Data-driven models to predict the elimination of sleeping sickness in former Equateur province of DRC.

Approaching disease elimination, it is crucial to be able to assess progress towards key objectives using quantitative tools. For Gambian human African trypanosomiasis (HAT), the ultimate goal is to stop transmission by 2030, while intermediary targets include elimination as a public health problem - defined as <1 new case per 10,000 inhabitants in 90% of foci, and <2000 reported cases by 2020. Using two independent mathematical models, this study assessed the achievability of these goals in the former Equateur province of the Democratic Republic of Congo, which historically had endemic levels of disease. The two deterministic models used different assumptions on disease progression, risk of infection and non-participation in screening, reflecting biological uncertainty. To validate the models a censor-fit-uncensor procedure was used to fit to health-zone level data from 2000 to 2012; initially the last six years were censored, then three and the final step utilised all data. The different model projections were used to evaluate the expected transmission and reporting for each health zone within each province under six intervention strategies using currently available tools. In 2012 there were 197 reported HAT cases in former Equateur reduced from 6828 in 2000, however this reflects lower active testing for HAT (1.3% of the population compared to 7.2%). Modelling results indicate that there are likely to be <300 reported cases in former Equateur in 2020 if screening continues at the mean level for 2000-2012 (6.2%), and <120 cases if vector control is introduced. Some health zones may fail to achieve <1 new case per 10,000 by 2020 without vector control, although most appear on track for this target using medical interventions alone. The full elimination goal will be harder to reach; between 39 and 54% of health zones analysed may have to improve their current medical-only strategy to stop transmission completely by 2030.

Anti-tumour efficacy on glioma models of PHA-848125, a multi-kinase inhibitor able to cross the blood-brain barrier.

BACKGROUND AND PURPOSE: Malignant gliomas, the most common primary brain tumours, are highly invasive and neurologically destructive neoplasms with a very bad prognosis due to the difficulty in removing the mass completely by surgery and the limited activity of current therapeutic agents. PHA-848125 is a multi-kinase inhibitor with broad anti-tumour activity in pre-clinical studies and good tolerability in phase 1 studies, which could affect two main pathways involved in glioma pathogenesis, the G1-S phase progression control pathway through the inhibition of cyclin-dependent kinases and the signalling pathways mediated by tyrosine kinase growth factor receptors, such as tropomyosin receptors. For this reason, we tested PHA-848125 in glioma models. EXPERIMENTAL APPROACH: PHA-848125 was tested on a panel of glioma cell lines in vitro to evaluate inhibition of proliferation and mechanism of action. In vivo efficacy was evaluated on two glioma models both as single agent and in combination with standard therapy. KEY RESULTS: When tested on a subset of representative glioma cell lines, PHA-848125 blocked cell proliferation, DNA synthesis and inhibited both cell cycle and signal transduction markers. Relevantly, PHA-848125 was also able to induce cell death through autophagy in all cell lines. Good anti-tumour efficacy was observed by oral route in different glioma models both with s.c. and intracranial implantation. Indeed, we demonstrate that the drug is able to cross the blood-brain barrier. Moreover, the combination of PHA-848125 with temozolomide resulted in a synergistic effect, and a clear therapeutic gain was also observed with a triple treatment adding PHA-848125 to radiotherapy and temozolomide. CONCLUSIONS AND IMPLICATIONS: All the pre-clinical data obtained so far suggest that PHA-848125 may become a useful agent in chemotherapy regimens for glioma patients and support its evaluation in phase 2 trials for this indication.

Anaplastic Lymphoma Kinase: role in specific tumours, and development of small molecule inhibitors for cancer therapy.

The Anaplastic Lymphoma Kinase (ALK) is a receptor tyrosine kinase first identified as the product of a gene rearrangement in Anaplastic Large Cell Lymphoma. ALK has subsequently been found to be rearranged, mutated, or amplified in a further series of tumours including neuroblastoma, and Non-Small Cell Lung Cancer. There is strong preclinical evidence that ALK is a driving force for oncogenesis in these cases, and that inhibition of ALK kinase activity results in anti-tumoural efficacy. These observations have sparked the development of small molecule kinase inhibitors, the most advanced of which is currently in clinical testing and which has shown promising preliminary activity in the subset of lung cancer patients whose tumours harbour activated ALK. In this review, we describe the various oncogenic forms of ALK, relevant clinical settings, and give a detailed overview of current drug discovery efforts in the field.

Primary and secondary tuberculosis preventive treatment in HIV clinics: simulating alternative strategies.

