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Objectives: To describe clinical and serological characteristics of a South Australian primary Sjögren's syndrome (pSS) cohort., Methods: The South Australian Sjögren's Syndrome Research Clinic and Database is a clinical cohort of patients with pSS at a single site. Baseline clinical and laboratory data from 172 patients were retrospectively examined to determine their prevalence and clinical associations. Results were compared to findings from 10,500 patients from The Big Data Sjogren Project Consortium; an international, multicentre registry established in 2014, which included the South Australian data., Results: Of 172 South Australian patients with pSS, 90.1% were female with a mean age at diagnosis of 57 years. Ocular and oral sicca symptoms were common, affecting 97.1% and 99.4% respectively. Anti-Ro ± La positivity was detected in 82.6%, ANA positivity in 77%, and in 9% of patients both ANA and ENA were negative. Mean ESSDAI was 6.8 at baseline, slightly higher than the international cohort at 6.1; the most commonly positive domains being biological, articular and glandular. Pulmonary manifestations represented the most significant morbidity over time. Lymphoma was recorded in 5.2% of patients and congenital heart block in 4 offspring of 52 patients with longitudinal follow-up (7.7%), although incomplete data likely resulted in underestimation of both., Conclusions: Despite the relatively small sample size of the South Australian cohort, clinical and serological characteristics correspond closely with international descriptions.

Objective: The aim of this study was to compare the incidence of airway haemorrhage between participants who received manual cardiopulmonary resuscitation (CPR) and those who had received mechanical CPR using the LUCAS device., Methods: A retrospective cohort study was conducted by means of a medical chart review. All non-traumatic cardiac arrest patients that presented to the ED, from May 2014 to February 2018, were recruited. The groups were stratified according to those who had the majority of CPR performed using the LUCAS and those who had the majority of CPR performed manually. The primary outcome was the proportion of participants with airway haemorrhage, defined as blood observed in the endotracheal tube, pharynx, trachea or mouth, and documented in the doctor or nursing notes. Logistic regression analysis was performed to adjust for confounders., Results: 12 of 54 (22%) participants in the majority LUCAS CPR group had airway haemorrhage, compared with 20 of 215 (9%) participants in the majority manual CPR group, a difference of 13% (95% CI 3% to 26%, p=0.02). The unadjusted odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.8 (95% CI 1.3 to 6.1). After adjusting for confounders, the odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.5 (95% CI 1.1 to 5.7)., Conclusions: The LUCAS mechanical CPR device is associated with a higher incidence of airway haemorrhage compared with manual CPR. Limitations in the study design mean this conclusion is not robust., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Kawasaki disease (KD), an acute, self-limiting, medium-sized arterial vasculitis, is now the most common cause of acquired heart disease in childhood in the developed world. In this review, we discuss the diagnosis of KD, predicting resistance to traditional therapy and treatment options in refractory or high-risk disease. We also highlight ongoing clinical trials and other potential avenues of research which may prove beneficial in managing children, especially those with resistant KD., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 Duignan et al.)

Age-related macular degeneration (AMD) is the leading cause of central vision loss in the over 50s worldwide. Activation of the immune system has been implicated in disease progression, but while polymorphisms in genes associated with the immune system have been identified as risk factors for disease, the underlying pathways and mechanisms involved in disease progression remain incompletely characterised. Typically inflammatory responses are mediated by microbial infection; however, in chronic conditions, a form of 'sterile' inflammation exists whereby immune responses occur in areas of the body, in the absence of microbes; 'sterile' inflammation is likely to be central to AMD. In this case the innate immune response is triggered when alarm signals released by stressed cells or damaged tissue are identified by pattern recognition receptors (PRRs). Toll-like receptors (TLRs) are a family of membrane-spanning PRRs for which host-derived ligands have been identified; these include heat shock proteins, extracellular matrix breakdown products, mRNA from necrotic cells and modified lipids. Here we review the evidence for TLR involvement in the pathogenesis of AMD.

