Hybrid Gene Origination Creates Human-Virus Chimeric Proteins during Infection.

RNA viruses are a major human health threat. The life cycles of many highly pathogenic RNA viruses like influenza A virus (IAV) and Lassa virus depends on host mRNA, because viral polymerases cleave 5'-m7G-capped host transcripts to prime viral mRNA synthesis ("cap-snatching"). We hypothesized that start codons within cap-snatched host transcripts could generate chimeric human-viral mRNAs with coding potential. We report the existence of this mechanism of gene origination, which we named "start-snatching." Depending on the reading frame, start-snatching allows the translation of host and viral "untranslated regions" (UTRs) to create N-terminally extended viral proteins or entirely novel polypeptides by genetic overprinting. We show that both types of chimeric proteins are made in IAV-infected cells, generate T cell responses, and contribute to virulence. Our results indicate that during infection with IAV, and likely a multitude of other human, animal and plant viruses, a host-dependent mechanism allows the genesis of hybrid genes.

Direct sequencing of total Saccharomyces cerevisiae tRNAs by LC-MS/MS.

Among RNAs, transfer RNAs (tRNAs) contain the widest variety of abundant posttranscriptional chemical modifications. These modifications are crucial for tRNAs to participate in protein synthesis, promoting proper tRNA structure and aminoacylation, facilitating anticodon:codon recognition, and ensuring the reading frame maintenance of the ribosome. While tRNA modifications were long thought to be stoichiometric, it is becoming increasingly apparent that these modifications can change dynamically in response to the cellular environment. The ability to broadly characterize the fluctuating tRNA modification landscape will be essential for establishing the molecular level contributions of individual sites of tRNA modification. The locations of modifications within individual tRNA sequences can be mapped using liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). In this approach, a single tRNA species is purified, treated with ribonucleases, and the resulting single-stranded RNA products are subject to LC-MS/MS analysis. The application of LC-MS/MS to study tRNAs is limited by the necessity of analyzing one tRNA at a time, because the digestion of total tRNA mixtures by commercially available ribonucleases produces many short digestion products unable to be uniquely mapped back to a single site within a tRNA. We overcame these limitations by taking advantage of the highly structured nature of tRNAs to prevent the full digestion by single-stranded RNA-specific ribonucleases. Folding total tRNA prior to digestion allowed us to sequence Saccharomyces cerevisiae tRNAs with up to 97% sequence coverage for individual tRNA species by LC-MS/MS. This method presents a robust avenue for directly detecting the distribution of modifications in total tRNAs.

Ethical argument for establishing good manufacturing practice for phage therapy in the UK.

Antimicrobial resistance (AMR) poses an increasing threat to patient care and population health and there is a growing need for novel therapies to tackle AMR. Bacteriophage (phage) therapy is a re-emerging antimicrobial strategy with the potential to transform how bacterial infections are treated in patients and populations. Currently, in the UK, phages can be used as unlicensed medicinal products on a 'named-patient' basis. We make an ethical case for why it is crucially important for the UK to invest in Good Manufacturing Practice (GMP) for both ongoing unlicensed and future licensed phage therapy. Access to phages produced to GMP (GMP phages) will ensure effective patient care and better outcomes as well as health systems benefits. The UK also has the potential to become a global leader in the timely and cost-efficient manufacturing and supply of a therapy that meets internationally recognised standards.

Nuclease P1 Digestion for Bottom-Up RNA Sequencing of Modified siRNA Therapeutics.

siRNA therapeutics provide a selective and powerful approach to reduce the expression of disease-causing genes. For regulatory approval, these modalities require sequence confirmation which is typically achieved by intact tandem mass spectrometry sequencing. However, this process produces highly complex spectra which are difficult to interpret and typically results in less than full sequence coverage. We sought to develop a bottom-up siRNA sequencing platform to ease sequencing data analysis and provide full sequence coverage. Analogous to bottom-up proteomics, this process requires chemical or enzymatic digestion to reduce the oligonucleotide length down to analyzable lengths, but siRNAs commonly contain modifications that inhibit the degradation process. We tested six digestion schemes for their feasibility to digest the 2' modified siRNAs and identified that nuclease P1 provides an effective digestion workflow. Using a partial digestion, nuclease P1 provides high 5' and 3' end sequence coverage with multiple overlapping digestion products. Additionally, this enzyme provides high-quality and highly reproducible RNA sequencing no matter the RNA phosphorothioate content, 2'-fluorination status, sequence, or length. Overall, we developed a robust enzymatic digestion scheme for bottom-up siRNA sequencing using nuclease P1, which can be implemented into existing sequence confirmation workflows.

