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Bulk analysis of renal allograft biopsies (rBx) identified RNA transcripts associated with acute cellular rejection (ACR); however, these lacked cellular context critical to mechanistic understanding. We performed combined single cell RNA transcriptomic and TCRα/β sequencing on rBx from patients with ACR under differing immunosuppression (IS): tacrolimus, iscalimab, and belatacept. TCR analysis revealed a highly restricted CD8+T cell clonal expansion (CD8EXP), independent of HLA mismatch or IS type. Subcloning of TCRα/β cDNAs from CD8EXPinto Jurkat76 cells (TCR-/-) conferred alloreactivity by mixed lymphocyte reaction. scRNAseq analysis of CD8EXPrevealed effector, memory, and exhausted phenotypes that were influenced by IS type. Successful anti-rejection treatment decreased, but did not eliminate, CD8EXP, while CD8EXPwere maintained during treatment-refractory rejection. Finally, most rBx-derived CD8EXPwere also observed in matching urine samples. Overall, our data define the clonal CD8+T cell response to ACR, providing novel insights to improve detection, assessment, and treatment of rejection.

Therapeutic targeting of immune checkpoints has garnered significant attention in the area of cancer immunotherapy, in which efforts have focused in particular on cytotoxic T lymphocyte antigen 4 (CTLA4) and PD1, both of which are members of the CD28 family. In autoimmunity, these same pathways can be targeted to opposite effect: to curb the over-exuberant immune response. The CTLA4 checkpoint serves as an exemplar, whereby CTLA4 activity is blocked by antibodies in cancer immunotherapy and augmented by the provision of soluble CTLA4 in autoimmunity. Here, we review the targeting of co-stimulatory molecules in autoimmune diseases, focusing in particular on agents directed at members of the CD28 or tumour necrosis factor receptor families. We present the state of the art in co-stimulatory blockade approaches, including rational combinations of immune inhibitory agents, and discuss the future opportunities and challenges in this field. Immune activating antibodies that target co-stimulatory molecules have altered the cancer therapy landscape. Here, Walker and colleagues discuss therapies — particularly those that target molecules in the same families as CTLA4 and PD1 or TNF receptor — that inhibit the immune system and are being investigated for the treatment of autoimmune diseases. They describe the future opportunities and challenges for the field, including combination approaches.

Summary Background Primary Sjogren's syndrome is an autoimmune disease that presents as dryness of the mouth and eyes due to impairment of the exocrine glands. To our knowledge, no systemic therapies for primary Sjogren's syndrome have shown efficacy. CD40–CD154-mediated T cell–B cell interactions in primary Sjogren's syndrome contribute to aberrant lymphocyte activation in inflamed tissue, leading to sialadenitis and other tissue injury. Therefore, we investigated the safety and preliminary efficacy of iscalimab (CFZ533), a novel anti-CD40 monoclonal antibody, in patients with primary Sjogren's syndrome. Methods This multicentre, randomised, double-blind, placebo-controlled, proof-of-concept study took place at ten investigational sites across Europe (UK, n=4; Germany, Switzerland, and Hungary, n=1 each) and the USA (n=3). Eligible patients were aged 18–75 years and fulfilled the 2002 American European consensus group diagnostic classification criteria for primary Sjogren's syndrome. In the double-blind phase of the trial, patients were randomly assigned (2:1) via computer-generated unique randomisation numbers to receive subcutaneous iscalimab (3 mg/kg) or placebo at weeks 0, 2, 4, and 8 (cohort 1) or intravenous iscalimab (10 mg/kg) or placebo at weeks 0, 2, 4, and 8 (cohort 2). Randomisation was stratified according to baseline intake of oral corticosteroids. At week 12, patients in both cohorts received open-label iscalimab (same dose and route) for 12 weeks. The primary objectives of the study were to assess the safety, tolerability, and efficacy of multiple doses of iscalimab in the two sequential dose cohorts. Safety and tolerability were assessed by adverse events and efficacy of iscalimab versus placebo was assessed by clinical disease activity, as measured by the change in European League Against Rheumatism Sjogren's syndrome disease activity index (ESSDAI) score after 12 weeks of treatment. Analyses were done on a per-protocol basis. The trial was registered with ClinicalTrials.gov , NCT02291029 . Findings Between Oct 22, 2014, and June 28, 2016, we assessed 82 patients for eligibility (25 for cohort 1 and 57 for cohort 2). 38 patients were excluded because of ineligibility. In cohort 1, 12 patients were randomly assigned to receive either 3 mg/kg doses of iscalimab (n=8) or placebo (n=4), and in cohort 2, 32 patients were randomly assigned to receive either intravenous 10 mg/kg doses of iscalimab (n=21) or placebo (n=11). Adverse events were similar between iscalimab treatment groups and placebo groups, with adverse events occurring in all patients in cohort 1, and in 52% and 64% of the iscalimab and placebo groups, respectively, in cohort 2. Two serious adverse events were reported (one case of bacterial conjunctivitis in cohort 1 and one case of atrial fibrillation in cohort 2), which were unrelated to treatment with iscalimab. Intravenous treatment with iscalimab resulted in a mean reduction of 5·21 points (95% CI 0·96–9·46; one-sided p=0·0090) in ESSDAI score compared with placebo. There was no signficiant difference in ESSDAI score between subcutaneous iscalimab and placebo. Interpretation To our knowledge, this is the first randomised, placebo-controlled proof-of-concept study of a new investigational drug for primary Sjogren's syndrome that indicates preliminary efficacy. Our data suggest a role of CD40–CD154 interactions in primary Sjogren's syndrome pathology and the therapeutic potential for CD40 blockade in this disease should be investigated further. Funding Novartis Pharma.

