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The Community Medi-Corps Program - designed and implemented by the George Washington University (GW) School of Medicine and Health Sciences (SMHS) faculty with Growth and Opportunity Virginia funding (GO Virginia) - is aimed at leveraging the power of community, educational institutions, mentors, industry, and business partners to close the opportunity gap, transform student learning, and enrich the regional workforce. This program transforms educational experience through innovative virtual reality, augmented reality, and a mix between the two that is the enhanced reality (e-REAL). Students will be better prepared in the pathways they choose for high demand health and life sciences industry jobs that will help grow the economy.

Inclusion body myositis (IBM) is an autoimmune and degenerative disorder of skeletal muscle. The B cell infiltrates in IBM muscle tissue are predominantly fully differentiated Ab-secreting plasma cells, with scarce naive or memory B cells. The role of this infiltrate in the disease pathology is not well understood. To better define the humoral response in IBM, we used adaptive immune receptor repertoire sequencing, of human-derived specimens, to generate large BCR repertoire libraries from IBM muscle biopsies and compared them to those generated from dermatomyositis, polymyositis, and circulating CD27+ memory B cells, derived from healthy controls and Ab-secreting cells collected following vaccination. The repertoire properties of the IBM infiltrate included the following: clones that equaled or exceeded the highly clonal vaccine-associated Ab-secreting cell repertoire in size; reduced somatic mutation selection pressure in the CDRs and framework regions; and usage of class-switched IgG and IgA isotypes, with a minor population of IgM-expressing cells. The IBM IgM-expressing population revealed unique features, including an elevated somatic mutation frequency and distinct CDR3 physicochemical properties. These findings demonstrate that some of IBM muscle BCR repertoire characteristics are distinct from dermatomyositis and polymyositis and circulating Ag-experienced subsets, suggesting that it may form through selection by disease-specific Ags.

An approach for identifying antibodies derived from distinct B cell populations demonstrates how secondary immunization responses are dominated by mature B cells generated during primary responses.

Introduction: There is ample evidence of a B cell response in human stroke patients, and evidence that long-term cognitive decline is linked to ongoing B cell activation in ischemic stroke models in mice. However, the role of B cells in hemorrhagic stroke, particularly at late timepoints, is unknown. Methods: Intracerebral hemorrhage (ICH) was induced in 12-week male C57BL/6 mice by collagenase (or saline for sham controls) injection into the striatum. Mice were perfused 2, 4, or 8 weeks post-ICH or sham, ipsilateral and contralateral hemispheres were harvested and B cell counts analyzed by flow cytometry. Motor deficits were measured via grid walk test and short-term memory was tested by Y maze at 1, 2, 4, 8, 12, and 16 weeks post-ICH or sham. B cell repertoire analysis was conducted by PCR amplification and molecular cloning of B cells in 8 week post-ICH or naïve brain tissue, followed by Sanger sequencing and comparison to the IMGT database. Results: B cells are robustly recruited to the ipsilateral hemisphere as early as 2 weeks post-ICH (2439 +/- 987 cells; n=5) and persist at 8 weeks (14,162 +/- 12,103 cells, n=4). At 2 and 4 weeks a small fraction of B cells in the ipsilateral hemisphere are IgA+ (2 weeks=14.0% +/- 6.8%, n=5; 4 weeks=13.3% +/- 4.6%, n=3). Interestingly, by 8 weeks post-ICH this proportion significantly increased in ICH (41.3% +/- 22.8, n=6) but not sham controls (12.0% +/- 11.8%, n=5). While our work has demonstrated no significant motor deficit after 2 weeks post-ICH, preliminary data suggests a cognitive short-term memory deficit starting 16 weeks post-ICH. Furthermore, we have found that post-ICH brain-infiltrating IgA+ B cells are somatically hypermutated and show diverse V gene usage. Conclusion: Our findings suggest that ICH induces a robust, delayed IgA+ B cell response within the affected brain hemisphere, underscoring the need to better understand how B cells shape post-stroke inflammation and recovery, particularly at late timepoints.

Muscle-specific tyrosine kinase myasthenia gravis (MuSK MG) is an autoimmune disease that causes life-threatening muscle weakness due to anti-MuSK autoantibodies that disrupt neuromuscular junction signaling. To avoid chronic immunosuppression from current therapies, we engineered T cells to express a MuSK chimeric autoantibody receptor with CD137-CD3ζ signaling domains (MuSK-CAART) for precision targeting of B cells expressing anti-MuSK autoantibodies. MuSK-CAART demonstrated similar efficacy as anti-CD19 chimeric antigen receptor T cells for depletion of anti-MuSK B cells and retained cytolytic activity in the presence of soluble anti-MuSK antibodies. In an experimental autoimmune MG mouse model, MuSK-CAART reduced anti-MuSK IgG without decreasing B cells or total IgG levels, reflecting MuSK-specific B cell depletion. Specific off-target interactions of MuSK-CAART were not identified in vivo, in primary human cell screens or by high-throughput human membrane proteome array. These data contributed to an investigational new drug application and phase 1 clinical study design for MuSK-CAART for the treatment of MuSK autoantibody-positive MG.