Pseudouridinylation of mRNA coding sequences alters translation.

Chemical modifications of RNAs have long been established as key modulators of nonprotein-coding RNA structure and function in cells. There is a growing appreciation that messenger RNA (mRNA) sequences responsible for directing protein synthesis can also be posttranscriptionally modified. The enzymatic incorporation of mRNA modifications has many potential outcomes, including changing mRNA stability, protein recruitment, and translation. We tested how one of the most common modifications present in mRNA coding regions, pseudouridine (Ψ), impacts protein synthesis using a fully reconstituted bacterial translation system and human cells. Our work reveals that replacing a single uridine nucleotide with Ψ in an mRNA codon impedes amino acid addition and EF-Tu GTPase activation. A crystal structure of the Thermus thermophilus 70S ribosome with a tRNAPhe bound to a ΨUU codon in the A site supports these findings. We also find that the presence of Ψ can promote the low-level synthesis of multiple peptide products from a single mRNA sequence in the reconstituted translation system as well as human cells, and increases the rate of near-cognate Val-tRNAVal reacting on a ΨUU codon. The vast majority of Ψ moieties in mRNAs are found in coding regions, and our study suggests that one consequence of the ribosome encountering Ψ can be to modestly alter both translation speed and mRNA decoding.

The microbiology of diabetic foot infections: a meta-analysis.

BACKGROUND: Diabetic foot ulcers are a common complication of poorly controlled diabetes and often become infected, termed diabetic foot infection. There have been numerous studies of the microbiology of diabetic foot infection but no meta-analysis has provided a global overview of these data. This meta-analysis aimed to investigate the prevalence of bacteria isolated from diabetic foot infections using studies of any design which reported diabetic foot infection culture results. METHODS: The Medline, EMBASE, Web of Science and BIOSIS electronic databases were searched for studies published up to 2019 which contained microbiological culture results from at least 10 diabetic foot infection patients. Two authors independently assessed study eligibility and extracted the data. The main outcome was the prevalence of each bacterial genera or species. RESULTS: A total of 112 studies were included, representing 16,159 patients from which 22,198 microbial isolates were obtained. The organism most commonly identified was Staphylococcus aureus, of which 18.0% (95% CI 13.8-22.6%; I2 = 93.8% [93.0-94.5%]) was MRSA. Other highly prevalent organisms were Pseudomonas spp., E. coli and Enterococcus spp. A correlation was identified between Gross National Income and the prevalence of Gram positive or negative organisms in diabetic foot infections. CONCLUSION: The microbiology of diabetic foot infections is diverse, but S. aureus predominates. The correlation between the prevalence of Gram positive and negative organisms and Gross National Income could reflect differences in healthcare provision and sanitation. This meta-analysis has synthesised multiple datasets to provide a global overview of the microbiology of diabetic foot infections that will help direct the development of novel therapeutics.

Anatomical variations of the circle of Willis and their prevalence, with a focus on the posterior communicating artery: A literature review and meta-analysis.

