collagen disease drug

as only you probably have seen me here introducing speakers in the past. today we are a ttle delayed and we will be back in about 10-15 minutes. so we're going to start with our first speaker dr. richard siegal who is the director of the

clinical program at the nins. and in between the two speakers -- he's here. you can do your introduction right now. >> we're just a little bit delayed. at any rate, so i want to begin this and read something to you.

so those of you will remember we talked with this with paul -- at the time when we discussed sexually transmitted diseases. great discovery of 606, magic drug to treat syphilis for many years until penicillin came1 around. but urlich was one of the great

founders of immunology and it's interesting that in the 18th century i wrote the following. we pointed out if the organism possesses certain contrivances where immunity reaction produced by all kinds of cells is prevented from acting against the organism's own elements so

as to give rise to auto toxins. if that happened we might be justified in speaking what he called the horror auto toxicas. of course it turns out he was right and the body can we made to self destruct under certain circumstances which are the subject of today's demystifying

medicine. so now we jump to the 21st century and 22 nobel prize later all for immunology and essential questions kind of remain although much has been learned along the way. that's also part of today's demystifying session.

really so much has been learned about autoimmunity that the basic question is raised what is atone immunity. it turns out as you'll hear to be more complex than just that the name implies. so how does autoimmunity occur? if you have some marker, can you

literally predict a disease many years before it's manifested. and are these markers cause or are they effect. are they prognostic, do they offer some approach to therapy. and even most recently like yesterday, what to me was an all new element, there's an article

in science that we'll put on the web side. so this is from march 1st science, a very interesting study in which the intestinal micro biome has been manipulated and in these studies the authors claim that it plays a role in driving the hormone dependence

immunity. this is on mice. based in general the autoimmunity diseases are frequently more common in women than in men. and the last one is not important. there's another recent

incriminatary -- that's reminiscent of the days when many of these autoimmune diseases what we now call them things like rheumatoid arthritis, all sorts of diseases that you'll hear about because nobody really knew what they were called.

it was a fashion when they were called psychosomatic diseases. there was another fashion related to focus of infection so people had their tonsils taken out and so forth to control their joint pains. there's this whole business of a search to understand the

mechanism and right in with it are therapeutic approaches much these diseases are extreme and serious. so we are very e to have two colleagues at nih to be with us today and discuss this topic. and i'll briefly introduce them both to you.

so the first speaker's going to be richard siegal who took his mdph degree at the university of pense and trained in medicine, rheumatology, came here and spent some time at michael lenardo who you may remember spoke earlier in this course, is an outstanding immunologist.

he's the director of nih ph.d. program and his official -- no, i don't have it. he's the clinical drucker of niams. there are certain populations of immune sites in the process and so or. our second speaker will be abner

notkins who graduate from yale, got his md at new york university, did clinical training at hopkins, came to nih and he's fundamentally a renaissance man. most specifically in virus infections and diabetes and the relationship between them.

in recent year has become really one of the leaders in thinking and doing research in this field of autoimmunity and he coined the concept of developing a battery of auto antigens that could be widely used in the auto antigen oem. oemics are both at six.

we're happy both these distinguished colleagues are here and will present this topic of autoimmunity. richard, i understand that ... good. >> thanks very much. thanks for inviting me. i'm happy to talk to you today

we have. have a patient in our lupus research program and has undergone some treatments here and i'll introduce her in a second. we'll talk for 15 minutes and i'll give a general talk about autoimmunity and dr. notkins

will hone in on auto antibodies if i understand your talk right. since we're going to put our guest on the spot a little bit telling us about lupus, maybe i can just put you on the spot for a second so i understand who i'm talking to. so i guess it's a pretty diverse

audience but just sort of show of hands who sees patients here medically trained? okay, some but not the majority. i'm going to talk in more generalities. when we have our patient talk we'll try to stay away from jargon.

our patient is more versed at medicine because she's been through a lot. this is our guest,ths aviles. anyway wire going to just have a talk about your disease. tell us how old you are now and when you first -- how old when you first were diagnosed with

lupus. >> 37 years old right now and i was 20 when i was diagnosed in 1996. >> so maybe just tell us a little bit about what was happening that you, what was happening to you that you thought you went to the doctor

and what you were diagnosed with. >> i had a rash on my legs. they were red and they used to get hot. and they hurt a lot. >> how long did that go on before you saw a physician. >> like two months.