Patients with multiple sclerosis display broad EBV-specific TCR repertoires driven by an enduring anti-EBV immune response.

BackgroundAutoantibodies targeting the acetylcholine receptor (AChR), found in patients with myasthenia gravis (MG), mediate pathology through three mechanisms: complement-directed tissue damage, blocking of the acetylcholine binding site, and internalization of the AChR. Clinical assays, used to diagnose and monitor patients, measure only autoantibody binding. Consequently, they are limited in providing association with disease burden, understanding of mechanistic heterogeneity, and monitoring therapeutic response.ObjectiveDevelop a cell-based assay that measures AChR autoantibody-mediated complement membrane attack complex (MAC) formation.MethodsAn HEK293T cell line—modified using CRISPR/Cas9 genome editing to disrupt expression of the complement regulator genes (CD46, CD55 and CD59)—was used to measure AChR autoantibody-mediated MAC formation via flow cytometry.ResultsSerum samples (n=155) from 96 clinically confirmed AChR MG patients, representing a wide range of disease burden and autoantibody titer, were tested along with 32 healthy donor (HD) samples. AChR autoantibodies were detected in 139 of the 155 (89.7%) MG samples via a cell-based assay. Of the 139 AChR positive samples, autoantibody-mediated MAC formation was detected in 83 (59.7%), while MAC formation was undetectable in the HD group or AChR positive samples with low autoantibody levels. MAC formation was positively associated with autoantibody binding in most patient samples; ratios (MFI) of MAC formation to AChR autoantibody binding ranged between 0.27–48, with a median of 0.79 and interquartile range of 0.43 (0.58–1.1). However, the distribution of ratios was asymmetric and included extreme values; 16 samples were beyond the 10–90 percentile, with high-MAC to low-AChR autoantibody binding ratio or the reverse. Correlation between MAC formation and clinical disease scores suggested a modest positive association (rho=0.34, p=0.0023), which included a subset of outliers that did not follow this pattern. MAC formation did not associate with exposure to immunotherapy, thymectomy, or MG subtypes defined by age-of-onset.ConclusionsA novel assay for evaluating AChR autoantibody-mediated complement activity was developed. A subset of patients that lack association between MAC formation and autoantibody binding or disease burden was identified. The assay may provide a better understanding of the heterogeneous autoantibody molecular pathology and identify patients expected to benefit from complement inhibitor therapy.

T cells can acquire CD20 from B cells via trogocytosis, then contribute to autoimmune neurological disease while becoming targets for therapeutically effective B cell depletion.

A rapidly expanding and clinically distinct group of CNS diseases are caused by pathogenic autoantibodies that target neuroglial surface proteins. Despite immunotherapy, patients with these neuroglial surface autoantibody (NSAb)-mediated diseases often experience clinical relapse, high rates of long-term morbidity and adverse effects from the available medications. Fundamentally, the autoantigen-specific B cell lineage leads to production of the pathogenic autoantibodies. These autoantigen-specific B cells have been consistently identified in the circulation of patients with NSAb-mediated diseases, accompanied by high serum levels of autoantigen-specific antibodies. Early evidence suggests that these cells evade well-characterized B cell tolerance checkpoints. Nearer to the site of pathology, cerebrospinal fluid from patients with NSAb-mediated diseases contains high levels of autoantigen-specific B cells that are likely to account for the intrathecal synthesis of these autoantibodies. The characteristics of their immunoglobulin genes offer insights into the underlying immunobiology. In this Review, we summarize the emerging knowledge of B cells across the NSAb-mediated diseases. We review the evidence for the relative contributions of germinal centres and long-lived plasma cells as sources of autoantibodies, discuss data that indicate migration of B cells into the CNS and summarize insights into the underlying B cell pathogenesis that are provided by therapeutic effects.

The thermal design process for electronic products often minimizes the use of computational fluid dynamics and heat transfer (CFD/HT) software in favor of quick prototyping and testing to determine the thermal characteristics of the product. For large-scale products with many thermal challenges, such a strategy can be impractical due to the high cost of prototyping cycles, time constraints, and inevitable iterations involved. In such cases, thorough CFD/HT models developed early in the design process are valuable for driving the product design. Based on this idea, the study examines thermal performance of 55” outdoor digital displays using CFD/HT tools and a prediction under hazardous outdoor condition is made for two different brightness outputs. The prediction is extrapolated and validated through the outdoor testing and simulation comparisons. It is shown that CFD/HT software can be used as a means of making conservative design choices.

