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Objectives To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Design Retrospective cohort study. Setting Primary care practices of an academic healthcare system. Participants Adults (aged 28–93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Measurements Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Results Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. Conclusion Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.

The following on esophageal disease provides updated information the mucosal defense against acid and acid-pepsin injury; the roles of platelet activating factor, mast cells, proinflammatory cytokines, and chemokines in inflammation; differences and similarities in erosive and nonerosive esophagitis; acid and vanilloid receptors in esophageal mucosa; and bile acid receptors in esophageal epithelium.

A frequently observed feature of active infection with filarial nematodes is the presence of lymphocytes in the bloodstream that have impaired responsiveness to antigen. It is generally accepted that such a defect in lymphocyte function could contribute to the failure of the immune system to eliminate filarial nematodes. For this reason, understanding the mechanism underlying lymphocyte 'hyporesponsiveness' is an important goal for immunologists who study filarial nematodes. Thus, although there has long been an interest in answering questions such as what stage(s) of the nematode causes hyporesponsiveness, more recently, lymphocyte hyporesponsiveness has been increasingly studied at the molecular level. The result of this is that we are now beginning to learn much of the nature and cause of phenotypic changes in the hyporesponsive lymphocyte and also of the identity of the nematode-derived molecules that induce them. As this information continues to be generated, the challenge will be to use it to find a way of reversing lymphocyte hyporesponsiveness in the hope that this will lead to rejection of filarial nematodes in the parasitized human host.

SUMMARY Modulation of macrophage/dendritic cell (DC) cytokine production by the filarial nematode phosphorylcholine (PC)-containing product, ES-62, is mediated by Toll-like receptor (TLR) 4 and signal transduction depends on the TLR adaptor MyD88. Intriguingly, comparison of TLR4 knock-out (ko) mice with TLR4 mutant C3H/HeJ mice indicates that ES-62 cytokine responses are not dependent on the Pro712 residue of TLR4, which is crucial for the response to bacterial lipopolysaccharide (LPS). Because other immunomodulatory effects of ES-62 have been attributed to PC we have now investigated, using PC conjugated to ovalbumin (PC-Ova), whether PC is responsible for the interaction of ES-62 with TLR4. PC-Ova mimicked the modulation of interleukin (IL)-12 production by ES-62 in a TLR4- and MyD88-dependent manner and as with native ES-62, PC-Ova effects were not dependent on Pro712. Furthermore, both native ES-62 and PC-Ova suppressed Akt phosphorylation, whereas neither altered the activation of p38 or Erk MAP kinases. To rule out any role for the ES-62 protein component, we tested a PC-free recombinant ES-62 (rES-62) generated in the yeast Pichia pastoris. Surprisingly, rES-62 also modulated IL-12 production, but in a TLR4/MyD88-independent manner. Furthermore, rES-62 strongly activated both the p38 and Erk MAP kinases and Akt. However, recent biophysical analysis suggests there are differences in folding/shape between native and rES-62 and hence data obtained with the latter should be treated with caution. Nevertheless, although our study indicates that PC is likely to be primarily responsible for the modulation of cytokine production observed with native ES-62, an immunomodulatory role for the protein component cannot be ruled out.

Long-term infection with parasitic worms is generally associated with an immunological phenotype that is Th2-like and anti-inflammatory. This phenotype is probably an unintentional consequence of molecular characteristics of worms (as free-living worms also express polarising molecules) in combination with deliberate attempts by the parasites, via molecular secretions, to modulate the phenotype. This review is concerned with the identity of immunomodulatory worm products, the receptors that they interact with and the signal transduction pathways that they activate. It hopes to indicate how knowledge of these factors can explain the changes in gene expression that result in the characteristic worm-induced immunological phenotype.

