How to make epidemiological training infectious

Modern infectious disease epidemiology builds on two independently developed fields: classical epidemiology and dynamical epidemiology. Over the past decade, integration of the two fields has increased in research practice, but training options within the fields remain distinct with few opportunities for integration in the classroom. The annual Clinic on the Meaningful Modeling of Epidemiological Data (MMED) at the African Institute for Mathematical Sciences has begun to address this gap. MMED offers participants exposure to a broad range of concepts and techniques from both epidemiological traditions. During MMED 2010 we developed a pedagogical approach that bridges the traditional distinction between classical and dynamical epidemiology and can be used at multiple educational levels, from high school to graduate level courses. The approach is hands-on, consisting of a real-time simulation of a stochastic outbreak in course participants, including realistic data reporting, followed by a variety of mathematical and statistical analyses, stemming from both epidemiological traditions. During the exercise, dynamical epidemiologists developed empirical skills such as study design and learned concepts of bias while classical epidemiologists were trained in systems thinking and began to understand epidemics as dynamic nonlinear processes. We believe this type of integrated educational tool will prove extremely valuable in the training of future infectious disease epidemiologists. We also believe that such interdisciplinary training will be critical for local capacity building in analytical epidemiology as Africa continues to produce new cohorts of well-trained mathematicians, statisticians, and scientists. And because the lessons draw on skills and concepts from many fields in biology--from pathogen biology, evolutionary dynamics of host--pathogen interactions, and the ecology of infectious disease to bioinformatics, computational biology, and statistics--this exercise can be incorporated into a broad array of life sciences courses.     

Diagnosing Severe Falciparum Malaria in Parasitaemic African Children: A Prospective Evaluation of Plasma PfHRP2 Measurement

Background

In African children, distinguishing severe falciparum malaria from other severe febrile illnesses with coincidental Plasmodium falciparum parasitaemia is a major challenge. P. falciparum histidine-rich protein 2 (PfHRP2) is released by mature sequestered parasites and can be used to estimate the total parasite burden. We investigated the prognostic significance of plasma PfHRP2 and used it to estimate the malaria-attributable fraction in African children diagnosed with severe malaria.

Methods and Findings

Admission plasma PfHRP2 was measured prospectively in African children (from Mozambique, The Gambia, Kenya, Tanzania, Uganda, Rwanda, and the Democratic Republic of the Congo) aged 1 month to 15 years with severe febrile illness and a positive P. falciparum lactate dehydrogenase (pLDH)-based rapid test in a clinical trial comparing parenteral artesunate versus quinine (the AQUAMAT trial, ISRCTN 50258054). In 3,826 severely ill children, Plasmadium falciparum PfHRP2 was higher in patients with coma (p = 0.0209), acidosis (p<0.0001), and severe anaemia (p<0.0001). Admission geometric mean (95%CI) plasma PfHRP2 was 1,611 (1,350–1,922) ng/mL in fatal cases (n = 381) versus 1,046 (991–1,104) ng/mL in survivors (n = 3,445, p<0.0001), without differences in parasitaemia as assessed by microscopy. There was a U-shaped association between log₁₀ plasma PfHRP2 and risk of death. Mortality increased 20% per log₁₀ increase in PfHRP2 above 174 ng/mL (adjusted odds ratio [AOR] 1.21, 95%CI 1.05–1.39, p = 0.009). A mechanistic model assuming a PfHRP2-independent risk of death in non-malaria illness closely fitted the observed data and showed malaria-attributable mortality less than 50% with plasma PfHRP2≤174 ng/mL. The odds ratio (OR) for death in artesunate versus quinine-treated patients was 0.61 (95%CI 0.44–0.83, p = 0.0018) in the highest PfHRP2 tertile, whereas there was no difference in the lowest tertile (OR 1.05; 95%CI 0.69–1.61; p = 0.82). A limitation of the study is that some conclusions are drawn from a mechanistic model, which is inherently dependent on certain assumptions. However, a sensitivity analysis of the model indicated that the results were robust to a plausible range of parameter estimates. Further studies are needed to validate our findings.