>> were you feeling well or not well with that? was it just a rash and otherwise you were feeling well. >> i was very tired. >> a lot of fatigue. before 20, before that age, you had you think normal energy, normal childhood.

>> a lot of energy. >> right, okay. you brought me some pictures actually really looked like your whole body changed a lot with that. >> yes. >> and then so the rash was going on for about two months.

any other things happening along with the rash that you noticed? >> that was the only thing. >> and then at the time when you went to the doctor for that, did they diagnose you with lupus right away or did it take a long time. >> they diagnosed me right away

because my mom had lupus and she was diagnosed in 1978 and she passed in 1991. she was 38 years old. >> right away the doctors knew -- >> i had it in the background so they test me right away. >> because your mom had lupus

were you tested for that test before you had any symptoms. >> no, i don't think so. >> the reason i ask that is we know from studies of people in the military, very interesting, i'm not going to talk specifically about lupus today bepeople have these ant borders

in their blood 10 or 20 years before the onset of disease. there was a nice study of military recruits because everybody that goes to the military they get a blood test and they went back and found people who developed lupus maybe 20 years later and those same

auto antibodies were actually there before. we kind of know in people, you probably had that dna in your blood even before you got sick. so you have the rash been, you got the blood fess, it was positive at that time. you already, when they did more

tests on you were you already having other problems from the lupus at that time. >> no. i took ten years to get nephritis. >> so right at the beginning to treat the fatigue and the rash you took some medicine for that.

>> i took -- and prednisone. >> how did that do? did that seem to help. >> that helped with the rash and oh, i also had joint pain. my joints used to get swelled up and very painful. >> that's an important thing. lupus is our prototypical

disease that affects almost every organ in the body but it does affect the joints very often. that's why we as rheumatologists affects different organs. for ten years you had that and tell us what happened when you developed the nephritis.

>> in 2003, my blood pressure went really high and my ankles were swelled up. and i couldn't wear shoes or anything. i had a -- doctor and he gave me -- for six months. once a month. >> by vein.

it was once a month. they gave me -- and that didn't work either. they referred me here. >> so the kidney function we talked a little bit about this. her kidney junction which was normal before that started getting worse and despite these

two treatments have been kind of the standard treatments for lupus nephritis kidney inflammation things kept getting worse. you came here and you can tell us what kind of therapy. >> when i came here in 2006, i was in need of kidney transplant

on both kidneys. >> the kidney function was at a point. that is one of the most serious consequences of lupus and what we try to prevent with the sigh toxin. in your case it didn't work tell us what happened.

>> i got a stem cell transplant in may 16, 2006. >> that's the procedure. we're going to talk about it again where we did more intensive chemotherapy and gave back your own stem cells. it's an auto transplant not somebody else's and that's the

attempt to reset the immune system. we can separate things out. there are a lot of complications after that but then in terms of the lupus, tell us what happened with your kidneys and those kind of things that were failing before the transplant.

i don't need the kidney transplant. they're working fine right now. >> in terms of the lan es we really did reset and that went into remission. let's talk in terms of that. you have only one manifestation that we think was a new thing

that happened to you you were telling me when we talked before about your lupus. >> last year i had -- rash which i never had before even when i was diagnosed the first time. and it was after the stem cell. >> so that was very interesting to us.

this rash which we'll show a picture of, not yours but somebody else's, is a very characteristic and often the first manifestation of lupus, and that's actually what caused it to be named lupus. lupus is the latin word for wolf.

somebody thought this very red rash looked like wolf patches under their eyes. you got that in the wrong order you got it backwards but it did tell us that some element of your disease was still there even though very suppressed. and right now for lupus, do you

take any medicines. i just take ten milligrams of prednisone every day. >> so that's something that we sometimes use for that but pack nil you're not taking anymore. >> you can tell us a little bit, this was a success in terms of lupus but we won't go through

everything but you were in the hospital for quite a while. >> almost two years inpatient. >> there were a number of complications and i guess i'll sort of go through it briefly. there were some, you had a number of infections which needed some gastrointestinal

surgery and then infection that went to your spine and i guess that was the thing that still bothers you right now. >> my -- got infected and the infection went to the l4 and l5. and i couldn't walk for three months. it was osteomelitis.