The circle of Willis is an anastomotic network of arteries surrounding the base of the brain, providing collateral circulation to prevent ischemia. It has, however, long been established that it exhibits considerable anatomical variation when compared to Thomas Willis' originally described circle. This study aimed primarily to determine an accurate prevalence of the variation of the circle of Willis in the general population and the prevalence of common posterior communicating artery variations. Additional aims were to explain why such a wide range of reported variations exist, and whether different types of studies report significantly different prevalence of variation. A comprehensive literature search identified 764 papers. A three-phase screening process was undertaken, involving a critical analysis of papers, and a total of 33 papers were selected for analysis and literature review. A descriptive statistics test with bootstrap was performed to estimate the average prevalence of variations. The estimated prevalence of general variation, unilateral, and bilateral posterior communicating artery hypoplasia or aplasia was 68.22 ± 14.32%, 19.45 ± 8.63%, and 22.83 ± 14.58%, respectively. Over half of the population exhibit a circle of Willis with some form of variation. To provide a more accurate estimation for the prevalence of variations, a universal classification system needs to be established, collating all the work from high-quality studies, to provide a comprehensive database of the circle's variations. Knowing the prevalence of variations and how they can impact neurosurgical approaches or patterns of ischemic pathology can be crucial in providing effective patient care.

A retrospective analysis of the microbiology of diabetic foot infections at a Scottish tertiary hospital.

BACKGROUND: This study represents the first Scottish retrospective analysis of the microbiology of diabetic foot infections (DFIs). The aims were to compare the microbiological profile of DFIs treated at a Scottish tertiary hospital to that in the literature, gather data regarding antimicrobial resistance and investigate potential trends between the microbiological results and nature or site of the clinical sample taken and age or gender of the patients. METHODS: A retrospective analysis of wound microbiology results was performed, data were obtained from one multidisciplinary outpatient foot clinic during the 12 months of the year 2017. Seventy-three patients and 200 microbiological investigations were included. In cases of soft tissue infection, the deepest part of a cleansed and debrided wound was sampled. In cases of osteomyelitis a bone biopsy was obtained. Factors influencing the pattern of microbial growth or prevalence of Staphylococcus aureus were investigated. RESULTS: Of the 200 microbiological investigations, 62% were culture positive, of which 37.9% were polymicrobial and 62.1% monomicrobial. Among the monomicrobial results (n = 77), most were Gram positive isolates (96.1%) and the most frequently isolated bacteria was S. aureus (84.4%). No methicillin-resistant S. aureus was reported. The prevalence of S. aureus in DFIs was associated with increasing age (p = 0.021), but no evidence of association with gender, anatomical sample site or sample material was found. CONCLUSION: The microbiological profile of DFIs in Scotland resembles that reported elsewhere in the UK. In this context, Gram positive organisms, primarily S. aureus, are most frequently isolated from DFIs. The S. aureus isolates identified were largely susceptible to antibiotic therapy. An association between increasing patient age and the prevalence of S. aureus in DFIs was observed.

High-Resolution Analysis of Coronavirus Gene Expression by RNA Sequencing and Ribosome Profiling.

Members of the family Coronaviridae have the largest genomes of all RNA viruses, typically in the region of 30 kilobases. Several coronaviruses, such as Severe acute respiratory syndrome-related coronavirus (SARS-CoV) and Middle East respiratory syndrome-related coronavirus (MERS-CoV), are of medical importance, with high mortality rates and, in the case of SARS-CoV, significant pandemic potential. Other coronaviruses, such as Porcine epidemic diarrhea virus and Avian coronavirus, are important livestock pathogens. Ribosome profiling is a technique which exploits the capacity of the translating ribosome to protect around 30 nucleotides of mRNA from ribonuclease digestion. Ribosome-protected mRNA fragments are purified, subjected to deep sequencing and mapped back to the transcriptome to give a global "snap-shot" of translation. Parallel RNA sequencing allows normalization by transcript abundance. Here we apply ribosome profiling to cells infected with Murine coronavirus, mouse hepatitis virus, strain A59 (MHV-A59), a model coronavirus in the same genus as SARS-CoV and MERS-CoV. The data obtained allowed us to study the kinetics of virus transcription and translation with exquisite precision. We studied the timecourse of positive and negative-sense genomic and subgenomic viral RNA production and the relative translation efficiencies of the different virus ORFs. Virus mRNAs were not found to be translated more efficiently than host mRNAs; rather, virus translation dominates host translation at later time points due to high levels of virus transcripts. Triplet phasing of the profiling data allowed precise determination of translated reading frames and revealed several translated short open reading frames upstream of, or embedded within, known virus protein-coding regions. Ribosome pause sites were identified in the virus replicase polyprotein pp1a ORF and investigated experimentally. Contrary to expectations, ribosomes were not found to pause at the ribosomal frameshift site. To our knowledge this is the first application of ribosome profiling to an RNA virus.