Conclusions

Plasma PfHRP2 has prognostic significance in African children with severe falciparum malaria and provides a tool to stratify the risk of “true” severe malaria-attributable disease as opposed to other severe illnesses in parasitaemic African children. Please see later in the article for the Editors'' Summary.     

Risk stratification for sudden cardiac death

Recent advances in pharmacological and device-based therapies have provided a range of management options for patients at risk of sudden cardiac death (SCD). Since all such interventions come with their attendant risks, however, stratification procedures aimed at identifying those who stand to benefit overall have gained a new degree of importance. This review assesses the value of risk stratification measures currently available in clinical practice, as well as of others that may soon enter the market. Parameters that may be obtained only by performing invasive cardiac catheterisation procedures are considered separately from those that may be derived using more readily available non-invasive techniques. It is concluded that effective stratification is likely to require the use of composite parameters and that invasive procedures might only be justified in specific sub-groups of patients.     

Small Molecule,Non-Peptide p75NTR Ligands Inhibit Aβ-Induced Neurodegeneration and Synaptic Impairment

The p75 neurotrophin receptor (p75^NTR) is expressed by neurons particularly vulnerable in Alzheimer''s disease (AD). We tested the hypothesis that non-peptide, small molecule p75^NTR ligands found to promote survival signaling might prevent Aβ-induced degeneration and synaptic dysfunction. These ligands inhibited Aβ-induced neuritic dystrophy, death of cultured neurons and Aβ-induced death of pyramidal neurons in hippocampal slice cultures. Moreover, ligands inhibited Aβ-induced activation of molecules involved in AD pathology including calpain/cdk5, GSK3β and c-Jun, and tau phosphorylation, and prevented Aβ-induced inactivation of AKT and CREB. Finally, a p75^NTR ligand blocked Aβ-induced hippocampal LTP impairment. These studies support an extensive intersection between p75^NTR signaling and Aβ pathogenic mechanisms, and introduce a class of specific small molecule ligands with the unique ability to block multiple fundamental AD-related signaling pathways, reverse synaptic impairment and inhibit Aβ-induced neuronal dystrophy and death.     

Mutating the tight-dimer interface of dihydrodipicolinate synthase disrupts the enzyme quaternary structure: toward a monomeric enzyme

Dihydrodipicolinate synthase (DHDPS) is a tetrameric enzyme that is the first enzyme unique to the ( S)-lysine biosynthetic pathway in plants and bacteria. Previous studies have looked at the important role of Tyr107, an amino acid residue located at the tight-dimer interface between two monomers, in participating in a catalytic triad of residues during catalysis. In this study, we examine the importance of this residue in determining the quaternary structure of the DHDPS enzyme. The Tyr107 residue was mutated to tryptophan, and structural, biophysical, and kinetic studies were carried out on the mutant enzyme. These revealed that while the solid-state structure of the mutant enzyme was largely unchanged, as judged by X-ray crystallography, it exists as a mixture of primarily monomer and tetramer in solution, as determined by analytical ultracentrifugation, size-exclusion chromatography, and mass spectrometry. The catalytic ability of the DHDPS enzyme was reduced by the mutation, which also allowed the adventitious binding of alpha-ketoglutarate to the active site. A reduction in the apparent melting temperature of the mutant enzyme was observed. Thus, the tetrameric quaternary structure of DHDPS is critical to controlling specificity, heat stability, and intrinsic activity.     

Plant distribution and dispersal mechanisms at the Hassayampa River Preserve, Arizona, USA

This study focuses on the relationships between plant dispersal syndromes and plant distributions at the community scale. Species composition and cover are reported from 29 10 × 20-m vegetation plots along five topographic cross-sections in the riparian zone of the Hassayampa River Preserve, Arizona. We find that spatial patterns of dispersal guilds vary within the flood plain of this semiarid region river. Our main results are: (1) wind-dispersed species are fairly evenly distributed at all elevations and distances from the river, whereas cover of animal-dispersed species increases with elevation above, and at greater distances from, the river; (2) wind-dispersed species are proportionally more abundant in the pioneer Populus–Salix community, whereas plants in the late-seral Prosopis community are predominantly animal-dispersed; (3) most of the species classified as obligate-wetland and facultative-wetland are wind-dispersed, whereas facultative-upland and obligate-upland species are mostly animal-dispersed; and (4) there are significantly fewer wind-dispersed species in areas of high total vegetation cover. These results may reflect successional patterns resulting from periodic flooding. Low areas close to the river flood more frequently and with greater intensity than areas farther from the river. Many pioneer species that establish in disturbed areas are wind-dispersed. Over successional time, pioneer species cede to more drought tolerant species that are predominantly animal-dispersed.     