Drug repurposing is promoted as a cost- and time-effective mechanism for providing new medicines. Often, however, there is insufficient consideration by academic researchers of the processes required to ensure that a repurposed drug can be used for a new indication. This may explain the inability of drug repurposing to fulfill its promise. Important aspects, often overlooked, include financial and intellectual property considerations, the clinical and regulatory path, and clinical equipoise, which provides ethical justification for randomized controlled trials. The goal of drug repurposing is to obtain a new regulator-approved label for an existing drug, and so, the trajectory for drug repurposing and traditional drug development is similar. Here, we discuss factors critical for a successful repurposed medicine to help academic investigators better identify drug repurposing opportunities.

Context The CD40-CD154 co-stimulatory pathway plays an important role in the pathogenesis of Graves disease (GD) by promoting autoreactive B-cell activation. Objective Evaluate efficacy and safety of a human, blocking, nondepleting anti-CD40 monoclonal antibody, iscalimab, in hyperthyroid patients with GD. Design Open-label, phase II proof-of-concept study. Setting Multicenter. Patients Fifteen with GD. Intervention Patients received 5 doses of iscalimab at 10 mg/kg intravenously over 12 weeks. Main outcome measures Thyroid-related hormones and autoantibodies, plasma soluble CD40, free CD40 on B cells, soluble CXCL13, pharmacokinetics, and safety were assessed. Results The iscalimab intervention resulted in complete CD40 engagement for up to 20 weeks. A clinical response and biochemical euthyroidism was observed in 7 of 15 (47%) patients. Free and total triiodothyronine and thyroxine normalized in 7 patients who did not receive any rescue medication with antithyroid drugs (ATD), and 2/15 (13.3%) showed normal thyrotropin. Six (40%) patients required ATD. Four of 7 responders relapsed after treatment completion. Serum concentrations of thyrotropin receptor autoantibodies (TSH-R-Ab) significantly declined in all patients (mean 15.3 IU/L vs 4.0 IU/L, 66% reduction; P < 0.001) and TSH-R-Ab levels normalized in 4 (27%). Thyroperoxidase and thyroglobulin autoantibodies significantly decreased in responders. Iscalimab rapidly reduced serum CXCL13 concentrations (P < 0.001). Twelve (80.0%) patients reported at least 1 adverse event (AE). All treatment-related AE were mild or moderate and resolved by end of the study. Conclusion Iscalimab was generally safe and clinically effective in a subgroup of hyperthyroid GD patients. The potential therapeutic benefit of iscalimab should be further tested.

ObjectiveTo examine the role of CD40–CD154 costimulation and effects of therapeutic pathway blockade in the non-obese diabetic (NOD/ShiLtJ) model of Sjögren’s syndrome (SS).MethodsWe assessed leucocyte infiltration in salivary glands (SGs) from NOD/ShiLtJ mice by immunohistochemistry and examined transcriptomics data of SG tissue from these animals for evidence of a CD40 pathway gene signature. Additionally, we dosed MR1 (anti-CD154 antibody) in NOD mice after the onset of SS-like disease and examined the effects of MR1 treatment on sialadenitis, autoantibody production, SG leucocyte infiltration, gene expression downstream of CD40 and acquaporin 5 (AQP5) expression.ResultsWe could detect evidence of CD40 expression and pathway activation in SG tissue from NOD mice. Additionally, therapeutic treatment with MR1 suppressed CD40 pathway genes and sialadenitis, inhibited ectopic lymphoid structure formation and autoantibody production, as well as decreased the frequency of antibody-secreting cells in SGs but had minimal effects on AQP5 expression in NOD/ShiLtJ SGs.ConclusionCD40–CD154 interactions play an important role in key pathological processes in a mouse model of SS, suggesting that blockade of this costimulatory pathway in the clinic may have beneficial therapeutic effects in patients suffering from this autoimmune exocrinopathy.

Tumor necrosis factor (TNF) is a key driver of several inflammatory diseases, such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis, in which affected tissues show an interferon-stimulated gene signature. Here, we demonstrate that TNF triggers a type-I interferon response that is dependent on the cyclic guanosine monophosphate-AMP synthase (cGAS)-stimulator of interferon genes (STING) pathway. We show that TNF inhibits PINK1-mediated mitophagy and leads to altered mitochondrial function and to an increase in cytosolic mtDNA levels. Using cGAS-chromatin immunoprecipitation (ChIP), we demonstrate that cytosolic mtDNA binds to cGAS after TNF treatment. Furthermore, TNF induces a cGAS-STING-dependent transcriptional response that mimics that of macrophages from rheumatoid arthritis patients. Finally, in an inflammatory arthritis mouse model, cGAS deficiency blocked interferon responses and reduced inflammatory cell infiltration and joint swelling. These findings elucidate a molecular mechanism linking TNF to type-I interferon signaling and suggest a potential benefit for therapeutic targeting of cGAS/STING in TNF-driven diseases.

