Gout is a form of inflammatory arthritis caused by chronic elevation of serum uric acid. There is usually an outbreak every year in the world, Hong Kong is not exempt from this phenomenon:
According to the latest figures from Non-Communicable Disease Watch at 2019 from the Department of Health, HKSAR, 2,700,000 cases have attended out-patient clinics or emergency departments of the Housing Authority were recorded, affecting Hong Kong significantly every year undoubtedly in terms of public healthcare system, economy. In order for our design to suit the needs of potential users, it is necessary to understand their concerns and integrate them into our project.
We have come up with 4 major potential users: genome experts, citizens, professionals including doctor and lawyer and the Government.
1. Professor Godfrey Chan (23/5/2019)
Before starting our project, we interviewed Prof. Godfrey at the Department of Paediatrics & Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong . Prof. Tsui is the head in the Division of Genomics and Bioinformatics. He is also a Chief of Service of Department of Paediatrics & Adolescent Medicine, Hong Kong Children's Hospital .
Professor Chan had explained the efficiency of enzymatic activities in great detail. He emphasized that the efficiency of enzymatic activities are highly related to the existing environment including pH and temperature and occurrence of intermediate products associated with its potential toxicity during degradation should be considered. Especially the extracellular digestion, enzyme secreted out from the cell may not be effectively bind with the substrate due to the presence of other chemicals and specific pH range. Therefore, intracellular digestion is employed.
After listening to his advice, we have to consider whether extracellular enzymatic activity is appropriate to use. He emphasized most of extracellular enzyme after purification can enter into blood stream to the conversion of uric acid. However, the thermal and pH stability is an important and useful consideration. Presence of metal ion like iron(III) ion and copper(II) ion will alter the conformation of an enzyme like Candida, so we have chosen to inhibit its enzymatic activities. Initially, we divided our design into two approaches according to the suggestions: capsule or probiotics food that detect gout. However, Professor Chan pointed out that the impression of taking capsule is not that widely convenient from the elderly especially to those have swallowing difficulties. Therefore, we have to consider whether it is appropriate to use.
2. Professor Tsui kwok-wing, Stephen (14/6/2019)
We have also met Professor Stephen Tsui at the Department in Biochemistry, CUHK . Prof. Tsui is the head in the Division of Genomics and Bioinformatics. He is also a director of Centre of Microbial Genomics and Proteomics. His advice are very useful because he is an expert in choosing E coli.
Similar to what Prof. Chan suggested, Professor Tsui also agreed that the project can be divided into 2 directions: the type of host cell chosen is important as most of the yeast cannot multiply in the digestive tract unlike the E. coli and self-multiplication inside the intestine is essential for a patient without non-stopping medication. He put emphasis on the potential harmful effects of the intermediate of HIU during the conversion process of uric acid to allantoin, we have to synthesize one more protein of HIU hydrolase to speed up the catalytic process as well as to reduce the chance of HIU accumulation.
After meeting two medical experts, we concluded that the efficacy and efficiency of extra-cellular digestion is always being critizied due to the uncertainties of the environment with varying pH and temperature etc, we employed the intracellular digestion.
We have interview a doctor working in Queen Mary Hospital. A patent has been found on both enzyme with specific gene coding. Modification on plasmid is needed with specific promoter and transporter or mixed two enzymes cloned in a single plasmid to increase the novelty.
2. Dr. Li Lai Fung, Honorary Clinical Assistant Professor
We interviewed Dr. Li Lai Fung. Globally, Pegloticase is one of the treatment to subside gout. However, back to Hong Kong, it is not registered and so not available. They use NSAID and colchicine for acute attack. For prevention of attack, it is a life style modification by the intake of allopurinol and febuxostat, but allopurinol has a risk of severe allergic reaction, Steven Johnson syndrome. Also, febuxostat is associate with cardiac problem. Moreover, acute case cannot be solved by surgery. Gout is quite common especially in elderly. With a chronic attack, they are given allopurinol or febuxostat. On the other hand, if there is an acute attack, the supply of allopurinol is stopped. Therefore, NSAID and colchicine is given for several days. Once the attack is subsided, the supply of allopurinol is resumed. There are not much short-term side effects for NSAID, but gastritis and kidney toxicity is the long term side effect for it. The side effect of colchicine is diarrhea, which are needed to terminate the medication.
