The VH repertoire and clonal diversification of B cells in myositis and vasculitis

Autoimmune inflammatory reactions occur in a number of disorders to a variety of self antigens but the precise cellular and molecular mechanisms resulting in pathology are largely unresolved. In some instances T cell mediated reactions are thought to be the main contributors to disease mechanisms but it is becoming increasingly evident that B cells, and their cognate antibodies, play a significant and contributory role in disease pathogenesis. Therefore establishing the occurrence of highly-specific B cell antigen-driven adaptive immune responses within autoimmune disorders would provide a valuable understanding into the roles of B cells within these disorders. The work of this study sought to determine the incidence of these B cell antigen-driven adaptive immune responses in the target tissues of the autoimmune disorders myositis and vasculitis, two autoimmune disorders characterised by a wide range of autoantibodies which have been implicated in the pathological mechanisms of these diseases. This study aimed to test the hypothesis that infiltrating B cells within the target tissue of myositis and vasculitis patients were being stimulated by antigen present within the tissue resulting in clonal diversification and affinity maturation mechanisms which would contribute to the pathological mechanisms of these disorders. Initially the cellular phenotypes and organisations of the inflammatory infiltrating cell population were characterised by immunohistochemical techniques, with particular interest on the infiltrating B cell and plasma cell populations. No typical ectopic germinal centre structures were observed in the target tissues from either disorder; cellular aggregations varied from loose aggregations to dense cellular follicles. Both B cell and plasma cell phenotypes were included in these infiltrating populations in correlation with varying numbers of cells positive for helper, cytotoxic and regulatory T cell, follicular dendritic cell, macrophage and proliferating cell markers. Double fluorescent labelling of B cells with the Ki67 proliferation marker indicated the possible expansion and clonal diversification of these cells within the target tissues. To address the main objective of this study and the possible antigen-driven mechanisms and active participation of these infiltrating B cells within the target tissue of these disorders, Ig gene repertoires, mutational characteristics, clonal diversification and affinity maturation were examined from infiltrating cells microdissected from areas of aggregation within the target tissues of both disorders. From the muscle infiltrating cells, Ig gene selections which were both patient and disease specific, mutational characteristics and oligoclonal expansion of B cells were observed establishing the involvement of muscle infiltrating B cells in the antigen-driven responses within inflamed muscle. Alternatively in the inflamed skin of vasculitis patients very few Ig gene rearrangements could be identified and no clonally related sequences or oligoclonal expansion of B cells were observed despite mutational characteristics indicating that antigen-driven diversification had occurred within these cells. Collectively the results indicate a role for B cells in the antigen-driven responses towards autoantigens within both disorders, either within an active antigen-driven response within the target tissue or at alternative sites resulting in cell migration into the target tissues. In the final part of this study recombinant antigens were used to identify antigen-specific B and plasma cells within the inflammatory infiltrating cell population in some cases of myositis. Pilot experiments were conducted to establish the sequence characteristics of Ig genes from these antigen-specific cells. Results of this study demonstrate the influence of B cell antigen-driven responses, either directly or indirectly, within the target tissues of myositis and vasculitis patients respectively, although the exact mechanisms leading to autoimmune reactions, and additional roles of B cells within these reactions, remain unresolved. The work presented from this study provides a foundation for further work to fully ascertain the role of B cells and antibodies within the target tissues of autoimmune disorders and in characterising the disease-associated antibodies, identifying stimulating antigens as well as assessing the effects of somatic hypermutation on the affinity and specificity of autoantigen specific antibodies. Increased understanding of B cells in these disorders will ultimately assist in the diagnosis and management of these diseases

The V_H repertoire and clonal diversification of B cells in inflammatory myopathies

The contribution of antigen-driven B-cell adaptive immune responses within the inflamed muscle of inflammatory myopathies (IMs) is largely unknown. In this study, we investigated the immunoglobulin VH gene repertoire, somatic hypermutation, clonal diversification, and selection of infiltrating B cells in muscle biopsies from IM patients (dermatomyositis and polymyositis), to determine whether B cells and/or plasma cells contribute to the associated pathologies of these diseases. The data reveal that Ig V<sub>H</sub> gene repertoires of muscle-infiltrating B cells deviate from the normal VH gene repertoire in individual patients, and differ between different types of IMs. Analysis of somatic mutations revealed clonal diversification of muscle-infiltrating B cells and evidence for a chronic B-cell response within the inflamed muscle. We conclude that muscle-infiltrating B cells undergo selection, somatic hypermutation and clonal diversification in situ during antigen-driven immune responses in patients with IMs, providing insight into the contribution of B cells to the pathological mechanisms of these disorders

