From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination.

BACKGROUND: Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003. METHODS: We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys. RESULTS: The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis. CONCLUSIONS: Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

Evidence for constitutive protein synthesis in hippocampal LTP stabilization.

UNLABELLED: The notion that blockade of constitutive protein synthesis underlies the effect of protein synthesis inhibitors (PSIs) on long-term potentiation (LTP) stabilization was examined using the rat hippocampal CA3-CA1 synapse. Using a biochemical assay we found protein synthesis rate largely recovered 1h after wash-out of cycloheximide (CHX). Nonetheless, a 4-h CHX application followed by wash-out 1h prior to LTP resulted in a significant decrement of LTP stabilization. Wash-out initiated just prior to LTP, thus extending protein synthesis inhibition well into the post-LTP period, resulted in no further effect on LTP. However, short pre- and continuous post-tetanization application of PSIs failed to influence LTP persistence for up to 7 h. Addition of hydrogen peroxide (H2O2) 5-25 min following LTP induction resulted in parallel depression of potentiated and non-potentiated inputs, leaving LTP seemingly unaltered. However, in the presence of cyxloheximide the H2O2 application resulted in a significant reduction of LTP. IN CONCLUSION: LTP stabilization was impaired by pre-LTP application of protein synthesis inhibition but not by post-LTP application unless the slices were exposed to oxidative stress. We submit that these results favor the notion that constitutive rather than triggered protein synthesis is important for LTP stabilization.

Thermoregulation of Premature Infants during and after Skin-to-Skin Care.

OBJECTIVE: Providing normothermia is an important issue in daily routine care of premature neonates. We recently found with infrared thermography (IRT) a drop in skin temperature of premature babies after they were positioned from skin-to-skin care (SSC) back into the incubator. Since this did not disappear within 10 min, we wanted to find out how long it takes until the baby has fully warmed up after SSC and if the IRT measurements correlate with conventional rectal temperature? STUDY DESIGN: A prospective observational study was undertaken with 5 premature infants [3 male, median gestational age 28 weeks (25-29), median age at study 34 d (28-52), median birth weight 898 g (400-1095), median weight at study 1263 g (790-1465)], temperature was determined with IRT (leg, back, arm, head, upper abdomen; diameter 1 cm, scale 0.00°C), comparison with 2 conventional sensors and rectal temperature. Temperatures were recorded every 2 min and displayed for 4 time points, namely at the beginning and the end of skin-to-skin care (SSC1, SSC2), as well as at the beginning and the end of a subsequent 60 min incubator period (I). RESULTS: A significant rise during SSC occurred while the cooling after SSC persisted during the complete incubator measurement time (I; p<0.05). Rectal temperature remained stable through the whole measuring period. CONCLUSION: While SSC in our setting led to an increase in temperature, the lack of compensation of peripheral heat loss in the incubator after 60 min may express an inadequate peripheral regulation of body temperature. This should be taken into account before routine care after SSC.

Clinical "case series": a concept analysis.

OBJECTIVES: To analyze the concept of "case series" in the medical literature compared with case reports. METHODS: A PubMed search for articles published during 2009 which had "case series" in their title was performed. A total number of 621 articles were retrieved. 586 papers were included in the analysis and 35 were excluded (18 were commentary letters, 5 were not in English, and twelve could not be retrieved by our Library). The number of patients and category of these articles were analyzed. RESULTS: The median (range) of the number of cases of articles having "case series" in their title was 7 (1-6432) cases. 186/ 586 articles had less than 5 cases (31.7%, 95% CI (28.3-35.1%)). The median (range) of the number of cases of articles having "case report" as their publication type was 4 (1-178) cases. Out of the 219 articles categorized as case reports 114 (52.1%, 95% CI (45.6-58.6%)) had less than five cases. CONCLUSIONS: The concept of "case series" is not well defined in the literature and does not reflect a specific research design. We suggest that a case series should have more than four patients while four paitents or less should be reported individually as case reports.

Akt provides the CD28 costimulatory signal for up-regulation of IL-2 and IFN-gamma but not TH2 cytokines.