>> five out of ten patients don't have an interest in these medications anymore but there were a lot of complications and you had some of that because of the transplant. how would you characterize your health now. >> good.

but i still have a lot of fatigue. i always feel tired. and, but i have ion somnia also at night. >> your back still bothers you. >> my back still bothers me and right now my knees. >> great.

anything else you want to tell this group about lupus what it means to you to have had this disease. >> it's very hard and sometimes you can look fine but this is a quiet disease and people sometimes tell me like you don't look sick or you look fine.

but i only know how i go through a lot of jointed pain. sometimes i can't get up with my back pain and stuff like that. >> so i think it is a disease that really even though we have treatments that can dramatically alter the course can stay with people your whole life and

unfortunately your mother had come to that disease and it looks like your family has a genetic predisposition. any questions from the audience? thank you so much for sharing with us. [applause] >> again, i think that was a

great introduction. thanks again forths aviles to voluntee share that. this is disease which lupus included is a larger part of diseases of autoimmunity. and i introduced the concept at nih where this concept was discovered.

we can't not talk about auto inflammation as well. can you hear me with this one? one mic's enough. so in general, i think our challenge in understanding these diseases is how do we think about, we as room tall jises in the world of autoimmunity and

auto inflammation have to deal with an enormous panoply of different manifestations of this is the butterfly rash of lupus and that you can see this is sort of a textbook case. you can see text one of the manifestations and that can happen of skin.

this is the hand of somebody with rheumatoid arthritis. this is an autoimmune disease. you can see it's incredibly disstuckion to the joints. this is somebody with type one diabetes giving themselves insulin shots. you can have somebody with

absolutely no, nothing you can see on the outside type one diabetes is a laser with an attack on the beta cells. we'll hear about that more. in lupus you can have immune attack on almost every organ of the body. you have somebody here with a

disease called anlessing respond lie tice. it's a specific disease of the spine over many years fusion of the spine. you have this woman here in a wheelchair from multiple sclerosis. so again an autoimmune disease

that can attack specifically the white matter of the brain. and then you have this person here whose toe is swollen and has gout. that's also an inflammatory disease but how does that fit in with all of these other diseases.

what i'm going to tell you today what kind of unifying concepts and mechanisms we can think about to help us understand these diseases in general. and i like to think that autoimmunity one of the reasons i went into this and a lot of people interested in research go

into autoimmune disease research really we don't understand despite whatever i'm going to tell you today, we don't understand a lot of the basic mechanisms of autoimmunity. we're still at a very primitive phase. i would say compared to cancer,

we understand cancer in a very deep way. we understand that this is a disease of misbehavior of genes of somatic mutation of genes, specific genes. we understand infectious these are caused by specific pathogens.

in autoimmunity we have concepts bulb we don't always have molecular mechanisms and it's really the interplay of a lot of different things. so it really is one of the final frontiers in medicine. those of you out there they're interested in medical unsolved

problems. there's a lot of work to be done in this field and that's one of the reason we're having this lecture. so i think one of the first thing is what do we need to understand about autoimmune one of the thing as we learn

from our patients, these are life long diseases. they fake a persist over many years. although as i think you've experienced, these diseases are not like this. they do have fluctuations which we call flares.

almost all of our autoimmune diseases have that. lan es and rheumatoid arthritis certainly do. some diseases are only flares that we call them periodic fever syndromes. in between the patients are absolutely fine.

some diseases are exquisitely targeted to one tissue the type like type one diabetes where others are systemic. some we know have nothing to do with these cells but it's attacking the body through inflammation and that's our auto inflammatory diseases.

interestingly when we started to do genetics, i don't want to go into the individual genes but we found some genes have associations with autoimmune that's the beginning of putting together some logical framework. if the same gene is a risk factor for rheumatoid

arthritis -- it is an autoimmune controlling gene. we know some of those now. what about infections. infectious tirgz -- we'll talk about how they can happen but most people don't develop auto immunity after an infection or injury.