Purpose: Paediatric Epilepsy surgery in the UK has recently been centralised in order to improve expertise and quality of service available to children. Video EEG monitoring or telemetry is a highly specialised and a crucial component of the pre-surgical evaluation. Although many Epilepsy Monitoring Units work to certain standards, there is no national or international guideline for paediatric video telemetry., Methods: Due to lack of evidence we used a modified Delphi process utilizing the clinical and academic expertise of the clinical neurophysiology sub-specialty group of Children's Epilepsy Surgical Service (CESS) centres in England and Wales. This process consisted of the following stages I: Identification of the consensus working group, II: Identification of key areas for guidelines, III: Consensus practice points and IV: Final review. Statements that gained consensus (median score of either 4 or 5 using a five-point Likerttype scale) were included in the guideline., Results: Two rounds of feedback and amendments were undertaken. The consensus guidelines includes the following topics: referral pathways, neurophysiological equipment standards, standards of recording techniques, with specific emphasis on safety of video EEG monitoring both with and without drug withdrawal, a protocol for testing patient's behaviours, data storage and guidelines for writing factual reports and conclusions. All statements developed received a median score of 5 and were adopted by the group., Conclusion: Using a modified Delphi process we were able to develop universally-accepted video EEG guidelines for the UK CESS. Although these recommendations have been specifically developed for the pre-surgical evaluation of children with epilepsy, it is assumed that most components are transferable to any paediatric video EEG monitoring setting., (Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Age-related macular degeneration (AMD) is the leading cause of central vision loss worldwide. Loss of retinal pigment epithelium (RPE) is a major pathological hallmark in AMD with or without pathological neovascularization. Although activation of the immune system is implicated in disease progression, pathological pathways remain diverse and unclear. Here, we report an unexpected protective role of a pro-inflammatory cytokine, interleukin-33 (IL-33), in ocular angiogenesis. IL-33 and its receptor (ST2) are expressed constitutively in human and murine retina and choroid. When RPE was activated, IL-33 expression was markedly elevated in vitro. We found that IL-33 regulated tissue remodelling by attenuating wound-healing responses, including reduction in the migration of choroidal fibroblasts and retinal microvascular endothelial cells, and inhibition of collagen gel contraction. In vivo, local administration of recombinant IL-33 inhibited murine choroidal neovascularization (CNV) formation, a surrogate of human neovascular AMD, and this effect was ST2-dependent. Collectively, these data demonstrate IL-33 as a potential immunotherapy and distinguishes pathways for subverting AMD pathology. © 2016 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland., (© 2016 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.)

Toll-like receptors (TLR) survey the extracellular space, cytoplasm, and endosomal compartments for signs of infection or tissue injury. Over the past decade, it has become evident that TLR activation and signal transduction can be regulated by subcellular compartmentalization of both the receptors and their downstream signaling components. Immunofluorescence and/or overexpression of fluorescently "tagged"' proteins teamed with confocal microscopy presents a powerful technique for studying the spatial organization of TLRs, their signaling mediators, and the dynamic processes they activate. This chapter details the common methods for determining the subcellular location of TLRs in both live and fixed cells.

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly individuals in the developed world, affecting 30-50 million people worldwide. AMD primarily affects the macular region of the retina that is responsible for the majority of central, color and daytime vision. The presence of drusen, extracellular protein aggregates that accumulate under the retinal pigment epithelium (RPE), is a major pathological hallmark in the early stages of the disease. The end stage 'dry' and 'wet' forms of the disease culminate in vision loss and are characterized by focal degeneration of the RPE and cone photoreceptors, and choroidal neovascularization (CNV), respectively. Being a multifactorial and genetically heterogeneous disease, the pathophysiology of AMD remains unclear, yet, there is ample evidence supporting immunological and inflammatory processes. Here, we review the recent literature implicating some of these immune processes in human AMD and in animal models.

Age-related macular degeneration (AMD) is the leading cause of central vision loss worldwide and while polymorphisms in genes associated with the immune system have been identified as risk factors for disease development, the underlying pathways and mechanisms involved in disease progression have remained unclear. In AMD, localised inflammatory responses related to particulate matter accumulation and subsequent "sterile" inflammation has recently gained considerable interest amongst basic researchers and clinicians alike. Typically, inflammatory responses in the human body are caused as a result of bacterial or viral infection, however in chronic conditions such as AMD, extracellular particulate matter such as drusen can be "sensed" by the NACHT, LRR and PYD domains-containing protein 3 (NLRP3) inflammasome, culminating in the release of the two pro-inflammatory cytokines IL-1β and IL-18 in the delicate local tissue of the retina. Identification at the molecular level of mediators of the inflammatory response in AMD may yield novel therapeutic approaches to this common and often severe form of blindness. Here, we will describe the role of IL-18 in AMD and other forms of retinal disorders. We will outline some of the key functions of IL-18 as it pertains to maintaining tissue homeostasis in a healthy and degenerating/diseased retina.