The use of duplex-specific nuclease in ribosome profiling and a user-friendly software package for Ribo-seq data analysis.

Ribosome profiling is a technique that permits genome-wide, quantitative analysis of translation and has found broad application in recent years. Here we describe a modified profiling protocol and software package designed to benefit more broadly the translation community in terms of simplicity and utility. The protocol, applicable to diverse organisms, including organelles, is based largely on previously published profiling methodologies, but uses duplex-specific nuclease (DSN) as a convenient, species-independent way to reduce rRNA contamination. We show that DSN-based depletion compares favorably with other commonly used rRNA depletion strategies and introduces little bias. The profiling protocol typically produces high levels of triplet periodicity, facilitating the detection of coding sequences, including upstream, downstream, and overlapping open reading frames (ORFs) and an alternative ribosome conformation evident during termination of protein synthesis. In addition, we provide a software package that presents a set of methods for parsing ribosomal profiling data from multiple samples, aligning reads to coding sequences, inferring alternative ORFs, and plotting average and transcript-specific aspects of the data. Methods are also provided for extracting the data in a form suitable for differential analysis of translation and translational efficiency.

Physical Demands of Representative Match-Play in Adolescent Rugby Union.

Read, DB, Jones, B, Phibbs, PJ, Roe, GAB, Darrall-Jones, J, Weakley, JJS, and Till, K. Physical demands of representative match-play in adolescent rugby union. J Strength Cond Res 31(5): 1290-1296, 2017-The purpose of this study was to quantify the physical demands of representative adolescent rugby union match-play and investigate the difference between playing positions and age groups. Players (n = 112) were classified into 6 groups by playing position (forwards and backs) and age group (U16, U18, and U20). The physical demands were measured using microsensor-based technology and analyzed using magnitude-based inferences to assess practical importance. Backs had a greater relative distance (except U16s) and a greater high-speed running distance per minute than forwards, with the magnitude of difference between the positions becoming larger in older age groups. Forwards had higher values of PlayerLoad (PL) per minute (accumulated accelerations from the 3 axes of movement) and PL slow per minute (accumulated accelerations from the 3 axes of movement where velocity is <2 m·s) than backs at all age groups. Relative distance, low-, and high-speed running per minute all had a trend to be lower in older age groups for both positions. PlayerLoad per minute was greater in U18 than that in U16 and U20 for both positions. PlayerLoad slow per minute was greater for older age groups besides the U18 and U20 comparisons, which were unclear. The contrasts in physical demands experienced by different positions reinforce the need for greater exposure to sprinting and collision-based activity for backs and forwards, respectively. Given PL metrics peak at U18 and locomotor demands seem to be lower in older ages, the demands of representative adolescent rugby union do not seem to be greater at U20 as expected.

Reliability and Usefulness of Linear Sprint Testing in Adolescent Rugby Union and League Players.

The purpose of this study was to evaluate (a) whether there were differences in sprint times at 5, 10, 20, 30, and 40 m between rugby union and rugby league players, (b) determine the reliability and usefulness of linear sprint testing in adolescent rugby players. Data were collected on 28 rugby union and league academy players over 2 testing sessions, with 3-day rest between sessions. Rugby league players were faster at 5 m than rugby union players, with further difference unclear. Sprint time at 10, 20, 30, and 40 m was all reliable (coefficient of variation [CV] = 3.1, 1.8, 2.0, and 1.3%) but greater than the smallest worthwhile change (SWC [0.2 × between-subject SD]), rating the test as marginal for usefulness. Although the test was incapable of detecting the SWC, we recommend that practitioners and researchers use Hopkins' proposed method; whereby plotting the change score of the individual at each split (±typical error [TE] expressed as a CV) against the SWC and visually inspecting whether the TE crosses into the SWC are capable of identifying whether a change is both real (greater than the noise of the test, i.e., >TE) and of practical significance (>SWC). Researchers and practitioners can use the TE and SWC from this study to assess changes in performance of adolescent rugby players when using single beam timing gates.

