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Background: Primary sclerosing cholangitis (PSC) patients have a risk of developing cholangiocarcinoma (CCA). Establishing predictive models for CCA in PSC is important. Methods: In a large cohort of 1,459 PSC patients seen at Mayo Clinic (1993-2020), we quantified the impact of clinical/laboratory variables on CCA development using univariate and multivariate Cox models and predicted CCA using statistical and artificial intelligence approaches. We explored plasma bile acid (BA) levels’ predictive power of CCA (subset of 300 patients, BA cohort). Results: Eight significant risk factors (false discovery rate: 20%) were identified with univariate analysis; prolonged inflammatory bowel disease (IBD) was the most important one. IBD duration, PSC duration, and total bilirubin remained significant (pConclusions: In a large PSC cohort, we identified clinical and laboratory risk factors for CCA development and demonstrated the first artificial intelligence based predictive models that performed significantly better than common risk scores. More predictive data modalities are needed for clinical adoption of these models.

Recent studies identified underlying genetic causes in a proportion of patients with various forms of kidney disease. In particular, genetic testing reclassified some focal segmental glomerulosclerosis (FSGS) cases into collagen type 4 (COL4)-related nephropathy. This knowledge has major implications for counseling prospective transplant recipients about recurrence risk and screening biologically related donors. We describe our experience incorporating genetic testing in our kidney transplant multidisciplinary practice.Patients' DNA was analyzed using whole exome sequencing for a comprehensive kidney gene panel encompassing 344 genes associated with kidney diseases and candidate genes highly expressed in the kidney. Results were correlated with phenotype by a multidisciplinary committee of nephrologists, renal pathologists, geneticists, and genetic counselors. Between October 2018 and July 2020, 30 recipient and 5 donor candidates completed testing.Among recipient candidates, 24 (80%) carried the diagnosis of FSGS, 2 (6.7%) tubulointerstitial nephritis, and 1 (3.3%) nephrolithiasis, and 3 (10%) had an unknown cause of kidney disease. The yield for pathogenic/likely pathogenic variants was 43.3%, with majority being COL4 variants (53.8%). Among those with FSGS diagnosis, the yield was 10 of 24 (41.6%), with 29% reclassified into a COL4-related nephropathy. Family history of kidney disease was the only clinical characteristic difference between recipients with positive and negative results (76.9 versus 29.4%; P = 0.025). One of 5 donors tested positive for a pathogenic/likely pathogenic variant and was excluded from donation.We conclude that thoughtful use of genetic testing can be valuable for kidney donor selection and transplant recipient management.

To assess possible color changes of natural teeth after surgical orthodontic treatment. This prospective controlled clinical pilot trial included 6 consecutively treated surgical orthodontic patients with class III malocclusion and neutral vertical relation (ST: surgical treatment), 3 of which received double jaw osteotomies (SGI: surgical subgroup I) and 3 received single mandibular sagittal split ramus osteotomies (SGII: surgical subgroup II). Eleven untreated individuals (UC: untreated control) and 9 individuals who received conventional comprehensive orthodontic treatment only (OC: orthodontic control) served as controls. Tooth color measurements were performed using a reflectance spectrophotometer on the upper and lower incisors before the initiation of the surgical orthodontic treatment (T1) and after its completion (T2). Primary endpoint was ∆E* (T1–T2) of summarized CIE-L*a*b* color differences. The null hypothesis of this study was that there is no statistically significant change in total tooth color difference ∆E* CIE-(L*a*b*) in vivo at baseline and following surgical orthodontic treatment. There was a statistically significant increase in ∆E* (T1–T2) in the ST group compared to the UC and OC groups. Single mandibular surgery had a stronger effect on the lower teeth in comparison to double jaw surgery, while Le Fort I osteotomy, as part SGI, had a stronger effect on the upper teeth. Despite statistical significance, the majority of mean values of these color changes were lower than the threshold value of color alterations considered to be perceivable by the naked eye in a clinical setting (3.7 ∆E units), with the exception of the mandibular incisors in SGII, where this threshold value was slightly exceeded. Orthognathic surgery showed a measurable effect on tooth color. However, esthetic disturbance or patient discomfort based on these color and lightness alterations are unlikely, due to their small impact and low perceptibility in a clinical setting.