BACKGROUND: Isoniazid preventive treatment (IPT) has been recommended for human immunodeficiency virus (HIV) infected individuals. OBJECTIVE/DESIGN: We used a mathematical model to simulate the benefits and risks of preventive treatment delivered through antiretroviral (ARV) clinics using clinical data from Botswana. RESULTS: Preventive treatment was found to reduce the incidence of tuberculosis (TB) by at least 12 cases per 100000 population per year versus the scenario without such treatment over a 50-year simulation. Isoniazid (INH) resistant TB was observed to increase by <1% per year, even when using pessimistic assumptions about resistance emergence. The use of tuberculin skin testing had little impact as a screening procedure, while secondary treatment was observed to nearly double the impact of a preventive treatment program. Regardless of whether or not preventive treatment was implemented, INH-resistant TB rose in the context of increasing HIV prevalence, but was minimally amplified by preventive treatment itself. CONCLUSIONS: IPT programs implemented through ARV clinics may be effective at reducing TB incidence. The resistance contribution of IPT appears unlikely to supersede its overall incidence and mortality benefits.

Impact of insecticide interventions on the abundance and resistance profile of Aedes aegypti.

Insecticide-based vector control is the primary strategy for curtailing dengue transmission. We used a mathematical model of the seasonal population dynamics of the dengue mosquito vector, Aedes aegypti, both to assess the effectiveness of insecticide interventions on reducing adult mosquito abundance and to predict evolutionary trajectories of insecticide resistance. We evaluated interventions that target larvae, adults, or both. We found that larval control and adult control using ultra-low-volume insecticide applications can reduce adult mosquito abundance with effectiveness that depends on the frequency of applications. We also found that year-long continuous larval control and adult control, using either insecticide treatment of surfaces and materials or lethal ovitraps, imposed the greatest selection for resistance. We demonstrated that combined targeting of larvae and adults at the start of the dengue season is optimal. This intervention contrasts with year-long continuous larval control policies adopted in settings in which dengue transmission occurs.

Disability adjusted life years lost to dengue in Brazil.

OBJECTIVES: To assess the dengue burden in Brazil, and to compare it over three spatial scales: in the city of Rio de Janeiro, the state of Rio de Janeiro, and in Brazil overall. METHODS: We calculated disability adjusted life years (DALYs) lost to dengue per million individuals annually from 1986 through 2006. To calculate DALYs, we compiled data on the number of dengue cases by age, clinical syndrome and outcome. We evaluated the sensitivity of our results to multiplication factors used to adjust for inaccuracies in reporting using a Monte Carlo method. RESULTS: From 1986 through 2006, a mean of 56, 47 and 22 DALYs per million individuals annually were lost to dengue in the city of Rio de Janeiro, in the state of Rio de Janeiro and in Brazil, respectively. Over 80% of the dengue burden derived from dengue fever cases. The dengue burden was highest at the city-level with a maximum single-year estimate of 560 DALYs per million individuals for 2002. CONCLUSIONS: Assessment of dengue burden requires consideration of all clinical syndromes over multiple years. Our results indicate that the dengue burden is as high as the burden of other major infectious diseases that afflict the Brazilian population, including malaria. These results may prompt policy makers to elevate the prioritization of dengue control, and allocate resources needed to curtail the increasing dengue burden.

The transmission and control of XDR TB in South Africa: an operations research and mathematical modelling approach.

Extensively drug-resistant tuberculosis (XDR TB) has emerged as a threat to TB control efforts in several high-burden areas, generating international concern. XDR TB is now found in every region of the world, but appears most worrisome in the context of HIV and in resource-limited settings with congregate hospital wards. Here, we examine the emergence and transmission dynamics of the disease, incorporating the mathematical modelling literature related to airborne infection and epidemiological studies related to the operations of TB control programmes in resource-limited settings. We find that while XDR TB may present many challenges in the setting of resource constraints, the central problems highlighted by the emergence of XDR TB are those that have plagued TB programmes for years. These include a slow rate of case detection that permits prolonged infectiousness, the threat of airborne infection in enclosed spaces, the problem of inadequate treatment delivery and treatment completion, and the need to develop health systems that can address the combination of TB and poverty. Mathematical models of TB transmission shed light on the idea that community-based therapy and rapid detection systems may be beneficial in resource-limited settings, while congregate hospital wards are sites for major structural reform.

Reservoir interactions and disease emergence.