Inflammatory diseases including psoriasis are associated with metabolic and cardiovascular comorbidities, including obesity and metabolic syndrome. Obesity is associated with greater psoriasis disease severity and reduced response to treatment. Therefore, targeting metabolic comorbidities could improve patients’ health status and psoriasis-specific outcomes. METABOLyx is a randomized controlled trial evaluating the combination of a lifestyle intervention program with secukinumab treatment in psoriasis. Here, the rationale, methodology and baseline patient characteristics of METABOLyx are presented. A total of 768 patients with concomitant moderate to severe plaque psoriasis and metabolic syndrome were randomized to secukinumab 300 mg, or secukinumab 300 mg plus a tailored lifestyle intervention program, over 24 weeks. A substudy of immunologic and metabolic biomarkers is ongoing. The primary endpoint of METABOLyx is PASI90 response at week 24. Other endpoints include patient-reported outcomes and safety. METABOLyx represents the first large scale clinical trial of an immunomodulatory biologic in combination with a standardized lifestyle intervention.

Therapeutic targeting of immune checkpoints has garnered significant attention in the area of cancer immunotherapy, in which efforts have focused in particular on cytotoxic T lymphocyte antigen 4 (CTLA4) and PD1, both of which are members of the CD28 family. In autoimmunity, these same pathways can be targeted to opposite effect: to curb the over-exuberant immune response. The CTLA4 checkpoint serves as an exemplar, whereby CTLA4 activity is blocked by antibodies in cancer immunotherapy and augmented by the provision of soluble CTLA4 in autoimmunity. Here, we review the targeting of co-stimulatory molecules in autoimmune diseases, focusing in particular on agents directed at members of the CD28 or tumour necrosis factor receptor families. We present the state of the art in co-stimulatory blockade approaches, including rational combinations of immune inhibitory agents, and discuss the future opportunities and challenges in this field.

Iscalimab is a fully human, CD40 pathway blocking, nondepleting monoclonal antibody being developed as an immunosuppressive agent. We describe a first-in-human, randomized, double-blind, placebo-controlled study investigating the safety, tolerability, pharmacokinetics, and pharmacodynamics of iscalimab in healthy subjects and rheumatoid arthritis patients. Healthy subjects (n = 56) received single doses of intravenous iscalimab (0.03, 0.1, 0.3, 1, or 3 mg/kg), or subcutaneous iscalimab (3 mg/kg), or placebo. Rheumatoid arthritis patients (n = 20) received single doses of intravenous iscalimab (10 or 30 mg/kg) or placebo. Iscalimab exhibited target-mediated drug disposition resulting in dose-dependent and nonlinear pharmacokinetics. Complete (≥90%) CD40 receptor occupancy on whole blood B cells was observed at plasma concentrations >0.3-0.4 µg/mL. In subjects receiving 3 mg/kg iscalimab, antibody responses to keyhole limpet hemocyanin were transiently suppressed. CD40 occupancy by iscalimab prevented ex vivo human rCD154-induced expression of CD69 on B cells in whole blood. All doses were generally safe and well tolerated, with no clinically relevant changes in any safety parameters, including no evidence of thromboembolic events. Iscalimab appears to be a promising blocker of the CD40-CD154 costimulatory pathway with potential use in transplantation and other autoimmune diseases.

