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Introduction: Overt Hepatic Encephalopathy (OHE) is an integral clinical syndrome in decompensated cirrhosis with significant morbidity. Recurrent hospitalization carries Hospital-acquired infections with threatens risk and further decompensation. Imposes hazards: driving skill, domestic affair, social conduct affecting Global QOL score. Rifaximin, lactulose, Metronidazole and are existing therapy of choice. Several others have been postulated: LOPA, Probiotics, Rivastigmine with moderate efficacy. This clinical trial will evaluate the added efficacy and shorten the course of Rifaximin in clinically OHE. Methods: Overt Hepatic Encephalopathy patients recruited in three groups: A single center: dedicated Psychologist, Dedicated lab; single driving instructor, 3 arm study (groups A, B, and C), n=20 in each. Group A=Rifaximin 550mg BID,BCAA (Branched Chain Amino Acids) x 3 months Group B=Rifaximin 550mg BID,Bovine IG x 3 months Group C=Rifaximin 550mg BID,Bovine IG,BCAA x 3 months Exclusion Criteria: MELD 23 or greater, Uncontrolled DM, SBP Severe Constipation HCC CDAD Active drug or Alcohol use On DAAs therapy PBC PSC Schistosoma AIH Post-Transplant HBV HIV Results: Table 1 Primary Endpoint Global Encephalopathy score Group A median 43% Group B median 63% Group C median 66% Secondary Endpoint impaired Social skill (driving test) Group A median 21% Group B median 33% Group C median 31% Recurrent Hospitalization Time in six months Group A median 65% Group B median 68% Group C median 71% Conclusion: For morbidity in CLF and ACLF with Cognitive and Psychosocial impairment rifaximin is the standard of care. Oral Bovine Immunoglobulin has been used as gut sterilizer and generates Gut specific immune Restitution. This study evaluates adding Oral Bovine immunoglobulin in OHE and concludes that it is not beneficial over the standard of care and not cost effective.

Therapeutic human polyclonal antibodies (hpAbs) derived from pooled plasma from human donors are Food and Drug Administration approved biologics used in the treatment of a variety of human diseases. Powered by the natural diversity of immune response, hpAbs are effective in treating diseases caused by complex or quickly-evolving antigens such as viruses. We previously showed that transchromosomic (Tc) cattle carrying a human artificial chromosome (HAC) comprising the entire unrearranged human immunoglobulin heavy-chain (hIGH) and kappa-chain (hIGK) germline loci (named as κHAC) are capable of producing functional hpAbs when both of the bovine immunoglobulin mu heavy-chains, bIGHM and bIGHML1, are homozygously inactivated (double knockouts or DKO). However, B lymphocyte development in these Tc cattle is compromised, and the overall production of hpAbs is low. Here, we report the construction of an improved HAC, designated as cKSL-HACΔ, by incorporating all of the human immunoglobulin germline loci into the HAC. Furthermore, for avoiding the possible human-bovine interspecies incompatibility between the human immunoglobulin mu chain protein (hIgM) and bovine transmembrane α and β immunoglobulins (bIgα and bIgβ) in the pre-B cell receptor (pre-BCR) complex, we partially replaced (bovinized) the hIgM constant domain with the counterpart of bovine IgM (bIgM) that is involved in the interaction between bIgM and bIgα/Igβ; human IgM bovinization would also improve the functionality of hIgM in supporting B cell activation and proliferation. We also report the successful production of DKO Tc cattle carrying the cKSL-HACΔ (cKSL-HACΔ/DKO), the dramatic improvement of B cell development in these cattle and the high level production of hpAbs (as measured for the human IgG isotype) in the plasma. We further demonstrate that, upon immunization by tumor immunogens, high titer tumor immunogen-specific human IgG (hIgG) can be produced from such Tc cattle.