Background and ObjectiveTo determine whether rituximab is safe and potentially beneficial, warranting further investigation in an efficacy trial for acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR-Ab+ gMG).MethodsThe B-Cell Targeted Treatment in MG (BeatMG) study was a randomized, double-blind, placebo-controlled, multicenter phase 2 trial that utilized a futility design. Individuals 21–90 years of age, with AChR-Ab+ gMG (MG Foundation of America Class II–IV) and receiving prednisone ≥15 mg/d were eligible. The primary outcome was a measure of steroid-sparing effect, defined as the proportion achieving ≥75% reduction in mean daily prednisone dose in the 4-weeks prior to week 52 and with clinical improvement or no significant worsening as compared to the 4-week period prior to randomization. The coprimary outcome was safety. Secondary outcomes included MG-specific clinical assessments. Fifty-two individuals were randomized (1:1) to a 2-cycle rituximab/placebo regimen, with follow-up through 52 weeks.ResultsOf the 52 participants included, mean ± SD age at enrollment was 55.1 ± 17.1 years; 23 (44.2%) were women and 31 (59.6%) were Myasthenia Gravis Foundation of America Class II. The mean ± SD baseline prednisone dose was 22.1 ± 9.7 mg/d. The primary steroid-sparing outcome was achieved in 60% of those on rituximab vs 56% on placebo. The study reached its futility endpoint (p = 0.03), suggesting that the predefined clinically meaningful improvement of 30% due to rituximab over placebo was unlikely to be achieved in a subsequent, larger trial. No safety issues were identified.DiscussionAlthough rituximab was safe and well-tolerated, these results suggest that there is a low probability of observing the defined clinically meaningful steroid-sparing effect over a 12-month period in a phase 3 trial of mild to moderately symptomatic AChR-Ab+ gMG.Classification of EvidenceThis study provides Class I evidence that for mild to moderate AChR-Ab+ gMG, compared with placebo, rituximab is safe but unlikely to reduce steroid use by an absolute difference of at least 30% at 1 year.Trial Registration InformationClinicalTrials.gov identifier: NCT02110706.

Sporadic inclusion body myositis (IBM) is a debilitating disease which leads to impaired ambulation and loss of hand function. Yale IBM Registry (IBMR) was launched in November 2016 to address the knowledge gap in IBM natural history data. The registry interface provides an IBM personalized index calculator (IBM-PIC) based on the IBM-functional rating scale (IBM-FRS). While the calculator is based on the IBM-FRS, it has not been directly compared to the IBM-FRS score. Therefore, in this study, we compared the patient-reported IBM-PIC score from this calculator with the physician-obtained IBM-FRS score.IBM-FRS was administered over the phone within two weeks of their most recent IBM-PIC entry in the IBMR to 35 participants. To compare the agreement between IBM-FRS and IBM-PIC scores, Interrater Correlation Coefficient (ICC) analysis was performed. For individual questions, Fleiss Kappa statistics was used.Thirty-five active IBM-PIC users participated. Eighty percent of the participants were men, and 91% were White Caucasians. The reported IBM-FRS score of this group was 23.5 ± 7.4 (range 1-38). The Interrater Correlation Coefficient (ICC) between the physician-administered IBM-FRS score and the IBM-PIC was 0.98 (0.96-0.99). There was moderate to substantial agreement on all the questions on IBM-FRS except for handwriting and fine motor skills.IBM-PIC is a reliable indicator of the IBM-FRS score obtained by the physician. It is anticipated that this online platform will be a valuable tool for assessing IBM severity and monitoring disease progression remotely both in clinical practice and research studies.

Epileptic seizures can be mediated by patient autoantibodies targeting ion channels expressed in the brain.

Elevated N-linked glycosylation of immunoglobulin G variable regions (IgG-V(N-Glyc)) is an emerging molecular phenotype associated with autoimmune disorders. To test the broader specificity of elevated IgG-V(N-Glyc), we studied patients with distinct subtypes of myasthenia gravis (MG), a B cell-mediated autoimmune disease. Our experimental design focused on examining the B cell repertoire and total IgG. It specifically included adaptive immune receptor repertoire sequencing to quantify and characterize N-linked glycosylation sites in the circulating B cell receptor repertoire, proteomics to examine glycosylation patterns of the total circulating IgG, and an exploration of human-derived recombinant autoantibodies, which were studied with mass spectrometry and antigen binding assays to respectively confirm occupation of glycosylation sites and determine whether they alter binding. We found that the frequency of IgG-V(N-Glyc) motifs was increased in the total B cell receptor repertoire of MG patients when compared to healthy donors. The elevated frequency was attributed to both biased V gene segment usage and somatic hypermutation. IgG-V(N-Glyc) could be observed in the total circulating IgG in a subset of MG patients. Autoantigen binding, by four patient-derived MG autoantigen-specific monoclonal antibodies with experimentally confirmed presence of IgG-V(N-Glyc), was not altered by the glycosylation. Our findings extend prior work on patterns of immunoglobulin variable region N-linked glycosylation in autoimmunity to MG subtypes.

Proton therapy is increasing in utilization worldwide at a rapid rate. With process improvements in costs, footprints, and continued advances in the delivery of care, including intensity modulation and image guidance, proton therapy may evolve into standard treatment with photon radiation therapy. This chapter reviews process improvements in proton therapy and the application in modern care.