January 14, 2016
The central figure in the American TV series Dr. House is a doctor who is brilliant in the diagnosis of unusual medical conditions but personally very difficult. When I first saw this series I found the character so unpleasant that I did not want to watch the programme. However in the course of time I got drawn in to watching it by the interest of the medical content. While some aspects of this series are quite exaggerated and far from reality the medical parts are very accurate and well researched. As I learned yesterday even details seen there like the numbers on heart monitors accurately reflect the situation being portrayed. I have this information from a lecture I attended yesterday at the Medizinische Gesellschaft Mainz [Mainz Medical Society]. The speaker was Professor Jürgen Schäfer, a man who has become known in the media as the German Dr. House. I am pleased to report that I detected no trace of the social incompetence of Dr. House in Dr. Schäfer.
Jürgen Schäfer is trained as a cardiologist. He and his wife, who is a gastroenterologist, got so interested by the series Dr. House that they would spend time discussing the details of the diagnoses and researching the background after they has seen each programme. Then Schäfer had the idea that he could use Dr. House in his lectures at the University of Marburg. The first obstacle was to know if he could legally make use of this material. After a casual conversation with one of his patients who is a lawyer he contacted the necessary people and signed a suitable contract. At this time his project attracted considerable attention in the media even before it had started. In the lectures he analyses the cases occurring in the series. The students are encouraged to develop their own diagnoses in dialogue with the professor. These lectures are held in the evenings and are very popular with the students. In the evaluations the highest score was obtained for the statement that ‘the lectures are a lot of fun’.
This is only the start of the story. During a consultation in one of the episodes of Dr. House he suddenly makes a deep cut with a scalpel in the body of the patient (one of the melodramatic elements), opens the wound and shows that the flesh inside is black. The diagnosis is cobalt poisoning. After seeing this it occurred to Dr. Schäfer that this diagnosis might also apply to one of his own patients and this turned out to be true. In addition to serious heart problems this patient was becoming blind and deaf. He had had a hip joint replacement with an implant made of a ceramic material. At some point this became damaged and was replaced. In order to try to avoid the implant breaking again the new one was made of metal. The old implant fragmented and left splitters in the body. These had acted like sandpaper on the new joint and at the time of removal it had been reduced to 70% of its original size by this process. As a result large quantities of cobalt was released, resulting in the poisoning. The speaker showed a picture of the operation of another of his patients with a similar problem where the wound could be seen to be filled with a black oily liquid. Together with colleagues Schäfer published an account of this case in The Lancet with the title ‘Cobalt intoxication diagnosed with the help of Dr. House’. Not all his coauthors were happy with this title but Schäfer wanted to acknowledge his debt to the series. At the same time it was a great piece of advertizing for him which lead to a lot of attention in the international media.
Due to his growing fame Schäfer started to get a lot of letters from patients with mysterious illnesses. This was more than he could handle. He informed the administration of the university clinic where he worked that he was going to start sending back letters of this type unopened, since he just did not have the time to cope with them. To his surprise they wanted him to continue with this work and arranged from him to be relieved from other duties. They set up a new institute for him called Zentrum für unerkannte Krankheiten [centre for unrecognized diseases]. This was perhaps particularly surprising since this is a privately funded clinic and the work of this institute costs money rather than making money. The techniques used there include toxicological and genomic analyses.