Polyunsaturated fatty acids (PUFA) can modulate the immune response, however the mechanism by which they exert this effect remains unclear. Previous studies have clearly demonstrated that the cis-9, trans-11 isomer of conjugated linoleic acid (c9,t11-CLA), found predominantly in beef and dairy products, can modulate the response of immune cells to the toll-like receptor (TLR) 4 ligand, lipopolysaccharide (LPS). This study aimed to investigate further the mechanism by which these effects are mediated. Treatment of macrophages with c9,t11-CLA significantly decreased CD14 expression and partially blocked its association with lipid rafts following stimulation with LPS. Furthermore the c9,t11-CLA isomer inhibited both nuclear factor-κB (NF-κB) and IRF3 activation following TLR4 ligation while eicosapentaenoic acid (EPA) only suppressed NF-κB activation. Given that the ability of LPS to activate IRF3 downstream of TLR4 depends on internalisation of the TLR4 complex and involves CD14, we examined TLR4 endocytosis. Indeed the internalisation of TLR4 to early endosomes following activation with LPS was markedly inhibited in c9,t11-CLA treated cells. These effects were not seen with the n-3 fatty acid, EPA, which was used as a comparison. Our data demonstrates that c9,t11-CLA inhibits IRF3 activation via its effects on CD14 expression and localisation. This results in a decrease in the endocytosis of TLR4 which is necessary for IRF3 activation, revealing a novel mechanism by which this PUFA exerts its anti-inflammatory effects., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Reflexivity is fundamental to qualitative health research, yet notoriously difficult to unpack. Drawing on Wilfred Bion's work on the development of the capacity to think and to learn, I show how the capacity to think is an impermanent and fallible capacity, with the potential to materialize or evaporate at any number of different points. I use this conceptualization together with examples from published interview data to illustrate the difficulties for researchers attempting to sustain a reflexive approach, and to direct attention toward the possibilities for recovering and supporting the capacity to think. I counter some of the criticisms suggesting that reflexivity can be self-indulgent, and suggest instead that self-indulgence constitutes a failure of reflexivity. In the concluding discussions I acknowledge tensions accompanying the use of psychoanalytic theories for research purposes, and point to emerging psychosocial approaches as one way of negotiating these.

Purpose: This study examined relationships between caregiver mental health and the extent to which needs were met in families of individuals with traumatic brain injury (TBI) in Mexico City, Mexico., Method: Sixty-eight TBI caregivers completed Spanish versions of instruments assessing their own mental health and whether specific family needs were met., Results: Twenty-seven per cent of caregivers reported clinically significant depression levels, 40% reported below-average life satisfaction and 49% reported mild-to-severe burden. Several of the most frequently met family needs were in the emotional support domain, whereas the majority of unmet needs were in the health information domain. Family needs and caregiver mental health were significantly and highly related. When family needs were met, caregiver mental health was better. The strongest pattern of connections in multivariate analyses was between family instrumental support (assistance in the completion of daily life tasks) and caregiver burden, such that caregivers with less instrumental support had greater burden. Additional results suggested that instrumental support uniquely predicted caregiver satisfaction with life, burden and depression., Conclusions: Interventions for TBI caregivers, especially in Latin America, should help family members determine how best to meet their health information and instrumental needs, with the former being likely to improve caregiver mental health.

Solid tumors are heterogeneous tissues composed of a mixture of cancer and normal cells, which complicates the interpretation of their molecular profiles. Furthermore, tissue architecture is generally not reflected in molecular assays, rendering this rich information underused. To address these challenges, we developed a computational approach based on standard hematoxylin and eosin-stained tissue sections and demonstrated its power in a discovery and validation cohort of 323 and 241 breast tumors, respectively. To deconvolute cellular heterogeneity and detect subtle genomic aberrations, we introduced an algorithm based on tumor cellularity to increase the comparability of copy number profiles between samples. We next devised a predictor for survival in estrogen receptor-negative breast cancer that integrated both image-based and gene expression analyses and significantly outperformed classifiers that use single data types, such as microarray expression signatures. Image processing also allowed us to describe and validate an independent prognostic factor based on quantitative analysis of spatial patterns between stromal cells, which are not detectable by molecular assays. Our quantitative, image-based method could benefit any large-scale cancer study by refining and complementing molecular assays of tumor samples.

