Measuring stock and change in the GB countryside for policy--key findings and developments from the Countryside Survey 2007 field survey

Countryside Survey is a unique large scale long-term monitoring programme investigating stock and change of habitats, landscape features, vegetation, soil and freshwaters of Great Britain. Repeat field surveys combine policy and scientific objectives to provide evidence on how multiple aspects of the environment are changing over time, a key goal of international science in the face of profound human impacts on ecosystems. Countryside Survey 2007 (CS2007), the fifth survey since 1978, retained consistency with previous surveys, whilst evolving in line with technological and conceptual advances in the collection and integration of data to understand landscape change. This paper outlines approaches taken in the 2007 survey and its subsequent analysis and presents some of the headline results of the survey and their relevance for national and international policy objectives. Key changes between 1998 and 2007 included: a) significant shifts in agricultural land cover from arable to grassland, accompanied by increases in the area of broadleaved woodland, b) decreases in the length of managed hedges associated with agricultural land, as a proportion deteriorated to lines of trees and c) increases in the areas and numbers of wet habitats (standing open water, ponds) and species preferring wetter conditions (1998-2007 and 1978-2007). Despite international policy directed at maintaining and enhancing biodiversity, there were widespread decreases in species richness in all linear and area habitats, except on arable land, consistent with an increase in competitive and late successional species between 1998 and 2007 and 1978 and 2007. Late successional and competitive species: Stinging nettle (Urtica dioica), Hawthorn (Cratageous monogyna) and Bramble (Rubus fruticosus), in the top ten recorded species recorded in 2007, all increased between 1998 and 2007. The most commonly recorded species in CS (1990, 1998 and 2007) was agricultural Ryegrass (Lolium perenne). Increases in both water quality and soil pH were in line with policy aimed at addressing previous deterioration of both. Headwater streams broadly showed continued improvements in biological quality from 1998 to 2007, continuing trends seen since 1990. In soils, there were significant increases in soil pH between 1998 and 2007 consistent with recovery from acidification.

Training teachers to teach mental health skills to staff in primary care settings in a vast, under-populated area

Background The Arkhangelsk Oblast is an area the size of France with a sparsely distributed population. The existing primary care staff have had very little training in the management of mental health disorders, despite the frequency of these disorders in the population. They requested special teaching on depression, suicide, somatisation and alcohol problems. Methods An educational intervention was developed in partnership with mental health and primary care staff in Russia, to develop mental health skills using established, evidence-based methods. After a preliminary demonstration of teaching methods to be employed, a 5-day full-time teaching course was offered to trainers of general practitioners and feldshers. Results The findings are presented by providing details of improvements that occurred over a 3-month period in four areas, namely depression in primary care, somatic presentations of distress, dealing with suicidal patients, and alcohol problems. We present preliminary data on how the training has generalised since our visits to Archangelsk. Conclusions Teachers who are used to teaching by didactic lectures can be taught the value of short introductory talks that invite discussion, and mental health skills can be taught using role play. The content of such training should be driven by perceived local needs, and developed in conjunction with local leaders and teachers within primary care services. Further research will be needed to establish the impact on clinical outcomes.

Laparoscopic and open colorectal surgery: a prospective cost analysis

AIM

Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery.

METHOD

Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared.

RESULTS

In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant).

CONCLUSION

The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.

Number of suture throws and its impact on the biomechanical properties of the four-strand cruciate locked flexor tendon repair with FiberWire

FiberWire is a popular suture in flexor tendon repair that allows for early mobilization, but its poor knot-holding properties have raised concerns over the potential effects on tendon healing and strength. We examined how the number of knot throws affects the 2 mm gap force, ultimate tensile strength, and mode of failure in a four-strand cruciate locked tendon repair in porcine flexor tendons in order to elucidate the optimal number of suture throws. There was no effect on the 2 mm gap force with increasing knot throws, but there was a significant increase in ultimate tensile strength. A minimum of six-knot throws prevents unravelling, whereas five out of 10 of repairs unravelled with less than six throws.

