was induced by H₂O₂, the peroxynitrite donor SIN-1 and 4-hydroxynonenal (4-HNE). Cell death was assessed by 3-(4,5-dimethyl-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and lactate dehydrogenase (LDH) assays. Mitochondrial membrane potential (DCm) was determined in situ by flow cytometry. Endogenous H₂S synthesis was inhibited by siRNA-mediated knockdown of CSE and CBS and pharmacological inhibitors D,L-propargylglycine and aminoxyacetate, respectively. Exogenous H₂S was generated using GYY4137. Under basal conditions HACs and MPCs expressed CBS and CSE and synthesized H₂S in a CBS-dependent manner, whereas CSE expression and activity was induced by treatment of cells with IL-1β, TNF-α, IL-6 or LPS. Oxidative stress-induced cell death was significantly inhibited by GYY4137 treatment but increased by pharmacological inhibition of H₂S synthesis or by CBS/CSE-siRNA treatment. These data suggest CSE is an inducible source of H₂S in cultured HACs and MPCs. H₂S may represent a novel endogenous mechanism of cytoprotection in the inflamed joint, suggesting a potential opportunity for therapeutic intervention.

Structured approach to measure performance in construction research and development

Purpose

The aim of this study is to explore performance measurement applications within construction research and development (R&D) to develop a structured approach to measure the performance of a collaborative construction R&D project during its lifecycle from initiation, conceptualisation, development, and launch stages, and during project management.

Design/methodology/approach

During the exploratory phase of the study, semi‐structured interviews and a questionnaire survey were carried out to develop the performance measurement system (PMS). During the explanatory phase, the developed PMS was refined with a series of semi‐structured interviews. The data were gathered from principal investigators, researchers and industrial partners involved in collaborative construction R&D work.

Findings

The main finding is the developed PMS to measure the performance of construction R&D that consists of critical success factors, performance indicators and performance measures during the lifecycle of a R&D project.

Practical implications

The PMS developed through the study provides critical success factors, performance indicators and measures that need to be considered during construction R&D projects to measure the performance. Thus, through the implementation of the PMS, this study contributes to practice by assisting the performance improvement within construction R&D projects.

Originality/value

The developed PMS to measure the performance of construction R&D projects will provide value for those who are engaged in R&D work (principal investigators, researchers and industrial partners) to ensure the success of their projects.

DEVELOPING CAPACITIES FOR DISASTER RISK REDUCTION IN THE BUILT ENVIRONMENT: CAPACITY ANALYSIS IN SRI LANKA

This paper introduces a framework for capacity development for disaster risk reduction in the built environment. The framework was developed as a part of an ongoing research which aims to strengthen the capacities of individuals and institutions in the built environment to ensure that disaster risk reduction meets its mission and goals in a sustainable way. It is presented as a matrix that identifies four stages of capacity development against six groups of stakeholders in the built environment. The stages and the stakeholder groups were derived through a series of expert interviews and a comprehensive literature review. The four stages are named as Analysis, Creation, Utilisation and Retention. This paper in its latter sections focuses on the first stage, Analysis, and presents some of the initial findings of the research. Analysis attempts to capture capacity gaps in the relevant context in order to identify required capacity development. The study reviews literature on Sri Lanka and discusses such capacity gaps. Problems in the regulatory structure, deficiencies in necessary laws and regulations including problems in their implementation, and lack of required resources and skills have been identified as the major capacity gaps in the country. Santruka Šiame darbe pristatoma sistema, leidžianti ugdyti gebejima mažinti nelaimiu keliama rizika užstatytoje aplinkoje. Sistema sudaryta vykdant nuolatini tyrima, kuriuo siekiama didinti užstatytoje aplinkoje veikiančiu individu ir instituciju gebejimus, idant nelaimiu keliamos rizikos mažinimas darniai atitiktu jo misija ir tikslus. Sistema pateikiama kaip matrica, kuria sudaro keturi gebejimu ugdymo etapai ir šešios užstatytoje aplinkoje veikiančios interesu grupes. Etapai ir interesu grupes buvo nustatytos apklausiant ekspertus ir išsamiai apžvelgiant literatūra. Keturi etapai pavadinti “Analize”, “Kūrimas”, “Panaudojimas” ir “Išlaikymas”. Tolesnese šio darbo dalyse aptariamas pirmasis etapas “Analize” ir pateikiamos kelios pradines tyrimo išvados. Analize siekiama užfiksuoti atitinkamame kontekste esančias gebejimu spragas, kad būtu aišku, kuriuos gebejimus reikia ugdyti. Tyrime apžvelgiama literatūra apie Šri Lanka ir aptariamos tokios gebejimu spragos. Nustatyta, kad pagrindines šalies gebejimu spragos yra šios: problemos reglamentavimo struktūroje, būtinu istatymu ir reglamentu trūkumai, iskaitant ju igyvendinimo problemas, ir reikiamu ištekliu bei igūdžiu stoka.