A New Pathway for the Preparation of Highly Qualified Teachers: The Master of Arts in Teaching (MAT)

This article reports on the development and initial implementation of a Master of Arts in Teaching (MAT) degree, an accelerated graduate program that encourages and scaffolds individuals with existing disciplinary expertise in entering the teaching profession. First, the context for developing the program is outlined. Next, the unique structure of the 15-month program, which consists of three blocks, is described. Expectations about students are then shared, quality control features of the program are highlighted, and the lessons we learned about program development and implementation are detailed. Finally, thoughts about the future of this program and others of its type are shared based upon our experience

\u27Links2HealthierBubs\u27 cohort study: Protocol for a record linkage study on the safety, uptake and effectiveness of influenza and pertussis vaccines among pregnant Australian women

Introduction: Pregnant women and infants are at risk of severe influenza and pertussis infection. Inactivated influenza vaccine (IIV) and diphtheria-tetanus-acellular pertussis vaccine (dTpa) are recommended during pregnancy to protect both mothers and infants. In Australia, uptake is not routinely monitored but coverage appears sub-optimal. Evidence on the safety of combined antenatal IIV and dTpa is fragmented or deficient, and there remain knowledge gaps of population-level vaccine effectiveness. We aim to establish a large, population-based, multi-jurisdictional cohort of mother-infant pairs to measure the uptake, safety and effectiveness of antenatal IIV and dTpa vaccines in three Australian jurisdictions. This is a first step toward assessing the impact of antenatal vaccination programmes in Australia, which can then inform government policy with respect to future strategies in national vaccination programmes. Methods and analysis: ‘Links2HealthierBubs’ is an observational, population-based, retrospective cohort study established through probabilistic record linkage of administrative health data. The cohort includes births between 2012 and 2017 (~607 605 mother-infant pairs) in jurisdictions with population-level antenatal vaccination and health outcome data (Western Australia, Queensland and the Northern Territory). Perinatal data will be the reference frame to identify the cohort. Jurisdictional vaccination registers will identify antenatal vaccination status and the gestational timing of vaccination. Information on maternal, fetal and child health outcomes will be obtained from hospitalisation and emergency department records, notifiable diseases databases, developmental anomalies databases, birth and mortality registers. Ethics and dissemination: Ethical approval was obtained from the Western Australian Department of Health, Curtin University, the Menzies School of Health Research, the Royal Brisbane and Women’s Hospital, and the West Australian Aboriginal Health Ethics Committees. Research findings will be disseminated in peer-reviewed journals, at scientific meetings, and may be incorporated into communication materials for public health agencies and the public

Magnetic Resonance Imaging Tissue Signatures Associated With White Matter Changes Due to Sporadic Cerebral Small Vessel Disease Indicate That White Matter Hyperintensities Can Regress

Background White matter hyperintensities (WMHs) might regress and progress contemporaneously, but we know little about underlying mechanisms. We examined WMH change and underlying quantitative magnetic resonance imaging tissue measures over 1 year in patients with minor ischemic stroke with sporadic cerebral small vessel disease. Methods and Results We defined areas of stable normal‐appearing white matter, stable WMHs, progressing and regressing WMHs based on baseline and 1‐year brain magnetic resonance imaging. In these areas we assessed tissue characteristics with quantitative T1, fractional anisotropy (FA), mean diffusivity (MD), and neurite orientation dispersion and density imaging (baseline only). We compared tissue signatures cross‐sectionally between areas, and longitudinally within each area. WMH change masks were available for N=197. Participants' mean age was 65.61 years (SD, 11.10), 59% had a lacunar infarct, and 68% were men. FA and MD were available for N=195, quantitative T1 for N=182, and neurite orientation dispersion and density imaging for N=174. Cross‐sectionally, all 4 tissue classes differed for FA, MD, T1, and Neurite Density Index. Longitudinally, in regressing WMHs, FA increased with little change in MD and T1 (difference estimate, 0.011 [95% CI, 0.006–0.017]; −0.002 [95% CI, −0.008 to 0.003] and −0.003 [95% CI, −0.009 to 0.004]); in progressing and stable WMHs, FA decreased (−0.022 [95% CI, −0.027 to −0.017] and −0.009 [95% CI, −0.011 to −0.006]), whereas MD and T1 increased (progressing WMHs, 0.057 [95% CI, 0.050–0.063], 0.058 [95% CI, 0.050 –0.066]; stable WMHs, 0.054 [95% CI, 0.045–0.063], 0.049 [95% CI, 0.039–0.058]); and in stable normal‐appearing white matter, MD increased (0.004 [95% CI, 0.003–0.005]), whereas FA and T1 slightly decreased and increased (−0.002 [95% CI, −0.004 to −0.000] and 0.005 [95% CI, 0.001–0.009]). Conclusions Quantitative magnetic resonance imaging shows that WMHs that regress have less abnormal microstructure at baseline than stable WMHs and follow trajectories indicating tissue improvement compared with stable and progressing WMHs

