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Figure 2.

Longitudinal series of isolates. Each series (collected from patients P01 to P16) is depicted as a row of dots to represent sampling time points. Colors indicate different RAPD genotypes, and relative dot size indicates patient lung function (%FEV) at that time point. Gray circles indicate no associated %FEV (percentage of predicted forced expiratory volume in 1 sec) measurement (also see Supplemental Fig. S1 ).

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Table 1.

Summary of 16 longitudinal series

The majority of patients were colonized by subgroup A isolates (202 of 215 isolates) primarily from one of the major B. cenocepacia epidemic lineages. Except for the single patient P09 infected with subgroup B, all isolates from the same patient belonged to the same RAPD type. By using these 215 isolates, we conducted a comprehensive survey of clinically relevant phenotypes and carried out whole-genome sequence analysis of all isolates.

To understand how bacterial phenotypes change over time during chronic infections, we systematically cataloged phenotypic variation for all isolates. Specifically, we measured: growth in two liquid media types (lysogeny broth [LB]; and synthetic cystic fibrosis medium [SCFM]), swimming motility, biofilm formation, acute virulence in an insect model, and mucoidy morphotype ( Mid Star sneakers Green Golden Goose Visit Cheap Price YHh8G
). The results reveal extensive phenotypic variation among B. cenocepacia isolates both within and among RAPD types and within patient series. Detailed descriptions and results for each phenotype are in Supplemental Text S1 , Womens Menscha282074 Derbys Blue Think Buy Cheap 100% Authentic Nicekicks Cheap Online lylYgDV
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By considering these phenotypes on a global level, we found that RAPD genotype was a significant predictor of phenotypic variation, explaining between ∼20% and 50% of the variation ( Table 2 ; Supplemental Fig. S4 ). However, considerable variation was also seen within patient series and within RAPD type. We also identified progressive phenotypic changes in many longitudinal series ( Table 3 ). Six of the 16 series showed progressive decreases in motility, five showed temporal changes in biofilm formation (two increasing and three decreasing), two showed decreases in acute virulence as measured in an insect model, none showed changes in mucoidy, and, finally, seven showed changes in one or more growth parameters.

View this table:
Table 2.

Correlation between RAPD type and clinically relevant phenotypes

View this table:
Table 3.

Percentage change per year in clinically relevant phenotypes across longitudinal series

Given that each individual phenotype could have a complex genetic basis, we examined pairwise phenotypic correlations across all isolates and for each RAPD type individually ( Discount Great Deals Original For Sale Loafers In Black Leather With White Sole And Snaffle Black Asos Pay With Paypal For Sale W7BdGSxGOl
). In general, most phenotypes we measured were positively correlated; with the exception that biofilm formation was negatively correlated with acute insect virulence and growth in LB ( Mens Boston Leather Balmorals Salvatore Ferragamo Low Price For Sale Latest For Sale Free Shipping Fake Clearance Amazon sV49Vq1KN
A). This is not surprising; biofilm has been associated with persistent infection and not with acute virulence ( Furukawa et al. 2006 ; Wu et al. 2015 ). Overall, motility was positively correlated with biofilm formation and mucoidy (Spearman correlation, ρ = 0.48 and 0.40, respectively, adjusted P -value <0.0001) ( Mens A/O Lug New Leather Ankle Boots Sperry TopSider Outlet 100% Guaranteed Discount 100% Authentic Outlet Real us9sH2rrd
A). A strong positive correlation was found between motility and biofilm formation for most RAPD genotypes, except for a negative correlation was seen for subgroup B RAPD44 isolates (ρ = −0.85, adjusted P -value = 0.001) ( Fig. 3 B–G).

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Where a local authority feels that an applicant is refusing to cooperate and that the refusal is 'deliberate and unreasonable', it can follow a specific procedure for notifying the applicant.

The information on this page applies only to homelessness applications made on or after 3 April 2018 .

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An applicant refuses to cooperate when s/he does not take a step (or steps) in her/his personalised housing plan (PHP) . [1] This might be a step which:

In order for the applicant to be penalised, the refusal must have been deliberate and unreasonable.

An applicant cannot be found not to have cooperated with a step which was identified as a 'good idea' in her/his plan, but which s/he was not was required to take. Wideleg Indigodyed Selvedge Cottoncanvas Trousers Chimala Countdown Package Online For Sale Cheap Online Excellent Online TuioC87Br

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Neither 'deliberate' nor 'unreasonable' is defined in the Act or in the Homelessness Code of Guidance. The Code suggests that a local authority follows a four stage determination to decide whether a failure to take a step was deliberate and unreasonable: [3]

The Code suggests that where an applicant appears not to be cooperating, the local authority should review its assessment of her/his needs and the appropriateness of the steps in the personalised housing plan. [4] It may be found that certain steps in the PHP are not reasonable, or have become unreasonable. For example, even if requiring an applicant to search for accommodation in a particular area at first seemed reasonable, it may be s/he has tried all of the private landlords in an area and none of them are willing to offer accommodation. In these circumstances, it is unlikely to be reasonable to require her/him to keep looking. If steps are not reasonable, or are no longer reasonable, then the applicant should be notified and should not face consequences for failing to take them. [5]

It may emerge during the authority's investigations (see below) that the applicant did not understand one of the steps in the plan (perhaps because of a language difficulty) and if so, s/he should not be found to have deliberately and unreasonably refused to cooperate. Clearance Big Sale Conny sneakers Yellow amp; Orange Premiata Buy Cheap Footlocker Finishline Quality For Sale Free Shipping Buy Cheap Many Kinds Of Cheap Discount OGUO4tHw

The Code requires that local authorities take into account any particular difficulties the applicant has in managing communication. It suggests, for example, that cooperation may be particularly difficult where an applicant is street homeless or moving between temporary places to stay. Free Shipping Cleo sandals Blue Tabitha Simmons Buy Cheap 2018 New Manchester Free Shipping With Paypal Manchester For Sale Q9x2iS
The problems may be around, for example, an applicant having a learning disability or more practical issues such as being required to contact landlords and not having telephone access. In circumstances such as these, it is less likely that failing to cooperate would be counted as deliberate or unreasonable.

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