Extracellular calreticulin is present in the joints of patients with rheumatoid arthritis and inhibits FasL (CD95L)-mediated apoptosis of T cells

OBJECTIVE

The binding of FasL (CD95L) to its receptor, Fas (CD95), induces apoptosis. Studies have shown that in patients with rheumatoid arthritis (RA), T lymphocytes are resistant to FasL-induced apoptosis in vivo but are susceptible to FasL-induced apoptosis in vitro. Dysfunction in this mechanism may be an important contributor to the pathophysiology of RA. Thus, the present study was undertaken to determine which factors might inhibit FasL-Fas binding in vivo and those that would inhibit apoptosis of T lymphocytes in an in vitro model system.

METHODS

Human Jurkat T cells rendered apoptotic by FasL exposure were analyzed by flow cytometry. Necrosis was determined according to measurement of lactate dehydrogenase release. Quantification of calreticulin in plasma and synovial fluid and of calreticulin-FasL binding was performed by enzyme-linked immunosorbent assay. Measurement of nitrite/nitrate in the plasma and synovial fluid was carried out by chemiluminescence assay.

RESULTS

Extracellular calreticulin was present at a significantly higher concentration in the plasma (median 10.3 ng/ml, interquartile range [IQR] 14.8 ng/ml) and synovial fluid (median 10.3 ng/ml, IQR 12.0 ng/ml) of RA patients (each P < 0.05) compared with the plasma (median 3.1 ng/ml, IQR 1.3 ng/ml) and synovial fluid (median 2.9 ng/ml, IQR 0.9 ng/ml) of patients with psoriatic arthritis and the plasma of healthy control subjects (median 2.9 ng/ml, IQR 0.9 ng/ml). Calreticulin concentrations in the synovial fluid correlated with the tender and swollen joint counts and the activity scores on the 28-joint Disease Activity Score assessment. Calreticulin also bound directly to FasL. In vitro, calreticulin (2-16 ng/ml) inhibited FasL-induced apoptosis of Jurkat T cells.

CONCLUSION

Calreticulin was present at higher concentrations in the plasma and synovial fluid of RA patients. Calreticulin had the capacity to bind directly to FasL and to inhibit FasL-mediated apoptosis of Jurkat T cells, and thus might play a role in inhibiting apoptosis of inflammatory T cells in RA.

CAPACITY BUILDING FOR POST‐DISASTER INFRASTRUCTURE DEVELOPMENT AND MANAGEMENT

„Capacity building for post‐disaster infrastructure development and management" International Journal of Strategic Property Management, 13(2), p. 83-86

A HUMAN‐COMPUTER INTERACTION PRINCIPLES BASED FRAMEWORK TO ASSESS THE USER PERCEPTION OF WEB BASED VIRTUAL RESEARCH ENVIRONMENTS