Anthropometric, Sprint, and High-Intensity Running Profiles of English Academy Rugby Union Players by Position.

The purpose of this study was to evaluate the anthropometric, sprint, and high-intensity running profiles of English academy rugby union players by playing positions, and to investigate the relationships between anthropometric, sprint, and high-intensity running characteristics. Data were collected from 67 academy players after the off-season period and consisted of anthropometric (height, body mass, sum of 8 skinfolds [∑SF]), 40-m linear sprint (5-, 10-, 20-, and 40-m splits), the Yo-Yo intermittent recovery test level 1 (Yo-Yo IRTL-1), and the 30-15 intermittent fitness test (30-15 IFT). Forwards displayed greater stature, body mass, and ∑SF; sprint times and sprint momentum, with lower high-intensity running ability and sprint velocities than backs. Comparisons between age categories demonstrated body mass and sprint momentum to have the largest differences at consecutive age categories for forwards and backs; whereas 20-40-m sprint velocity was discriminate for forwards between under 16s, 18s, and 21s. Relationships between anthropometric, sprint velocity, momentum, and high-intensity running ability demonstrated body mass to negatively impact on sprint velocity (10 m; r = -0.34 to -0.46) and positively affect sprint momentum (e.g., 5 m; r = 0.85-0.93), with large to very large negative relationships with the Yo-Yo IRTL-1 (r = -0.65 to -0.74) and 30-15 IFT (r = -0.59 to -0.79). These findings suggest that there are distinct anthropometric, sprint, and high-intensity running ability differences between and within positions in junior rugby union players. The development of sprint and high-intensity running ability may be impacted by continued increases in body mass as there seems to be a trade-off between momentum, velocity, and the ability to complete high-intensity running.

Changes in Adductor Strength After Competition in Academy Rugby Union Players.

This study determined the magnitude of change in adductor strength after a competitive match in academy rugby union players and examined the relationship between locomotive demands of match-play and changes in postmatch adductor strength. A within-subject repeated measures design was used. Fourteen academy rugby union players (age, 17.4 ± 0.8 years; height, 182.7 ± 7.6 cm; body mass, 86.2 ± 11.6 kg) participated in the study. Each player performed 3 maximal adductor squeezes at 45° of hip flexion before and immediately, 24, 48, and 72 hours postmatch. Global positioning system was used to assess locomotive demands of match-play. Trivial decreases in adductor squeeze scores occurred immediately (-1.3 ± 2.5%; effect size [ES] = -0.11 ± 0.21; likely, 74%) and 24 hours after match (-0.7 ± 3%; ES = -0.06 ± 0.25; likely, 78%), whereas a small but substantial increase occurred at 48 hours (3.8 ± 1.9%; ES = 0.32 ± 0.16; likely, 89%) before reducing to trivial at 72 hours after match (3.1 ± 2.2%; ES = 0.26 ± 0.18; possibly, 72%). Large individual variation in adductor strength was observed at all time points. The relationship between changes in adductor strength and distance covered at sprinting speed (VO2max ≥ 81%) was large immediately postmatch (p = 0.056, r = -0.521), moderate at 24 hours (p = 0.094, r = -0.465), and very large at 48 hours postmatch (p = 0.005, r = -0.707). Players who cover greater distances sprinting may suffer greater adductor fatigue in the first 48 hours after competition. The assessment of adductor strength using the adductor squeeze test should be considered postmatch to identify players who may require additional rest before returning to field-based training.

Anthropometric and Physical Profiles of English Academy Rugby Union Players.