Assessing the performance of a continuous infusion for potassium supplementation in the critically ill

Hypokalaemia is a common problem in critically ill patients, which if untreated, can result in dysrhythmia or another adverse outcome. We assessed the safety and efficacy of a continuous infusion of potassium chloride versus an existing intermittent infusion regimen. In this open-label randomised parallel-arm active-controlled pilot study, critically ill adults with plasma potassium concentration between 2.5 and 3.8 mmol/l were randomised to receive either a continuous infusion or intermittent infusions of potassium chloride for establishment and maintenance of normokalaemia. The primary outcome was the mean difference in plasma potassium concentration over time between the two study arms as assessed by a linear mixed-effects model. Although a statistically significant difference was observed (0.22 mmol/l; 95% confidence interval 0.17, 0.27; P <0.0001), this did not reach the pre-determined level indicative of a treatment effect (0.5 mmol/l). The continuous group demonstrated less variance in (mean) plasma potassium as reflected in narrower confidence intervals in a prediction-by-time model. The incidence rate ratio of dysrhythmia, assessed by a mixed-effects Poisson model, was similar in each group (0.62; 95% confidence interval 0.32, 1.21; P=0.16). We recorded no adverse events directly attributable to infusion of potassium chloride in either study arm. Although titrated continuous infusion did not demonstrate a clinically important difference by comparison with intermittent infusions for the maintenance of normokalaemia, there was more consistent control of plasma potassium with no observed complications or adverse events. Therefore, this trial showed an acceptable efficacy and safety profile for the continuous infusion regimen, suggesting scope for further study.

P1-07-04: Gene Expression Module Biomarkers To Stratify Multiple Clinical and Therapeutic Endpoints for Universal Breast Cancer Companion Diagnostic

Gene expression patterns are increasingly capable of stratifying patients based on prognosis and response to therapy. Given the limited availability of sample tissue, however, it is not feasible to run many tests, suggesting the need for a universal companion diagnostic assay that is informative with respect to multiple clinical and therapeutic endpoints. Key challenges are identification of appropriate gene expression biomarkers, translation of biomarkers to clinical assays, and development of reliable gene expression profiling of formalin-fixed clinical specimens. Here, we describe a meta-analysis approach that identifies novel biomarker modules that results in multiple clinical and therapeutic read-outs.

A co-expression meta-analysis of 5,339 breast tumors from 56 microarray datasets identified highly co-expressed sets of genes (modules) across multiple datasets. These module based biomarkers were tested for their ability to associate with prognostic and predictive targets in published datasets. In addition, each module was reduced from 10 - 1,000 genes to the top performing 2–3 genes based on the degree of co-expression across the meta-analysis and validation by quantitative PCR in an independent panel of FFPE tumor samples. This study demonstrates that a single 96 gene qPCR test utilizing multiple module biomarkers is not only capable of stratifying patients by standard histopathological parameters (ER, PR and Her2), but also stratifies by other diverse elements of the disease (cell lineage, dysregulated core biological functions, factors of cell growth, underlying genomic aberrations and the tumor microenvironment). Taken together, these biological variables represent the major biological diversity present within the breast cancer population. A series of retrospective analyses demonstrated that different single module and combinations of modules were capable of predicting a variety of clinical endpoints, including 5-year survival, neoadjuvant chemotherapy response in ER- patients and targeted therapy response in model systems.The molecular heterogeneity of breast cancer can be summarized by discrete gene expression modules that individually represent distinct biological pathways, and that collectively can be represented by as few as 96 genes. These breast cancer modules, together with outlier genes, allow for summation of the entire transcriptional program and provide a universal assay with broad application to companion diagnostics development.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-04.

Partnering to harmonize IRBs for community-engaged research to reduce health disparities

Emerging advances in health disparities research include controlled trials and comparative effectiveness studies that are frequently conducted at multiple community and academic sites. Review by different institutional review boards (IRBs) presents a major impediment to the timely and effective conduct of such research. When research involves minority and underserved communities as well as multiple geographic regions, institutional requirements and interpretation of ethical standards may vary substantially. Such variations can complicate the informed consent process and research protocol, and may undermine participant respect and trial quality. In addition, multiple IRB review can lead to unnecessary delays, jeopardizing funding and capacity to perform collaborative projects. In response to these issues, the Research Centers in Minority Institutions (RCMI) Translational Research Network (RTRN) is developing a community-partnered approach to streamlining IRB review across its consortium of 18 RCMI grantee institutions that will ensure compliance while enhancing the quality of health disparities research.