Due to various challenges and opportunities such as globalisation of research agenda and advancements in information and communication technologies, research collaborations (both international and national) have become popular during the last decade more than ever before. Within this context, the concept of Virtual Research Environments(VRE) is an emerging concept looking at addressing the complex challenges associated with conducting collaborative research. Even though concept of VRE is at its infancy, it is important to assess user perception about those, both to establish its success of uptake and future development strategies. However, to date, there is no formal method established to evaluate VREs .This paper reports a strategy adopted within an international collaborative research project (EURASIA) to evaluate its custom built VRE, VEBER, using the well known Computer Human Interaction principles. Santruka Ivairiausi iššūkiai ir galimybes, tokios kaip planuojamu moksliniu tyrimu globalizacija ir informacijos bei komunikacijos technologiju pažanga, pastaraji dešimtmeti leme didesni nei bet kada tiriamojo bendradarbiavimo (ir tarptautinio, ir nacionalinio) populiaruma. Šiame kontekste virtualiosios moksliniu tyrimu aplinkos (VMTA) savoka – tai gimstanti savoka, kuria siekiama imtis sudetingu iššūkiu, susijusiu su tiriamuoju bendradarbiavimu. Nors VMTA savoka kol kas žengia pirmuosius žingsnius, svarbu ivertinti, kaip vartotojai ja suvokia, siekdami nustatyti, kaip jai seksis prigyti, ir būsimasias pletros strategijas. Tačiau formalaus metodo VMTA vertinti kol kas nera. Šiame darbe pristatoma strategija, taikyta tarptautiniame moksliniu tyrimu bendradarbiavimo projekte (EURASIA), nes norima ivertinti specialiai tam sukurta VMTA, pavadinta VEBER, naudojant gerai žinomus kompiuterio ir žmogaus saveikos principus.

KNOWLEDGE MODEL FOR POST‐DISASTER MANAGEMENT

The main aim of this research is to help post‐disaster managers to find most rational solutions by using advanced knowledge and developed Model. Post‐disaster management is shared, purposeful activities based upon the development of common understandings and interpretations of means and ends. Stakeholders generate the personal and group decisions which contribute to post‐disaster management success. This article describes the development (during EurAsia project) of a Knowledge Model for Post‐disaster Management based upon multiple criteria decision making theory. The developed Model involves six stages that help to determine rational post‐disaster management alternatives by evaluating post‐disaster management’ life cycle, stakeholders, micro and macro environment. Santruka Pagrindinis šio darbo tikslas - padeti asmenims, kurie vadovauja darbams likviduojant stichiniu nelaimiu padarinius, rasti racionaliausius sprendimus, naudojant pažangias žinias ir sukurta modeli. Vadyba po stichiniu nelaimiu ‐ tai bendra, tikslinga veikla, grindžiama priemoniu ir bendro tikslu supratimo bei interpretavimo kūrimu. Suinteresuotos grupes priima asmeninius ir grupinius sprendimus, kurie prisideda prie vadybos po stichiniu nelaimiu sekmes. Šiame straipsnyje aprašoma, kaip buvo sukurtas vadybos po stichiniu nelaimiu žiniu modelis (vykdant EurAsia projekta), pagristas daugiakriterinio sprendimu priemimo teorija. Sukurta modeli sudaro šešios dalys, padedančios nustatyti racionalias vadybos po stichiniu nelaimiu alternatyvas, ivertinant vadybos po stichiniu nelaimiu gyvavimo cikla, suinteresuotas grupes, mikro‐ ir makroaplinka.

