Medical Mitigation Model: Quantifying the Benefits of the Public Health Response to a Chemical Terrorism Attack

The Chemical Terrorism Risk Assessment (CTRA) and Chemical Infrastructure Risk Assessment (CIRA) are programs that estimate the risk of chemical terrorism attacks to help inform and improve the US defense posture against such events. One aspect of these programs is the development and advancement of a Medical Mitigation Model—a mathematical model that simulates the medical response to a chemical terrorism attack and estimates the resulting number of saved or benefited victims. At the foundation of the CTRA/CIRA Medical Mitigation Model is the concept of stock-and-flow modeling; “stocks” are states that individuals progress through during the event, while “flows” permit and govern movement from one stock to another. Using this approach, the model is able to simulate and track individual victims as they progress from exposure to an end state. Some of the considerations in the model include chemical used, type of attack, route and severity of exposure, response-related delays, detailed treatment regimens with efficacy defined as a function of time, medical system capacity, the influx of worried well individuals, and medical countermeasure availability. As will be demonstrated, the output of the CTRA/CIRA Medical Mitigation Model makes it possible to assess the effectiveness of the existing public health response system and develop and examine potential improvement strategies. Such a modeling and analysis capability can be used to inform first-responder actions/training, guide policy decisions, justify resource allocation, and direct knowledge-gap studies.     

Effects of Communities That Care on the Adoption and Implementation Fidelity of Evidence-Based Prevention Programs in Communities: Results from a Randomized Controlled Trial

This paper describes findings from the Community Youth Development Study (CYDS), a randomized controlled trial of the Communities That Care (CTC) prevention system, on the adoption and implementation fidelity of science-based prevention programming in 24 communities. Data were collected using the Community Resource Documentation (CRD), which entailed a multi-tiered sampling process and phone and web-based surveys with directors of community-based agencies and coalitions, school principals, service providers, and teachers. Four years after the initiation of the CTC prevention system, the results indicated increased use of tested, effective prevention programs in the 12 CTC intervention communities compared to the 12 control communities, and significant differences favoring the intervention communities in the numbers of children and families participating in these programs. Few significant differences were found regarding implementation quality; respondents from both intervention and control communities reported high rates of implementation fidelity across the services provided.     

Mapping glycan-mediated galectin-3 interactions by live cell proximity labeling

Galectin-3 is a glycan-binding protein (GBP) that binds β-galactoside glycan structures to orchestrate a variety of important biological events, including the activation of hepatic stellate cells and regulation of immune responses. While the requisite glycan epitopes needed to bind galectin-3 have long been elucidated, the cellular glycoproteins that bear these glycan signatures remain unknown. Given the importance of the three-dimensional (3D) arrangement of glycans in dictating GBP interactions, strategies that allow the identification of GBP receptors in live cells, where the native glycan presentation and glycoprotein expression are preserved, have significant advantages over static and artificial systems. Here we describe the integration of a proximity labeling method and quantitative mass spectrometry to map the glycan and glycoprotein interactors for galectin-3 in live human hepatic stellate cells and peripheral blood mononuclear cells. Understanding the identity of the glycoproteins and defining the structures of the glycans will empower efforts to design and develop selective therapeutics to mitigate galectin-3–mediated biological events.