Association of gene expression module biomarkers with clinical and therapeutic endpoints and their use with a universal companion diagnostic assay

228

Background: Gene expression patterns are increasingly capable of stratifying patients based on prognosis and response to therapy. Given the limited availability of sample tissue, however, it is not feasible to utilize every test for every patient, suggesting the need for a universal companion diagnostic assay that is informative with respect to multiple clinical and therapeutic endpoints. Key challenges are identification of appropriate gene expression biomarkers, translation of biomarkers to clinical assays, and development of reliable gene expression profiling of formalin-fixed clinical specimens. Here we describe a novel RT-PCR biomarker assay optimized for FFPE clinical samples that has broad prognostic and predictive potential.

Methods: A co-expression meta-analysis of 5,339 breast tumors from 56 microarray datasets identified highly co-expressed sets of genes (modules) across multiple datasets. Module biomarkers were tested for their ability to associate with prognostic and predictive targets in published datasets. In addition, each module was reduced from 10–1000 genes to 2-3 genes for use in companion diagnostic assays based on degree of co-expression across the meta-analysis, and validated against an independent panel of tumor samples.

Results: This study demonstrates that a single test utilizing multiple module biomarkers is informative with respect to standard parameters such as ER, PR and Her2, and in addition reproduces existing prognostic and predictive genomic signatures. Furthermore, we show that modules of 10-1000 genes can be represented by 2-3 genes for direct use in companion diagnostics development.

Conclusions: The molecular heterogeneity of breast cancer can be summarized by discrete gene expression modules that individually represent distinct biological programs, and that collectively can be represented by as few as 96 genes. Modules, together with outlier genes, allow for summation of the entire transcriptional program and provide a universal assay with broad application to companion diagnostics development.

Non-operative management of non-destructive extra-peritoneal rectal injury

This is a case report of extra-peritoneal rectal injury, secondary to a gunshot, that was managed non-operatively. A 57-year old male presented with a single gunshot to the right buttock and had blood per rectum. Extra-peritoneal rectal injuries were seen on proctoscopy and he had no genitourinary injury. He was managed successfully without rectal injury repair orfaecal stream diversion.

Double-blind, controlled phase II study of a 5-HT6 receptor antagonist, SB-742457, in Alzheimer's disease

BACKGROUND

This randomized, double-blind, placebo-controlled study investigated the efficacy and tolerability of the 5-HT6 receptor antagonist, SB-742457, in subjects with mild-to-moderate probable Alzheimer's disease (AD).

METHODS

Participating subjects had a Mini-Mental State Examination (MMSE) score of 12 to 26 after a 4-week, single-blind, placebo run-in phase, and were randomized (2:1:1:2) to receive placebo, SB-742457 5 mg, 15 mg, or 35 mg once daily for 24 weeks. Coprimary efficacy endpoints were the Clinician's Interview-Based Impression of Change with caregiver input (CIBIC+) score and change from baseline in Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) score at Week 24, in the intent-to-treat (ITT) population. A model-based design provided 90% power to detect a linear trend in treatment response across increasing doses and > or =90% power to compare SB-742457 35 mg with placebo.

RESULTS

371 subjects were randomized. In the ITT population (n=357), linear trend analysis at Week 24 suggested a dose response for CIBIC+ with a mean slope of -0.05 points/5-mg dose increase (95% confidence interval [CI]: -0.09, -0.01; p=0.016). The dose response slope for change from baseline in ADAS-Cog was -0.22 points/5-mg dose increase (95% CI: -0.45, 0.01; p=0.059). The adjusted mean treatment difference from placebo at Week 24 for SB-742457 35 mg (-0.31) was significant on CIBIC+ (95% CI: -0.62, -0.00; p=0.047) but non-significant on ADAS-Cog (-1.28 [95% CI: -2.96, 0.40]; p=0.135). Adverse events occurred in 24-37% in the SB-742457 groups vs 29% for placebo; 11-16% discontinued SB-742457 vs 15% for placebo.