Here is another example from the lecture. Schäfer’s institute uses large scale DNA analysis to screen for a broad range of parasites in patients with unclear symptoms. In one patient they found DNA of the parasite causing schistosomiasis. This disease is usually got by bathing in infected water in tropical or subtropical areas. The patient tested negatively for the parasite and had never been to a place where this disease occurs. The mystery was cleared up due to the help of a vet of Egyptian origin. He was familiar with schistosomiasis and due to his experience with large animals he was not afraid of analysing very large stool samples. He succeeded in finding eggs of the parasite in the patient’s stool. The diffculty was that the numbers of eggs were very low and that for certain reasons they were difficult to recognise in this case, except by an expert. The patient was treated for schistosomiasis as soon as the genetic results were available but it was very satisfying to have a confirmation by more classical techniques. The mystery of how the patient got infected was solved as follows. As a hobby he kept lots of fish and he imported these from tropical regions. The infection presumably came from the water in his aquarium. We see that in the modern world it is easy to import tropical diseases by express delivery after placing an order in the internet
I do not want to end before mentioning that Schäfer said something nice about how mathematicians can help medical doctors. He had a patient who is a mathematics professor and had the following problem. From time to time he would collapse and was temporarily paralysed although fully conscious. A possible explanation for this would have been an excessively high level of sodium in the body. On the other hand measurements showed that the concentration of sodium in his blood was normal, even after an attack. The patient then did a calculation (just simple arithmetic). On the basis of known data he worked out the amount of sodium and potassium in different types of food and noted a correlation between negative effects of a food on his health and the ratio of the sodium to potassium concentrations. This supported the hypothesis of sodium as a cause and encouraged the doctors to look more deeply into the matter. It turned out that in this type of disease the sodium is concentrated near the cell membrane and cannot be seen in the blood. A genetic analysis revealed that the patient had a mutation in a little-known sodium channel.
I think that this lecture was very entertaining for the audience, including my wife and myself. However this is not just entertainment. With his institute Schäfer is providing essential help for many people in very difficult situations. He has files of over 4000 patients. This kind of work requires a high investment in time and money which is not possible for a usual university clinic, not to mention an ordinary GP. It is nevertheless the case that Schäfer is developing resources which could be used more widely, such as standard protocols for assessing patients of this type. As he emphasized, while by definition a rare disease only effects a small number of patients the collection of all rare diseases together affects a large number of people. If more money was invested in this kind of research it could result in a net saving for the health system since it would reduce the number of people running from one doctor to another since they do not have a diagnosis.
November 23, 2015
I discussed the deficiency zero theorem of chemical reaction network theory (CRNT) in a previous post. (Some further comments on this can be found here and here.) This semester I am giving a lecture course on chemical reaction network theory. Lecture notes are growing with the course and can be found in German and English versions on the web page of the course. The English version can also be found here. Apart from introductory material the first main part of the course was a proof of the Deficiency Zero Theorem. There are different related proofs in the literature and I have followed the approach in the classic lecture notes of Feinberg on the subject closely. The proof in those notes is essentially self-contained apart from one major input from a paper of Feinberg and Horn (Arch. Rat. Mech. Anal. 66, 83). In this post I want to give a high-level overview of the proof.
The starting point of CRNT is a reaction network. It can be represented by a directed graph where the nodes are the complexes (left or right hand sides of reactions) and the directed edges correspond to the reactions themselves. The connected components of this graph are called the linkage classes of the network and their number is usually denoted by . If two nodes can be connected by oriented paths in both directions they are said to be strongly equivalent. The corresponding equivalence classes are called strong linkage classes. A strong linkage class is called terminal if there is no directed edge leaving it. The number of terminal strong linkage classes is usually denoted by . From the starting point of the network making the assumption of mass action kinetics allows a system of ODE to be obtained in an algorithmic way. The quantity is a vector of concentrations as a function of time. Basic mathematical objects involved in the definition of the network are the set of chemical species, the set of complexes and the set of reactions. An important role is also played by the vector spaces of real-valued functions on these finite sets which I will denote by , and , respectively. Using natural bases they can be identified with , and . The vector is an element of . The mapping from to itself can be written as a composition of three mappings, two of them linear, . Here , the complex matrix, is a linear mapping from to . is a linear mapping from to itself. The subscript is there because this matrix is dependent on the reaction constants, which are typically denoted by . It is also possible to write in the form where describes the reaction rates and is the stoichiometric matrix. The image of is called the stoichiometric subspace and its dimension, the rank of the network, is usually denoted by . The additive cosets of the stoichiometric subspace are called stoichiometric compatibility classes and are clearly invariant under the time evolution. Finally, is a nonlinear mapping from to . The mapping is a generalized polynomial mapping in the sense that its components are products of powers of the components of . This means that depends linearly on the logarithms of the components of . The condition for a stationary solution can be written as . The image of is got by exponentiating the image of a linear mapping. The matrix of this linear mapping in natural bases is . Thus in looking for stationary solutions we are interested in finding the intersection of the manifold which is the image of with the kernel of . The simplest way to define the deficiency of the network is to declare it to be . A fact which is not evident from this definition is that is always non-negative. In fact is the dimension of the vector space where is the set of complexes of the network. An alternative concept of deficiency, which can be found in lecture notes of Gunawardena, is the dimension of the space . Since this vector space is a subspace of the other we have the inequality . The two spaces are equal precisely when each linkage class contains exactly one terminal strong linkage class. This is, in particular, true for weakly reversible networks. The distinction between the two definitions is often not mentioned since they are equal for most networks usually considered.