POST DISASTER WASTE MANAGEMENT STRATEGIES IN DEVELOPING COUNTRIES: CASE OF SRI LANKA

Disasters cause substantial damage around the world. This causes serious environmental and economic burden on normal living conditions, reconstruction and general waste collection processes. Within this context, waste management has emerged as a critical issue in responding to a disaster. Thus, this paper addresses post disaster waste management strategies adopted in developing countries and applicability of best global practices in respect of challenges encountered. Comprehensive literature review and field survey among national level institutes in Sri Lanka were conducted to gather information and semi‐structured interviews were used as a method of data collection. The findings revealed that strategies, issues and challenges are varying according to type of disaster, magnitude, location, country etc. Further, poor implementation of prevailing rules and regulations; poor standards of local expertise and capacities, inadequate funds, lack of communication and coordination are identified as key issues encountered. Santruka Stichines nelaimes visame pasaulyje pridaro daug žalos. Tai labai pasunkina aplinkosaugine ir ekonomine situacija iprastomis gyvenimo salygomis, atstatant aplinka ir vykdant bendruosius atlieku rinkimo procesus. Šiame kontekste atlieku tvarkymas išryškejo kaip esmine problema, reaguojant i stichine nelaime. Taigi šiame darbe nagrinejamos atlieku tvarkymo po stichiniu nelaimiu strategijos, taikomos besivystančiose šalyse, ir geriausiu pasauliniu praktiku taikymas, imantis kilusiu iššūkiu. Siekiant surinkti informacija, išsamiai apžvelgta literatūra ir tiesiogiai ištirtos Šri Lankos valstybines institucijos, o duomenims rinkti pasitelktas pusiau struktūriniu interviu metodas. Iš rezultatu aišku, kad strategijos, problemos ir iššūkiai skiriasi priklausomai nuo stichines nelaimes pobūdžio, masto, vietos, valstybes ir pan. Be to, nustatyta, kad pagrindines problemos yra prastas visuotiniu taisykliu ir reglamentu taikymas, prasti vietines patirties standartai ir menkos galimybes, lešu trūkumas, komunikacijos ir koordinavimo trūkumas.

The management of patients with painful total knee replacement

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient's pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Consequence of neo-antigenicity of the 'altered self'

Post-translational modifications play a central role in determining the function of proteins. Such protein modifications come in a great variety of guises, and include phosphorylation, proteolysis, glycosylation, citrullination and oxidative modifications. In relation to inflammatory autoimmune diseases, some post-translational modifications appear to result in the generation of new antigens, and hence autoantibodies. Examples include: the induction of peptide immunogenicity by the spontaneous conversion of aspartic acid residues to isoaspartic acid; granzyme B-mediated cleavage of SLE autoantigens; the oxidative modification--on the surface of apoptotic cells--of lipids and proteins, rendering them immunogenic; and the presence of antibodies to oxidatively modified type II collagen and C1q in RA and SLE patients, respectively. The measurement of autoantibodies to citrullinated proteins has been verified as a very useful diagnostic tool in RA. Proteomics techniques, in principle, allow the detection of all types of in vivo protein modifications, and the increasing application of such technologies to the study of rheumatological diseases will further our understanding of autoantigenicity.

The effect of substance P on nitric oxide release in a rheumatoid arthritis model

OBJECTIVE

The inflammatory mediator substance P (SP) acts principally through the neurokinin (NK1) receptor. We assessed the influence of SP on production of NO and its possible role in the pathogenesis of rheumatoid arthritis (RA).

METHODS

The effect of SP (0.1-100 nM) on concentrations of the NO metabolite, nitrite, produced by synovial fibroblasts from RA patients was studied. For comparison, the effects of TNF-alpha (0.57 pM-5.7 nM) and IL-1beta (0.57 pM-5.7 nM) were also studied. In parallel studies, footpad inflammation was induced in NK1 receptor knock-out (KO) and wild-type (WT) mice, and swelling and NO metabolite levels were measured.

RESULTS

In cultured synoviocytes, SP, TNF-alpha and IL-1beta induced significantly increased nitrite concentrations. Consistent with a role for NO in SP-mediated inflammatory reactions, the plasma NO metabolite level in WT mice was significantly increased at 3 days following an injection of 10 mg/ml Mycobacterium tuberculosis, but there was no significant change in NK1 KO mice. These results were paralleled by the changes in footpad swelling in WT mice compared to NK1 KO mice.

CONCLUSION

SP, like TNF-alpha and IL-1beta, induces NO in both rheumatoid synoviocytes and experimental models of inflammation. Treatments directed against SP may have important and hitherto unrecognised anti-inflammatory effects.