Background: Primary Sjogren’s syndrome (pSS) is a systemic progressive autoimmune disease characterised by formation of lymphoid structures and germinal centres within glandular tissue. Iscalimab (CFZ533) is a novel monoclonal antibody that potently and selectively blocks CD40, a co-stimulatory pathway receptor important for germinal centre reactions and B cell activation. Iscalimab showed clinical efficacy in a Proof of Concept randomised controlled trial at a dose of 10 mg/kg intravenously (IV), whereas subcutaneous (SC) dosing at 3 mg/kg was associated with unexpectedly low plasma concentrations and reduced efficacy, likely due to efficient pre-systemic target-mediated clearance. Objectives: To test IV versus SC loading doses of iscalimab followed by SC maintenance dosing, as a means of achieving target drug exposure and clinical efficacy. Methods: Patients with clinically active pSS [EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI) ≥6] were randomised to receive either 600 mg SC iscalimab weekly on 4 occasions, followed by 300 mg SC weekly until week 12, or a single IV dose of 10 mg/kg iscalimab on study Day 1, followed by 300 mg SC weekly until week 12. Subjects and investigator staff remained blinded to study treatment allocation until first dosing. Results: Twenty-five patients were randomised; 13 in the SC loading and 12 in the IV loading arms. Baseline characteristics were similar to the previous phase IIa cohorts with mean ESSDAI scores of 12.7 (SD 6.1) and 10.4 (5.9) in the SC and IV loading arms respectively. In Arm 1 (SC) and Arm 2 (IV), the mean trough plasma concentrations were 169 μg/mL (SD 64.1, CV 38%) and 135 μg/mL (SD 70.9, CV 53%) on Day 85, respectively. Both values were well above levels previously reported to be sufficient for suppression of germinal centre development and T dependent antigen responses in cynomolgus monkeys. Consistent with this finding, clinically important improvements were seen in both arms with a mean decrease in ESSDAI scores of -5.5 (+/- SD: 5.5) and -7.6 (+/- 7.1) points from baseline to Day 85 in the SC and IV dosing arms. Improvements were also seen in EULAR Sjogren’s Syndrome Patient Reported Index (ESSPRI) scores: -1.67 (+/- 1.8) and -1.17 (+/- 2.3), respectively. Other secondary efficacy outcomes showed similar patterns of improvement. Treatment with iscalimab was associated with a reduction in the germinal centre-related serum biomarker CXCL13 in both groups. Overall, iscalimab was safe and well-tolerated with no new safety signal emerging. One subject experienced three SAEs (hemarthrosis, worsening of right knee pain and swelling requiring arthroscopy) in the safety follow-up period, all unrelated to study drug. Conclusion: These results further support the safety and efficacy of iscalimab in pSS and the suitability of SC dosing for future development. Disclosure of Interests: Benjamin Fisher Consultant for: Novartis, Roche, MedImmune, Bristol-Myers Squibb, Antonia Szanto: None declared, Wan Fai Ng: None declared, Michele Bombardieri Grant/research support from: Celgene, Consultant for: Medimmune, Maximilian Posch: None declared, Athena Papas Grant/research support from: Novartis, Consultant for: Novartis, Arwa Farag: None declared, Thomas Daikeler: None declared, Bettina Bannert: None declared, Alan Kivitz Shareholder of: Novartis, Consultant for: Abbvie, Janssen, Pfizer, UCB, Genzyme, Sanofi, Regeneron, Boehringer Ingelheim, Sun Pharma Advanced Research, Flexion., Paid instructor for: Celgene, Horizon, Merck, Novartis, Pfizer, Genzyme, Sanofi, Regeneron, Speakers bureau: Celgene, Horizon, Merck and Genetech, Flexion, Steven Carsons Grant/research support from: Novartis, David Isenberg: None declared, Francesca Barone Grant/research support from: GlaxoSmithKline, Roche, UCB Pharma, Actelion, ONO Pharmaceutical, Consultant for: GlaxoSmithKline, Roche, Actelion, ONO Pharmaceutical, Simon J. Bowman Grant/research support from: Previously UCB Pharma (to University of Birmingham) and Roche, Consultant for: 2016-7: Novartis, Mitsubishi Tanabe Pharma 2017-8: AstraZeneca, MedImmune, GFK, Xtlbio, ONO Pharmaceutical 2018-9: Novartis, AstraZeneca, UCB Pharma, Pascal Espie Employee of: Novartis, Grazyna Wieczorek Employee of: Novartis, Pierre Moulin Employee of: Novartis, David Floch Employee of: Novartis, Cyrielle Dupuy Employee of: Novartis, Amanda Nguyen Employee of: Novartis, Andrew Wright Shareholder of: Novartis, Employee of: Novartis, Michael Rotte Employee of: Novartis, James Rush Employee of: Novartis, Peter Gergely Employee of: Novartis

Objective: Graves’ disease (GD) is an autoimmune disorder characterized by thyrotropin receptor autoantibody (TSHR-Ab)-mediated pathology, leading to hyperthyroidism. To date there is no pharmacotherapy that addresses the underlying pathogenesis. The CD40-CD154 (CD40L) co-stimulatory pathway plays an important role in the pathogenesis of GD by promoting auto-reactive B cell activation and intrathyroidal ectopic lymphoid structure formation and function. Iscalimab (CFZ533) is a fully human, blocking and non-depleting anti-CD40 monoclonal antibody. The purpose of this study was to investigate the efficacy and safety of Iscalimab in patients with Graves’ hyperthyroidism. Methods: In total, fifteen patients with Graves’ hyperthyroidism were enrolled in an open label Phase I proof-of concept study and all completed the trial. Each patient received five doses of Iscalimab at 10 mg/kg IV over 12 weeks. We assessed the effects of Iscalimab on thyroid-related hormones (baseline TSH, free and total T3/T4) and autoantibodies (TSHR-Ab) over 36 weeks following the first dose of Iscalimab. Safety, pharmacokinetics, soluble CD40 levels in plasma, free CD40 on whole blood CD19-positive B cells, and CXCL13 were also assessed. Results: Based on the CD40 occupancy and plasma levels of soluble CD40, the intervention resulted in full CD40 engagement for up to 20 weeks (12-week treatment + 8 week follow up). A clinical response and biochemical euthyroidism was observed in seven out of 15 (46.7%) by Day 211. Free T3/T4 normalized in seven (46.7%) patients who did not received any rescue medication with anti-thyroid drugs. Two further patients (13.3%) did not normalize but did not require rescue medication. In contrast, six (40%) patients required rescue medication with anti-thyroid drugs by Day 141. No patients achieved normalization of TSH by Day 85, however, two out of 15 patients (13.3%) showed normal TSH by Day 169. The levels of free thyroid hormones and TSHR-Ab levels declined over time up to Day 211. The mean levels of TSHR-Ab declined from 15.3 IU/L (baseline) to 9.4 IU/L at Day 85 (35% reduction, P

