It is well documented that the density of Plasmodium in its vertebrate host modulates the physiological response induced; this in turn regulates parasite survival and transmission. It is less clear that parasite density in the mosquito regulates survival and transmission of this important pathogen. Numerous studies have described conversion rates of Plasmodium from one life stage to the next within the mosquito, yet few have considered that these rates might vary with parasite density. Here we establish infections with defined numbers of the rodent malaria parasite Plasmodium berghei to examine how parasite density at each stage of development (gametocytes; ookinetes; oocysts and sporozoites) influences development to the ensuing stage in Anopheles stephensi, and thus the delivery of infectious sporozoites to the vertebrate host. We show that every developmental transition exhibits strong density dependence, with numbers of the ensuing stages saturating at high density. We further show that when fed ookinetes at very low densities, oocyst development is facilitated by increasing ookinete number (i.e., the efficiency of ookinete–oocyst transformation follows a sigmoid relationship). We discuss how observations on this model system generate important hypotheses for the understanding of malaria biology, and how these might guide the rational analysis of interventions against the transmission of the malaria parasites of humans by their diverse vector species.

BackgroundDaily mortality is an important determinant of a vector's ability to transmit pathogens. Original simplifying assumptions in malaria transmission models presume vector mortality is independent of age, infection status and parasite load. Previous studies illustrate conflicting evidence as to the importance of Plasmodium-induced vector mortality, but very few studies to date have considered the effect of infection density on mosquito survival.MethodsA series of three experiments were conducted, each consisting of four cages of 400-1,000 Anopheles stephensi mosquitoes fed on blood infected with different Plasmodium berghei ookinete densities per microlitre of blood. Twice daily the numbers of dead mosquitoes in each group were recorded, and on alternate days a sample of live mosquitoes from each group were dissected to determine parasite density in both midgut and salivary glands.ResultsSurvival analyses indicate that mosquito mortality is both age- and infection intensity-dependent. Mosquitoes experienced an initially high, partly feeding-associated, mortality rate, which declined to a minimum before increasing with mosquito age and parasite intake. As a result, the life expectancy of a mosquito is shown to be dependent on both insect age and the density of Plasmodium infection.ConclusionThese results contribute to understanding in greater detail the processes that influence sporogony in the mosquito, indicate the impact that parasite density could have on malaria transmission dynamics, and have implications for the design, development, and evaluation of transmission-blocking strategies.

The utility of using evolutionary and ecological frameworks to understand the dynamics of infectious diseases is gaining increasing recognition. However, integrating evolutionary ecology and infectious disease epidemiology is challenging because within-host dynamics can have counterintuitive consequences for between-host transmission, especially for vector-borne parasites. A major obstacle to linking within- and between-host processes is that the drivers of the relationships between the density, virulence, and fitness of parasites are poorly understood. By experimentally manipulating the intensity of rodent malaria (Plasmodium berghei) infections in Anopheles stephensi mosquitoes under different environmental conditions, we show that parasites experience substantial density-dependent fitness costs because crowding reduces both parasite proliferation and vector survival. We then use our data to predict how interactions between parasite density and vector environmental conditions shape within-vector processes and onward disease transmission. Our model predicts that density-dependent processes can have substantial and unexpected effects on the transmission potential of vector-borne disease, which should be considered in the development and evaluation of transmission-blocking interventions.

BackgroundThe combined effects of multiple density-dependent, regulatory processes may have an important impact on the growth and stability of a population. In a malaria model system, it has been shown that the progression of Plasmodium berghei through Anopheles stephensi and the survival of the mosquito both depend non-linearly on parasite density. These processes regulating the development of the malaria parasite within the mosquito may influence the success of transmission-blocking interventions (TBIs) currently under development.MethodsAn individual-based stochastic mathematical model is used to investigate the combined impact of these multiple regulatory processes and examine how TBIs, which target different parasite life-stages within the mosquito, may influence overall parasite transmission.ResultsThe best parasite molecular targets will vary between different epidemiological settings. Interventions that reduce ookinete density beneath a threshold level are likely to have auxiliary benefits, as transmission would be further reduced by density-dependent processes that restrict sporogonic development at low parasite densities. TBIs which reduce parasite density but fail to clear the parasite could cause a modest increase in transmission by increasing the number of infectious bites made by a mosquito during its lifetime whilst failing to sufficiently reduce its infectivity. Interventions with a higher variance in efficacy will therefore tend to cause a greater reduction in overall transmission than a TBI with a more uniform effectiveness. Care should be taken when interpreting these results as parasite intensity values in natural parasite-vector combinations of human malaria are likely to be significantly lower than those in this model system.ConclusionsA greater understanding of the development of the malaria parasite within the mosquito is required to fully evaluate the impact of TBIs. If parasite-induced vector mortality influenced the population dynamics of Plasmodium species infecting humans in malaria endemic regions, it would be important to quantify the variability and duration of TBI efficacy to ensure that community benefits of control measures are not overestimated.