so clearly there has to be something else. it's the coming together of all these different mechanisms. so a big question that i struggle with and i think is important to think about as a conceptual question is, are autoimmune responses just

misdirected normal responses. is the immune system doing what it should except the target is wrong. are they targeting a cell component versus the foreign component or is there something fundamentally different a disregulation of the whole

immune system. those some of things i'll thank you about. a lot of you aren't immunologists and they make up a lot of terms to try to keep people out of the field. it's sort of a little thing we do to try to keep it specialized

so we can have all the fun. but i think hopefully you've heard this idea before but i want to, it's very important when you're thinking about autoimmunity, we do have to understand the normal immune and the normal immune system i think can be thought of as

divided up into two different parts. you have your innate immune cell. what we mean by innate cells, they don't see specific antigen. they can attack the specific antigens with molecules like antibodies but they're not

themselves specific except the fact that we now know that how they recognize pathogens is they have jetally encoded pattern recognition receptors. these are hard wired for viral components. we now know some of the reasons you make an anti-dna amount body

is some of these cells have receptors for dna on their surfaces or inside. that's why these cells are these cells help activate the adaptive immune system which has these cells which receptors are automatically rearranged. i don't have time to go into the

details but allows these type of cells to be exquisite. they can make billions of different receptor types. we know there are certain cells in between that have characteristics of lymphocytes but left restricted or left averse repertoires.

why am i putting a picture of the brain here. it's similar what we think of as our lower brain and more developed brain the cortex, the word adapted comes from the fact our higher brains can adapt to circumstances where our lower brains are preprogrammed to

respond to give us reflexes. that's why people think of the adaptive immune system is layered on top of the innate the other big property which i think is maybe a cause of relapses in our disease is the relapse immune system has memory.

p cells and t cells go into a state and can recall much quicker than initial responses and that's why you have immunlogical memory. it's thought thennate immune system has no memory but there's recent data in the innate system that might be a type of memory

as well that could allow more rapid responses to a second challenge. and really the immune system has evolved to defend us against pathogens that you know all you have, if you take care of patients of immune deficiency you know the main problem with

immunodeficiency either genetic in the case of our patient where we induced immunodeficiency in the contest of a bone marrow transplant then you're awe ceptable to infection. this is kind of where we're going to have to integrate those concepts.

the when i went to medical school, we thought of autoimmune diseases on this axis. we thought okay, they're systemic so systemic is even in the name of systemic lupus which can affect the scan of joints the kidneys brain, lungs all these different organs with

autoimmune attacks or they can be organ specific such as these diseases with autoimmune type one diabetes, thyroid diseases. there's a whole slew of autoimmune diseases where only one organ is the target. that was the axis and you can see that there are a number of

different common diseases that fall across this multiple sclerosis and rheumatoid arthritis are orient specific that they have systemic effect as well. inflammatory bowel disease again. mostly inflammation in the colon

and the small intestine but in association with other organs as well. however, what that doesn't take into account is what kind of immune response is going around. so if we think of the kind of immune response that happens in lupus, we know that auto

antibodies and auto reactive t cells are important through the animal experiments and also experiments where we've reset the immune system and that can get rid of a lot of pathology. there are diseases where you have incredible amounts of inflammation but no evidence of

auto antibodies or auto reactive b or t cells. those diseases the term was coined by -- where there's a genetic predisposition, these diseases are called auto inflammatory. we need to come up with something else for autoimmune

because the immune system encompasses the use but these are the terms we use. when you hear about autoimmune disease think about diseases where the t or b cells are involved and auto inflammatory diseases think about diseases where the innate immune system

is the bad guy so to speak. so how can we think of the general scheme of how these happen to an individual. so the way we think bit is an individual has a genetic component of innate immune responses. that's inherited along with gene

that control this and that's actually variable just like the hla is variable. it's probably good to have genetic variability in an innate immune responsiveness. this very important step happens where you start out with a self limiting non-specific

inflammation as we would all get after an injury or infection but then something happens in people who develop autoimmune disease that doesn't happen in people who don't which is an important step loss of self tolerance. we'll talk about immune tolerance a little bit.