Age-related macular degeneration (AMD) is the leading cause of central vision loss worldwide. Drusen accumulation is the major pathological hallmark common to both dry and wet AMD. Although activation of the immune system has been implicated in disease progression, the pathways involved are unclear. Here we show that drusen isolated from donor AMD eyes activates the NACHT, LRR and PYD domains-containing protein 3 (NLRP3) inflammasome, causing secretion of interleukin-1b (IL-1b) and IL-18. Drusen component C1Q also activates the NLRP3 inflammasome. Moreover, the oxidative-stress-related protein-modification carboxyethylpyrrole (CEP), a biomarker of AMD, primes the inflammasome. We found cleaved caspase-1 and NLRP3 in activated macrophages in the retinas of mice immunized with CEP-adducted mouse serum albumin, modeling a dry-AMD–like pathology. We show that laser-induced choroidal neovascularization (CNV), a mouse model of wet AMD, is exacerbated in Nlrp3(-/-) but not Il1r1(-/-) mice, directly implicating IL-18 in the regulation of CNV development. These findings indicate a protective role for NLRP3 and IL-18 in the progression of AMD.

Toll-like receptor 4 is an innate immune receptor responsible for the recognition of the Gram-negative cell wall component lipopolysaccharide. Here we show that transmembrane emp24 domain-containing protein 7 (TMED7) inhibits MyD88-independent toll-like receptor 4 signalling. TMED7 overexpression inhibits the ability of TRAM, an adaptor utilized by toll-like receptor 4, or lipopolysaccharide to activate the interferon regulatory factor 3-signalling pathway, whereas TMED7 knockdown enhances production of the cytokine, RANTES, following lipopolysaccharide stimulation. Upon lipopolysaccharide stimulation, TMED7 co-localizes with TRAM and toll-like receptor 4 in late endosomes where it encounters the negative regulator of TRAM, TAG. The TMED7 sequence is found in TAG because of a read-through from the tmed7 gene into the ticam2 gene. TMED7 is essential for TAG-mediated disruption of the TRAM/TRIF complex and the degradation of toll-like receptor 4. A TMED homologue, logjam, has a negative role in the Toll and IMD pathways in Drosophila melanogaster; therefore, TMEDs may have a conserved role in the regulation of innate immunity.

IL-10 is a potent anti-inflammatory cytokine that is crucial for down-regulating pro-inflammatory genes, which are induced by Toll-like receptor (TLR) signaling. In this study, we have examined whether modulation of microRNAs plays a role in the inhibitory effect of IL-10 on TLR4 signaling. Analyzing microRNAs known to be induced by TLR4, we found that IL-10 could inhibit the expression of miR-155 in response to lipopolysaccharide but had no effect on miR-21 or miR-146a. IL-10 inhibited miR-155 transcription from the BIC gene in a STAT3-dependent manner. This inhibitory effect of IL-10 on miR-155 led to an increase in the expression of the miR-155 target, SHIP1. This is the first example of IL-10 playing a role in microRNA function and suggests that through its inhibitory effect on miR-155, IL-10 has the ability to promote anti-inflammatory gene expression.

Aim: The aim of this study was to determine whether there is an association between a child's first name and the likelihood of inpatient admission following presentation to a paediatric emergency department (ED)., Methods: This was a retrospective review of electronic records held in the ED of an urban tertiary paediatric hospital. Data were obtained for all presentations up to the age of 16 years for a single month (n= 4260), each being allocated to 1 of the 10 predetermined first name categories., Results: A statistically significant increased risk for hospital admission was found for the following first name categories: popular culture (relative risk (RR) = 1.91, P= 0.000, 95% confidence interval (CI) = 1.60-2.28), apparently unique (RR = 1.52, P= 0.000, 95% CI = 1.23-1.87), Old Testament (RR = 1.39, P= 0.001, 95% CI = 1.14-1.69) and surname as first name (RR = 1.36, P= 0.015, 95% CI = 1.07-1.72)., Conclusions: Our data confirm the impression that children with certain categories of first names have an increased likelihood of admission to hospital after presenting to the ED. We speculate that our findings, which are in concordance with those from educational and psychological literature, may reflect socio-economic status and/or a 'self-fulfilling prophecy'. Further research may make it possible to assign names an RR rating (e.g. for hospital admission in the first 16 years of life), thus providing parents with another factor to consider when choosing names for their children. More studies are of course needed.