Animal populations act as reservoirs for emerging diseases. In order for transmission to be self-sustaining, a pathogen must have a basic reproduction number R0>1. Following a founding transmission event from an animal reservoir to humans, a pathogen has not yet adapted to its new environment and is likely to have an R0<1. However, subsequent evolution may rescue the pathogen from extinction in its new host. Recent applications of branching process theory investigate how the emergence of a novel pathogen is influenced by the number and rates of intermediate evolutionary steps. In addition, repeated contacts between human and reservoir populations may promote pathogen emergence. This article extends a stepping-stone model of pathogen evolution to include reservoir interactions. We demonstrate that the probability of a founding event culminating in an emerged pathogen can be significantly influenced by ongoing reservoir interactions. While infrequent reservoir interactions do not change the probability of disease emergence, moderately frequent interactions can promote emergence by facilitating adaptation to humans. Frequent reservoir interactions promote emergence even with minimal adaptation to humans. Thus, these results warn against perpetuated interaction between humans and animal reservoirs, as occurs when there are ecological or environmental changes that bring humans into more frequent contact with animal reservoirs.

Features discriminating SARS from other severe viral respiratory tract infections.

This study investigated the discriminatory features of severe acute respiratory syndrome (SARS) and severe non-SARS community-acquired viral respiratory infection (requiring hospitalization) in an emergency department in Hong Kong. In a case-control study, clinical, laboratory and radiological data from 322 patients with laboratory-confirmed SARS from the 2003 SARS outbreak were compared with the data of 253 non-SARS adult patients with confirmed viral respiratory tract infection from 2004 in order to identify discriminatory features. Among the non-SARS patients, 235 (93%) were diagnosed as having influenza infections (primarily H3N2 subtype) and 77 (30%) had radiological evidence of pneumonia. In the early phase of the illness and after adjusting for baseline characteristics, SARS patients were less likely to have lower respiratory symptoms (e.g. sputum production, shortness of breath, chest pain) and more likely to have myalgia (p < 0.001). SARS patients had lower mean leukocyte and neutrophil counts (p < 0.0001) and more commonly had "ground-glass" radiological changes with no pleural effusion. Despite having a younger average age, SARS patients had a more aggressive respiratory course requiring admission to the ICU and a higher mortality rate. The area under the receiver operator characteristic curve for predicting SARS when all variables were considered was 0.983. Using a cutoff score of >99, the sensitivity was 89.1% (95%CI 82.0-94.0) and the specificity was 98.0% (95%CI 95.4-99.3). The area under the receiver operator characteristic curve for predicting SARS when all variables except radiological change were considered was 0.933. Using a cutoff score of >8, the sensitivity was 80.7% (95%CI 72.4-87.3) and the specificity was 94.5% (95%CI 90.9-96.9). Certain clinical manifestations and laboratory changes may help to distinguish SARS from other influenza-like illnesses. Scoring systems may help identify patients who should receive more specific tests for influenza or SARS.

Giardia and Cryptosporidium in source waters of São Paulo State, Brazil.

Giardia lamblia and Cryptosporidium parvum are two protozoan intestinal parasites responsible for many drinking-water-related disease outbreaks in recent years. They are very resistant to conventional water treatment processes, can persist for long times in the environment and are, therefore, of great concern for public health. This work aimed to evaluate the presence of Giardia and Cryptosporidium in water sources from São Paulo State, Brazil, as part of the "Evaluation of Inland Waters from São Paulo State" project from CETESB. Over a period of 19 months, 278 water samples from 28 sites located in 10 watersheds were analysed. The immunofluorescence assay was used after concentration of the samples by the calcium carbonate flocculation technique. Thermotolerant (faecal) coliforms, faecal streptococci and Clostridium perfringens were also determined in order to verify the existence of correlation between these bacterial indicators and the protozoa. Giardia and Cryptosporidium were detected in 27% and 2.5% of the samples, respectively, a lower figure compared with the results reported by other authors, especially for Cryptosporidium. A Spearman rank correlation test demonstrated a significant correlation between Giardia and faecal indicator concentrations. According to the American Regulation of Monitoring (ICR), treated water from 16 of these 28 collection sites should also be analysed to evaluate whether the treatment process could remove the parasites. Some technical deficiencies of these methods still limit the utilisation of the monitoring results for public health decisions, but the data here reported will help to improve the quality of drinking water in São Paulo State.

Transgene-mediated post-transcriptional gene silencing is inhibited by 3' non-coding sequences in Paramecium.