Beliefs Matter: Cultural Beliefs and the Use of Cervical Cancer-Screening Tests

In this article we examine the influence of cultural beliefs on behavior or, more specifically, beliefs about cervical cancer risk factors and the use of Pap exams. Individual Latinas' (Hispanic women) holding of beliefs similar to Latinas' generally (cultural consonance) did not significantly influence their use of Pap exams. Rather, structural factors such as medical insurance, age, marital status, education, and language acculturation explained Latinas' use of this medical service. However, when Latinas held beliefs similar to those of Anglo women, then they were significantly more likely to have had a Pap exam within the past two years. Latinas whose beliefs were closer to those of physicians were significantly less likely to have had the exam recently. Arriving at these findings involved both ethnographic interviews and survey research. That these beliefs proved to be significant influences on behavior suggests not only the important ways that beliefs matter but that ethnographic methods for examining those beliefs also matter. [ Latinas and cervical cancer, Pap exams, culture and behavior, ethnography and survey research ]     

The trail of chromium(III) in vivo from the blood to the urine: the roles of transferrin and chromodulin

The chromium-binding oligopeptide chromodulin (also known as low-molecular-weight chromium-binding substance) has been shown to activate the tyrosine kinase activity of the insulin receptor in response to insulin and has been proposed to be part of a novel autoamplification mechanism for insulin signaling. The model requires that Cr3+ be moved from the blood to insulin-sensitive tissues in response to insulin and subsequently be lost in the urine as chromodulin; however, the model has not been tested by in vivo studies. In vivo studies with rats have shown that the iron transport protein transferrin serves as the major chromic ion transport agent and that this transport is stimulated by insulin. The ion is transported to a variety of tissues, while liver and kidneys are the major target. In hepatocytes, chromodulin occurs in appreciable levels in the cytosol and in the nucleus. Apochromodulin levels appear to be maintained under homeostatic control, although the only detectable form of urinary chromium is probably chromodulin. Increases in urinary chromium loss in response to insulin are reflected by increases in chromodulin, establishing a direct link between carbohydrate metabolism and the oligopeptide.     

Use of papain in the preparation of adult mammalian skeletal muscle for tissue culture

Summary This report describes in detail a method of enzymatic separation of adult mammalian muscle using papain. The procedure has proved valuable in the preparation of suspensions of muscle cell pieces from normal human skeletal muscle obtained from patients of all ages, from 3 months to 79 years. Muscle cultures have been successfully growth from biopsy material from boys with Duchenne’s muscular dystrophy and from their mothers. The procedure was initially established with adult canine skeletal muscle and has also been used for monkey muscle. Small pieces of skeletal muscle are chopped in a solution of 0.05% papain and 0.01% cysteine hydrochloride in Ca²⁺-and Mg²⁺-free balanced salt solution and transferred in the papain solution to a flask, in which they are incubated at 37°C for 10 min with occasional agitation. The resulting cell suspension is collected and the remaining pieces are treated with further portions of fresh papain until only connective tissue remains. The cell pellets obtained by centrifugation are resuspended in Eagle’s minimum essential medium (supplemented with 20% fetal calf serum) and transferred to culture chambers. The muscle can be observed at all times, during the separation procedure and subsequently in culture. The events occurring during skeletal muscle regeneration can be followed. Using the same papain preparation, myoblasts and myotubes may be subcultured and collected for indefinite frozen storage in dimethylsulfoxide. This work was supported by a grant-in-aid from the American Heart Association with funds contributed in part by the Chicago Heart Association, the Pharmaceutical Manufactures Association, and National Institutes of Health Research Grant NS 10385 from the Institute of Neurological Diseases and Stroke.