A region of the interleukin-2 (IL-2) promoter known as the RE/AP element is activated in concert by signals that originate from the T cell antigen receptor and the CD28 coreceptor. We show here that the serine-threonine kinase Akt can provide a costimulatory signal for RE/AP activation that is indistinguishable from the signal provided by CD28. This includes the ability of Akt, like antibodies to CD28, to synergize with protein kinase C theta (PKC-theta) in the induction of RE/AP. Retrovirus-mediated expression of activated Akt in primary T cells from CD28-deficient mice is capable of selectively restoring production of IL-2 and interferon gamma, but not IL-4 or IL-5. Our results provide evidence that CD28 costimulation of different cytokines is mediated by discrete signaling pathways, one of which includes Akt.

CTLA-4 regulates induction of anergy in vivo.

The requirement for CTLA-4 during the induction of peripheral T cell tolerance in vivo was investigated using naive TCR transgenic T cells lacking CTLA-4. CTLA-4(-/-) T cells are resistant to tolerance induction, as demonstrated by their proliferative responses, IL-2 production, and progression into the cell cycle. Following exposure to a tolerogenic stimulus in vivo and restimulation in vitro, wild-type T cells are blocked at the late G1 to S restriction point of the cell cycle. In contrast, CTLA-4(-/-) T cells enter into the S phase of the cell cycle, as shown by downregulation of p27(kip1), elevated cdk2 kinase activity, and Rb hyperphosphorylation. Thus, CTLA-4 has an essential role in determining the outcome of T cell encounter with a tolerogenic stimulus.

Expression of bcl-X(L) restores cell survival, but not proliferation off effector differentiation, in CD28-deficient T lymphocytes.

Lymphocytes deficient in the T cell costimulatory molecule CD28 exhibit defects in cell survival, clonal expansion, and differentiation into effector cells. It is known that CD28-mediated signaling results in the upregulation of the Bcl family member Bcl-X(L). To investigate the role that Bcl-X(L) plays in the various functions of CD28, we expressed Bcl-X(L) in CD28-deficient primary T lymphocytes using retrovirus-mediated gene transfer. T cells were activated in vitro and infected with Bcl-X(L) or control retroviruses; this method allows gene expression in activated, cycling cells. Expression of Bcl-X(L) in naive T cells was achieved by reconstitution of the immune system of lethally irradiated recipient mice with retrovirus-infected purified bone marrow stem cells from CD28(-/)- or wild-type donor mice. Our studies demonstrate that Bcl-X(L) prolongs the survival of CD28(-/)- T cells but does not restore normal proliferation or effector cell development. These results indicate that the various functions of CD28 can be dissociated, and provide an experimental approach for testing the roles of downstream signals in the functions of cellular receptors such as CD28.

Combined effect of exposure to lead and chlordane on the testicular tissues of swiss mice.

Chlordane, is one of many environmental pollutants that reach human or animal body through food and water consumption, its presence may frequently be associated with other metals such as lead. In this work, the toxicity of chlordane and lead to reproductive tissues in Swiss mice was studied. Oral daily doses of 75 and 275 mg/kg b.w. were administered to male mice, for 35 days, animals were sacrificed at the 2nd, 3rd, 4th, and 5th week. The results show that chloradane had a damaging effect on testicular tissues, the effect was obvious through reduction in diameter of the seminiferous tubules, number of spermatogonia, and primary and secondary spermatocytes and spermatids. The effect was remarkably increased by the presence of lead, which needs more investigation in order to determine whether it's a synergistic or additive effect.

The roles of CD28 and CD40 ligand in T cell activation and tolerance.

Costimulation of T cell activation involves both the B7:CD28 as well as the CD40 ligand (CD40L):CD40 pathway. To determine the importance of these pathways to in vitro and in vivo T cell activation, a direct comparison was made of the responses of TCR transgenic T cells lacking either CD28 or CD40L. In vitro, CD28-/- T cells showed a greater reduction in proliferative responses to Ag than did CD40L-/- T cells. The absence of CD28 resulted in defective Th2 responses, whereas CD40L-/- T cells were defective in Th1 development. In vivo, CD28-/- T cells failed to expand upon immunization, whereas CD40L-/- T cells could not sustain a response. These results suggest that CD28 is critical for initiating T cell responses, whereas CD40L is required for sustained Th1 responses. The different functional roles of these costimulatory pathways may explain why blocking B7:CD28 and CD40L:CD40 interactions has an additive effect in inhibiting T cell responses.

Functional responses and costimulator dependence of memory CD4+ T cells.