If is a stationary solution then belongs to . If (and in particular if ) then this means that . In other words belongs to the kernel of . Stationary solutions of this type are called complex balanced. It turns out that if is a complex balanced stationary solution the stationary solutions are precisely those points for which lies in the orthogonal complement of the stoichiometric subspace. It follows that whenever we have one solution we get a whole manifold of them of dimension . It can be shown that each manifold of this type meets each stoichiometric class in precisely one point. This is proved using a variational argument and a little convex analysis.
It is clear from what has been said up to now that it is important to understand the positive elements of the kernel of . This kernel has dimension and a basis each of whose elements is positive on a terminal strong linkage class and zero otherwise. Weak reversibility is equivalent to the condition that the union of the terminal strong linkage classes is the set of all complexes. It can be concluded that when the network is not weakly reversible there exists no positive element of the kernel of . Thus for a network which is not weakly reversible and has deficiency zero there exist no positive stationary solutions. This is part of the Deficiency Zero Theorem. Now consider the weakly reversible case. There a key statement of the Deficiency Zero Theorem is that there exists a complex balanced stationary solution . Where does this come from? We sum the vectors in the basis of and due to weak reversibility this gives something which is positive. Then we take the logarithm of the result. When this can be represented as a sum of two contributions where one is of the form . Then . A further part of the deficiency zero theorem is that the stationary solution in the weakly reversible case is asymptotically stable. This is proved using the fact that for a complex balanced stationary solution the function is a Lyapunov function which vanishes for
November 17, 2015
EMBL, the European Molecular Biology Laboratory, is an international institution consisting of laboratories at five sites, two in Germany, one in the UK, one in France and one in Italy. I recently attended a meeting on the theme ‘Biological Oscillators’ at the site in Heidelberg. The impressive building is in the form of a double helix. There are two spiral ramps over several stories which are linked by bridges (‘hydrogen bonds’, in German Wasserstoffbrücken). This helix provides an original setting for the poster sessions. The building is reached by ascending steep hills in the area behind the castle. I took the comfortable option of using the bus provided by the institute. This meeting had about 130 participants but I think that the capacity is much greater.
One of the most interesting talks on the first day from my point of view was by Petra Schwille from the Max Planck Institute for Biochemistry. She talked about the Min system which is used by bacteria to determine their plane of division. The idea is that certain proteins (whose identity is explicitly known) oscillate between the ends of the cell and that the plane of division is the nodal surface of the concentration of one of these. The speaker and her collaborators have been able to reconstitute this system in a cell-free context. A key role is played by the binding of the proteins to the cell membrane. Diffusion of bound proteins is much slower than that of proteins in solution and this situation of having two different diffusion constants in a coupled system is similar to the classical scenario known from the Turing instability. It sounds like modelling this system mathematically can be a lot of fun and that there is no lack of people interested in doing so.
There was also a ‘Keynote Lecture’ by Jordi Garcia-Ojalvo which lived up to the promise of its special title. The topic was the growth of a colony of Bacillus subtilis. (The published reference is Nature 523, 550.) In fact, to allow better control, the colony is constrained to be very thin and is contained in a microfluidic system which allows its environment to be manipulated precisely. A key observation is that the colony does not grow at a constant rate. Instead its growth rate is oscillatory. The speaker explained that this can be understood in terms of the competition between the cells near the edge of the colony and those in the centre. The colony is only provided with limited resources (glycerol, glutamate and salts). It may be asked which resource limits the growth rate. It is not the glycerol, which is the primary carbon source. Instead it is the glutamate, which is the primary source of nitrogen. An important intermediate compound in the use of glutamate is ammonium. If cells near the boundary of the colony produced ammonium it would be lost to the surroundings. Instead they use ammonium produced by the interior cells. It is the exterior cells which grow and they can deprive the inner cells of glutamate. This prevents the inner cells producing ammonium which is then lacking for the growth of the outer cells. This establishes a negative feedback loop which can be seen as the source of the oscillations in growth rate. The feasibility of this mechanism was checked using a mathematical model. The advantage of the set-up for the bacteria is that if the colony is exposed to damage from outside it can happen that only the exterior cells die and the interior cells generate a new colony. The talk also included a report on further work (Nature 527, 59) concerning the role of ion channels in biofilms. There are close analogies to the propagation of nerve signals and the processes taking place can be modelled by equations closely related to the Hodgkin-Huxley system.