Continuous Multi-Parameter Heart Rate Variability Analysis Heralds Onset of Sepsis in Adults

BACKGROUND: Early diagnosis of sepsis enables timely resuscitation and antibiotics and prevents subsequent morbidity and mortality. Clinical approaches relying on point-in-time analysis of vital signs or lab values are often insensitive, non-specific and late diagnostic markers of sepsis. Exploring otherwise hidden information within intervals-in-time, heart rate variability (HRV) has been documented to be both altered in the presence of sepsis, and correlated with its severity. We hypothesized that by continuously tracking individual patient HRV over time in patients as they develop sepsis, we would demonstrate reduced HRV in association with the onset of sepsis. METHODOLOGY/PRINCIPAL FINDINGS: We monitored heart rate continuously in adult bone marrow transplant (BMT) patients (n = 21) beginning a day before their BMT and continuing until recovery or withdrawal (12+/-4 days). We characterized HRV continuously over time with a panel of time, frequency, complexity, and scale-invariant domain techniques. We defined baseline HRV as mean variability for the first 24 h of monitoring and studied individual and population average percentage change (from baseline) over time in diverse HRV metrics, in comparison with the time of clinical diagnosis and treatment of sepsis (defined as systemic inflammatory response syndrome along with clinically suspected infection requiring treatment). Of the 21 patients enrolled, 4 patients withdrew, leaving 17 patients who completed the study. Fourteen patients developed sepsis requiring antibiotic therapy, whereas 3 did not. On average, for 12 out of 14 infected patients, a significant (25%) reduction prior to the clinical diagnosis and treatment of sepsis was observed in standard deviation, root mean square successive difference, sample and multiscale entropy, fast Fourier transform, detrended fluctuation analysis, and wavelet variability metrics. For infected patients (n = 14), wavelet HRV demonstrated a 25% drop from baseline 35 h prior to sepsis on average. For 3 out of 3 non-infected patients, all measures, except root mean square successive difference and entropy, showed no significant reduction. Significant correlation was present amongst these HRV metrics for the entire population. CONCLUSIONS/SIGNIFICANCE: Continuous HRV monitoring is feasible in ambulatory patients, demonstrates significant HRV alteration in individual patients in association with, and prior to clinical diagnosis and treatment of sepsis, and merits further investigation as a means of providing early warning of sepsis

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy International Clinical Practice Guideline Based on Systematic Reviews:International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE: Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. OBJECTIVE: To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. EVIDENCE REVIEW: The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. FINDINGS: Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). CONCLUSIONS AND RELEVANCE: When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline

The role of microRNA-155/liver X receptor pathway in experimental and idiopathic pulmonary fibrosis

Background: Idiopathic Pulmonary Fibrosis (IPF) is progressive and rapidly fatal. Improved understanding of pathogenesis is required to prosper novel therapeutics. Epigenetic changes contribute to IPF therefore microRNAs may reveal novel pathogenic pathways. Objectives: To determine the regulatory role of microRNA(miR)-155 in the pro-fibrotic function of murine lung macrophages and fibroblasts, IPF lung fibroblasts and its contribution to experimental pulmonary fibrosis. Methods: Bleomycin-induced lung fibrosis in wild-type and miR-155-/- mice was analyzed by histology, collagen and pro-fibrotic gene expression. Mechanisms were identified by in silico and molecular approaches; validated in mouse lung fibroblasts and macrophages, and in IPF lung fibroblasts, using loss-and-gain of function assays, and in vivo using specific inhibitors. Results: miR-155-/- mice developed exacerbated lung fibrosis, increased collagen deposition, collagen 1 and 3 mRNA expression, TGFβ production, and activation of alternatively-activated macrophages, contributed by deregulation of the microRNA-155 target gene the liver X receptor (LXR)α in lung fibroblasts and macrophages. Inhibition of LXRα in experimental lung fibrosis and in IPF lung fibroblasts reduced the exacerbated fibrotic response. Similarly, enforced expression of miR-155 reduced the pro-fibrotic phenotype of IPF and miR-155-/- fibroblasts. Conclusion: We describe herein a molecular pathway comprising miR-155 and its epigenetic LXRα target that when deregulated enables pathogenic pulmonary fibrosis. Manipulation of the miR-155/LXR pathway may have therapeutic potential for IPF