Antigen-specific immune responses are crucially involved in both multiple sclerosis (MS) and myasthenia gravis (MG). Teriflunomide is an immunomodulatory agent approved for treatment of MS through inhibition of lymphocyte proliferation. MG associated with muscle-specific tyrosine kinase (MuSK) antibodies often manifests with a severe disease course, prompting development of effective treatment methods. To evaluate whether teriflunomide treatment may ameliorate MuSK-autoimmunity, experimental autoimmune MG (EAMG) was induced by immunizing C57BL/6 (B6) mice three times with MuSK in complete Freund's adjuvant (CFA) (n = 17). MuSK-immunized mice were treated daily with teriflunomide (n = 8) or PBS (n = 9) starting from the third immunization (week 8) to termination (week 14). Clinical severity of EAMG was monitored. Immunological alterations were evaluated by measurement of anti-MuSK IgG, neuromuscular junction deposits, and flow cytometric analysis of lymph node cells. In MS patients under teriflunomide treatment, the peripheral blood B cell subset profile was analyzed. B6 mice treated with teriflunomide displayed relatively preserved body weight, lower EAMG prevalence, reduced average clinical grades, higher inverted screen scores, diminished anti-MuSK antibody and NMJ deposit levels. Amelioration of EAMG findings was associated with reduced memory B cell ratios in the lymph nodes. Similarly, MS patients under teriflunomide treatment showed reduced memory B cell, plasma cell, and plasmablast ratios. Teriflunomide treatment has effectively ameliorated MuSK-autoimmunity and thus may putatively be used in long-term management of MuSK-MG as an auxiliary treatment method. Teriflunomide appears to exert beneficial effects through inhibition of effector B cells.

Background and AimsMyasthenia gravis (MG) is a T-cell dependent antibody-mediated autoimmune disease in which the nicotinic acetylcholine receptor (AChR) is the major autoantigen, comprising several T and B cell auto-epitopes. We hypothesized that an efficacious drug candidate for antigen-specific therapy in MG should comprise a broad range of these auto-epitopes and be administered in a noninflammatory and tolerogenic context.MethodsWe used a soluble mutated form of the extracellular domain of the α1 chain of the AChR (α1-ECDm), which represents the major portion of auto-epitopes involved in MG, and investigated, in a well-characterized rat model of experimental autoimmune myasthenia gravis (EAMG) whether its intravenous administration could safely and efficiently treat the autoimmune disease.ResultsWe demonstrated that intravenous administration of α1-ECDm abrogates established EAMG, in a dose and time dependent manner, as assessed by clinical symptoms, body weight, and compound muscle action potential (CMAP) decrement. Importantly, the effect was more pronounced compared to drugs representing current standard of care for MG. The protein had a short plasma half-life, most of what could be recovered was sequestered in the liver, kidneys and spleen. Further, we did not observe any signs of toxicity or intolerability in animals treated with α1-ECDm.ConclusionWe conclude that intravenous treatment with α1-ECDm is safe and effective in suppressing EAMG. α1-ECDm is in preclinical development as a promising new drug candidate for MG.

Dental agenesis is one of the most common developmental anomalies in humans. It occurs as part of a genetic syndrome or as an isolated sporadic or familial finding. Third molars, second mandibular premolars and maxillary lateral incisors are the most frequently targeted teeth of the permanent dentition. Clinically, patients with congenitally missing permanent teeth seeking treatment present with unesthetic diastemas, midline deviation and tilting of adjacent teeth in the edentulous areas. The impact of tooth agenesis reflects on esthetics, function, psychological and social well-being of the individuals affected. Orthodontics can contribute to the treatment plan selected by rearranging the present teeth so as to open spaces for prosthetic restorations or close spaces by reshaping teeth if needed. Following orthodontic space opening/maintaining, the usual alternatives involve single implants, two-(cantilever) or full coverage(cantilever) prostheses. Less frequently, the treatment modality of autotransplantation is proposed with a good esthetic result but feasible only in young patients where the roots of the premolars are still developing. In orthodontic space closure, treatment is accomplished sooner without waiting for the completion of growth of the patient. Depending on various factors such as the malocclusion, the dento-skeletal profile, the smile line, the space requirements, the teeth missing, the periodontal issues, the age of the patient and any financial issues, the clinician will determine the most appropriate treatment approach. The final esthetic and functional result should resemble an intact natural dentition.

Recent capillary flow experiments, conducted on a combined wetting/non-wetting assemble, consistently feature an anomalous flow over the non-wetting substrate: (i) apparent abrupt or gradual recession stages in the motion of the contact line, (ii) non-monotonic abrupt changes in the receding contact angle, and (iii) contact angle overshoot above the nominal equilibrium contact angle. We find that such behavior of a liquid metal alloy cannot be explained by the standard capillary flow models. However, a model that includes the ageing of the equilibrium contact angle predicts all the observed features qualitatively. We use the phase field formulation for capillary flows with a diffusive motion of the triple line to accommodate the novel diffusive boundary condition with the time-evolving quasi-equilibrium contact angle. We discover that the observed anomalies in capillary flow are qualitatively explained by two factors: (1) time evolution (ageing) of the quasi-equilibrium contact angle and (2) high viscosity of the partially molten braze. We also discover that for the given flow geometry, the transition from the initial to the final configuration may follow two distinct topological paths: one is characterized by a coalescence of liquid–solid contact domains, the other by a contact separation. The selection of the two paths in the configurational space is dependent on both contact ageing parameters and viscosity.