COMMENTS

SB-742457 was generally safe and well tolerated and may be efficacious in AD.

GMCSF-interleukin fusion cytokines induce novel immune effectors that can serve as biopharmaceuticals for treatment of autoimmunity and cancer

We created the GIFTs, fusions of granulocyte-colony macrophage-stimulating-factor with IL-2, or IL-15 or IL-21, in order to stimulate distinct, but complimentary elements of the immune response. We found that the physical coupling of two functionally distinct cytokines as a bifunctional hybrid allowed for synergistic bioactivity not seen by the simple combined use of parent components. Indeed, despite how these interleukins are pro-inflammatory cytokines that serve essential roles in the maturation of CD8(+) T cells and NK cells, the GIFTs were remarkably different from one another, with GIFT-2 and GIFT-21 promoting and GIFT-15 downregulating inflammation. The common denominator to the biochemistry of these fusokines was their ability to hijack the signalling machinery associated with common to their respective γ-chain interleukin receptors, radically altering the activation status of responding lymphomyeloid cells. By studying the GIFTs, we found that both secreted and cell surface factors presented by GIFT-activated lymphomyeloid cells were required to modulate the immune responses in murine models of multiple sclerosis and cancer. The ability of GIFTs to co-opt the normal signalling machinery of interleukin receptors leads to the acquisition of functional responder cell phenotypes unparalleled in nature. These novel properties provide opportunities to alter maladapted immune responses in health and disease.

The genetic basis of colorectal cancer in a population-based incident cohort with a high rate of familial disease

BACKGROUND AND AIMS

Colorectal cancer (CRC) is the second most frequent cancer in developed countries. Newfoundland has the highest incidence of CRC in Canada and the highest rate of familial CRC yet reported in the world. To determine the impact of mutations in known CRC susceptibility genes and the contribution of the known pathways to the development of hereditary CRC, an incident cohort of 750 patients with CRC (708 different families) from the Newfoundland population was studied.

METHODS

Microsatellite instability (MSI) testing was performed on tumours, together with immunohistochemistry analysis for mismatch repair (MMR) genes. Where indicated, DNA sequencing and multiplex ligation-dependent probe amplifications of MMR genes and APC was undertaken. DNA from all patients was screened for MUTYH mutations. The presence of the BRAF variant, p.V600E, and of MLH1 promoter methylation was also tested in tumours.

RESULTS

4.6% of patients fulfilled the Amsterdam criteria (AC), and an additional 44.6% fulfilled the revised Bethesda criteria. MSI-high (MSI-H) was observed in 10.7% (n=78) of 732 tumours. In 3.6% (n=27) of patients, CRC was attributed to 12 different inherited mutations in six known CRC-related genes associated with chromosomal instability or MSI pathways. Seven patients (0.9%) carried a mutation in APC or biallelic mutations in MUTYH. Of 20 patients (2.7%) with mutations in MMR genes, 14 (70%) had one of two MSH2 founder mutations. 17 of 28 (61%) AC families did not have a genetic cause identified, of which 15 kindreds fulfilled the criteria for familial CRC type X (FCCTX).

CONCLUSIONS

Founder mutations accounted for only 2.1% of cases and this was insufficient to explain the high rate of familial CRC. Many of the families classified as FCCTX may have highly penetrant mutations segregating in a Mendelian-like manner. These families will be important for identifying additional CRC susceptibility loci.

