Cost Analysis of the Mongolian ATLS© Program: A Framework for Low- and Middle-Income Countries.

BACKGROUND: Trauma is the leading cause of death among Mongolians aged 24-44. To improve initial management of injured patients, the Mongolian National University of Medical Sciences (MNUMS) implemented the American College of Surgeons' (ACS) Advanced Trauma Life Support (ATLS) training program in 2015. Cost analysis demonstrates that such programs can have clear pathways to self-sufficiency. METHODS: Costs associated with an ACS Mongolian ATLS program were quantified based on discussions with the Mongolian government, MNUMS, ATLS Australasia headquarters, and existing pricing data. Costs were then classified as either essential or contingencies. These classifications determined budgetary items for each program. Savings projections for contingencies included training Mongolian instructors and educators. Scenarios for funding the budget were then assessed. RESULTS: The minimum annual cost of ATLS in Mongolia, which includes 3 ATLS student courses/1 instructor course, is $10,709. A budget of $19,900 includes additional contingencies. The scenario that involves foreign instructors is the most expensive one. An initial investment of $85,000 to train Mongolian instructors reduces annual costs by $48,305 (71% reduction). An investment of $4050 to train a Mongolian educator will reduce costs by $1750 annually. ATLS can be sustained with 0.04% of Mongolia's current spending on public health and preventative services. CONCLUSIONS: Initial investment to train Mongolian ATLS instructors leads to substantial savings. Training a Mongolian educator lowers long-term costs. When minimum costs for ATLS courses are understood, these can be scaled up and supported with different contingencies and minimal funding by government or third-party stakeholders.

DNA Targeting by a Minimal CRISPR RNA-Guided Cascade.

Bacteria employ surveillance complexes guided by CRISPR (clustered, regularly interspaced, short palindromic repeats) RNAs (crRNAs) to target foreign nucleic acids for destruction. Although most type I and type III CRISPR systems require four or more distinct proteins to form multi-subunit surveillance complexes, the type I-C systems use just three proteins to achieve crRNA maturation and double-stranded DNA target recognition. We show that each protein plays multiple functional and structural roles: Cas5c cleaves pre-crRNAs and recruits Cas7 to position the RNA guide for DNA binding and unwinding by Cas8c. Cryoelectron microscopy reconstructions of free and DNA-bound forms of the Cascade/I-C surveillance complex reveal conformational changes that enable R-loop formation with distinct positioning of each DNA strand. This streamlined type I-C system explains how CRISPR pathways can evolve compact structures that retain full functionality as RNA-guided DNA capture platforms.

Structures of a CRISPR-Cas9 R-loop complex primed for DNA cleavage.

Bacterial adaptive immunity and genome engineering involving the CRISPR (clustered regularly interspaced short palindromic repeats)-associated (Cas) protein Cas9 begin with RNA-guided DNA unwinding to form an RNA-DNA hybrid and a displaced DNA strand inside the protein. The role of this R-loop structure in positioning each DNA strand for cleavage by the two Cas9 nuclease domains is unknown. We determine molecular structures of the catalytically active Streptococcus pyogenes Cas9 R-loop that show the displaced DNA strand located near the RuvC nuclease domain active site. These protein-DNA interactions, in turn, position the HNH nuclease domain adjacent to the target DNA strand cleavage site in a conformation essential for concerted DNA cutting. Cas9 bends the DNA helix by 30°, providing the structural distortion needed for R-loop formation.

Structural biology. Structures of the CRISPR-Cmr complex reveal mode of RNA target positioning.

Adaptive immunity in bacteria involves RNA-guided surveillance complexes that use CRISPR (clustered regularly interspaced short palindromic repeats)-associated (Cas) proteins together with CRISPR RNAs (crRNAs) to target invasive nucleic acids for degradation. Whereas type I and type II CRISPR-Cas surveillance complexes target double-stranded DNA, type III complexes target single-stranded RNA. Near-atomic resolution cryo-electron microscopy reconstructions of native type III Cmr (CRISPR RAMP module) complexes in the absence and presence of target RNA reveal a helical protein arrangement that positions the crRNA for substrate binding. Thumblike ß hairpins intercalate between segments of duplexed crRNA:target RNA to facilitate cleavage of the target at 6-nucleotide intervals. The Cmr complex is architecturally similar to the type I CRISPR-Cascade complex, suggesting divergent evolution of these immune systems from a common ancestor.

Rational design of a split-Cas9 enzyme complex.

Cas9, an RNA-guided DNA endonuclease found in clustered regularly interspaced short palindromic repeats (CRISPR) bacterial immune systems, is a versatile tool for genome editing, transcriptional regulation, and cellular imaging applications. Structures of Streptococcus pyogenes Cas9 alone or bound to single-guide RNA (sgRNA) and target DNA revealed a bilobed protein architecture that undergoes major conformational changes upon guide RNA and DNA binding. To investigate the molecular determinants and relevance of the interlobe rearrangement for target recognition and cleavage, we designed a split-Cas9 enzyme in which the nuclease lobe and α-helical lobe are expressed as separate polypeptides. Although the lobes do not interact on their own, the sgRNA recruits them into a ternary complex that recapitulates the activity of full-length Cas9 and catalyzes site-specific DNA cleavage. The use of a modified sgRNA abrogates split-Cas9 activity by preventing dimerization, allowing for the development of an inducible dimerization system. We propose that split-Cas9 can act as a highly regulatable platform for genome-engineering applications.

RNA targeting by the type III-A CRISPR-Cas Csm complex of Thermus thermophilus.

CRISPR-Cas is a prokaryotic adaptive immune system that provides sequence-specific defense against foreign nucleic acids. Here we report the structure and function of the effector complex of the Type III-A CRISPR-Cas system of Thermus thermophilus: the Csm complex (TtCsm). TtCsm is composed of five different protein subunits (Csm1-Csm5) with an uneven stoichiometry and a single crRNA of variable size (35-53 nt). The TtCsm crRNA content is similar to the Type III-B Cmr complex, indicating that crRNAs are shared among different subtypes. A negative stain EM structure of the TtCsm complex exhibits the characteristic architecture of Type I and Type III CRISPR-associated ribonucleoprotein complexes. crRNA-protein crosslinking studies show extensive contacts between the Csm3 backbone and the bound crRNA. We show that, like TtCmr, TtCsm cleaves complementary target RNAs at multiple sites. Unlike Type I complexes, interference by TtCsm does not proceed via initial base pairing by a seed sequence.