Background Identification of non-invasive differentially regulated markers in SLE are valuable to improve diagnosis, prediction of response to treatment(s) or classification of disease subpopulations. Our goal was to assess a broad range of serum protein markers in a large cohort of SLE patients and further characterize the role of autoantibodies in serum of these patients for their functional capacity as specific immune complexes to activate the IFN axis. Methods In this multicenter study, we have characterised a large cohort of mostly pediatric SLE patients (n=150) with longitudinal sera samples (total n=269). Serum cytokines/chemokines levels and their extractable nuclear antigen antibody (ENA) and antinuclear antibody (ANA) profiles measured from SLE patients and healthy subjects using a 30-panel Multiplex and individual enzyme-linked immunosorbent assays. Patient sera containing autoantibodies and specific antigens activating the IFN pathway quantified on human primary cells using AlphaLisa technology. Statistics for significance Mann-Whitney (*p Results Differentially regulated cytokines/chemokines were elevated in sera of SLE patients compared to healthy individuals. Notably, IFN-related proteins (IFNalpha*, IFNgamma* and IP10****), B-cell and monocytes chemokines including CXCL13**** and MCP-1***, as well as Th1/17 activating cytokines (IL-12****, IL-17**) and those involved in antibody production by B lymphocytes (IL-10**, IL-13**, IL-6*) being more significant. Collectively, these peripheral markers may serve to help inform diagnosis and support the choice treatment in the clinic. We established a miniaturized functional assay and show that the vast majority of SLE patient sera containing common ENAs (against RNP/Sm, SS-A) and ANAs (dsDNA) could specifically activate the type I IFN pathway as an immune-complex on healthy peripheral blood mononuclear cells (PBMCs) (figure 1). We demonstrate that SLE containing immune-complexes (with specific antigens) can trigger IFN release potentially via nucleic-acid RNA/DNA sensors. Clustering patient autoantibody ENAs profiles reveal that most of the SLE patients in this cohort display a stronger IFN functional activation profile. Conclusions Given the high incidence of elevated IFN signatures in SLE patients, it is not surprising that increased IFN-related proteins and ENA/ANAs that trigger IFN responses are more evident in SLE patient serum. The prevalence of ENA/ANAs in patient sera that have the functional capacity to activate IFN downstream of nucleic acid sensors may help to define subpopulations of SLE. Funding Source(s): National Council for Scientific and Technological Development (CNPq 157534/2015–4) PBMCs were prepared from fresh healthy human blood, stimulated with individual patient SLE serum in combination with defined antigens corresponding to their ENA or ANA titer profile. After 20 hour, IFNalpha protein levels were quantified and expressed relative to agonist ssRNA40. Data shown are from 2 more independent donors with total SLE patients numbers indicated in parenthesis. ****p

CFZ533 is a pathway blocking, nondepleting anti-CD40 antibody that is in clinical development for inhibition of transplant organ rejection and therapy for autoimmune diseases. A 26-week GLP toxicity study in sexually mature Cynomolgus monkeys was conducted in order to support chronic application of CFZ533. CFZ533 was subcutaneously administered at doses up to 150 mg/kg/week and was safe and generally well tolerated. CFZ533 showed no adverse effects for cardiovascular, respiratory, and neurobehavioral endpoints, and no changes were observed for blood lymphocyte and platelet counts or blood coagulation markers. In line with the nondepleting nature of CFZ533, CD20+ B cells in the blood were only marginally reduced. A complete suppression of germinal center (GC) development in lymph nodes and spleen was the most prominent result of post-mortem histological investigations. This was corroborated by an abrogated T-dependent antibody response (TDAR) to the antigen Keyhole Limpet Hemocyanin (KLH) as well as an absence of anti-drug antibodies (ADAs) in the absence of B cell depletion as seen with immunophenotyping and histology. When serum levels of CFZ533 in recovery animals dropped levels necessary for full CD40 occupancy on B cells, all animals were able to mount a TDAR to KLH. All histological changes also reverted to normal appearance after recovery. In summary, CFZ533 was shown to be well tolerated and safe in the 26-week toxicity study with a distinct pharmacodynamic profile in histology and immune function.

The eleven countries of Southeast Asia are diverse in every way, from the ethnicities and religions of their residents to their political systems and levels of prosperity. These nations—Myanmar, Thailand, Malaysia, Indonesia, Vietnam, Singapore, the Philippines, Laos, Cambodia, Brunei, and East Timor—are each unique, yet shared traditions mean that each country is also typically Southeast Asian. Southeast Asia: A Very Short Introduction traces the region’s history from the earliest “mandala” kingdoms to the colonial era and the present day. Synthesizing the ideas of leading scholars, it provides an analysis of contemporary Southeast Asia that accommodates its bewildering ethnic, religious, and political complexities while exposing the underlying patterns that make it a unified world region.

The mandala world of Southeast Asia was fragile, but it was also rich. The first Europeans that were drawn to Southeast Asia to gain access to the region’s precious goods directly were from Portugal and Spain. “Colonies” describes the arrival of the Portuguese in Goa in 1510 and their capture of Melaka; the Spanish seizure of the Philippine islands from the Aztecs in 1521; and the colonizing of the Dutch and British. By the early twentieth century, the colonial spheres of Holland and England had expanded dramatically and both France and the United States had also seized colonial territories in Southeast Asia. Of the region’s indigenous kingdoms, only Siam survived.