The implication on our current research is to formulate a host cell containing the enzyme which can induce a prolong effects on reduction of uric acid inside the body and the medication can be sustainable without frequent medication. We would like to use probiotics E.coli, Nissle 1917 for the uricase and HIU hydrolase protein synthesis which can live along our intestine for long to remove the uric acid inside the intestine.
At the beginning, we hoped to have face-to-face interview, along with laboratory visit. Unfortunately, due to the government’s policies and instructions, they refused our visit requirement. In alternative, we interviewed, Department of Health through written replies.
1. Department of Health
Offering laboratory diagnostic services for disease surveillance and control is one of the main duties of the Public Health Laboratory Services Branch under the Centre for Health Protection of the Department of Health. We have sent an email asking for the information of gout and we have received their reply. They have stated that they organized talks for elderlies about gout, in order to educate them some related preventive measures, such as drink more water, avoid obesity etc. Most importantly, they have stated that there is currently NO medical treatment that can cure gout completely.
These pieces of information help us to confirm there is no effective medical treatment to lower uric acid level to cure gout. Government can only do some preventive measures to reduce the number of patients. Therefore, we are confident to say that our project is absolutely necessary for our world.
General public in Hong Kong
As our major target is local users, the questionnaire’s version is different to those international versions, in which place more emphases on understanding about Gout and government’s policies so as to develop customized promotion plans on both health education and product promotion in Hong Kong. We conducted the questionnaires as there is higher public engagement than that in university, rendering a fairer result. The sample size is 175.
In the first part, 67% respondents have no idea what gout is . Noted that most people have probiotics food trial, but 49.3% refuse to take probiotics food owing to diarrhea and fatality. Hong Kong people don't have the metacognition of gout and probiotics. Thus, education and promotion is needed.
Secondly, in terms of effectiveness , 89% respondents think it has high effectiveness, Same with the focus of the medical experts, citizens emphasize much on accuracy. Therefore, high accuracy will be our ultimate goal. On the other hand, 77% respondents think it has side effects, there are potential side effects from the medicine intake, so a few people consider about whether long-term medicine intake will affect our health.
As reminded by teachers, price is another consideration criteria because the cost of current detection method is quite high, render less availability in private clinic/ market. So lower price can help us to enter the market of private clinic. Noticed that in developing countries, their acceptable price range is much lower than that of hk/india. So in future, we need to cut down our prices if we want to enter the market of developing countries.
Considering negative perspectives against the use of E.coli may be held by the general public, we want to evaluate their degree of acceptance, and try to explain the principles behind more. Similar to our prediction, most people feel disturbed when mentioning the involvement of E.coli, however, almost all respondents gain their composure after the explanation and around 75% people accept such application in our design eventually.
General public in other countries
Although gout doesn’t affect Hong Kong recently, it is still considered as endemic in poultry in three places (Australia, Britain, Taiwan) according to WHO. If we would like to promote our product to them, we should know about their opinions. Therefore, we conducted the same online questionnaires in some of the countries , including Australia (29) and Britain (11) (the number inside the bracket indicates the number of respondents respectively). All of these have had an very high prevalence than countries.Thus,more than a half of respondents are interested in our project.
If we want to promote our detection kit to the international level, especially for those gout-prevalent regions, it is necessary for us to cut down the price. Apart from the price, people in developing countries may find it difficult to use the kit, so it is recommended to cooperate with the authorities/health department there, for example, promote the significance of early detection.
During interviews with different stakeholders, we integrated the opinions to improve our research design. For example, our initial or preliminary stage we are puzzling of either using extracellular or intracellular enzymatic activities. After the conversation with the genome experts and with reference of the literature review, the efficacy and efficiency of extra-cellular digestion is always being critizied due to the uncertainties of the environment with varying pH and temperature etc, we employed the intracellular digestion. Apart from the collaboration, different stakeholders are associated, for instance, Both professors emphasized the potential harmful effects of the intermediate of HIU during the conversion process of uric acid to allantoin, we have to synthesize one more protein of HIU hydrolase to speed up the catalytic process as well as to reduce the chance of HIU accumulation. However, when communicating with the general public, we found that some of them thought that early detection is not really important. If there is a medium between the general public and medical experts and help convey some useful advice to the public, public awareness on early detection of gout may be escalated, and we believe that’s also the mission of human practice.