Polymeric immunoglobulin receptor (pIgR), the transmembrane transporter of polymeric immunoglobulin A and M, has multiple immune functions. To explore the characteristics of pIgR expression in Bactrian camel lungs, twelve healthy adult (2-7 years old) Bactrian camels were systematically studied. The results showed that pIgR was mainly expressed in the cytoplasm and membrane of ciliated cells, as well as in the cytoplasm and membrane of basal cells, serous cells of bronchial glands, club cells and alveolar type 2 cells in Bactrian camel lungs. Specially, as the bronchial branches extended, the pIgR expression level in ciliated cells significantly declined (p<0.05), and the corresponding bronchial luminal areas obviously decreased (p<0.05). However, pIgR was not expressed in goblet cells, endocrine cells, alveolar type 1 cells and mucous cells of bronchial glands. The results demonstrated that ciliated cells continuously distributed throughout the whole bronchial tree mucosa were the major expression sites of pIgR, and pIgR was also expressed in basal cells, serous cells of bronchial glands, club cells and alveolar type 2 cells, which would facilitate secretory immunoglobulin A (SIgA) transmembrane transport by pIgR and form an intact protective barrier. Moreover, the pIgR expression level in ciliated cells was positively correlated with the bronchial luminal areas; but negatively correlated with the cleanliness of airflow through the bronchial cross-sections, showing that the pIgR expression level in the bronchial epithelium was inhomogeneous. Our study provided a foundation for further exploring the regulatory functions of immunoglobulins (i.e., SIgA) after transport across the membrane by pIgR in Bactrian camel lungs.

IntroductionMyasthenia gravis (MG) is an antibody-mediated autoimmune disease of neuromuscular transmission. 6 to 12 percent of MG are negative for acetyl choline receptor (AChR) and MuSK antibodies and are defined as seronegative MG. Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune condition with antibodies to presynaptic voltage-dependent calcium channelCaseA 39 year old male presented with blurred vision and right-sided ptosis. Initial examination showed a pupil-sparing left complete third nerve palsy. Demyelination and intracranial aneurysms were ruled out with gadolinium-enhanced MRI/MRA. Outpatient follow-up 2 weeks later showed new onset proximal muscle weakness of the upper limbs with fatigability and a complex ophthalmoplegia with almost complete paralysis of gaze. A repeat MRI with gadolinium and CSF analysis were normal. His AChR and MuSK antibodies were negative; however, voltage-dependent calcium channel antibodies, ANA, dsDNA, and SSA were positive. Initial nerve conduction tests were normal, but repeat NCS on two separate occasions showed decrement on repetitive stimulation in the right trapezius with no evidence of facilitation post exercise. CT chest, abdomen and pelvis was normal. He improved with pulsed steroids and was discharged on a tapering dose of oral steroids, pyridostigmine and regular IVIG infusions as a steroid-sparing agent.ConclusionLambert-Eaton myasthenic syndrome shares the same pathologic site and similar pathophysiology with MG but has a markedly different clinical and electro-physiological picture. There are reports of MG and LEMS overlap syndrome, however, they exhibit phenotypic characteristics of both LEMS and MG. Voltage-dependent calcium channel antibodies have not been described in patients with seronegative MG. Ours is potentially the first reported case of seronegative myasthenia with voltage-dependent calcium channel antibodies and only clinical and neurophysiological features of MG.

IntroductionWe analysed the efficacy and safety of IVIG IgPro10 (CSL Behring) in two CIDP studies: PRIMA and PATH.MethodsPRIMA was a prospective, open-label, single-arm study in 28 CIDP patients (n=13 IVIG-pretreated; n=15 untreated) investigating efficacy and safety of IgPro10 for induction (2 g/kg) and maintenance therapy (1 g/kg every 3 weeks for 21 weeks). This regimen was also used for 207 IVIG-pretreated patients during the 10–13 week pre-randomization phase of the PATH study (before randomization to subcutaneous immunoglobulin maintenance therapy or placebo). Both studies investigated a 1-point decrease in adjusted Inflammatory Neuropathy Cause and Treatment (INCAT) disability score as a response parameter, and evaluated changes in mean grip strength and Medical Research Council (MRC) score. Treatment-emergent adverse events (AEs) were assessed.ResultsResponse rate was 76.9% (95% confidence interval [CI] 49.7–91.8) in PRIMA (IVIG-pretreated patients) at week 21% and 72.9% (95%CI 66.5–78.5) in PATH at week 13; median time to first INCAT response was 3.0 and 3.7 weeks, respectively. Median (Q1;Q3) improvements in outcome measures (baseline to last observation) for PRIMA pre-treated patients and PATH, respectively, were: INCAT, −2.0 (-3.0;−1.0) and −1.0 (-2.0;0.0) points; grip strength, 5.0 (-9.0;22.0) and 9.4 (1.3;18.8) kPa; and MRC score, 5.0 (3.0;10.0) and 3.0 (0.0;6.0) points. In the PRIMA safety population (n=28), 108 AEs occurred in 22 (78.6%) patients (0.417/infusion); 284 AEs in 100 (48.3%) patients (0.175/infusion) were reported in the PATH safety population (n=207). Headache was the most frequent AE. Causally related serious AEs in PRIMA and PATH occurred in 2 and 7 patients, respectively.ConclusionSimilar efficacy results of IgPro10 in CIDP were observed in PRIMA and the PATH pre-randomization period. IgPro10 is well tolerated, with clinically meaningful improvement in disability in CIDP patients.Study SupportCSL Behring