Molecular battles between plant and pathogenic bacteria in the phyllosphere

The phyllosphere, i.e., the aerial parts of the plant, provides one of the most important niches for microbial colonization. This niche supports the survival and, often, proliferation of microbes such as fungi and bacteria with diverse lifestyles including epiphytes, saprophytes, and pathogens. Although most microbes may complete the life cycle on the leaf surface, pathogens must enter the leaf and multiply aggressively in the leaf interior. Natural surface openings, such as stomata, are important entry sites for bacteria. Stomata are known for their vital role in water transpiration and gas exchange between the plant and the environment that is essential for plant growth. Recent studies have shown that stomata can also play an active role in limiting bacterial invasion of both human and plant pathogenic bacteria as part of the plant innate immune system. As counter-defense, plant pathogens such as Pseudomonas syringae pv tomato (Pst) DC3000 use the virulence factor coronatine to suppress stomate-based defense. A novel and crucial early battleground in host-pathogen interaction in the phyllosphere has been discovered with broad implications in the study of bacterial pathogenesis, host immunity, and molecular ecology of bacterial diseases.

TLR4 mediates early graft failure after intraportal islet transplantation

We have previously shown that islet emboli in the portal vein block blood flow and induce local inflammatory reaction, resulting in functional loss of islet grafts following intraportal transplantation. This study was designed to test whether Toll-like receptor (TLR) activation mediates early islet graft failure. Syngeneic islet grafts were transplanted into chemically induced diabetic mice, and TLR deficient mice were used as donors and/or recipients of islet grafts. Islet viability, proinflammatory cytokines, high-mobility group box-1 (HMGB1) and NF-kappaB activation were analyzed by bioluminesce imaging (BLI), quantitative RT-PCR (qRT-PCR) and histology. Early islet graft failure was observed in mice with intraportal islet engrafts with increased proinflammatory cytokines, HMGB1 expression, NF-kappaB activation, caspase-3 and TUNEL positive cells. Deficiency of TLR4 in donor, but not in recipient, inhibited NF-kappaB activation, reduced proinflammatory cytokines and improved viability of islet grafts. Blockade of HMGB1 with anti-HMGB1 monoclonal antibody (mAb, 2g7) inhibited inflammatory reactions, as evidenced by reduced TNFalpha and IL-1ss production, and improved islet viability. We conclude that TLR4 activation mediates early graft failure following intraportal islet transplantation. Inhibition of TLR4 activation represents a novel strategy to attenuate early graft failure following intraportal islet transplantation.

Quantitative liquid chromatography-tandem mass spectrometry profiling of activated methyl cycle metabolites involved in LuxS-dependent quorum sensing in Escherichia coli

A rapid, selective, and sensitive liquid chromatography-tandem mass spectrometry assay has been developed and validated for the simultaneous quantification of the metabolites and precursors of the activated methyl cycle, reported in preliminary form by Heurlier et al. (2009) [43]. Analytes were extracted from Escherichia coli MG1655 and chemically derivatized as N(O,S)-iso-butyloxycarbonyl iso-butyl esters using iso-butyl chloroformate in an aqueous iso-butanol/pyridine environment. S-Adenosylmethionine, S-adenosylhomocysteine, S-ribosylhomocysteine, homocysteine, methionine, cystathionine, cysteine, and homoserine were quantified by liquid chromatography-positive ion tandem electrospray ionization mass spectrometry. Internal standards were isotopically labeled [(13)CD(3)]methionine and S-adenosylcysteine. Linearity of the assay was established up to a concentration of 700 microg/g cell dry weight for each analyte. The validated assay was used to quantitatively profile the intracellular activated methyl cycle metabolites as a function of growth in E. coli MG1655 and its derivative Deltapfs and DeltaluxS mutants to determine the metabolic consequences of a disruption to the activated methyl cycle and, hence, LuxS-dependent quorum sensing.