What remains today of Southeast Asia’s former kingdoms and colonies and its first-draft nations? “The past is in the present” suggests the answer is quite a lot. The extraordinary heterogeneity of Southeast Asia has not changed. Beneath the skin of the region’s national identities, thousands of separate ethnicities and languages and dialects remain, playing a role in local power struggles and sometimes in national ones. The impressive survival of the new states since independence, and their formal incorporation into a web of international organizations, suggest that Southeast Asia’s nations are here to stay. And yet, Southeast Asia remains rife with conflict. Often, the sleeping mandalas provide an explanation.

“What is Southeast Asia?” provides a geographical, political, social, and historical overview of each of the eleven nations that make up Southeast Asia. Mainland Southeast Asia is home to hundreds of ethnic groups that are today the citizens of Myanmar, Thailand, Laos, Cambodia, and Vietnam. Island (or maritime) Southeast Asia includes the Malay Peninsula and two huge archipelagos whose even more diverse populations are now citizens of Indonesia, Malaysia, Singapore, Brunei, East Timor, and the Philippines. The entire region stretches some 5,000 kilometers from end to end and 4,000 kilometers north to south. It contains 625 million people, around 9% of the world’s population.

By the second or third millennium bce, the people of Southeast Asia were cultivating rice, domesticating pigs, chickens, and cattle, and forming the region’s earliest settled communities in several mainland areas congruent with present-day north Vietnam, Thailand, and Malaya. “Kingdoms” describes what little is known about the early civilizations through the region, such as at Funan and Angkor. It also describes pre-modern Southeast Asia as a world of mandala kingdoms and how Southeast Asian societies and states evolved in communication with adjacent Asian civilizations in India and China, absorbing Islam and Theravada Buddhism. After China’s withdrawal from the region, the Europeans arrived from the 1500s bringing new trade and cultural influence.

Most of Southeast Asia’s colonies had been created by conquest and coercion. Almost everywhere, Southeast Asians attempted to fend off European rule in every way possible. “Nations” describes the processes of resistance to colonial powers, growing nationalism, and new movements for political reform and independence. Japan’s entry to World War II changed everything. The impact of the war on Southeast Asia is explained along with the move to independence and nation-building that followed. It also outlines the effects of the Cold War, the signing of the ground-breaking Treaty of Amity and Cooperation by the ASEAN members, and the financial booms and crashes of the 1990s and 2000s.

The CD40-CD154 costimulatory pathway is essential for T cell-dependent immune responses, development of humoral memory, and antigen presenting cell function. These immune functions have been implicated in the pathology of multiple autoimmune diseases as well as allograft rejection. We have generated CFZ533, a fully human, pathway blocking anti-CD40 monoclonal antibody that has been modified with a N297A mutation to render it unable to mediate Fcγ-dependent effector functions. CFZ533 inhibited CD154-induced activation of human leukocytes in vitro, but failed to induce human leukocyte activation. Additionally, CFZ533 was unable to mediate depletion of human CD40 expressing B cells. In vivo, CFZ533 blocked primary and recall T cell-dependent antibody responses in nonhuman primates and abrogated germinal formation without depleting peripheral blood B cells. We also established a relationship between plasma concentrations of CFZ533 and CD40 pathway-relevant pharmacodynamic effects in tissue. Collectively these data support the scientific rationale and posology for clinical utility of this antibody in select autoimmune diseases and solid organ transplantation.

Background Precision medicine aims at providing intervention based on clinical and molecular stratification of patients, and is an important approach for targeting heterogeneous diseases. A diverse autoimmune disease is systemic lupus erythematosus (SLE), where dysregulation of several immune processes affects multiple organs. Fundamental for targeted treatment of such a heterogeneous disease is the identification of biomarkers predictive for the biological basis of clinical phenotypes. Objectives Despite recent progress, few markers for SLE are currently used in the clinic. In order to learn SLE pathological mechanisms and associated biomarkers, we obtained a diverse dataset from a cohort of active SLE patients (SLEDAI >6), including blood transcriptomics, serum proteomics, cytokines, and auto-antibody profiles. Integration of multi-omics data provides a rich dataset to explore associations between molecular and clinical readouts. Methods From a machine-learning perspective, biomarker discovery is defined as the process of selecting an optimal subset of variables for the prediction of parameters of interest. However, variable selection approaches are often underpowered for datasets that contain fewer samples than the number of variables. To overcome this problem we present a method based on L1 regularized regression and recursive variable elimination to generate networks of predictive markers across multiple data types. Results The proposed method allows us to graphically visualize the relationships among SLE phenotypes, and their molecular fingerprints. Identified networks of markers are validated by mapping to known biological pathways, and when available by comparison to independent patient cohorts. Despite the small number of patients (n=20), we identify known pathological mechanisms, including a type I IFN gene signature, several cell type specific signatures, and potential novel markers of clinically defined SLE subtypes. Conclusions Systemic lupus erythematosus is a complex autoimmune disease characterized by a variety of clinical manifestations. While multi-omics profiles from SLE patients pose challenges because of their intrinsic high dimensionality, they also provide a unique insight into the molecular processes of disease. Our integrated analysis gives a novel perspective on the pathological mechanisms of clinical SLE phenotypes. Disclosure of Interest None declared