Homology-dependent gene silencing is achieved in Paramecium by introduction of gene coding regions into the somatic nucleus at high copy number, resulting in reduced expression of all homologous genes. Although a powerful tool for functional analysis, the relationship of this phenomenon to gene silencing mechanisms in other organisms has remained obscure. We report here experiments using the T4a gene, a member of the trichocyst [corrected]matrix protein (TMP) multigene family encoding secretory proteins, and the ND7 gene, a single copy gene required for exocytotic membrane fusion. Silencing of either gene leads to an exocytosis-deficient phenotype easily scored on individual cells. For each gene we have tested the ability of different combinations of promoter, coding and 3' non-coding regions to provoke silencing, and analyzed transcription and steady-state RNA in the transformed cells. We provide evidence that homology-dependent gene silencing in Paramecium is post-transcriptional and that both sense and antisense RNA are transcribed from the transgenes, consistent with a role for dsRNA in triggering silencing. Constructs with and without promoters induce gene silencing. However, transgenes that contain 3' non-coding regions do not induce gene silencing, despite antisense RNA production. We present a model according to which different pathways of RNA metabolism compete for transcripts and propose that the relative efficiencies of dsRNA formation and of 3' RNA processing of sense transgene transcripts determine the outcome of transformation experiments.

Genetic interference in protozoa.

RNA interference first described in Caenorhabditis elegans and transgene-induced post-transcriptional gene silencing first described in plants and fungi now appear as different means of activating a conserved and ancient mechanism that can protect genomes against viruses and transposons and perhaps also control expression of endogenous genes. We present here similar genetic interference phenomena in highly divergent protozoa, Trypanosoma and Paramecium, and look ahead to what contribution these microorganisms could bring to this fast-moving area.

[Extracorporeal membrane oxygenation (ECMO) in a neonate with respiratory distress due to meconium aspiration syndrome: Effect of the administration of exogenous surfactant] / Circulação extracorpórea prolongada (ECMO) em recém-nascido com insuficiência respiratória por Síndrome de Aspiração Meconial: efeitos da administração de surfactante exógeno.

OBJECTIVES: To present the clinical outcome of a newborn with severe respiratory distress secondary to meconium aspiration syndrome and treated by extracorporeal membrane oxygenation (ECMO); and to present the effect of the use of exogenous surfactant in this case and the cost of the procedure. METHODS: Case report of a newborn with meconium aspiration syndrome and treated at the neonatal ICU of the Instituto da Criança Prof. Pedro de Alcantara, Hospital das Clínicas of the Universidade de São Paulo. RRESULTS: ECMO was carried out for 5 days with no clinical or mechanical complications. On the 4th day of ECMO, we administered porcine exogenous surfactant; a significant improvement in lung compliance was observed and the newborn was decannulated shortly after that. Treatment costs were compatible with the situation of healthcare in Brazil for treatment of critically ill newborn patients. CONCLUSIONS: ECMO is indicated in cases of neonatal respiratory distress not responding to other treatments. The technique should be made available in neonatal Intensive Care Units (ICUs) of tertiary hospitals according to well-established protocols. The use of exogenous surfactant apparently allowed for earlier decannulation of the patient and should be considered in similar cases. The treatment costs do justify the organizing of ECMO teams in this type of ICUs.

Brain abscess by citrobacter diversus in infancy: case report.

Citrobacter diversus is closely related to brain abscess in newborn infants. We describe a case of brain abscess by this bacteria in a newborn infant and his clinical and cranial computed tomographic evaluation until the fourth month of life and discuss therapeutic management of this patient.

Regulation of secretory protein gene expression in paramecium role of the cortical exocytotic sites.

In cells that possess a regulated secretory pathway, exocytosis can lead to transcriptional activation of genes encoding products stored in secretory granules as well as genes required for granule biogenesis. With the objective of understanding this response, we have examined the expression of Paramecium secretory protein genes in different physiological and genetic contexts. The genes belong to the trichocyst matrix protein (TMP) multigene family, encoding polypeptides that form the crystalline matrix of the secretory granules, known as trichocysts. Approximately 1000 trichocysts per cell are docked at pre-formed cortical exocytotic sites. Their rapid and synchronous exocytosis can be triggered by vital secretagogues such as aminoethyldextran without harming the cells. Using this exocytotic trigger, we found that the transcription of TMP genes undergoes rapid, transient and co-ordinate 10-fold activation in response to massive exocytosis, leading to a 2.5-fold increase in the pool of TMP mRNA. Experiments with exocytosis-deficient mutants show that the secretagogue-induced increase in intracellular free calcium implicated in stimulus/secretion coupling is not sufficient to activate TMP gene expression. We present evidence that the state of occupation of the cortical exocytotic sites can affect TMP gene expression and suggest that these sites play a role in gene activation in response to exocytosis.