Disialoysl antibodies target the paired alpha-2–8 linked sialic acid residues found on gangliosides such as GQ1b, GT1b and GD1b. They are associated with specific inflammatory neuropathies – notably Miller Fisher syndrome (MFS) and CANOMAD, which are characterised clinically by sensory and cerebellar ataxia, ophthalmoplegia and areflexia. However, the pathological relevance and topographical targets of disialosyl antibodies in these conditions remain a subject of debate. We used sensory neurons derived from human induced pluripotent stem cells to investigate this area. In co-culture with Schwann cells, myelination occurs and nodes of Ranvier form. In this system, disialosyl antibodies target the nodal axolemma and also bind unmyelinated fibres. When the paranodal junction protein CASPR is disrupted, antibodies penetrate into the internodal region. Incubation with antibody followed by a source of complement results in a neuronal calcium spike followed by acute axonal blebbing and degeneration. In prolonged cultures, the presence of disialosyl antibodies both impairs myelination and induces demyelination. In assays using microfluidic chambers, disialosyl antibodies impair the extent of axonal regeneration at 24 hours. These assays thus reveal the pleiotropic effects of disialosyl antibodies. The utility of this culture system for further investigating MFS, CANOMAD and other inflammatory neuropathies is clearly demonstrated.

It is well established that high doses of monomeric immunoglobulin G (IgG) purified from pooled human plasma [intravenous immunoglobulin (IVIG)] confer anti-inflammatory activity in a variety of autoimmune settings. However, exactly how those effects are mediated is not clear because of the heterogeneity of IVIG. Recent studies have demonstrated that the anti-inflammatory activity of IgG is completely dependent on sialylation of the N-linked glycan of the IgG Fc fragment. Here we determine the precise glycan requirements for this anti-inflammatory activity, allowing us to engineer an appropriate IgG1 Fc fragment, and thus generate a fully recombinant, sialylated IgG1 Fc with greatly enhanced potency. This therapeutic molecule precisely defines the biologically active component of IVIG and helps guide development of an IVIG replacement with improved activity and availability.

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Introduction The bronchial mucosa is protected by a specialized immune system focused on the prevention of colonization and infection by potentially pathogenic microorganisms (PPMs), being immunoglobulin A (IgA) the principal immunoglobulin and a key element in this mechanism. Methods Levels of specific IgA for PA in sputum were determined by ELISA, and expressed as a ratio using as reference the level of 10 healthy subjects (Optical Density (OD10 patients/OD450 controls).

Transcytosis of polymeric IgA and IgM from the basolateral surface to the apical side of the epithelium and subsequent secretion into mucosal fluids are mediated by the polymeric immunoglobulin receptor (pIgR). Secreted IgA and IgM have vital roles in mucosal immunity in response to pathogenic infections. Binding and recognition of polymeric IgA and IgM by pIgR require the joining chain (J chain), a small protein essential in the formation and stabilization of polymeric Ig structures. Recent studies have identified marginal zone B and B1 cell-specific protein (MZB1) as a novel regulator of polymeric IgA and IgM formation. MZB1 might facilitate IgA and IgM transcytosis by promoting the binding of J chain to Ig. In this review, we discuss the roles of pIgR in transcytosis of IgA and IgM, the roles of J chain in the formation of polymeric IgA and IgM and recognition by pIgR, and focus particularly on recent progress in understanding the roles of MZB1, a molecular chaperone protein.