Opium and empire in Southeast Asia: Regulating consumption in British Burma By ASHLEY WRIGHT Hampshire and New York: Palgrave Macmillan, 2014. Pp. 214. Appendix, Notes, Bibliography, Index. doi:10.1017/S0022463414000757 Opium was a mainstay of colonial revenues throughout Asia during the high colonial age. The Dutch, French, Spanish, and, briefly, Americans all sold opium to their subjects through one state-led scheme or another. Britain was the key player in this vast enterprise. It sold opium to its own subjects in India and Southeast Asia and to legions of others in China and elsewhere. And it was largely British opium from the poppy fields of Bengal that flowed through government and private hands to smokers in the Dutch East Indies, French Indochina, and countless other markets in Asia. Opium and empire in Southeast Asia tells a small part of this large story. It traces how Britain went about selling opium to its subjects in British Burma and how its officials managed to square this practice with both their imperial priorities and their imperial consciences. Opium was significant enough in the kingdom of Burma for King Bodawhpaya (r. 1782-1819) to declare it a capital crime. Yet, as the English East India Company moved into Arakan and Tenasserim--outlying territories of the kingdom's large mandala--after the First Anglo-Burmese War of 1824, among the first institutions it imported from British Bengal was the retail opium-licensing system, alongside similar revenue-farming arrangements for gambling and toddy shops. A certain amount of trial and error followed. A.D. Maingy, the first commissioner of Tenasserim, became an early critic of selling opium to native subjects. By the time the Company seized Lower Burma (Pegu) following the Second Anglo-Burmese War, certain assumptions about opium were in place. In this discourse, it was perfectly all right to peddle opium to some colonial subjects, including Chinese, Indians, and certain local ethnic minorities such as the Shan and Kachin; no ill effects appeared to accompany the practice among these groups. But it was not all right to peddle opium to ethnic Burmans, whose childlike ways and self-indulgent habits made them prey to addiction, sloth, and crime. Britain's solution to this dilemma, never perfectly executed, was to regulate opium sales so that consumption among Burmans was curtailed, if not completely eliminated, and so that profits flowed freely from selling opium to the others. This strategy was the essence of Chief Commissioner Charles Aitchison's landmark 1881 memorandum, adopted as law in 1891. Wright's book emphasises the recurring policy debates around this strategy--as Britain completed its conquest of Burma in 1885, executed the India-wide Royal Commission on Opium inquiry of the 1890s (in response to anti-opium sentiments in Britain), confronted rising international and much-resented American pressure in the twentieth century in one international opium conference after another, and as reformist Burmese nationalists agitated for prohibition from within the colony itself. To the end, as Wright amply demonstrates, colonial officials nimbly adopted the rhetoric of opium suppression even as they employed every strategy possible to prevent or delay the end of government opium sales. …

This paper discusses in a general way the acquisition of computing facilities. Guidelines are given for how to start in computing, what factors to consider in the acquisition of one's own equipment, where to get advice, who should use the facilities, and how to provide security and privacy for the user and for the facility.

Cross-presentation is the process by which professional APCs load peptides from an extracellularly derived protein onto class I MHC molecules to trigger a CD8(+) T cell response. The ability to enhance this process is therefore relevant for the development of antitumor and antiviral vaccines. We investigated a new TLR2-based adjuvant, Small Molecule Immune Potentiator (SMIP) 2.1, for its ability to stimulate cross-presentation. Using OVA as model antigen, we demonstrated that a SMIP2.1-adjuvanted vaccine formulation induced a greater CD8(+) T cell response, in terms of proliferation, cytokine production and cytolytic activity, than a non-adjuvanted vaccine. Moreover, using an OVA-expressing tumor model, we showed that the CTLs induced by the SMIP2.1 formulated vaccine inhibits tumor growth in vivo. Using a BCR transgenic mouse model we found that B cells could cross-present the OVA antigen when stimulated with SMIP2.1. We also used a flow cytometry assay to detect activation of human CD8(+) T cells isolated from human PBMCs of cytomegalovirus-seropositive donors. Stimulation with SMIP2.1 increased the capacity of human APCs, pulsed in vitro with the pp65 CMV protein, to activate CMV-specific CD8(+) T cells. Therefore, vaccination with an exogenous antigen formulated with SMIP2.1 is a successful strategy for the induction of a cytotoxic T cell response along with antibody production.