The purpose of this study was to evaluate the anthropometric and physical characteristics of English regional academy rugby union players by age category (under 16s, under 18s and under 21s). Data were collected on 67 academy players at the beginning of the preseason period and comprised anthropometric (height, body mass, and sum of 8 skinfolds) and physical (5-, 10-, 20-, and 40-m sprint, acceleration, velocity, and momentum; agility 505; vertical jump; Yo-Yo intermittent recovery test level 1; 30-15 intermittent fitness test; absolute and relative 3 repetition maximum front squat, split squat, bench press, prone row, and chin; and isometric mid-thigh pull). One-way analysis of variance demonstrated significant increases across the 3 age categories (p ≤ 0.05) for height (e.g., 16s = 178.8 ± 7.1; 18s = 183.5 ± 7.2; 21s = 186.7 ± 6.61 cm), body mass (e.g., 16s = 79.4 ± 12.8; 18s = 88.3 ± 11.9; 21s = 98.3 ± 10.4 kg), countermovement jump height and peak power, sprint momentum, velocity, and acceleration; absolute, relative, and isometric (e.g., 16s = 2,157.9 ± 309.9; 18s = 2,561.3 ± 339.4; 21s = 3,104.5 ± 354.0 N) strength. Momentum, maximal speed, and the ability to maintain acceleration were all discriminating factors between age categories, suggesting that these variables may be more important to monitor rather than sprint times. These findings highlight that anthropometric and physical characteristics develop across age categories and provide comparative data for English Academy Rugby Union players.

Phage therapy: Awareness and demand among clinicians in the United Kingdom.

Bacterial resistance or tolerance to antibiotics is costly to patients and healthcare providers. With the impact of antibiotic resistance forecast to grow, alternative antimicrobial approaches are needed to help treat patients with antibiotic refractory infections and reduce reliance upon existing antibiotics. There is renewed interest in bacteriophage (phage) therapy as a promising antimicrobial strategy. We therefore performed the first multi-specialty survey about phage therapy and the first such survey among clinicians in the United Kingdom. An anonymous 10-question survey of clinicians from medical and surgical specialties in two Scottish Health Boards was performed. The 90 respondents spanned 26 specialties and were predominantly consultants (73.3%). The respondents were concerned about antibiotic resistance in their clinical practice; 83 respondents estimated having seen 711 patients in the last 12 months whose infections were refractory to antibiotics (delaying or preventing resolution). Over half (58.8%) of the respondents had previously heard of phage therapy. Staphylococci, Pseudomonas and E. coli were identified as the highest cross-specialty priorities for the development of phage therapy. Together, 77 respondents estimated seeing 300 patients in the last 12 months for whom phage therapy may have been appropriate (an average of 3.9 patients per clinician). Most respondents (71.1%, n = 90) were already willing to consider using phage therapy in appropriate cases. Additional comments from the respondents affirmed the potential utility of phage therapy and highlighted a need for more information. The results of this survey demonstrate substantial demand for and willingness to use phage therapy in appropriate cases, both from individual clinicians and across specialties. Demand from a wide range of specialties illustrates the broad clinical utility of phage therapy and potential scope of impact. Widening access to phage therapy could deliver substantial clinical and financial benefits for patients and health authorities alike.

The Future of Clinical Phage Therapy in the United Kingdom.

Bacteriophage (phage) therapy is a promising alternative antimicrobial strategy with the potential to transform the way bacterial infections are treated. In the United Kingdom, phages are classed as a biological medicine. Although no phages are licensed for UK use, they may be used as unlicensed medicinal products where licensed alternatives cannot meet a patient's clinical needs. In the last 2 years, 12 patients in the UK have received phage therapy, and there is burgeoning clinical interest. Currently, clinical phage provision in the UK is ad hoc and relies upon networking with international sources of phages. The provision of phage therapy in the UK will not progress beyond an increasing number of ad hoc cases until an onshore sustainable and scalable source of well-characterised phages manufactured in accordance with Good Manufacturing Practice (GMP) is established. Here, we present an exciting new collaboration between UK Phage Therapy, the Centre for Phage Research at University of Leicester, CPI, and Fixed Phage. These partners, and others as we develop, will establish sustainable, scalable, and equitable phage therapy provision in the UK. We set out a vision for how phage therapy will be integrated into the NHS and healthcare more broadly, including the complementarity between licensed (cocktail) and unlicensed (personalised) phage preparations. Key elements of phage therapy infrastructure in the UK will be GMP phage manufacturing, a national phage library, and a national clinical phage centre. Together, this infrastructure will support NHS microbiology departments to develop and oversee phage therapy provision across the UK. As it will take time to deliver this, we also describe considerations for clinicians seeking to use unlicensed phage therapy in the interim. In summary, this review sets out a roadmap for the delivery of clinical phage therapy to the UK, the benefits of which we hope will reverberate for patients for decades to come.