once that happens then you get into what we think of as a cycle where you have the expression of proinflammatory cytokines, auto antibody, issue damage and very important concept is that tissue damage itself can create more auto antigens because they are released from the tissue and

help essentially fuel the fire to give you more auto reactive t cells, more priming of the immune system and that's the positive feedback group that we think allows this, these types of diseases to persist. why don't people just get a single attack of lupus and not

have another one. that's not what we see happening. and even so there has to be some positive feedback. now sometimes that can be through an environmental engine, we'll talk about that or environmental factors in gout

but sometimes there's an innate component there. so there's obviously modifiers. so there's genetic factors and such as gender. we know that women are highly pre disposed to lupus and we don't know why. there's host defense genes which

are in your genome and give thank you that innate immune responsiveness. we know immune response genes have come up in whole genome scans of lupus and other autoimmune diseases. so at this step, how responsive your t cells and b cells are

also matters. and then importantly, how your tissue responds to inflammation. these are all genetic factors that come up when we do our whole genome scans and start to look at the saw ceptability genes. now the other part that's really

important is the environment. we know for instance in rheumatoid arthritis and at first this is just some kind of even epidemiological course. in sweden they track every single person in the country who gets rheumatoid arthritis very helpful.

they found the huge signature that people who smoke had a big risk, not just one or two but a very high relative risk of developing rheumatoid arthritis. it turns out there's actually some science behind that that cigarette smoke environmentally mud fies antigens that then can

be targeted in room today arthritis and feel the fiber. uv light is people with lupus develop strong sensitivity to the sun. uv light causes changes in the skin that can then activate immune cells and can even trigger lupus flares.

infectious its we'll talk about how they can work and we know now there's data that the flora in our got is factors as well. there's some interesting data from mice we'll talker about a little bit later. then farther down the chain of autoimmunity you have these

other important regulatory effects. so can we ever counter this. it turns out there are cells in the process of immune tolerance tries to rein in t cells. there are mechanisms for colonially deleting t cells which would be greater therapy

and there are ways of turning off these cells and other immune else c. that falls under that heading. so that's you can see we have a lot of potential tool to try to harness here to modify this final common pathway that leads to autoimmunity.

so i'm just going to give some examples and i won't talk a lot about auto antibodies because doctor notkins is going to falk about it. it's important to think of mechanisms. some diseases we know for sure we talk about auto antibodies,

antibodies against self certain diseases have the characteristics that the auto antibody is the disease agent. for instance in miocene gravis, we have data incontrovertible data that those antibodies when you transfer them to a mouse can make a mouse sick.

and that's the kind of, if you think of -- for autoimmunity, transferring the disease for an ant body is an important test to determine if that's antibody is pathogenic. you'll hear more about that that second hour. that's one kind of auto, when

you think of, if you just thank you the immune system you know there are t cells and b cells, there can be auto antibody mediated and t cell autoimmunity. this is an experiment to prove an autoimmune disease is -- if you do this experiment with

rheumatoid factor that's an antibody igg igm against igg that develops a rheumatoid arthritis patient that antibody doesn't do anything. we've known for 50 years you can do that same transfer experiment, that antibody is a great biomarker but it's not

it may play a role once you have the disease in making it worse but it can't do this. that's an important concept. is the antibody actually on the other side, how do we prove that a t cell mediated disease is pathogenic. we can't take human t cells and

transfer them into mouse because of the histo compatibility but we can show an experimental system for instance that we can produce a disease that looks like multiple sclerosis and at least we can take t cells from that sick mouse, transfer them into a healthy mouse and get a

sick mouse. so that's kind of the way, the best we can do for a t cell mediated disease to show that the disease is actually caused by t cells. now we have therapies that are directed against t cells. we'll talk about at the end and

that's our human experiment that we can do that can show that. we know that humans can transfer occasionally children of patients with lupus develop autoimmune disease. we know from transfer of antibodies from mother to child and that kind of thing can

happen also t cells can also are thought to do that in certain diseases as well. but in the end, for autoimmune disease we have to remember that t cells and b cells work together and that's because b cells in addition to making antibodies, they're very

important antigen presenting cells for t cells. and that happens in lot of different autoimmune diseases and that is why a new therapy that was developed base on a cancer therapy where we deplete the b cells in the body and that's extremely effective even

in diseases by vascular lie tice where we don't think the auto amount body is the only pathogenic factor and that's because getting rid of b cells can also eliminate their ability to -- activate t cells. t cells get activated by recognizing antigens on the

surface of ought cells. you can see there are different diseases, there's certain area diseases where we know that antibodies, the main problem. so in the b cells arena we know miocene gravis anybody causes this disease but the t cells are providing very important factor

that we call t cell health for the antibodies. there are antibodies causing the disease but that doesn't happen in other diseases. and diabetes, the antibodies are important biomarkers but they're not the agent that causes the in autoimmune diseases there's