1. The 'hygiene hypothesis' postulates that the recent increased incidence of allergic or autoimmune diseases (e.g. asthma, type I diabetes) in the West reflects an absence of appropriate priming of the immune response by infectious agents, such as parasitic worms, during childhood. 2. Consistent with this, it has long been recognized that several autoimmune disorders, such as rheumatoid arthritis (RA), a T helper (Th) 1-mediated autoimmune disease characterized by excess production of pro-inflammatory cytokines, such as tumour necrosis factor-alpha, exhibit reduced incidence and severity in geographical regions with high parasite load, suggesting that environmental factors may subtly alter disease progression. 3. Infection with worms also appears to suppress Th2-biased inflammatory disorders, such as asthma, because there also appears to be an inverse correlation between parasite load and atopy. This is perhaps more surprising, given that helminths often induce strong Th2-type immune responses characterized by release of specific cytokines, such as interleukin (IL)-4, IL-5 and IL-13. 4. Therefore, these findings suggest that the co-evolution of helminths with hosts, which has resulted in the ability of worms to modulate inflammatory responses in order to promote parasite survival, may also have generated a predisposition for the host to develop autoimmunity and allergy in the absence of infection. 5. The mechanisms underlying such immunomodulation are not clear, but appear to involve the release of parasite-derived molecules that allow the worms to modulate or evade the host immune response by a number of mechanisms, including skewing of cytokine responses and the induction of T regulatory cells. 6. In the present review we discuss the properties of one such filarial nematode-derived immunomodulatory molecule, namely ES-62, its anti-inflammatory action and the therapeutic potential of small molecule derivatives and peptides that mimic its action.

ES-62 is a phosphorylcholine (PC)-containing glycoprotein secreted by filarial nematodes, parasites of vertebrates including humans. We have previously demonstrated that pre-exposure to this molecule in vitro interferes with subsequent B-cell receptor (BCR)-dependent activation of murine splenic B lymphocytes. To investigate the significance of this during filarial nematode infection, we now employ mice exposed to ES-62, at concentrations equivalent to those found for PC-containing molecules in the bloodstream of parasitized humans, via release from implanted osmotic pumps. Using this approach, we reveal that splenic and lymph node mononuclear cells, and also purified splenic B cells recovered from these mice have reduced ability ex vivo to proliferate in response to BCR ligation. The effect on BCR-induced proliferation was further investigated with respect to elucidating the mechanism of action of the parasite product and was shown to be associated with impaired signal transduction affecting the ErkMAPkinase pathway. Also, it was found that ES-62 did not act by promoting apoptosis or by priming for apoptosis following subsequent stimulation, but rather, appeared to render cells hyporesponsive to stimulation. ES-62 is thus shown for the first time to be a potent modulator of B lymphocyte function in vivo at a concentration relevant to natural filarial nematode infection. This finding considerably strengthens the idea that ES-62 plays a role in evasion of the immune response during parasitism.

SUMMARY Immunomodulatory properties of phosphorylcholine (PC)-containing glycosphingolipids from Ascaris suum were investigated utilizing immune cells from BALB/c mice. Proliferation of splenic B cells induced either via F(ab′)2 fragments of anti-murine Ig (anti-Ig) or LPS was significantly reduced when the glycosphingolipids were present in the culture medium. However whereas the LPS-mediated effect was dependent on the PC moiety of the glycosphingolipids, the result generated when using anti-Ig was not. Analysis of cell cycle status and mitochondrial potential indicated that the combination of the glycosphingolipids and anti-Ig reduced B cell proliferation, at least in part, by inducing apoptosis. Consistent with the observed suppression of B cell activation/cell cycle progression, investigation of the effect of glycosphingolipid pre-exposure on mitogenic B cell signal transduction pathways activated by anti-Ig, revealed a PC-independent inhibitory effect on dual (thr/tyr) phosphorylation and activation of ErkMAPKinase. The glycosphingolipids were also investigated for their inhibitory effect on LPS/IFN-γ induced Th1/pro-inflammatory cytokine production by peritoneal macrophages. It was found that IL-12 p40 production was inhibited and in an apparently PC-dependent manner. Overall these data indicate that PC-containing glycosphingolipids of A. suum appear to have at least two immunomodulatory constituents – PC and an as yet unknown component.