IntroductionThe gold standard in general radiography is to place a radiopaque anatomical side marker in the field of view for each radiographic image prior to exposure. The advent of digital radiography has allowed for anatomical side markers to be digitally added to films as part of post‐processing. The aim of this audit was to identify whether general X‐ray images performed in a tertiary Women's and Children's Hospital were being appropriately annotated with a definitive side marker, and to identify factors that may contribute to inappropriately labelled images.MethodsFour hundred images from 201 patients’ examinations occurring within a randomly selected time period were assessed to ascertain whether radiographic anatomical side markers were visible when images were viewed via the hospitals main viewing platform. The audit occurred in January 2014. The scope included both mobile and in‐department general X‐ray examinations, with the patient age range extending from 1 day to 18 years.ResultsOf the 400 images evaluated, 88 (22%) were found to have a lead marker that matched the anatomy being imaged within the primary beam; 289 (72.3%) images contained a correct digital marker inserted as part of the post‐processing of the image. In total, 377 (94.2%) images were appropriately marked. Of the 23 (5.8%) images not marked correctly, 22 images had no marker and 1 was incorrectly marked with a digital marker. There was a noticeable relationship between absent anatomical markers and chest X‐rays performed outside of the medical imaging department.ConclusionsWhile it is encouraging that the majority of the images assessed were correctly annotated, with only a small number of missing markers, there are opportunities for further improvement. The audit findings suggest that reduced access to lead markers influences marker use. Strategies that may improve compliance at an individual level include distribution of personalised anatomical side markers, and targeted staff education sessions. At a department level, regular audits and monitoring should be encouraged.

The impact of parasite density on malaria transmission remains unclear. We investigated sporogony temporal dynamics and the effect of parasite density on these dynamics. A series of experiments was conducted in which cages of mosquitoes were fed on blood containing a range of ookinete densities. Samples of surviving mosquitoes were dissected over time post-feeding to count oocyst and sporozoite numbers. Results reveal a humped (convex) pattern of oocyst numbers and suggest that transition rates between sporogony stages are density dependent. This has implications for the design of parasite-mosquito interface studies and the development of transmission-blocking strategies.

Objective: This study focused on describing local trends in sugar-sweetened beverage (SSB) consumption, including variations between subgroups, to inform equitable health policy to curb soft drink consumption. Methods: Weighted data were obtained from the South Australian Monitoring and Surveillance System, a state-based population health survey that monitors trends in health risk factors and chronic disease via computer-assisted telephone interviewing. From 2008 onwards, participants provided an estimate of the average amount of soft drink they consumed per day. Results: From 2008-2017, there were significant decreases in the proportion of adults who consumed any SSBs, but the mean consumption per consumer increased. High-risk dietary and lifestyle behaviours are the strongest predictors for consumption of soft drink, but there is also a significant association with socioeconomic status. Conclusions: Population trends mask increasing inequity. There is a societal trend away from the consumption of SSBs across all subgroups, but at-risk groups who engage in clusters of unhealthy behaviours remain high consumers. Implications for public health: The identification of at-risk populations allows research to focus more precisely on the structural barriers, beliefs, attitudes and facilitators of ongoing consumption of SSB in order to inform future health promotion efforts.

This article provides a detailed account of how to monitor and record neurological observations. It outlines the importance of neurological observations in acutely ill patients and focuses on carrying out observations using the Glasgow Coma Scale.