variable contribution of t cells and b cells to the actual what about tissue damage, how can tissue damage actually make things worse. and this is because what happens is, if you already have, so in all of us that don't have autoimmunity, you have tissue

damage, tissue antigens are released. that's a dangerous time. if you have an auto anybody already in your blood, when you release these antigens such as dna in the case of lupus, those antigens are now just not regular amount judges anymore,

they have antibodies that are bound to them and that can help fuel the fire because that antigen that your body's already making an antibody to becomes a more imeugenic and that can cause a loop and cause a disease and in many cases injury can perpetuate a disease or tissue

damage. that's one of the ways you can perpetuate disease and you can actually broaden the target and that's a phenomenon in immunology called thing taupe spreading where you start making antibodies against one thing and then a broader array related to

the organize one and we think that's partly due to this mechanism. to really understand autoimmunity we need to understand the mechanisms that prevent it. let's why there have been a few nobel prize to understand imyew

logical tolerances. i'll give you an overview of what that phenomena is. this is the phenomenon that prevents us, it doesn't involve us to not have optoimmunity or to regulate transplant rejection but this is an outcome of the fact that we have very, we have

molecules in our body the histo compatibility complex that prevents peptides to t cells and other molecules to other subsets of lymphocytes. and because of that, we have histo compatibility, incompatibility between people. but also we have to involve a

mechanic many when we have that infect -- mechanism when we have that infection not to initiate autoimmunity every time. we also have to have a mechanism in the development of t or b cells that are against their own self immunologically self component.

so in a nutshell, there are multiple mechanisms when immune cells develop. it terms out that t cells has been very well demonstrated. t cells are developed thank you against a component of our own bodies. they are actually gotten rid of

in the specialized organ where t cells develop, b cells also can do that. they can also choose a different immune receptor to the different immunoglobulin if they're used in making a self reactive b cell receptor. however this process is not fail

safe and i became interested in peripheral tolerance partly because that's something we can manipulate. central tolerance kind of happens once but peripheral tolerance -- has a number of differ types. so one is just its simplest one

where we call it immunology we like to make up these terms again we call it immunlogical ignorance. that's when you have a perfectly normal immune response against a components in your body say in the brain, yet those immune cells never get to your brain so

you don't get autoimmune now we know in model systems in mice, if you infect the mouse, if you set up a system where you have a strong immune response and give a brain infection, you can start an autoimmune disease because you've broken that barrier that preserves the

immunlogical ignoring of the antigen. you can delete t and b cells in the periphery particularly t cells and that's a process we might be able to harness. you can get t cells to turn themselves off. something i'm very involved in

these days is we know that a t cell and a b cell when they start out can become a lot of different types of cells. so cytokines and messengers that can influence the development of t cells can cause what we call an older term immune deviation. so if you can get a pathogenic t

cell to become a non-pathogenic t cell, you've essentially accomplished the same thing and cytokines can be very potent at doing that. so those are some of the different ways that the immune system regulates itself and you have to studying these could

help give us clues to understanding how to manipulate the immune system once you already have an immunlogical auto reactive situation to get rid of that. so sorry, that's out of order. if you have tra to an eye, this is a classic example of what's

called sympathetic opt thomas ma which can end up giving inflammation and destruction. even the eye that didn't have trauma. that's a very dramatic example of that tissue damage phenomena. that doesn't happen in everybody but the eye is a classic imohio

privileged site at which there's a lot of immune ignorance. when you have injury it can break this barrier and cause reactions. but importantly not only the injured eye but even the other eye can be involved in inflammation.

so here's a type of scenario where if you know at that time t cells can become all these different type of t cells including regulatory t cells that negatively regulate the immune system, you can imagine that if you can manipulate that in such a way to program t cells

to become regulatory t cells rather than t cells that make more destructive cytokine, that's another way of affecting immune tolerances. so that's sort of an overview of tolerance. i think it is one very important topic that i won't have time to

spend, you could have a whole hour on this, are t cells that are regulatory t cells. i kind of an interesting historical story. these were discovered in the 1970's, cellularly. you could take cells from one mouse and suppress disease in

another mouse so they clearly were there. when molecular biologists started cloning t cell receptors and started understanding what a t cell was regulatory t cells did not have a t cell receptor. thing got confusing for a long time but here at nih -- another