Obesity, one of the main causes of metabolic syndrome (MetS), is an increasingly common health and economic problem worldwide, and one of the major risk factors for developing type 2 diabetes and cardiovascular disease. Chronic, low-grade inflammation is associated with MetS and obesity. A dominant type 2/anti-inflammatory response is required for metabolic homoeostasis within adipose tissue: during obesity, this response is replaced by infiltrating, inflammatory macrophages and T cells. Helminths and certain protozoan parasites are able to manipulate the host immune response towards a TH2 immune phenotype that is beneficial for their survival, and there is emerging data that there is an inverse correlation between the incidence of MetS and helminth infections, suggesting that, as with autoimmune and allergic diseases, helminths may play a protective role against MetS disease. Within this review, we will focus primarily on the excretory-secretory products that the parasites produce to modulate the immune system and discuss their potential use as therapeutics against MetS and its associated pathologies.

Aggregation of the human high-affinity receptor for immunoglobulin G, FcgammaRI, results in initiation of intracellular signaling cascades. However, as the receptor contains no known signaling motif, it is required to recruit an accessory molecule. The gamma chain has been proposed to fulfil this role. Here, we show that in U937 cells differentiated to a more macrophage-like phenotype with dibutyryl cAMP, FcgammaRI no longer signals through the gamma chain but rather uses FcgammaRIIa to initiate tyrosine phosphorylation. Expression of the gamma chain is, however, increased in the dbcAMP-induced cells, but here the gamma chain specifically associates with the IgA receptor, FcalphaRI. Recruitment of the gamma chain either by FcgammaRI in cytokine-primed cells or by FcalphaRI in dbcAMP-induced cells couples ligand binding to the activation of phosphatidyl choline-specific phospholipase D.

Memory B-cell development is impaired by in vivo blockade of the CD40-CD40 ligand (CD40L) interaction using human Fc immunoglobulin G1 (IgG1)-mouse CD40 fusion protein (CD40-Ig); however, germinal centre (GC) formation is not. We show here that the block in B-cell differentiation in these mice is at the stage of rescue from apoptosis and exit from the GC. Thus, GC from CD40-Ig-treated mice contain a three- to fourfold higher level of apoptotic cells than found in control mice injected with human IgG1 alone. This increase in apoptosis is not caused by a blockade of the CD40L-mediated rescue signal but is the result of an intrinsic defect of GC B cells in CD40-Ig-treated mice to receive rescue signals via CD40. While anti-CD40 stimulation maintained the viability in culture of GC B cells from control mice, it did not rescue GC B cells from CD40-Ig-treated mice. This data is consistent with the notion that a 'rewiring' of the CD40 molecule is induced by CD40 ligation early in the response and is necessary to allow B-cell rescue from apoptosis when they subsequently enter the GC.

The human high affinity receptor for immunoglobulin G, FcgammaRI, in dibutyryl cyclic AMP (dbcAMP)-differentiated U937 cells, is coupled to the activation of phospholipase C (PLC) and the conventional protein kinase C (PKC) isoforms, alpha, beta, and gamma. Here we demonstrate that aggregation of FcgammaRI activates the tyrosine-kinase regulated form of phosphatidylinositol-3-kinase (PI-3-kinase) and that an increase of phosphatidylinositol trisphosphate (PIP3) is essential for the activation and translocation of PLCgamma1 in these cells. In addition, activation of the PKC isoforms was ablated by specific inhibitors of PI3-kinase or by overexpression of a dominant negative p85 subunit of PI3-kinase. The findings reported here demonstrate that PLCgamma1 and PKC activation by FcgammaRI are downstream of PI3-kinase, and that in contrast to cytokine primed cells, only the tyrosine-kinase activated isoform of PI3-kinase is coupled to FcgammaRI in dbcAMP-differentiated cells.