Melanotic neuroectodermal tumor of infancy (MNTI) is a clinically distinctive, benign neoplasm of neural crest origin. The tumor develops usually in the anterior maxilla and rarely in the skull and mandible. This is a report of the interdisciplinary treatment of a rare case of MNTI occurring in the mandible. The patient was initially addressed for examination at the age of 2 months with a rapidly growing tumor of the mandible that had increased double in size in a week. A well-defined lesion in the left mandible shown on MRI and high urine vanillylmandelic acid (VMA) level determined the diagnosis. The complete interdisciplinary treatment included four interventions. Surgery with enucleation and curettage, performed as first intervention, at the age of 2 months. The second intervention lasted from age 7 to age 15 and included a first phase of Orthodontic treatment to monitor normal growth, followed by interceptive Orthodontic treatment and Prosthodontic intervention with interim dentures. The third intervention accomplished after competition of growth and included the pre-prosthetic surgery with an augmentation of the height of the edentulous atrophic mandible and placement of 4 implants. In the fourth intervention the permanent prosthodontic restoration supported by implants was applied.

To assess possible color changes of natural teeth after surgical orthodontic treatment.This prospective controlled clinical pilot trial included 6 consecutively treated surgical orthodontic patients with class III malocclusion and neutral vertical relation (ST: surgical treatment), 3 of which received double jaw osteotomies (SGI: surgical subgroup I) and 3 received single mandibular sagittal split ramus osteotomies (SGII: surgical subgroup II). Eleven untreated individuals (UC: untreated control) and 9 individuals who received conventional comprehensive orthodontic treatment only (OC: orthodontic control) served as controls. Tooth color measurements were performed using a reflectance spectrophotometer on the upper and lower incisors before the initiation of the surgical orthodontic treatment (T1) and after its completion (T2). Primary endpoint was ∆E* (T1-T2) of summarized CIE-L*a*b* color differences. The null hypothesis of this study was that there is no statistically significant change in total tooth color difference ∆E* CIE-(L*a*b*) in vivo at baseline and following surgical orthodontic treatment.There was a statistically significant increase in ∆E* (T1-T2) in the ST group compared to the UC and OC groups. Single mandibular surgery had a stronger effect on the lower teeth in comparison to double jaw surgery, while Le Fort I osteotomy, as part SGI, had a stronger effect on the upper teeth. Despite statistical significance, the majority of mean values of these color changes were lower than the threshold value of color alterations considered to be perceivable by the naked eye in a clinical setting (3.7 ∆E units), with the exception of the mandibular incisors in SGII, where this threshold value was slightly exceeded.Orthognathic surgery showed a measurable effect on tooth color. However, esthetic disturbance or patient discomfort based on these color and lightness alterations are unlikely, due to their small impact and low perceptibility in a clinical setting.ZIELSETZUNG: Beurteilung möglicher Farbveränderungen der natürlichen Zähne nach kombiniert kieferorthopädisch-kieferchirurgischer Behandlung.Diese prospektive kontrollierte klinische Pilotstudie umfasste 6 konsekutiv kieferorthopädisch-kieferchirurgisch behandelte Patienten mit Klasse-III-Malokklusion und neutraler vertikaler Relation (ST: chirurgische Behandlung), von denen 3 eine bimaxilläre Umstellungsosteotomie (SGI: chirurgische Untergruppe I) und 3 eine monomaxilläre Unterkiefer-Sagittal-Split-Ramus-Osteotomie (SGII: chirurgische Untergruppe II) erhielten. Elf unbehandelte Personen (UC: unbehandelte Kontrolle) und 9 Personen, die nur eine konservative umfassende kieferorthopädische Behandlung erhielten (OC: kieferorthopädische Kontrolle), dienten als Kontrollen. Vor Beginn der kieferorthopädisch-kieferchirurgischen Behandlung (T1) und nach deren Abschluss (T2) wurden die Zahnfarben mit einem Reflexionsspektrophotometer an den oberen und unteren Schneidezähnen bestimmt. Primärer Endpunkt war der ∆E* (T1–T2) der zusammengefassten CIE-L*a*b*-Farbunterschiede. Die Nullhypothese dieser Studie war, dass es keine statistisch signifikante Veränderung der gesamten Zahnfarbdifferenz ∆E* CIE-(L*a*b*) in vivo zu Beginn und nach einer kieferorthopädisch-kieferchirurgischen Behandlung gibt.Es gab einen statistisch signifikanten Anstieg von ∆E* (T1-T2) in der ST-Gruppe im Vergleich zu den UC- und OC-Gruppen. Die monomaxilläre Unterkieferoperation hatte im Vergleich zur bimaxillären Umstellungsosteotomie einen stärkeren Effekt auf die unteren Zähne, während die Le-Fort-I-Osteotomie, als Teil der SGI, einen stärkeren Effekt auf die oberen Zähne hatte. Trotz statistischer Signifikanz lagen die meisten Mittelwerte dieser Farbveränderungen unter dem Schwellenwert für Farbveränderungen, die in einer klinischen Umgebung als mit dem bloßen Auge wahrnehmbar gelten (3,7 ∆E Einheiten), mit Ausnahme der Unterkieferschneidezähne in SGII, wo dieser Schwellenwert leicht überschritten wurde.Die kombiniert kieferorthopädisch-kieferchirurgische Behandlung zeigte einen messbaren Effekt auf die Zahnfarbe. Eine ästhetische Störung oder ein Unbehagen des Patienten aufgrund dieser Farb- und Helligkeitsveränderungen sind jedoch aufgrund ihrer geringen Auswirkung und geringen Wahrnehmbarkeit in einer klinischen Umgebung unwahrscheinlich.