I will now mention a collection of other topics at the conference which I found particularly interesting. One recurring theme was NFB. This transcription factor is known to exhibit oscillations. A key question is what their function is, if any. One of the pioneers in this area, Mike White, gave a talk at the conference. There were also a number of other people attending working on related topics. I do not want to go any deeper here since I think that this is a theme to which I might later devote a post of its own, if not more than one. I just note two points from White’s talk. One is that this substance is a kind of hub or bow-tie with a huge number of inputs and outputs. Another is that the textbook picture of the basic interactions of NFB is a serious oversimplification. Another transcription factor which came up to a comparable extent during the conference is Hes1, which I had never previously heard of. Jim Ferrell gave a talk about the coordination of mitosis in Xenopus eggs. These are huge cells where communication by means of diffusion would simply not be fast enough. The alternative proposed by Ferrell are trigger waves, which can travel much faster. Carl Johnson talked about mechanisms ensuring the stability of the KaiABC oscillator. He presented videos showing the binding of individual KaiA molecules to KaiC. I was was amazed that these things can be seen directly and are not limited to the cartoons to be found in biology textbooks. Other videos I found similarly impressive were those of Alexander Aulehla showing the development of early mouse embryos (segmentation clock) where it could be seen how waves of known chemical events propagating throught the tissues orchestrate the production of structures in the embryo. These pictures brought the usual type of explanations used in molecular biology to a new level of concreteness in my perception.
October 17, 2015
T cells are a class of white blood cells without which a human being usually cannot survive. An exception to this was David Vetter, a boy who lived 12 years without T cells. This was only possible because he lived all this time in a sterile environment, a plastic bubble. For this reason he became known as the bubble boy. The disease which he suffered from is called SCID, severe combined immunodeficiency, and it corresponds to having no T cells. The most common form of this is due to a mutation on the X chromosome and as a result it usually affects males. The effects set in a few months after birth. The mutation leads to a lack of the chain of the IL-2 receptor. In fact this chain occurs in several cytokine receptors and is therefore called the ‘common chain’. Probably the key to the negative effects caused by its lack in SCID patients is the resulting lack of the receptor for IL-7, which is important for T cell development. SCID patients have a normal number of B cells but very few antibodies due to the lack of support by helper T cells. Thus in the end they lack both the immunity usually provided by T cells and that usually provided by B cells. This is the reason for the description ‘combined immunodeficiency’. I got the information on this theme which follows mainly from two sources. The first is a documentary film ‘Bodyshock – The Boy in the Bubble’ about David Vetter produced by Channel 4 and available on Youtube. (There are also less serious films on this subject, including one featuring John Travolta.) The second is the chapter on X-linked SCID in the book ‘Case Studies in Immunology’ by Raif Geha and Luigi Notarangelo. I find this book a wonderful resource for learning about immunology. It links general theory to the case history of specific patients.
David Vetter had an older brother who also suffered from SCID and died of infection very young. Thus his parents and their doctors were warned. The brother was given a bone marrow transplant from his sister, who had the necessary tissue compatibility. Unfortunately this did not save him, presumably because he had already been exposed to too many infections by the time it was carried out. The parents decided to have another child, knowing that if it was a boy the chances of another case of SCID were 50%. Their doctors had a hope of being able to save the life of such a child by isolating him and then giving him a bone marrow transplant before he had been exposed to infections. The parents very soon had another child, it was a boy, he had SCID. The child was put into a sterile plastic bubble immediately after birth. Unfortunately it turned out that the planned bone marrow donor, David’s sister, was not a good match for him. It was necessary to wait and hope for an alternative donor. This hope was not fulfilled and David had to stay in the bubble. This had not been planned and it must be asked whether the doctors involved had really thought through what would happen if the optimal variant they had thought of did not work out.