Aggregation of receptors for the constant region (Fc) of immunoglobulin G on myeloid cells results in endocytosis or phagocytosis and cellular activation. Previous work has shown, using the cell line U937, that the high-affinity immunoglobulin G receptor, FcgammaRI, activates alternate intracellular signalling pathways depending on the cell differentiation state, which results in a marked change in the nature of calcium transients within the cell. Here, we show that protein kinase C (PKC) is activated in both interferon-gamma (IFN-gamma) -primed and dibutyryl cyclic AMP (dbcAMP) -differentiated cells but that the nature of the particular isoenzymes recruited differs. Thus, in IFN-gamma-primed U937 cells, FcgammaRI aggregation results in an increase of PKC activity which is essentially calcium independent resulting from the translocation to the membrane of the novel PKCs, delta and epsilon, together with the atypical PKC zeta. However, in cells differentiated to a more macrophage phenotype, all PKC enzyme activity after receptor aggregation is calcium dependent. Consistent with this finding, the isoenzymes translocated to the nuclear-free membrane fraction are the conventional PKCs alpha, beta and gamma; results consistent with our previous finding that FcgammaRI couples to phospholipase C in such dbcAMP-differentiated cells. Thus, the nature of PKC isoenzyme activated following FcgammaRI aggregation is defined by differentiation. The calcium dependence of the PKC isoenzyme is consistent with the duration of calcium transients previously reported in the two differentiation states.

The individual items of two birth scores and the scores themselves were examined for a sample of 2065 mothers and infants pairs for any changes between 1968 and 1986. About 100 births were randomly sampled for each year. The scoring systems used were the Sheffield risk score and the Christchurch-Invercargill-Dunedin score. A total of eight items from these scores was examined. The purpose was to discover whether the increasing cot death rate in Canterbury could be attributed to an increasing proportion of vulnerable infants, as determined by the items in the risk scores. No such relationship was uniformly found.

Background A distinction between symptomatic non-erosive reflux disease (NERD) and erosive esophagitis(EE) patients is supported by the presence of inflam-matory response in the mucosa of EE patients, leadingto a damage of mucosal integrity. To explore theunderlying mechanism of this difference, we assessedinflammatory mediators in mucosal biopsies from EEand NERD patients and compared them with controls.Methods Nineteen NERD patients, 15 EE patients, and16 healthy subjects underwent endoscopy aftera 3-week washout from PPI or H 2 antagonists. Biopsiesobtained from the distal esophagus were examined byquantitative real-time polymerase chain reaction(qPCR) and multiplex enzyme-linked immunosorbentassay for selected chemokines and lyso-PAF acetyl-transferase (LysoPAF-AT), the enzyme responsible forproduction of platelet-activating factor (PAF). KeyResults Expression of LysoPAF-AT and multiplechemokines was significantly increased in mucosalbiopsies derived from EE patients, when comparedwith NERD patients and healthy controls. Upregu-lated chemokines included interleukin 8, eotaxin-1,-2, and -3, macrophage inflammatory protein-1a (MIP-1a), and monocyte chemoattractant protein-1 (MCP-1). LysoPAF-AT and the chemokine profile in NERDpatients were comparable with healthy controls.Conclusions & Inferences Levels of selected cytokinesand Lyso-PAF AT were significantly higher in theesophageal mucosa of EE patients compared withNERD and control patients. This difference mayexplain the distinct inflammatory response occurringin EE patients’ mucosa. In contrast, as no significantdifferences existed between the levels of all mediatorsin NERD and control subjects, an inflammatoryresponse does not appear to play a major role in thepathogenesis of the abnormalities found in NERDpatients.Keywords chemokines, esophageal inflammation,gastro-esophageal reflux disease, platelet-activatingfactor.