We report here the sequence and functional characterization of a recombinantly expressed autoantibody (mAb 131) previously isolated from a myasthenia gravis patient by immortalization of thymic B cells using Epstein-Barr virus and TLR9 activation. The antibody is characterized by a high degree of somatic mutations as well as a 6 amino acid insertion within the VHCDR2. The recombinant mAb 131 is specific for the γ-subunit of the fetal AChR to which it bound with sub-nanomolar apparent affinity, and detected the presence of fetal AChR on a number of rhabdomyosarcoma cell lines. Mab 131 blocked one of the two α-bungarotoxin binding sites on the fetal AChR, and partially blocked the binding of an antibody (mAb 637) to the α-subunit of the AChR, suggesting that both antibodies bind at or near one ACh binding site at the α/γ subunit interface. However, mAb 131 did not reduce fetal AChR ion channel currents in electrophysiological experiments. These results indicate that mAb 131, although generated from an MG patient, is unlikely to be pathogenic and may make it a potentially useful reagent for studies of myasthenia gravis, rhabdomyosarcoma and arthrogryposis multiplex congenita which can be caused by fetal-specific AChR-blocking autoantibodies.

We present a mean-field fluctuating hydrodynamics (FHD) method for studying the structural and transport properties of ionic liquids in bulk and near electrified surfaces. The free energy of the system consists of two competing terms: (1) a Landau–Lifshitz functional that models the spontaneous separation of the ionic groups, and (2) the standard mean-field electrostatic interaction between the ions in the liquid. The numerical approach used to solve the resulting FHD-Poisson equations is very efficient and models thermal fluctuations with remarkable accuracy. Such density fluctuations are sufficiently strong to excite the experimentally observed spontaneous formation of liquid nano-domains. Statistical analysis of our simulations provides quantitative information about the properties of ionic liquids, such as the mixing quality, stability, and the size of the nano-domains. Our model, thus, can be adequately parameterized by directly comparing our prediction with experimental measurements and all-atom simulations. Conclusively, this work can serve as a practical mathematical tool for testing various theories and designing more efficient mixtures of ionic liquids.

Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction. Approximately 9% of MG patients have autoantibodies targeting the muscle specific kinase (MuSK), and are challenging therapeutically, since they often present with more severe symptoms. A useful therapy is plasmapheresis, but it is highly non-specific. Antigen-specific immunoadsorption would only remove the pathogenic autoantibodies, minimizing the possible side effects and maximizing the benefit. We used rats with human MuSK-induced experimental autoimmune MG to perform antigen-specific immunoadsorptions, and found it very effective, resulting in a dramatic autoantibody titer decrease, while immunoadsorbed, but not mock-treated, animals showed an significant improvement of their clinical symptoms. Overall, the procedure was efficient, supporting its application for MG treatment.

Autoimmunity mediated by IgG4 subclass autoantibodies is an expanding field of research. Due to their structural characteristics a key feature of IgG4 antibodies is the ability to exchange Fab-arms with other, unrelated, IgG4 molecules, making the IgG4 molecule potentially monovalent for the specific antigen. However, whether those disease-associated antigen-specific IgG4 are mono- or divalent for their antigens is unknown. Myasthenia gravis (MG) with antibodies to muscle specific kinase (MuSK-MG) is a well-recognized disease in which the predominant pathogenic IgG4 antibody binds to extracellular epitopes on MuSK at the neuromuscular junction; this inhibits a pathway that clusters the acetylcholine (neurotransmitter) receptors and leads to failure of neuromuscular transmission. In vitro Fab-arm exchange-inducing conditions were applied to MuSK antibodies in sera, purified IgG4 and IgG1-3 sub-fractions. Solid-phase cross-linking assays were established to determine the extent of pre-existing and inducible Fab-arm exchange. Functional effects of the resulting populations of IgG4 antibodies were determined by measuring inhibition of agrin-induced AChR clustering in C2C12 cells. To confirm the results, κ/κ, λ/λ and hybrid κ/λ IgG4s were isolated and tested for MuSK antibodies. At least fifty percent of patients had IgG4, but not IgG1-3, MuSK antibodies that could undergo Fab-arm exchange in vitro under reducing conditions. Also MuSK antibodies were found in vivo that were divalent (monospecific for MuSK). Fab-arm exchange with normal human IgG4 did not prevent the inhibitory effect of serum derived MuSK antibodies on AChR clustering in C2C12 mouse myotubes. The results suggest that a considerable proportion of MuSK IgG4 could already be Fab-arm exchanged in vivo. This was confirmed by isolating endogenous IgG4 MuSK antibodies containing both κ and λ light chains, i.e. hybrid IgG4 molecules. These new findings demonstrate that Fab-arm exchanged antibodies are pathogenic. publisher: Elsevier articletitle: IgG4 autoantibodies against muscle-specific kinase undergo Fab-arm exchange in myasthenia gravis patients journaltitle: Journal of Autoimmunity articlelink: http://dx.doi.org/10.1016/j.jaut.2016.11.005 content_type: article copyright: © 2016 The Authors. Published by Elsevier Ltd. ispartof: Journal of Autoimmunity vol:77 pages:104-115 ispartof: location:England status: published