At one point David started making punctures in his bubble as a way of attracting attention. Then it was explained to him what his situation was and why he must not damage the bubble. Later there was a kind of space suit produced for him by NASA which allowed him to move around outside his home. He only used it six times since he was too afraid there could be an accident. His physical health was good but understandably his psychological situation was difficult. New ideas in the practise of bone marrow transplantation indicated that it might be possible to use donors with a lesser degree of compatibility. On this basis David was given a transplant with his sister as the donor. It was not noticed that her bone marrow was infected with Epstein-Barr virus. As a result David got Burkitt’s lymphoma, a type of cancer which can be caused by that virus. (Compare what I wrote about this role of EBV here.) He died a few months after the operation, at the age of 12. Since that time treatment techniques have improved. The patient whose case is described in the book of Geha and Notarangelo had a successful bone marrow transplant (with his mother as donor). Unfortunately his lack of antibodies was not cured but this can be controlled with injections of immunoglobulin once every three weeks.
October 5, 2015
Last week I visited a few places in the US. My first stop was Morgantown, West Virginia where my host was Casian Pantea. There I had a lot of discussions with Casian and Carsten Conradi on chemical reaction network theory. This synergized well with the work I have recently been doing preparing a lecture course on that subject which I will be giving in the next semester. I gave a talk on MAPK and got some feedback on that. It rained a lot and there was not much opportunity to do anything except work. One day on the way to dinner while it was relatively dry I saw a Cardinal and I fortunately did have my binoculars with me. On Wednesday afternoon I travelled to New Brunswick and spent most of Thursday talking to Eduardo Sontag at Rutgers. It was a great pleasure to talk to an excellent mathematician who also knows a lot about immunology. He and I have a lot of common interests which is in part due to the fact that I was inspired by several of his papers during the time I was getting into mathematical biology. I also had the opportunity to meet Evgeni Nikolaev who told me a variety of interesting things. They concerned bifurcation theory in general, its applications to the kinds of biological models I am interested in and his successes in applying mathematical models to understanding concrete problems in biomedical research such as the processes taking place in tuberculosis. My personal dream is to see a real coming together of mathematics and immunology and that I have the chance to make a contribution to that process.
On Friday I flew to Chicago in order to attend an AMS sectional meeting. I had been in Chicago once before but that is many years ago now. I do remember being impressed by how much Lake Michigan looks like the sea, I suppose due to the structure of the waves. This impression was even stronger this time since there were strong winds whipping up the waves. Loyola University, the site of the meeting, is right beside the lake and it felt like home for me due to the combination of wind, waves and gulls. The majority of those were Ring-Billed Gulls which made it clear which side of the Atlantic I was on. There were also some Herring Gulls and although they might have been split from those on the other side of the Atlantic by the taxonomists I did not notice any difference. It was the first time I had been at an AMS sectional meeting and my impression was that the parallel sessions were very parallel, in other words in no danger of meeting. Most of the people in our session were people I knew from the conferences I attended in Charlotte and in Copenhagen although I did make a couple of new acquaintances, improving my coverage of the reaction network community.
In a previous post I mentioned Gheorghe Craciun’s ideas about giving the deficiency of a reaction network a geometric interpretation, following a talk of his in Copenhagen. Although I asked him questions about this on that occasion I did not completely understand the idea. Correspondingly my discussion of the point here in my blog was quite incomplete. Now I talked to him again and I believe I have finally got the point. Consider first a network with a single linkage class. The complexes of the network define points in the species space whose coordinates are the stoichiometric coefficients. The reactions define oriented segments joining the educt complex to the product complex of each reaction. The stoichiometric subspace is the vector space spanned by the differences of the complexes. It can also be considered as a translate of the affine subspace spanned by the complexes themselves. This makes it clear that its dimension is at most , where is the number of complexes. The number is the rank of the stoichiometric matrix. The deficiency is . At the same time . If there are several linkage classes then the whole space has dimension at most , where is the number of linkage classes. The deficiency is . If the spaces corresponding to the individual linkage classes have the maximal dimension allowed by the number of complexes in that class and these spaces are linearly independent then the deficiency is zero. Thus we see that the deficiency is the extent to which the complexes fail to be in general position. If the species and the number of complexes have been fixed then deficiency zero is seen to be a generic condition. On the other hand fixing the species and adding more complexes will destroy the deficiency zero condition since then we are in the case so that the possibility of general position is excluded. The advantage of having this geometric picture is that it can often be used to read off the deficiency directly from the network. It might also be used to aid in constructing networks with a desired deficiency.