The Influence of Older Age on Physician and Patient Decision-Making Regarding Enrollment to Breast Cancer Clinical Trials

Background: More than 50% of breast cancers occur in women ≥65 years. Clear guidelines for treatment do not exist for this population, however, due to underrepresentation of older patients on clinical trials. We reported that patients 65 and older are significantly underrepresented in Southwest Oncology Group (SWOG) trials, particularly in breast cancer. (Hutchins, 1999) We conducted a prospective study (S0316) to determine physician- and patient-perceived barriers to breast cancer clinical trial enrollment in older versus younger patients.Methods: Eight geographically diverse SWOG institutions, 5 academic and 3 community, participated in S0316. Breast cancer patients were registered at time of systemic treatment decision-making. The study prospectively assessed reasons behind patients' and physicians' decisions to either enroll in or decline clinical treatment trials, including demographics, return rates to the institution, trial availability, and eligibility. Patient questionnaires elicited concerns about treatment toxicities, confidence in medical staff or institution, opposition or support by family/friends, and financial or time commitment concerns. Physician questionnaires elicited factors influencing decisions either not to discuss a trial or not to enroll the patient, including treatment toxicities, patient age or medical status, demands on personal or staff time, and reimbursement issues. Results were compared between patients &lt;65 vs. ≥65 years.Results: 1,079 patients were registered and eligible, and 909 (84%) returned for follow-up. Clinical trial participation was 16%. The major reason for non-accrual was either trial unavailability or ineligibility (60%). Older patients were less likely to be eligible for trials (65% vs. 78%, p=.004). If eligible, trial participation rates did not differ significantly by age (34% vs. 40%, p=.32). Treatment-specific issues were the most common reasons cited by all patients for non-participation. Patients ≥65 more often were concerned about side effects (p=.02), had friends opposed to participation (p=.001), or believed that participation would not benefit other generations (p=.009). Concerns about transportation, time commitment, or posing a burden to family were similar between age groups. Physicians discussed trial participation when trials were available and patients were eligible with 76% &lt;65 years versus 58% ≥65 years (p=.008). The study regimen and toxicity were the most common reasons influencing physician decisions not to discuss a trial, but did not differ between age groups. For patients ≥65 years, 14% of physicians indicated age as a reason the patient did not participate vs. 3% for patients &lt;65 years (p=.002).Conclusions: Trial unavailability or patient ineligibility are major reasons for lack of enrollment on breast cancer clinical trials for patients of all ages in this prospective study. Older patients were less likely to be eligible for trials, but if eligible participated at similar rates to younger patients. Older age should not deter physicians in recommending clinical trials. Addressing stringent eligibility criteria may improve accrual rates of older patients.Supported by the Breast Cancer Research Foundation and the SWOG Hope Foundation

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3077.

Legionnaires’ disease cluster linked to a metal product aqueous pre-treatment process, Staffordshire, England, May 2008

In May 2008, a report of two workers from the same construction equipment manufacturing plant who were admitted to hospital with Legionnaires’ disease confirmed by urine antigen prompted an outbreak investigation. Both cases were middle aged men, smokers, and with no travel, leisure or other common community exposure to Legionella sources. There were no wet cooling towers at the plant or in the surrounding area. No increase in respiratory disease or worker absenteeism occurred at the plant during the preceding month. Wider case ascertainment including alerts to hospitals and medical practitioners yielded no further cases. The environmental investigation (and sampling of water systems for Legionella) identified a Legionella pneumophila serogroup1 (Mab 2b) count of >3.0x104cfu/l in water samples from an aqueous metal pre-treatment tunnel, which generates profuse water aerosol. Drainage, cleaning and biocide treatment using thiazalone eliminated Legionella from the system.

Legionnaires' disease cluster linked to a metal product aqueous pre-treatment process, Staffordshire, England, May 2008

In May 2008, a report of two workers from the same construction equipment manufacturing plant who were admitted to hospital with Legionnaires disease confirmed by urine antigen prompted an outbreak investigation. Both cases were middle aged men, smokers, and with no travel, leisure or other common community exposure to Legionella sources. There were no wet cooling towers at the plant or in the surrounding area. No increase in respiratory disease or worker absenteeism occurred at the plant during the preceding month. Wider case ascertainment including alerts to hospitals and medical practitioners yielded no further cases. The environmental investigation (and sampling of water systems for Legionella) identified a Legionella pneumophila serogroup1 (Mab 2b) count of >3.0x10(4)cfu/l in water samples from an aqueous metal pre-treatment tunnel, which generates profuse water aerosol. Drainage, cleaning and biocide treatment using thiazalone eliminated Legionella from the system.