Myasthenia gravis (MG) is an autoimmune disorder caused by autoantibodies that target the neuromuscular junction, leading to muscle weakness and fatigability. Currently available treatments for the disease include symptomatic pharmacological treatment, immunomodulatory drugs, plasma exchange, thymectomy and supportive therapies. Different autoantibody patterns and clinical manifestations characterize different subgroups of the disease: early-onset MG, late-onset MG, thymoma MG, muscle-specific kinase MG, low-density lipoprotein receptor-related protein 4 MG, seronegative MG, and ocular MG. These subtypes differ in terms of clinical characteristics, disease pathogenesis, prognosis and response to therapies. Patients would, therefore, benefit from treatment that is tailored to their disease subgroup, as well as other possible disease biomarkers, such as antibodies against cytoplasmic muscle proteins. Here, we discuss the different MG subtypes, the sensitivity and specificity of the various antibodies involved in MG for distinguishing between these subtypes, and the value of antibody assays in guiding optimal therapy. An understanding of these elements should be useful in determining how to adapt existing therapies to the requirements of each patient.

The importance of the problem of hole-filling by a molten metal lies in the application of brazing for repairs in space, under microgravity conditions. The negligible effects of gravity and dominance of capillary forces can be approximated under terrestrial conditions, provided that the hole and the quantity of liquid are small, as quantified by the Bond number. In this paper, we report experimental results, modeling, and analysis of the hole-filling problem using the liquid aluminum brazing alloy on aluminum substrate. Depending on the hole size, the capillary driven flow may result in the hole being either filled or not filled. The equilibrium problem (energy minimization) has multiple solutions in some regions of the parameter space. Therefore, the experimental outcomes may depend on the availability of sufficiently strong perturbation, required to dislodge the system from a metastable equilibrium. We report good agreement between experimental results and theoretical/computational predictions. In general, a deeper and narrower hole favors the filled outcome.

Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. Most patients have pathogenic autoantibodies against the acetylcholine receptor (AChR). In the last years a novel subpopulation of MG patients has been described that harbors antibodies against low-density lipoprotein receptor-related protein 4 (Lrp4), another postsynaptic neuromuscular antigen. In early-onset AChR MG (EOMG), the thymus plays an important role in immunopathogenesis, and early thymectomy is beneficial. It is still unknown if the thymus plays any role in Lrp4-MG. In this pilot study, we compared thymus samples from four patients with Lrp4-MG (one pre-treated with immunosuppressive drugs), four non-MG controls and five EOMG patients (not pretreated with immunosuppressive drugs). Immunohistochemistry of the Lrp4-MG thymi revealed normal architecture, with normal numbers and distribution of B-cells, lymphoid follicles and Hassall's corpuscles. Primary CD23(+) lymphoid follicles were similarly infrequent in Lrp4-MG and control thymic sections. In none of the control or Lrp4-MG thymi did we find secondary follicles with CD10(+) germinal centers. These were evident in 2 of the 5 EOMG thymi, where primary lymphoid follicles were also more frequent on average, thus showing considerable heterogeneity between patients. Even if characteristic pathological thymic changes were not observed in the Lrp4 subgroup, we cannot exclude a role for the thymus in Lrp4-MG pathogenesis, since one Lrp4-MG patient went into clinical remission after thymectomy alone (at one year followup) and one more improved after thymectomy in combination with immunosuppressive therapy.

Myasthenia gravis (MG) with antibodies against the acetylcholine receptor (AChR) is characterized by a chronic, fatigable weakness of voluntary muscles. The production of autoantibodies involves the dysregulation of T cells which provide the environment for the development of autoreactive B cells. The symptoms are caused by destruction of the postsynaptic membrane and degradation of the AChR by IgG autoantibodies, predominantly of the G1 and G3 subclasses. Active immunization of animals with AChR from mammalian muscles, AChR from Torpedo or Electrophorus electric organs, and recombinant or synthetic AChR fragments generates a chronic model of MG, termed experimental autoimmune myasthenia gravis (EAMG). This model covers cellular mechanisms involved in the immune response against the AChR, e.g. antigen presentation, T cell-help and regulation, B cell selection and differentiation into plasma cells. Our aim is to define standard operation procedures and recommendations for the rat EAMG model using purified AChR from the Torpedo californica electric organ, in order to facilitate more rapid translation of preclinical proof of concept or efficacy studies into clinical trials and, ultimately, clinical practice.