Background Transient receptor potential channel vanilloid subfamily member-1 (TRPV1) may play a role in esophageal perception. TRPV1 mRNA and protein expression were examined in the esophageal mucosa of non-erosive reflux disease (NERD) and erosive esophagitis (EE) patients and correlated to esophageal acid exposure. Methods Seventeen NERD patients, eight EE patients and 10 healthy subjects underwent endoscopy after a 3-week washout from proton pump inhibitors or H2 antagonists. Biopsies, obtained from the distal esophagus, were used for conventional histology, for Western blot analysis and/or quantitative real-time polymerase chain reaction (qPCR). Overall 13 NERD patients, four EE patients and five controls underwent ambulatory pH-testing. Key Results TRPV1 expression was increased in all NERD and EE patients, as measured by Western blot analysis (0.65 ± 0.07 and 0.8 ± 0.05 VS 0.34 ± 0.04 in controls; P

CBA/N mice, which carry the xid immunodeficiency, lack a mature subpopulation of B cells. The residual B cells in these mice do not make antibodies to type-2 T-independent antigens, nor do they synthesize DNA in response to mitogenic forms of anti-Ig antibodies. It is therefore an attractive hypothesis that the surface immunoglobulin receptors (sIgR) on xid B cells signal abnormally following cross-linking. We show here that anti-Ig antibodies do cause inositol phospholipid hydrolysis and Ca2+ mobilization in xid B cells. However, the responses of these cells are only 40%–50% of those of normal B cells. Studies with permeabilized cells demonstrated that the hyporesponsiveness is not due to ineffective coupling of sIgR to their associated G-protein. Rather it is apparently due to a quantitative and/or qualitative deficiency in the polyphosphoinositide-specific phosphodiesterase which mediates sIgR-induced inositol phospholipid hydrolysis. These observations may provide a biochemical explanation for the immunological abnormalities resulting from the xid mutation.

Cross-linking of surface Ig receptors (sIg) by mitogenic forms of anti-Ig antibodies (e.g. F(ab')2 fragments of rabbit anti-Ig) causes the rapid, and prolonged breakdown of phosphatidylinositol 4,5-bisphosphate. This response involves an unidentified guanine nucleotide regulatory protein (termed Gp), which couples sIg to the polyphosphoinositide-specific phosphodiesterase. Intact (IgG) rabbit anti-Ig antibodies, which co-cross-link sIg and Fc gamma receptors on B cells, only induce short-lived inositol phospholipid breakdown and abortive B cell activation. We show here that in permeabilized B cells intact anti-Ig inhibits the reconstituted breakdown of inositol phospholipids given by a combination of F(ab')2 anti-Ig and the non-hydrolyzable GTP analogue guanosine-5'-O-(3-thiotriphosphate) (GTP gamma S), but not the basal stimulation of Gp induced by GTP gamma S alone. These results therefore indicate that co-cross-linkage of sIg and Fc gamma receptors on B cells uncouples the antigen receptors from the associated G protein, but does not affect coupling between Gp and the phosphodiesterase. These observations therefore provide further insight into the mechanisms whereby engaging Fc receptors on B cells, by antigen-antibody complexes for example, could modulate antigen-induced B cell activation.

Cross-linking of surface IgM or IgD receptors on B cells initiates a signaling cascade involving the activation of an (uncharacterized) G-protein: this in turn activates a polyphosphoinositide-specific phosphodiesterase (PPI-PDE), thereby leading to the release of inositol phosphates. In order to investigate if the two isotypes of sIg share a common G-protein, we stimulated B cells sequentially with anti-mu and anti-delta antibodies. Ligation of either class of receptor for 1 h led to the activation of the PPI-PDE, which persisted for several hours. However, this was accompanied by inhibition of further stimulation of the enzyme via the heterologous receptors. This desensitization was shown to operate at the level of the coupling between G-protein and the PPI-PDE. These effects waned after 4-8 h of stimulation, when signaling via the heterologous receptors had essentially returned to normal. In addition, stimulation of B cells by anti-mu and anti-delta together did not elicit additive responses, either in terms of increases in inositol phosphate production, or in terms of increases in intracellular Ca2+ levels. Taken together, these results indicate that sIgM and IgD receptors share a common G-protein and that signaling via these receptors is under both positive and negative feedback control. The mechanisms involved are unknown, but these effects may well be due to modulation of the activities of components of the signaling cascade by protein kinase C.