Purpose: To determine whether E-cadherin loss causes nonlobular cancers (NLCs) detected at mammographic screening to have different mammographic appearances than do NLCs with normal E-cadherin expression., Materials and Methods: This study design had hospital ethics committee approval; informed consent was waived. Membranous expression of E-cadherin was assessed immunohistochemically in patients younger than 70 years from a consecutive series of 1944 operable invasive breast cancers. Of those, 276 NLC cases (age range, 45-70 years) were common to a prospectively collected database of breast cancer detected at screening. The mammographic features of 131 NLCs with reduced E-cadherin expression were compared with those of 145 NLCs with normal E-cadherin expression., Results: NLCs with E-cadherin loss were more likely to manifest as an ill-defined mass and less likely to manifest noncomedo microcalcifications at mammography than were NLCs with normal E-cadherin expression (47 [35.9%] of 131 vs 35 [24.1%] of 145, P = .03; and one [0.8%] of 131 versus 13 [9%] of 145, P = .001; respectively). NLCs with E-cadherin loss were significantly larger (>or=15 mm) than NLCs with normal E-cadherin expression (71 [54.2%] of 131 NLCs vs 57 [39.3%] of 145; P = .01). Both groups had a similar distribution of grade, tumor type, nodal metastases, and vascular invasion., Conclusion: Invasive NLCs with reduced E-cadherin expression detected at screening are more likely to appear as ill-defined masses and less likely to manifest noncomedo microcalcifications than are NLCs with normal E-cadherin expression. NLCs with reduced E-cadherin expression appear to have mammographic features that make them difficult to detect at small sizes.

Since first being described in the fruit fly Drosophila melanogaster, Toll-like receptors (TLRs) have proven to be of great interest to immunologists and investigators interested in the molecular basis to inflammation. They recognize pathogen-derived factors and also products of inflamed tissue, and trigger signaling pathways that lead to activation of transcription factors such as nuclear factor-kappaB and the interferon regulatory factors. These in turn lead to induction of immune and inflammatory genes, including such important cytokines as tumor necrosis factor-alpha and type I interferon. Much evidence points to a role for TLRs in immune and inflammatory diseases and increasingly in cancer. Examples include clear roles for TLR4 in sepsis, rheumatoid arthritis, ischemia/reperfusion injury, and allergy. TLR2 has been implicated in similar pathologic conditions and also in systemic lupus erythematosus (SLE) and tumor metastasis. TLR7 has also been shown to be important in SLE. TLR5 has been shown to be radioprotective. Recent advances in our understanding of signaling pathways activated by TLRs, structural insights into TLRs bound to their ligands and antagonists, and approaches to inhibit TLRs (including antibodies, peptides, and small molecules) are providing possiblemeans by which to interfere with TLRs clinically. Here we review these recent advances and speculate about whether manipulating TLRs is likely to be successful in fighting off different diseases.

Toll-like receptor 4 (TLR4) signals the induction of transcription factor IRF3-dependent genes from the early endosome via the adaptor TRAM. Here we report a splice variant of TRAM, TAG ('TRAM adaptor with GOLD domain'), which has a Golgi dynamics domain coupled to TRAM's Toll-interleukin 1 receptor domain. After stimulation with lipopolysaccharide, TRAM and TAG localized to late endosomes positive for the GTPase Rab7a. TAG inhibited activation of IRF3 by lipopolysaccharide. Knockdown of TAG with small interfering RNA enhanced induction of the chemokine CCL5 (RANTES), but not of interleukin 8, by lipopolysaccharide in human peripheral blood mononuclear cells. TAG displaced the adaptor TRIF from TRAM. TAG is therefore an example of a specific inhibitor of the adaptor MyD88-independent pathway activated by TLR4. Targeting TAG could be useful in the effort to boost the immunostimulatory effect of TLR4 without causing unwanted inflammation.