The noncovalent interactions between glycan-binding proteins (GBPs) and glycans dictate many important biological events. Among such GBPs is galectin-3, a 26-kDa β-galactoside GBP that plays key roles in many physiological and pathological events (1). In hepatic fibrosis, a disease that manifests as the excessive buildup of scar tissue, liver-resident macrophages secrete galectin-3 (2, 3), which then binds cell surface glycans on quiescent hepatic stellate cells (HSCs), activating them to transdifferentiate into a muscle-like phenotype. Galectin-3–null mice exhibit attenuated liver fibrosis even after induced injury, highlighting its critical role (3). Galectin-3 is also known to interact with cells of the innate immune system (4, 5) to regulate apoptosis (6) or control dendritic cell differentiation (7). In these cases, as well as in other cases in which galectin-3 is involved, the full complement of interacting glycoprotein receptors remains unknown.Despite significant advances in glycoscience, the study of GBP–glycan interactions and the identification of glycan-mediated counter-receptors remains a recurring challenge. Capturing these binding events often requires some form of artificial reconstitution to amplify individually weak interactions into high-avidity binding. Indeed, glycan microarrays with defined mixtures of homogenous glycans or recombinant GBPs have significantly propelled our understanding of glycan-mediated function (8). Conventional immunoprecipitation and lectin affinity techniques using cell lysates have similarly been used to reveal an initial catalog of 100 to 185 galectin-3–associated proteins (9–14). However, these manipulations alter the cell’s native and three-dimensional (3D) configuration and multivalent arrangement, both of which are critically important in the study of GBP–glycan interactions (15, 16).Another key issue involves the underlying glycoprotein ligand. Although many glycoproteins carry the glycan epitope for binding a GBP, only a limited set should be recognized as physiologically relevant receptors, owing to the physical constraints imposed by the living cell (17). While often overlooked, the glycoprotein carrying the glycan can impart specific biological functions to a GBP–glycan binding event (17). Recent work has put forth the concept of “professional glycoprotein ligands,” in which a specific set of glycoproteins (instead of a broadly defined glycome) can exhibit exquisite binding and functional roles (18). Thus, determining the identity of the underlying core protein that anchors the glycan can be greatly empowering. Not only can it provide an understanding of the 3D arrangement of the glycan (if the 3D structure of the core protein is known), but it can also provide additional insight into its expression levels in different cell types and tissues, further informing strategies for selective drug development.Thus, comprehensive approaches that permit the study of GBP–glycan interactions in live cells while simultaneously facilitating identification of the physiological glycoprotein receptors have great potential to impact glycoscience. We hypothesize that proximity labeling strategies (19) using an engineered ascorbate peroxidase, APEX2 (20), could be compatible for elucidating glycan-mediated GBP–glycoprotein interactions. In this approach (Fig. 1), APEX2 is fused to a protein of interest, followed by the treatment of cells with biotin-phenol and subsequently with hydrogen peroxide (H₂O₂). Under these conditions, APEX2 catalyzes the formation of highly reactive, short-lived (<1 ms), and proximally restricted (<20 nm) biotin-phenoxyl radicals that covalently tag nearby electron-rich residues. The biotinylated proteins can then be enriched and identified using quantitative mass spectrometry (MS)-based proteomics. Because the (glyco)proteins adjacent to the APEX2 fusion protein are preferentially biotinylated, the resulting MS data provide a readout of its immediate environment.Open in a separate windowFig. 1.Schematic illustration of the identification of galectin-3 (Gal-3) interacting proteins by in situ proximity labeling. Recombinant APEX2 and galectin-3 fusion proteins are applied to living cells where galectin-3 can freely diffuse to bind its cognate ligands. On addition of biotin phenol (yellow circle with “B”; 30 min) and hydrogen peroxide (H₂O₂; 1 min), APEX2 catalyzes the formation of highly-reactive biotin-phenoxyl radicals that react within a short range (<20 nm) of the galectin-3 complex within a short time frame (<1 ms). The biotin-tagged protein interactors can then be identified using MS-based proteomics.We reasoned that proximity labeling could offer significant advantages over other approaches to determining GBP–glycan interactions, including the opportunity to perform the labeling in live cells and the ability to tag weakly bound glycan-mediated interactors, as the covalent biotinylation reaction ensures that the enrichment step no longer relies on weak GBP–glycan interactions alone. When coupled with inhibitors, the proximity labeling strategy can also distinguish between glycan-mediated and non–glycan-mediated interactors. Integration of this approach with quantitative MS-based proteomics would also expedite the assignment of the interacting proteins and provide calculable measures to distinguish interactors from nonspecific binders.Here we report that the use of an APEX2 and galectin-3 fusion protein (PX-Gal3) provides a sensitive and comprehensive approach to mapping the proteome-wide glycan-mediated galectin-3 interactome in live human HSCs and peripheral blood mononuclear cells (PBMCs). We found that the exogenous incubation of cells with PX-Gal3 in HSCs leads to glycan-dependent interactions, whereas its cellular overexpression does not. We further validated the interactions between galectin-3 and candidate proteins in vitro and discovered that some proteins are direct glycan-mediated receptors. Using MS-based glycomics, we also examined the glycomes of HSC surfaces, PX-Gal3 tagged glycoproteins, and an individual glycoprotein receptor for galectin-3. Our results highlight the utility of the in situ proximity labeling approach in discovering physiologically relevant GBP interactors in living cells.     

Comparison of the risk of fatal coronary heart disease in treated xanthomatous and non-xanthomatous heterozygous familial hypercholesterolaemia: a prospective registry study

BACKGROUND: A clinical diagnosis of familial hypercholesterolaemia (FH) is often made in the absence of tendon xanthomata (TX), which are not usually present before the fourth decade of life. The prognosis of treated non-xanthomatous (TX-) FH is uncertain and the objective of this study was to compare mortality from coronary heart disease (CHD) in patients with treated TX+ (definite) and TX- (possible) heterozygous FH. METHODS: A diagnosis of definite or possible FH was based on raised cholesterol levels (>7.5 mmol/l) and a family history of premature CHD or hypercholesterolaemia. Patients were recruited from 21 outpatient lipid clinics in the UK from 1980 to 1998. The cohort of 1569 patients with TX+ FH were followed for 12754 person years and the cohort of 1302 patients with TX- FH for 10238 person years. The standardised mortality ratio (SMR) was calculated from the ratio of the number of deaths observed to the number expected in the general population of England and Wales (SMR=100 for reference population). FINDINGS AND DISCUSSION: CHD accounted for 64 (63%) of the 102 deaths in the TX+ cohort and 38 (57%) of the 67 deaths in the TX- cohort with the SMR for a fatal coronary event being, respectively, 294 (95% confidence interval 228, 380, P<0.00001) and 205 (95% CI 145, 282, P=0.0001). The similarly elevated CHD mortality risk suggests that, in adulthood, both groups of patients should be treated equally aggressively with HMG Co A reductase inhibitors (statins).     

Autonomic dysreflexia resulting from prolapsed hemorrhoids

PURPOSE: This article reports a case of autonomic dysreflexia associated with hemorrhoidal disease in a patient with high spinal cord lesions and successful treatment by surgical hemorrhoidectomy. METHODS: Following an unsuccessful attempt at conservative treatment which included bulk agents and warm compresses, the patient subsequently underwent three-column, closed surgical hemorrhoidectomy. RESULTS: The patient was symptom free and had normal bowel activity six weeks postoperatively, and five-year follow-up showed no recurrence of the hemorrhoidal prolapse or dysreflexia. CONCLUSION: Carefully controlled hemorrhoidectomy, when conservative measures fail, may be effective in managing autonomic dysreflexia in high spinal cord transection patients when prolapse serves as the stimulus.