September 20, 2015
A promising innovative approach to cancer therapy is to try to persuade the immune system to attack cancer cells effectively. The immune system does kill cancer cells and presumably removes many tumours which we never suspect we had. At the same time established tumours are able to successfully resist this type of attack in many cases. The idea of taking advantage of the immune system in this way is an old one but it took a long time before it became successful enough to reach the stage of an approved drug. This goal was achieved with the approval of ipilimumab for the treatment of melanoma by the FDA in 2011. This drug is a monoclonal antibody which binds the molecule CTLA4 occurring on the surface of T cells.
To explain the background to this treatment I first recall some facts about T cells. T cells are white blood cells which recognize foreign substances (antigens) in the body. The antigen binds to a molecule called the T cell receptor on the surface of the cell and this gives the T cell an activation signal. Since an inappropriate activation of the immune system could be very harmful there are built-in safety mechanisms. In order to be effective the primary activation signal has to be delivered together with a kind of certificate that action is really necessary. This is a second signal which is given via another surface molecule on the T cell, CD28. The T cell receptor only binds to an antigen when the latter is presented on the surface of another cell (an antigen-presenting cell, APC) in a groove within another molecule, an MHC molecule (major histocompatibility complex). On the surface of the APC there are under appropriate circumstances other molecules called B7.1 and B7.2 which can bind to CD28 and give the second signal. Once this has happened the activated T cell takes appropriate action. What this is depends on the type of T cell involved but for a cytotoxic T cell (one which carries the surface molecule CD8) it means that the T cell kills cells presenting the antigen. If the cell was a virus-infected cell and the antigen is derived from the virus then this is exactly what is desired. Coming back to the safety mechanisms, it is not only important that the T cell is not erroneously switched on. It is also important that when it is switched on in a justified case it should also be switched off after a certain time. Having it switched on for an unlimited time would never be justified. This is where CTLA4 comes in. This protein can bind to B7.1 and B7.2 and in fact does so more strongly than CD28. Thus it can crowd out CD28 and switch off the second signal. By binding to CTLA4 the antibody in ipilimumab stops it from binding to B7.1 and B7.2, thus leaving the activated T cell switched on. In some cases cancer cells present unusual antigens and become a target for T cells. The killing of these cells can be increased by CTLA4 via the mechanism just explained. At this point I should say that it may not be quite clear whether this is really the mechanism of action of CTLA4 in causing tumours to shrink. Alternative possibilities are mentioned in the Wikipedia article on CTLA4.
There are various things which have contributed to my interest in this subject. One is lectures I heard in the series ‘Universität im Rathaus’ [University in the Town Hall] in Mainz last February. The speakers were Matthias Theobald and Ugur Sahin and the theme was personalized cancer medicine. The central theme of what they were talking about is one step beyond what I have just sketched. A weakness of the therapy using antibodies to CTLA4 or the related approach using antibodies to another molecule PD-1 is that they are unspecific. In other words they lead to an increase not only in the activity of the T cells specific to cancer cells but of all T cells which have been activated by some antigen. This means that serious side effects are very likely. An approach which is theoretically better but as yet in a relatively early stage of development is to produce T cells which are specific for antigens belonging to the tumour of a specific patient and for an MHC molecule of that patient capable of presenting that antigen. From the talk I had the impression that doing this requires a lot of input from bioinformatics but I was not able to understand what kind of input it is. I would like to know more about that. Coming back to CTLA4, I have been interested for some time in modelling the activation of T cells and in that context it would be natural to think about also modelling the deactivating effects of CTLA4 or PD-1. I do not know whether this has been tried.