scientist in japan -- ki-- of kept thinking these cells had to be there. and we identified these cells ten years ago now. it's very clear there's a whole family of t cells that express the specific transcription factor that endowz them with the

property of being infected with other t cells. immediately that got people excited in the therapeutic field, what if we could just grow more of these t cells, then we could really supress immune responses in general. and there's human data to

support that meaning that patients who had a deficiency in this transcription factor there's an awe tore immune disease called i tech syndrome, a genetic immune disease -- mice have a similar syndrome. the problem with this idea that we can just grow regulatory

cells in culture and then choose them and cure disease is that actually if you look for instance in a pancreas in the middle of a severe autoimmune destructive disease you can find numbers in these regulatory t cells already there. so the body is already kind of

hooked up. this whole system is hooked up to do this but once you have autoimmune disease you might have failed. it's not clear by just making more of these we can do that. that's a very active area of what about at nih we study very

rare diseases. lan es is -- lupus is a very common disease. we learn a lot of diseases i won't go into the details but single jean autoimmune diseases if you know a single disease comes from a single gene you learn that's an important check

there's a whole bunch of examples where you can see that, where you have diseases, where you have for instance i've studied disease called alps where you have the failure of elimination of auto reactive t cells and that causes an autoimmune disease in people

that's very similar to an autoimmune disease in mice where you lose the same gene. that in fact induces a program it's an important check point in preventing t cells from becoming auto reactive. regulatory t cells, master regulated when that's delayed

you get autoimmune tease. these patients have normal regulatory t cells. these patients have normal t cell deletions. so that says that sometimes just one one gene, the defects in the single gene must overwhelm all the other redepthant mechanisms

to control self tolerances. so these are very important to understand because they tell us that that's a began that when you mutate it, that essentially trumps every mechanism we have. i want to introduce you to other diseases where that has fold us about inflammation.

these are genes that have given us insight into autoimmune what about diseases where you have insights into inflammation. and the story i wanted to tell you really starts with this disease, familial mediterranean fever. this was known for centuries

thought to be a disease restricted to patients in the mediterranean basis hence its name. these patients have arthritis but also have. -- discover that this gene involved a protein called -- what emerged over the last ten

years has been that actually a whole number of diseases that all involve these cyclic inflammatory cycles -- periodic syndromes have rashes that are actually triggered by the cold in some circumstances or just can be spontaneous. and that involved a very

important protein called nlrp3 and this protein turned out to be an important component of a cascade that involves one of the pro inflammatory cytokines interleukin one. over the last ten years we've actually found a whole number of diseases that all center around

defects and controlling the production of interleukin one. so we learned from a number of different human inflammatory diseases that if you disregulate this pathway, this can cause this chronic periodic syndrome. you might think these are weird and strange diseases but a huge

insite happened five years ago when it was realized one of the oldest diseases we know about is gout which is caused by uric acid crystal that accumulate in and i was taught in medical school these crystals irritate neutrophils and make them angry -- that's not a good

explanation but that's what i was taught. we now know uric acid and other -- triggered the exact same pathway. they activate nlrp3 to indoing il1 secretion. it's caused by an environmental antigen actually triggers the

same pathway as is genetically defective in all these rare familial auto inflammatory none of these diseases involve auto antibodies. we know we can take a mouse that gets this disease or a mouse model of this disease and we can completely get rid of t and b

cells and they're just as sick. that's the ultimate proof that these diseases are inflammation diseases not autoimmune. and these diseases really connected into interleukin 1 -- drug for -- it was tried and fda approved but it wasment very effective.

it turns out once these diseases were discovered very quickly we at nih and other spots why don't we use this drug fda approved for rheumatoid arthritis. that's try it on these diseases, are we on the right track. is interleukin one the key that drives that.

this was a remarkable success so these patients known as one of the most severe sun droams associated with nrlp3 sources -- almost every single manifestation of inflammation these patients were having and they would have these on the daily basis, this is a very fast

acting drug for these syndromes, eyes, skin and brain and inner ear the patient go deaf from inflammation in the inner ear. these were stabilized by interleukin one blockades. genetic disease you can very significantly affect the course of the disease and this is now

been used for over five years and with lasting success. so that's the simple cases. so we learn a huge amount from diseases of, that are rare. we learn that they are common diseases use those pathways. we know this list is old, even things like in the pancreas,

there's protein called am lynn type one and two and that fuels inflammation people are trying interleukin one inhibitors for diabetes now they've done that observation. common diseases use these same pathways when mutated cause single gene diseases.