Seronegativemyastheniagravis(MG) presents a serious gap in MG diagnosis and understanding. We applied acellbasedassay(CBA) for the detection of muscle specific kinase (MuSK) antibodies undetectable by radioimmunoassay. We tested 633 triple-seronegative MG patients' sera from 13 countries, detecting 13% as positive.MuSKantibodies were found, at significantly lower frequencies, in 1.9% of healthy controls and 5.1% of other neuroimmune disease patients, including multiple sclerosis and neuromyelitis optica. The clinical data of the newly diagnosedMuSK-MG patients are presented. 27% of ocular seronegative patients wereMuSKantibody positive. Moreover, 23% had thymic hyperplasia suggesting that thymic abnormalities are more common than believed.

Purpose:To compare the course of Scheimpflug corneal densitometry (CD) after Descemet membrane endothelial keratoplasty (DMEK) versus Descemet stripping automated endothelial keratoplasty (DSAEK).Methods:Fifty-four DMEK and 25 DSAEK cases without previous corneal surgery, complicated intraoperative or postoperative course, or vision-limiting ocular comorbidities were included. Pseudophakic eyes of age-matched subjects were recruited as controls (n = 20). Scheimpflug CD of the optically relevant zones (0-2 and 2-6 mm), best-corrected visual acuity (BCVA), endothelial cell density, and central corneal thickness were evaluated preoperatively and at 3, 6, 12, and 24 months postoperatively.Results:CD of the optical zone decreased from 34.4 9.4 grayscale units (GSU) before to 19.2 +/- 2.7 GSU at 24 months after DMEK. Respectively, CD decreased from 34.0 +/- 13.4 GSU before to 21.2 +/- 2.5 GSU at 24 months after DSAEK. Mean central CD in group 3 was 18.1 +/- 1.3 GSU. Compared with DSAEK, DMEK cases showed lower central CD at 3 and 6 months (P 0.012) but not at 12 and 24 months postoperatively. DSAEK showed higher CD values throughout the postoperative period compared with healthy controls (P < 0.001). DMEK showed higher CD compared with controls at 3, 6, and 12 but not at 24 months after surgery (P = 0.152). Postoperative BCVA was significantly better after DMEK for every examination time point. No difference in endothelial cell density was found between DMEK and DSAEK at any time point.Conclusions:DMEK showed lower CD and better BCVA compared with DSAEK in the first 6 postoperative months. Notably, although CD reached similar levels in the midterm after both DMEK and DSAEK, BCVA remained significantly better after DMEK.

Myasthenia gravis (MG) is caused by autoantibodies, the majority of which target the muscle acetylcholine receptor (AChR). Plasmapheresis and IgG-immunoadsorption are useful therapy options, but are highly non-specific. Antigen-specific immunoadsorption would remove only the pathogenic autoantibodies, reducing the possibility of side effects while maximizing the benefit. We have extensively characterized such adsorbents, but in vivo studies are missing. We used rats with experimental autoimmune MG to perform antigen-specific immunoadsorptions over three weeks, regularly monitoring symptoms and autoantibody titers. Immunoadsorption was effective, resulting in a marked autoantibody titer decrease while the immunoadsorbed, but not the mock-treated, animals showed a dramatic symptom improvement. Overall, the procedure was found to be efficient, suggesting the subsequent initiation of clinical trials.

Introduction: Le Fort I and sagittal split ramus osteotomies are the most commonly performed orthognathic surgery procedures on the maxilla and mandible, respectively. Techniques: Despite progress in the techniques, these procedures may still be associated with morbidity, expressed as inflammation, inadequate bony union, periodontal damages or in extreme cases even total bone loss. Discussion: Through a comprehensive review of the literature, the influences of maxillary and mandibular surgery on Pulpal Blood Flow (PBF), pulp sensitivity and pulp vitality are examined. Moreover, adverse effects of maxillary surgery on tooth color and periodontal tissues are also reported. The effects had a variety of expression. Concerning maxillary surgery, some studies showed an initial increase in PBF followed by a decrease to the baseline or even lower levels after 1-3 months. Other studies found an initial decrease in PBF followed by an increase soon after. There were also studies that showed no significant PBF changes, in contrast. Conclusion: Concerning mandibular surgery, a recent study showed a decrease in PBF immediately after sagittal split ramus osteotomy. Some authors detected tooth discoloration of maxillary teeth after Le Fort I osteotomy. Root resorption and root injury were also detected, but were of minor significance. Usually, these adverse effects derive from injury of the vessels of the palatal pedicle. This pedicle should be maintained intact for the avoidance of blood flow impairments. In addition, the descending palatine artery should be protected during maxillary surgery procedures in order to maintain the highest possible blood flow on the maxillary teeth.