Managing Patient and Clinician Expectations of Phage Therapy in the United Kingdom.

Bacteriophage (phage) therapy is a promising alternative antimicrobial approach which has the potential to transform the way we treat bacterial infections. Phage therapy is currently being used on a compassionate basis in multiple countries. Therefore, if a patient has an antibiotic refractory infection, they may expect their clinician to consider and access phage therapy with the hope of improvement. The expectations of clinicians may be similar and may also include expectations around data collection. However, there are multiple biological and practical barriers to fulfilling patient and clinician expectations. While it is possible to access phage therapy, the path to acquisition is not straightforward and expectations therefore need to be managed appropriately to avoid raising false hope and undermining confidence in phage therapy. Phage scientists have an important contribution to make in educating clinicians and the broader public about phage therapy. However, it is clinicians that are responsible for managing the expectations of their patients and this relies on clear communication about the barriers and limitations.

The Safety and Efficacy of Phage Therapy for Infections in Cardiac and Peripheral Vascular Surgery: A Systematic Review.

New approaches to managing infections in cardiac and peripheral vascular surgery are required to reduce costs to patients and healthcare providers. Bacteriophage (phage) therapy is a promising antimicrobial approach that has been recommended for consideration in antibiotic refractory cases. We systematically reviewed the clinical evidence for phage therapy in vascular surgery to support the unlicensed use of phage therapy and inform future research. Three electronic databases were searched for articles that reported primary data about human phage therapy for infections in cardiac or peripheral vascular surgery. Fourteen reports were eligible for inclusion, representing 40 patients, among which an estimated 70.3% of patients (n = 26/37) achieved clinical resolution. A further 10.8% (n = 4/37) of patients showed improvement and 18.9% (n = 7/37) showed no improvement. Six of the twelve reports that commented on the safety of phage therapy did not report adverse effects. No adverse effects documented in the remaining six reports were directly linked to phages but reflected the presence of manufacturing contaminants or release of bacterial debris following bacterial lysis. The reports identified by this review suggest that appropriately purified phages represent a safe and efficacious treatment option for infections in cardiac and peripheral vascular surgery.

Phage Therapy for Diabetic Foot Infection: A Case Series.

PURPOSE: Infected diabetic foot ulcers can be difficult to treat and, despite appropriate antibiotic therapy, some diabetic foot infections (DFIs) require amputation. Bacteriophages (phages) are viruses that infect and kill bacteria. Phage therapy has been repeatedly used to successfully treat DFIs and other chronic wounds. METHODS: This article reports the provision of topical adjunctive anti-staphylococcal phage therapy to 10 patients with DFI at high risk of amputation at two UK hospitals as part of clinical care; tolerability and efficacy were clinically assessed. FINDINGS: The opinion of the experienced clinical teams caring for these patients was that 9 of the 10 patients appeared to benefit from adjunctive phage therapy. No adverse effects were reported by clinicians or patients. In 6 of 10 patients the clinical impression was that phage therapy facilitated clinical resolution of infection and limb salvage. Resolution of soft tissue infection was observed in a 7th patient but unresolved osteomyelitis required amputation. An 8th patient demonstrated eradication of Staphylococcus aureus from a polymicrobial infection and a 9th showed signs of clinical improvement before early cessation of phage therapy due to an unrelated event. One patient, with a weakly susceptible S aureus isolate, had no significant response. IMPLICATIONS: This report describes the largest application of phage therapy in the United Kingdom to date and the first application of phage therapy for DFI in the United Kingdom and offers subjective hints toward impressive tolerability and efficacy. Phage therapy has the potential to transform the prevention and treatment of DFIs.