To examine the functional characteristics of memory CD4+ T cells, we used an adoptive transfer system to generate a stable population of Ag-specific memory cells in vivo and compared their responses to Ag with those of a similar population of Ag-specific naive cells. Memory cells localized to the spleen and lymph nodes of mice and exhibited extremely rapid recall responses to Ag in vivo, leaving the spleen within 3-5 days of Ag encounter. Unlike their naive counterparts, memory cells produced effector cytokines (IFN-gamma, IL-4, IL-5) within 12-24 h of Ag exposure and did not require multiple cycles of cell division to do so. Memory cells proliferated at lower Ag concentrations than did naive cells, were less dependent on costimulation by B7 molecules, and independent of costimulation by CD40. Furthermore, effector cytokine production by memory cells also occurred in the absence of either B7 or CD40 costimulation. Lastly, memory cells were resistant to tolerance induction. Together, these findings suggest that the threshold for activation of memory CD4+ cells is lower than that of naive cells. This would permit memory cells to rapidly express their effector functions in vivo earlier in the course of a secondary immune response, when the levels of Ag and the availability of costimulation may be relatively low.

Uncoupling IL-2 signals that regulate T cell proliferation, survival, and Fas-mediated activation-induced cell death.

IL-2 is an important growth and survival factor for T lymphocytes but also sensitizes these cells to Fas-mediated activation-induced cell death (AICD). The molecular basis of these different effects of IL-2 was studied by introducing wild-type and mutant forms of the IL-2 receptor beta (IL-2Rbeta) chain that lacked specific signaling capacities into receptor-deficient T cells by retroviral gene transfer. Activation of Stat5 by IL-2 was found to be involved in T cell proliferation and promoted Fas ligand (FasL) expression and AICD. T cell survival was dependent on a receptor region that activated Akt and the expression of Bcl-2. Thus, distinct IL-2Rbeta chain signaling modules regulate T cell fate by stimulating growth and survival or by promoting apoptosis.

Genetic models of abnormal apoptosis in lymphocytes.

Apoptosis is a critical mechanism for regulating cell numbers during development, normal responses to hormones and other stimuli, and immune and inflammatory reactions. Recent advances in defining the biochemical mechanisms of cell death, and the development of animal models with isolated defects in cell death pathways, have led to an increasing appreciation of the pathophysiologic importance of lymphocyte apoptosis. In this article, we review our current understanding of the pathways and roles of apoptosis in lymphocytes, with an emphasis on transgenic and knockout models. We also summarize the relevance of these animal models to human diseases.

The role of CTLA-4 in regulating Th2 differentiation.

To examine the role of CTLA-4 in Th cell differentiation, we used two newly generated CTLA-4-deficient (CTLA-4-/-) mouse strains: DO11. 10 CTLA-4-/- mice carrying a class II restricted transgenic TCR specific for OVA, and mice lacking CTLA-4, B7.1 and B7.2 (CTLA-4-/- B7.1/B7.2-/- ). When purified naive CD4+ DO11.10 T cells from CTLA-4-/- and wild-type mice were primed and restimulated in vitro with peptide Ag, CTLA-4-/- DO11.10 T cells developed into Th2 cells, whereas wild-type DO11.10 T cells developed into Th1 cells. Similarly, when CTLA-4-/- CD4+ T cells from mice lacking CTLA-4, B7. 1, and B7.2 were stimulated in vitro with anti-CD3 Ab and wild-type APC, these CTLA-4-/- CD4+ T cells produced IL-4 even during the primary stimulation, whereas CD4+ cells from B7.1/B7.2-/- mice did not produce IL-4. Upon secondary stimulation, CD4+ T cells from CTLA-4-/- B7.1/B7.2-/- mice secreted high levels of IL-4, whereas CD4+ T cells from B7.1/B7.2-/- mice produced IFN-gamma. In contrast to the effects on CD4+ Th differentiation, the absence of CTLA-4 resulted in only a modest effect on T cell proliferation, and increased proliferation of CTLA-4-/- CD4+ T cells was seen only during secondary stimulation in vitro. Administration of a stimulatory anti-CD28 Ab in vivo induced IL-4 production in CTLA-4-/- B7.1/B7.2-/- but not wild-type mice. These studies demonstrate that CTLA-4 is a critical and potent inhibitor of Th2 differentiation. Thus, the B7-CD28/CTLA-4 pathway plays a critical role in regulating Th2 differentiation in two ways: CD28 promotes Th2 differentiation while CTLA-4 limits Th2 differentiation.