Although the lower trunk brachial plexus palsy known as Klumpke's palsy is a familiar and challenging entity to the medical community, relatively little is known about Dr. Augusta Déjerine-Klumpke. Dr. Déjerine-Klumpke influenced generations of physicians with her contributions to the description and treatment of neurological diseases. We review the legacy of Dr. Déjerine-Klumpke by focusing on the life, career, and medical contributions of this remarkable woman, using translations of the French manuscripts composed at various times in her career. These publications, combined with the existing English-language literature that provides a tribute to her contributions as both a scientist and physician, give an insight into the condition that carries her name.

Toll-like receptors (TLRs) are a primary surveillance system for the detection of pathogens and are crucial to the activation of host defense. TLR7 and TLR8 sense single-stranded RNA from viruses or host ribonucleoproteins and synthetic imidazoquinolines such as R848, whereas TLR9 senses unmethylated CpG motifs in viral and bacterial DNA and in host DNA. Here we report the endogenous interaction between Brutons's tyrosine kinase (Btk) and human TLR8 and TLR9 in the monocytic cell line THP1. We also show that R848, single-stranded RNA, and CpGB-DNA activate Btk in THP1 cells as shown by phosphorylation of the tyrosine 223 residue of Btk and also by increased autokinase activity. We demonstrate that Btk is required for NFkappaB activation, participating in the pathway to increased phosphorylation of p65 on serine 536 activated by TLR8 and TLR9. Finally we demonstrate that peripheral blood mononuclear cells from patients with X-linked agammaglobulinaemia (XLA) that have dysfunctional Btk are impaired in the induction of interleukin-6 by CpGB-DNA. This study therefore establishes Btk as a key signaling molecule that interacts with and acts downstream of TLR8 and TLR9. Lack of functioning Btk in XLA patients downstream of TLR8 and TLR9 might explain the susceptibility of XLA patients to viral infections.

Background and Aims: We set out to test the hypothesis that irritable bowel syndrome (IBS) is characterized by an augmented cellular immune response with enhanced production of proinflammatory cytokines. We further aimed to explore whether symptoms and psychiatric comorbidity in IBS are linked to the release of proinflammatory cytokines., Methods: We characterized basal and Escherichia coli lipopolysaccharide (LPS)-induced cytokine production in peripheral blood mononuclear cells (PBMCs) from 55 IBS patients (18 mixed-, 17 constipation-, 20 diarrhea-predominant) and 36 healthy controls (HCs). PBMCs were isolated by density gradient centrifugation and cultured for 24 hours with or without (1 ng/mL) LPS. Cytokine production (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, and IL-6) was measured by enzyme-linked immunosorbent assay. Abdominal symptoms and psychiatric comorbidities were assessed by using the validated Bowel Disease Questionnaire and the Hospital Anxiety and Depression Scale., Results: IBS patients showed significantly (P < .017) higher baseline TNF-alpha, IL-1beta, IL-6, and LPS-induced IL-6 levels compared with HCs. Analyzing IBS subgroups, all cytokine levels were significantly (P < .05) higher in diarrhea-predominant IBS (D-IBS) patients, whereas constipation-predominant IBS patients showed increased LPS-induced IL-1beta levels compared with HCs. Baseline TNF-alpha and LPS-induced TNF-alpha and IL-6 levels were significantly higher in patients reporting more than 3 bowel movements per day, urgency, watery stools, and pain associated with diarrhea compared with patients without these symptoms (all P < .05). LPS-induced TNF-alpha production was associated significantly (r = 0.59, P < .001) with anxiety in patients with IBS., Conclusions: Patients with D-IBS display enhanced proinflammatory cytokine release, and this may be associated with symptoms and anxiety.

Toll-like receptors (TLRs) are key components of the innate immune system, functioning as pattern recognition receptors that recognise a wide range of microbial pathogens. TLRs represent a primary line of defence against invading pathogens in mammals, plants and insects. Recognition of microbial components by TLRs triggers a cascade of cellular signals that culminates in the activation of NFkappaB which leads to inflammatory gene expression and clearance of the infectious agent. The history of NFkappaB began with the TLR4 ligand lipopolysaccharide (LPS), a component of the cell wall of Gram-negative bacteria, since this was the stimulus first used to activate NFkappaB in pre-B-cells. However, since those early days it has been a circuitous route, made possible by drawing on information provided by many different fields, that has led us not only to the discovery of TLRs but also to an understanding of the complex pathways that lead from TLR ligation to NFkappaB activation. In this review we will summarize the current knowledge of TLR-mediated NFkappaB activation, and also the recent discoveries that subtle differences in kappaB binding sequences and NFkappaB dimer formation result in specific gene expression profiles.