CD40-CD154 pathway blockade prolongs renal allograft survival in nonhuman primates (NHPs). However, antibodies targeting CD154 were associated with an increased incidence of thromboembolic complications. Antibodies targeting CD40 prolong renal allograft survival in NHPs without thromboembolic events but with accompanying B cell depletion, raising the question of the relative contribution of B cell depletion to the efficacy of anti-CD40 blockade. Here, we investigated whether fully silencing Fc effector functions of an anti-CD40 antibody can still promote graft survival. The parent anti-CD40 monoclonal antibody HCD122 prolonged allograft survival in MHC-mismatched cynomolgus monkey renal allograft transplantation (52, 22, and 24 days) with accompanying B cell depletion. Fc-silencing yielded CFZ533, an antibody incapable of B cell depletion but still able to potently inhibit CD40 pathway activation. CFZ533 prolonged allograft survival and function up to a defined protocol endpoint of 98-100 days (100, 100, 100, 98, and 76 days) in the absence of B cell depletion and preservation of good histological graft morphology. CFZ533 was well-tolerated, with no evidence of thromboembolic events or CD40 pathway activation and suppressed a gene signature associated with acute rejection. Thus, use of the Fc-silent anti-CD40 antibody CFZ533 appears to be an attractive approach for preventing solid organ transplant rejection.

The paracaspase MALT1 plays an important role in immune receptor-driven signaling pathways leading to NF-κB activation. MALT1 promotes signaling by acting as a scaffold, recruiting downstream signaling proteins, as well as by proteolytic cleavage of multiple substrates. However, the relative contributions of these two different activities to T and B cell function are not well understood. To investigate how MALT1 proteolytic activity contributes to overall immune cell regulation, we generated MALT1 protease-deficient mice (Malt1PD/PD) and compared their phenotype with that of MALT1 knockout animals (Malt1−/−). Malt1PD/PD mice displayed defects in multiple cell types including marginal zone B cells, B1 B cells, IL-10–producing B cells, regulatory T cells, and mature T and B cells. In general, immune defects were more pronounced in Malt1−/− animals. Both mouse lines showed abrogated B cell responses upon immunization with T-dependent and T-independent Ags. In vitro, inactivation of MALT1 protease activity caused reduced stimulation-induced T cell proliferation, impaired IL-2 and TNF-α production, as well as defective Th17 differentiation. Consequently, Malt1PD/PD mice were protected in a Th17-dependent experimental autoimmune encephalomyelitis model. Surprisingly, Malt1PD/PD animals developed a multiorgan inflammatory pathology, characterized by Th1 and Th2/0 responses and enhanced IgG1 and IgE levels, which was delayed by wild-type regulatory T cell reconstitution. We therefore propose that the pathology characterizing Malt1PD/PD animals arises from an immune imbalance featuring pathogenic Th1- and Th2/0-skewed effector responses and reduced immunosuppressive compartments. These data uncover a previously unappreciated key function of MALT1 protease activity in immune homeostasis and underline its relevance in human health and disease.

Class switch recombination (CSR) is the process by which B cells alter the effector function properties of their Ig molecules. The decision to switch to a particular Ig isotype is determined primarily by the mode of B cell activation and cytokine exposure. More recent work indicates that the likelihood or probability of switching increases with successive cell divisions and is largely independent of time. We have analyzed different molecular features of CSR using cell division as a reference point in an attempt to gain insight into the mechanism of division-linked switching. Our results indicated that the accessibility of Ig heavy chain constant regions targeted for CSR was established after the cells had undergone a single cell division and did not vary significantly with subsequent cell divisions. In contrast, expression of activation-induced cytidine deaminase (AID) mRNA was found to increase with successive divisions, exhibiting a striking correlation with the frequency of CSR. Levels of AID in a given division remained constant at different time points, strongly suggesting that the regulation of AID expression was division-linked and independent of time. In addition, constitutive AID expression from a transgene accelerated division-linked CSR. Thus, we propose that the division-linked increase in AID expression provides an underlying molecular explanation for division-linked CSR.

Describes the NISO circulation interchange protocol (NCIP) and some of the design decisions that were made in developing it. When designing a protocol of the scale and scope of NCIP, certain decisions about what technologies to employ need to be made. Often there are multiple competing technologies that can be employed to accomplish the same functionality, and there are both positive and negative reasons for the choice of any particular one. Focuses specifically on the areas on which the protocol would be supported. Gives particular emphasis to the decision to choose XML as the encoding technology for the protocol messages. One of the main design goals for NCIP was to try to strike the appropriate balance between ease of implementation and providing appropriate functionality. This functionality includes that needed to support both application areas that the committee could anticipate would use the protocol in the short term, and new applications that might be developed in the future.

T cell stimulation of B cell proliferation during T-B collaboration requires membrane-bound stimulatory ligands, such as CD40 ligand and the secretion of soluble cytokines, such as IL-4. Nevertheless, it remains unclear whether T cell contact is required to provoke each consecutive B cell division, or whether B cells divide in a T cell-free burst following the initial stimulation. To test this, naive B cells were cultured with anti-CD40 monoclonal antibody (mAb) and IL-4 and, after various times, these stimuli were removed and the cells re-cultured with or without further stimulation. Following stimulus removal, B cells were able to continue proliferating, with the size of the B cell burst dependent on the strength of the initial anti-CD40 mAb stimulus. Furthermore, in the absence of activating signals from anti-CD40 and/or IL-4, re-cultured B cells died rapidly. In addition, B cells undergoing a stimulus-free division burst could switch to IgG1. Thus, maximal B cell proliferation, differentiation and survival may require continued, although not necessarily consecutive, cognate interactions with T cells. These results suggest that antigen persistence and T cell help are necessary to sustain B cell proliferation and differentiation in vivo.