Functional characteristics and survival requirements of memory CD4+ T lymphocytes in vivo.

The phenotypic and functional characteristics of Ag-specific memory CD4+ lymphocytes are poorly defined. To examine the properties and cytokine responsiveness of these cells, we have developed an adoptive transfer system using in vitro-activated T cells expressing the DO.11 transgenic TCR specific for OVA(323-339)+ I-Ad. In vitro-activated DO.11 CD4+ cells exhibit comparable survival patterns at 1, 6, and 10 wk after adoptive transfer, indicating that a stable population of memory cells has been generated. In the absence of Ag, previously activated T cells survive longer than their naive counterparts in vivo, rapidly revert to a partially naive phenotype, and maintain their effector cytokine profile. The DO.11 CD4+ memory cells are capable of proliferating in response to IL-2 and IL-4, while naive DO.11 CD4+ cells exhibit no such proliferative responses.

Autoimmunity as a consequence of retrovirus-mediated expression of C-FLIP in lymphocytes.

The induction of apoptosis by death receptors serves to regulate immune responses by eliminating unwanted and harmful cells. Mature lymphocytes express FLICE inhibitory proteins (FLIPs) that block death receptor-induced cell death. Here, we show that both B and T cells downregulate c-FLIP upon activation in vitro. Retrovirus-mediated expression of c-FLIP blocks Fas-induced apoptosis of activated lymphocytes but does not affect cell death resulting from cytokine withdrawal. In vivo, c-FLIP expression results in defective superantigen-mediated elimination of T cells, the accumulation of activated B cells, the production of autoantibodies, and the development of autoimmune disease. No effect was seen on negative selection of thyomocytes. These results suggest that activation-dependent downregulation of c-FLIP renders mature lymphocytes sensitive to death receptor-mediated apoptosis and is required to maintain self-tolerance.

Role of cytokines in autoimmunity.

Activation-induced apoptosis of T lymphocytes is an important mechanism for maintaining self-tolerance. The sensitivity of T cells to apoptosis by the Fas pathway is regulated by the exposure of these cells to different cytokines. IL-2 is a survival and growth factor for T cells, as well as a necessary potentiator of Fas-mediated cell death. The role of this cytokine in triggering death pathways is the likely explanation for the autoimmune disease that develops as a result of targeted disruption of the IL-2 or IL-2 receptor alpha or beta chain gene.

Mechanisms of peripheral T cell tolerance.

Peripheral tolerance to self proteins is induced because these antigens are presented to T lymphocytes under conditions that do not allow effective immune responses to develop, or because the responses of the specific T cells are tightly regulated. The two principal mechanisms of peripheral tolerance are activation-induced cell death (AICD) and anergy. In CD4+ T lymphocytes, AICD is induced by repeated stimulation, with high levels of interleukin (IL)-2 production. Under these conditions, the T cells co-express Fas (CD95) and Fas ligand (FasL), and engagement of Fas triggers apoptotic death of the T cells. Mice with defects in Fas, FasL, IL-2R alpha or beta chain exhibit defects in AICD and develop autoimmune disease. The induction of T cell anergy is dependent on the recognition of B7 co-stimulators by the inhibitory T cell counter-receptor, CTLA-4. Failure of anergy is the likely basis for the fatal autoimmune disease of CTLA-4 knockout mice. The single-gene defects that result in autoimmunity are all defects in lymphocyte regulation, indicating that tolerance is often maintained by the control of lymphocyte responses to self antigen. The existence of distinct pathways of T cell tolerance suggest that different types of antigens induce tolerance by distinct mechanisms.

Helper T cell subsets: heterogeneity, functions and development.

The discovery that the nature of cytokine production by CD4+ T lymphocytes could drastically alter an immune response led to the categorization of distinct helper T cell subsets, most notably Th1 and Th2. Recent evidence suggests that such helper responses are actually quite heterogeneous and ultimately, the course of an immune response depends upon the predominance of particular cytokines. While the factors leading to the production of individual cytokines are not completely defined, it is clear that the nature and dose of antigen, location of antigen challenge, and genetic composition of the individual all play a role in the process. Elucidating the cellular and molecular pathways responsible for helper T cell differentiation will ultimately permit the manipulation of immune responses to pathogens, as well as the development of novel vaccine strategies.