Myasthenia gravis (MG) with antibodies against the acetylcholine receptor (AChR-MG) is considered as a prototypic autoimmune disease. The thymus is important in the pathophysiology of the disease since thymus hyperplasia is a characteristic of early-onset AChR-MG and patients often improve after thymectomy. We hypothesized that thymic B cell and antibody repertoires of AChR-MG patients differ intrinsically from those of control individuals. Using immortalization with Epstein Barr Virus and Toll-like receptor 9 activation, we isolated and characterized monoclonal B cell lines from 5 MG patients and 8 controls. Only 2 of 570 immortalized B cell clones from MG patients produced antibodies against the AChR (both clones were from the same patient), suggesting that AChR-specific B cells are not enriched in the thymus. Surprisingly, many B cell lines from both AChR-MG and control thymus samples displayed reactivity against striated muscle proteins. Striational antibodies were produced by 15% of B cell clones from AChR-MG versus 6% in control thymus. The IgV(H) gene sequence analysis showed remarkable similarities, concerning V-H family gene distribution, mutation frequency and CDR3 composition, between B cells of AChR-MG patients and controls. MG patients showed clear evidence of clonal B cell expansion in contrast to controls. In this latter aspect, MG resembles multiple sclerosis and clinically isolated syndrome, but differs from systemic lupus erythemitosus. Our results support an antigen driven immune response in the MG thymus, but the paucity of AChR-specific B cells, in combination with the observed polyclonal expansions suggest a more diverse immune response than expected. (C) 2013 Elsevier Ltd. All rights reserved.

The muscle nicotinic acetylcholine receptor (AChR) has a central role in neuromuscular transmission, and is the major target in the autoimmune disease myasthenia gravis (MG). We created mutants of the extracellular domains (ECDs) of the human α1, β1, δ and e AChR subunits, whereby their Cys-loop was exchanged for that of the acetylcholine binding protein. The mutants were expressed in Pichia pastoris and had improved solubility resulting in 2- to 43-fold higher expression yields compared to the wild type. An additional mutant was created for the α1 ECD restoring its glycosylation site within the Cys-loop and its α-bungarotoxin binding ability. Furthermore, we constructed dimeric and pentameric concatamers of the mutant ECDs. All concatamers were successfully expressed as soluble secreted proteins, although the pentamers had about 10-fold lower expression than the dimers and were more susceptible to fragmentation. Initial crystallizations with the mutant ECDs were promising, and we reproducibly obtained crystals of the β1 ECD, diffracting at ~12 A. Further optimization is underway to obtain crystals suitable for high resolution crystallography. The proteins described herein are useful tools in structural studies of the human muscle AChR and can be used in applications requiring high yields such as therapeutic adsorbents for MG autoantibodies.

Double-seronegative myasthenia gravis (dSN-MG, without detectable AChR and MuSK antibodies) presents a serious gap in MG diagnosis and understanding. Recently, autoantibodies against the low-density lipoprotein receptor-related protein 4 (LRP4) have been identified in several dSN-MG sera, but with dramatic frequency variation (similar to 2-50%). We have developed a cell based assay (CBA) based on human LRP4 expressing HEK293 cells, for the reliable and efficient detection of LRP4 antibodies. We have screened about 800 MG patient sera from 10 countries for LRP4 antibodies. The overall frequency of LRP4-MG in the dSN-MG group (635 patients) was 18.7% but with variations among different populations (range 7-32.7%). Interestingly, we also identified double positive sera: 8/107 anti-AChR positive and 10/ 67 anti-MuSK positive sera also had detectable LRP4 antibodies, predominantly originating from only two of the participating groups. No LRP4 antibodies were identified in sera from 56 healthy controls tested, while 4/110 from patients with other neuroimmune diseases were positive. The clinical data, when available, for the LRP4-MG patients were then studied. At disease onset symptoms were mild (81% had MGFA grade I or II), with some identified thymic changes (32% hyperplasia, none with thymoma). On the other hand, double positive patients (AChR/LRP4-MG and MuSK/LRP4-MG) had more severe symptoms at onset compared with any single positive MG subgroup. Contrary to MuSK-MG, 27% of ocular dSN-MG patients were LRP4 antibody positive. Similarly, contrary to MuSK antibodies, which are predominantly of the IgG4 subtype, LRP4 antibodies were predominantly of the IgG1 and IgG2 subtypes. The prevalence was higher in women than in men (female/male ratio 2.5/1), with an average disease onset at ages 33.4 for females and 41.9 for males. Overall, the response of LRP4-MG patients to treatment was similar to published responses of AChR-MG rather than to MuSK-MG patients.

Myasthenia gravis (MG) is usually caused by antibodies against the muscle acetylcholine receptor (AChR). Experimental autoimmune MG (EAMG) is the animal model of MG, typically induced by immunization of rodents with AChR isolated from the electric organ of Torpedo californica. We have successfully induced EAMG in Lewis rats by immunization with the extracellular domains (ECDs) of the human AChR subunits (α, β, γ, δ and e) expressed in yeast. Analysis of the antibody titers revealed a robust antigenic response against all the peptides, but a marked difference in their pathogenicity; the α subunit ECD was the most pathogenic, resulting in the highest percentage of affected animals. Measurements of antibody titers, electromyographic tests and quantitation of the muscle AChR content, offered further support to these findings. The EAMG models presented herein, could be used for studying subunit-specific pathogenic mechanisms, and, more importantly, as tools for the evaluation of antigen-specific therapeutic approaches, which rely on the human AChR.