Objective: Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) is a key negative regulator of the T cell immune response, and the CTLA4 gene is highly polymorphic. Many positive associations between CTLA4 single-nucleotide polymorphisms (SNPs) and various autoimmune diseases have been identified. Two CTLA4 SNPs that are important relative to genetic susceptibility in human autoimmune diseases are the +49GA polymorphism in exon 1 and the CT60A/G polymorphism in the 3'-untranslated region. Using these 2 polymorphisms as markers, we investigated possible genetic associations of CTLA4 in Australian patients with primary Sjögren's syndrome., Methods: One hundred eleven Australian Caucasian patients with primary SS and 156 population-based controls were genotyped for CTLA4 by polymerase chain reaction-restriction fragment length polymorphism methods, using the restriction enzymes BseXI (+49G/A) and HpyCh4 IV (CT60)., Results: The CT60 and +49G/A SNPs were in strong linkage disequilibrium, and only 3 haplotypes were observed. Significant differences in the haplotype frequencies between patients with primary SS and controls (P = 0.032) were observed, with susceptibility to primary SS associated with both the +49A;CT60A haplotype and the +49A;CT60G haplotype, whereas the +49G;CT60G haplotype was protective against primary SS. The +49A;CT60G haplotype association was predominantly with Ro/La autoantibody-positive primary SS, and the dose of this haplotype influenced the severity of daytime sleepiness (P = 0.036). The +49A;CT60A haplotype appeared to be protective against the development of Raynaud's phenomenon in patients with primary SS (odds ratio 0.49, 95% confidence interval 0.27-0.91)., Conclusion: The CTLA4 +49G/A and CT60 haplotypes are associated with susceptibility to primary SS and with some extraglandular manifestations of the disease.

Members of the Toll-like receptor (TLR) family are essential players in activating the host innate immune response against infectious microorganisms. All TLRs signal through Toll/interleukin 1 receptor domain-containing adapter proteins. MyD88 adapter-like (Mal) is one such adapter that specifically is involved in TLR2 and TLR4 signaling. When overexpressed we have found that Mal undergoes tyrosine phosphorylation. Three possible phospho-accepting tyrosines were identified at positions 86, 106, and 187, and two mutant forms of Mal in which tyrosines 86 and 187 were mutated to phenylalanine acted as dominant negative inhibitors of NF-kappaB activation by lipopolysaccharide (LPS). Activation of THP-1 monocytic cells with the TLR4 agonist LPS and the TLR2 agonist macrophage-activating lipopeptide-2 induced phosphorylation of Mal on tyrosine residues. We found that the Bruton's tyrosine kinase (Btk) inhibitor LFM-A13 could block the endogenous phosphorylation of Mal on tyrosine in cells treated with macrophage-activating lipopeptide-2 or LPS. Furthermore, Btk immunoprecipitated from THP-1 cells activated by LPS could phosphorylate Mal. Our study therefore provides the first demonstration of the key role of Mal phosphorylation on tyrosine during signaling by TLR2 and TLR4 and identifies a novel function for Btk as the kinase involved.

Toll-like receptor (TLR) signals that initiate innate immune responses to pathogens must be tightly regulated to prevent excessive inflammatory damage to the host. The adaptor protein Mal is specifically involved in signaling via TLR2 and TLR4. We demonstrate here that after TLR2 and TLR4 stimulation Mal becomes phosphorylated by Bruton's tyrosine kinase (Btk) and then interacts with SOCS-1, which results in Mal polyubiquitination and subsequent degradation. Removal of SOCS-1 regulation potentiates Mal-dependent p65 phosphorylation and transactivation of NF-kappaB, leading to amplified inflammatory responses. These data identify a target of SOCS-1 that regulates TLR signaling via a mechanism distinct from an autocrine cytokine response. The transient activation of Mal and subsequent SOCS-1-mediated degradation is a rapid and selective means of limiting primary innate immune response.