The effects of host heterogeneity on pathogen population structure.

We have shown that among pathogens, populations may self-organize into strains with non-overlapping repertoires of antigenic variants as a consequence of strong immune selection operating on polymorphic antigens. Recently, we have also demonstrated that over a wide range of intermediate levels of immune selection, pathogens may still be structured into discrete strains, but different sets of non-overlapping pathogen types will replace each other in a cyclical or chaotic manner. These models assume that the ranking of antigens in terms of the strength of the induced immune response is the same for every host. However, host immune responses may be restricted by the genotype of the individual. To explore this issue, a mathematical model was constructed under the assumption that a proportion of the host population responds principally to a variable antigen while the remainder of the population responds principally to a conserved antigen. The results of this analysis indicate that discrete strain structure (DSS) will be maintained even with a high frequency of hosts that do not respond in a variant-specific manner. Furthermore, the range of the immune selection pressure over which DSS prevails is increased (and the region of cyclical or chaotic behaviour reduced) by the inclusion of hosts that respond in a cross-reactive rather than a variant-specific manner.

The effects of mating probability on the population genetics of nematodes.

We review how constraints on the mating probability of female worms by segregation within individual host guts form a critical element in the parasite population structure of nematodes. We consider the effects of these constraints on the population genetics of nematodes under various assumptions regarding worm competition as reflected in the relationship between the abundance of a certain genotype within the gut and the probability of reproductive success. The consequences for the emergence of resistance to drugs and immunotherapy and implications for host-parasite coevolution are discussed. We also review evidence for genetic heterogeneity in parasite populations as a necessary prerequisite for the applicability of mating probability models designed to assess the population genetics of nematodes.

Basic fibroblast growth factor stimulates hepatocyte growth factor/scatter factor secretion by human mesenchymal cells.

Basic fibroblast growth factor (bFGF) together with other pleiotropic factors plays an important role in many complex physiological processes such as embryonic development, angiogenesis, and wound repair. Among these factors, hepatocyte growth factor/scatter factor (HGF/SF) which is secreted by cells of mesodermal origin exerts its mito- and motogenic activities on cells of epithelial and endothelial origin. Knowledge of the regulatory mechanisms of HGF/SF may contribute to the understanding of its role in physio-pathological processes. We observed that the secretion of HGF/SF by MRC-5 cells and by other fibroblast-derived cell cultures in conditioned media was enhanced by exposure to bFGF. HGF/SF was measured by the scatter assay, a bioassay for cell motility, and was further characterized by Western blot analysis with anti-HGF/SF antibodies. Exposure of MRC-5 cultures to 10 ng/ml of bFGF resulted already 6 h posttreatment in a threefold higher amount of scatter factor secreted into the medium as compared to untreated cultures. HGF/SF secretion was sustained after bFGF treatment for the following 72 h when increased amounts of HGF/SF were detected both in conditioned media as well as associated to the extracellular matrix. The secretion of HGF/SF in cell supernatants increased dose dependently upon treatment with bFGF starting from basal levels of 6 U/ml and reaching 27 U/ml at 30 ng/ml bFGF, plateauing thereafter. Upregulation of HGF/SF by IL-1, already described by others, was confirmed in this study. Based on our findings an articulated interaction can be speculated for bFGF, HGF/SF, and IL-1, e.g., in tissue regeneration during inflammatory processes or in wound healing.

Suramin modulates cellular levels of hepatocyte growth factor receptor by inducing shedding of a soluble form.

Several growth factor receptors undergo shedding from the cell surface as a result of limited proteolysis via mechanisms that are at present poorly understood. By Western blotting of the conditioned media and cell lysates of several cell lines expressing the hepatocyte growth factor receptor, we found that suramin, a pharmacological agent that inhibits the activity of many growth factors, was able to induce shedding of this receptor. Increased levels of soluble hepatocyte growth factor receptor were observed in the conditioned media of GTL-16, a cell line over-expressing the receptor, as early as ten minutes after initial exposure to the agent, and incubation of this line with 300 microM suramin caused a 50% reduction in cell-associated levels of receptor after 6 hours. Although protein kinase C activation by treatment of cells with phorbol esters has previously been found to stimulate shedding of the hepatocyte growth factor receptor, this hitherto undescribed activity of suramin was not affected by protein kinase C inhibitors. Since shedding represents a possible means of down-modulation of receptor activity, suramin may inhibit the hepatocyte growth factor ligand/receptor system, not only by abrogation of hepatocyte growth factor binding to intact receptor, but also by induction of receptor shedding.