Aim. To determine which specific groups of occupational stress factors influence the duration of temporary work disability related to arterial hypertension and joint complications/co-morbidities. Methodology. Workers (n=1398; 1009 in the exposed group, 389 in the control group) with arterial hypertension who worked at one workplace for a minimum of 10 years were divided into 10 subgroups, depending on the presence of joint complications/co-morbidities. The intensity of seven groups of occupational stress factors, the total score of Occupational Stress Index (OSI) and the average number of lost working days during 1 year were analysed. Results. The number of lost working days due to arterial hypertension and joint complications/co-morbidities was significantly higher in the exposed group. In all subgroups of the exposed group there was a high correlation between the number of lost working days and the total OSI score. Specific occupational stress factors were associated with specific complications: High Demands with chronic myocardial infarction, Strictness with cerebral haemorrhage, Conflict/Uncertainty with cerebral infarction, Extrinsic Time Pressure with acute myocardial infarction, and Avoidance/Symbolic Aversiveness with non-insulin-dependent diabetes. Conclusion. There are specific groups of occupational stress factors which can influence the duration of work disability associated with certain complications and co-morbidities of arterial hypertension.

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction, usually caused by autoantibodies against the acetylcholine receptor (AChR) or the muscle-specific kinase (MuSK). Our aim is the development of a therapy based on the selective extracorporeal elimination of anti-AChR or anti-MuSK antibodies. To this end, the extracellular domains of the AChR subunits and MuSK have been expressed in yeast to be used as adsorbents, after optimization, and to obtain large quantities of proteins with near-native structure. We have characterized these proteins with respect to their use as specific immunoadsorbents for MG autoantibodies, and have begun large-scale experiments in order to verify the feasibility of application of the method for therapy. Furthermore, we have initiated animal studies to test possible toxicity and safety issues of the adsorbents or the procedure itself. The successful completion of the scale-up and safety tests will allow the initiation of clinical trials.

Hybrid techniques play a role in the treatment of patients who suffer from thoracoabdominal (TAAA) and pararenal aortic aneurysms (PAAA) but are unfit for open repair. The increasing number of TAAA patients treated by hybrid approaches has brought to light the severe procedure-related morbidity that can accompany these complex repairs. To overcome these issues, several techniques have been proposed to simplify them. This article reviews the most important technical advances of hybrid TAAA/PAAA repair, focusing on (1) the surgical approach, (2) the anastomotic technique for the renovisceral bypass, (3) antegrade versus retrograde renovisceral revascularization, and (4) simultaneous versus staged visceral hybrid repair. We discuss critical issues that may influence outcomes with these advanced procedures.

Acquired autoimmune myasthenia gravis (MG) is the most common disease that affects the neuromuscular junction (NMJ). MG is associated with autoantibodies (auto-Abs) to components of the NMJ. About 85-90% of MG patients have auto-Abs against the muscle nicotinic acetylcholine receptor (AChR), while about half of the remaining patients have auto-Abs against muscle-specific kinase. Auto-Abs, in combination with local deposition of complement, reduce the number of available post-synaptic nicotinic AChRs and thereby impair neuromuscular transmission. Current medications for MG are non-specific and include acetylcholinesterase inhibitors, immunosuppressants, plasma exchange, intravenous Ig administration and thymectomy. Treatments that selectively target the anti-AChR auto-Abs may prove to be more effective and free of side-effects. We here review two approaches aimed at the development of antigen-specific therapies for MG. The first is specific apheresis of Abs from patients' sera using immobilised recombinant AChR domains as immunoadsorbents. Indeed, we have recently shown that the combined recombinant extracellular domains of all human AChR subunits are capable of specifically immunoadsorbing the majority of pathogenic auto-Abs from several MG sera. The second therapeutic approach is the development of non-pathogenic anti-AChR monoclonal Abs that could potentially be used as protective agents by blocking the binding of patients' auto-Abs to the AChR.

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies targeting the neuromuscular junction of skeletal muscles. Triple-seronegative MG (tSN-MG, without detectable AChR, MuSK and LRP4 antibodies), which accounts for similar to 10% of MG patients, presents a serious gap in MG diagnosis and complicates differential diagnosis of similar disorders. Several AChR antibody positive patients (AChR-MG) also have antibodies against titin, usually detected by ELISA. We have developed a very sensitive radioimmunoprecipitation assay (RIPA) for titin antibodies, by which many previously negative samples were found positive, including several from tSN-MG patients. The validity of the RIPA results was confirmed by western blots. Using this RIPA we screened 667 MG sera from 13 countries; as expected, AChR-MG patients had the highest frequency of titin antibodies (40.9%), while MuSK-MG and LRP4-MG patients were positive in 14.6% and 16.4% respectively. Most importantly, 13.4% (50/372) of the tSN-MG patients were also titin antibody positive. None of the 121 healthy controls or the 90 myopathy patients, and only 3.6% (7/193) of other neurological disease patients were positive. We thus propose that the present titin antibody RIPA is a useful tool for serological MG diagnosis of tSN patients.