Bruton's tyrosine kinase (Btk) has recently been shown to participate in the induction of nuclear factor kappaB (NFkappaB)-dependent gene expression by the lipopolysaccharide (LPS) receptor Toll-like receptor-4 (TLR4). In this study we have examined the mechanism whereby Btk participates in this response. Treatment of the murine monocytic cell line Raw264.7 with LFM-A13, a specific Btk inhibitor, blocked LPS-induced NFkappaB-dependent reporter gene expression but not IkappaB alpha degradation. Transient transfection of HEK293 cells with Btk had no effect on NFkappaB-dependent reporter gene expression but strongly promoted transactivation of a reporter gene by a p65-Gal4 fusion protein. IkappaB alpha degradation activated by LPS was intact in macrophages from X-linked immunodeficiency (Xid) mice, which contain inactive Btk. Transfection of cells with a dominant negative form of Btk (BtkK430R) inhibited LPS-driven p65 mediated transactivation. Additionally LFM-A13 impaired phosphorylation of serine 536 on p65 induced by LPS in HEK293-TLR4 cells, and in Xid macrophages this response was impaired. This study therefore reveals a novel function for Btk. It is required for the signaling pathway activated by TLR4, which culminates in phosphorylation of p65 on serine 536 promoting transactivation by NFkappaB.

Objective: Functional antimuscarinic receptor autoantibodies have recently been described in both primary and secondary Sjögren's syndrome (SS) in a mouse bladder contraction assay. Most patients with these antibodies complained of severe lower urinary tract disturbances, which are not a recognized feature of SS. We compared the severity of self-reported urological symptoms, daytime somnolence, and fatigue between a cohort of patients with primary SS and controls with osteoarthritis (OA)., Methods: Female patients were recruited from rheumatology outpatient clinics at 2 hospitals. The American Urological Symptom Index (AUA-7), Epworth Sleepiness Scale, and FACIT-F fatigue self-administered instruments were employed. Results were obtained for 76 patients with primary SS and 43 controls (response rates 85% and 67%, respectively). The patient groups were matched for parity, hormone replacement and diuretic therapy, and number of bladder operations and urinary tract infections, although OA patients were slightly older., Results: AUA-7 urological symptoms were more severe in patients with primary SS compared to OA controls (p = 0.039). Severe urological symptoms were reported by 61% of primary SS patients compared with 40% of OA controls. This difference was predominantly attributable to bladder irritability associated with urgency (p = 0.015) and not nocturia (p = 0.85). Epworth Sleepiness Scale scores were also more severe in primary SS patients compared to OA controls (p = 0.02), independent of nocturia. The FACIT-F fatigue severity scores were not significantly different between patient groups (p = 0.14)., Conclusion: Urological symptoms and daytime somnolence may be previously unrecognized symptoms of primary SS. These symptoms are consistent with functional disturbances of muscarinic receptors, possibly mediated by muscarinic receptor autoantibodies.

In this study we have identified members of the Toll-like receptor (TLR) family (namely, TLRs 4, 6, 8, and 9) as proteins to which the intracellular protein tyrosine kinase, Bruton's tyrosine kinase (Btk), binds. Detailed analysis of the interaction between Btk and TLR8 demonstrates that the presence of both Box 2 and 3 motifs in the Toll/interleukin-1 receptor domain was required for the interaction. Furthermore, co-immunoprecipitation experiments revealed that Btk can also interact with key proteins involved in TLR4 signal transduction, namely, MyD88, Mal (MyD88 adapter-like protein), and interleukin-1 receptor-associated kinase-1, but not TRAF-6. The ability of Btk to interact with TLR4 and Mal suggests a role for Btk in lipopolysaccharide (LPS) signal transduction. Stimulation of the human monocytic cell line THP-1 with LPS resulted in an increase in the level of tyrosine phosphorylation of Btk (indicative of activation). The autokinase activity of Btk was also stimulated after LPS stimulation. In addition, a dominant negative form of Btk inhibited TLR4-mediated activation of a nuclear factor kappaB (NFkappaB)-dependent reporter gene in HEK293 cells as well as LPS-induced activation of NFkappaB in the astrocytoma cell line U373 and the monocytic cell line RAW264.7. Further investigation revealed that the Btk-specific inhibitor, LFM-A13, inhibited the activation of NFkappaB by LPS in THP-1 cells. Our findings implicate Btk as a Toll/interleukin-1 receptor domain-binding protein that is important for NFkappaB activation by TLR4.