before 2007 i think everybody could only really study single gene diseases in a sort of flushed out way. we knew for 20 or 30 years that there was a major role i told you about the major histo compatibility complex. this is a set of cell surface

proteins that presents peptides to t cells and restrict our t cells to our bodies and somebody else with t cells and somebody else with antigens. geneticists have known hla alleles were very strong risk factors so some as high as 90 times, 90 fold risk factor of

having a disease called anless respond lie tice if you have the hlh allele. there are other diseases this relatively high. mented -- we know this is very talk. how can we actually look at the entire genome and look at that.

i don't know how much has been talked about, about genome-ride association studies but this field has really been completely revolutionized since this paper came out in 2007 to now six years ago where the if you are large study of looking at the entire genome of individuals,

these were 14,000 people, and the diseases they looked at were hypertension, rheumatoid arthritis, type one diabetes and found a number of loci. what you can see here, these are colored so the hope was that we find five or ten genes that control all these major

but the reality is we're up to i can just, i'm not going to go through all the diseases but crohn's disease which you can see here, this number tells you how genetic an auto immune disease is. owe crohn's disease and inflammatory bowel disease is

one of the hooftd highest. if you have a brother or system that's one of the highest rheumatoid arthritis or lupus lower as you heard from our patient -- does that mean it's a man dalian disease. no, so we know for better or worse crohn's disease is over

100 contributory genes now. as we get more and more patients the latest crohn's disease genetic analysis cooling all the studies that have been done over six years has shown over a hundred different genetic variants are associated with crohn's disease.

we're up to that same number for rheumatoid arthritis, about 50 or lupus and 50 for type one diabetes. the other diseases like hypertension which have a much lower sibling recurrence risk it's much harder to find these folks.

autoimmune diseases have a very trackable genetic risk oem in you want to call it that. it's not one or two genes it's between 50 and 100 genes. good that explain all the genetic risks. you can do a calculation where you say are all the began we

found in these genetic association studies, does that account for the risk of the siblings getting the disease it turns outs only about 50%. there's dark matter and other genetic risks that we can't figure out. we have environmental factors

that could awe of course that as it's something that being actively study -- many in fact we use that now to say is it a disease autoimmune. is it auto inflammatory meaning it's like gout or something like that with no contribution, hla shouldn't happen at all.

and recently for instance we did a study of alopecia which is a disease where hair is loss and was always thought to be an hla should up and that's telling us it's likely an an autoimmune that's an intense study in the autoimmunity now to try to understand how to do that.

these risk factors are less than 10 so they are small risk factors but they're still i just want to even up talking about the environment, so we knew for many years certain drugs looked at autoimmune there's one called -- the mechanism isn't well established

for a different series of how that could happen with drugs -- that are immunogenic. there's autoimmunity. if we manipulate -- in kacials we try to get anti-karches t cells and infuse them back into steve rosenberg does that here. he's had tremendous success with

curing melanoma patients another patients developed vigiligo. we've created a therapist -- that's just now a side effect. some of our -- regulating immune system do that. now the thing that's really exciting and new when referred to is that it's really never

been thought about. what about the environmental contribution of our own bacteria, and this is a really interesting new thing that we know and the paper you talked about again was an animal study. what's been realized many animal models if you sterilize the

intestines, raise them in a germ-free environments -- the whole idea that this influences autoimmunity is now pretty accepted. the real huge surprise was somebody thought of this idea. what if we take the susceptible mouse transfer the contest to

the resistant mouse and in many cases what happened and this was the same in this recent paper that susceptibility can be transferred just by transferring those resident bacteria. what's thought to happen now is the arltded floor of the government set up reaction that

can trigger diseases that are sometimes in the gut and sometimes out the gut things like even type one diabetes type animal models. now the big question is does this have anything to do with us. we don't live in cages and share

our feces and do the thing mice do in the same way. so it's still not clear. we know that we can transplant, a recent paper for a complication of a bacteria dificil -- a lot of our animal models now you have to think about this as well.

and finally, i think i'll just finish up with therapy a little bit because i think it's time for the switch. all that that i told you, that very kind of superficial overview kind of hopefully got an idea there are regulatory pathways we can use.

and biotechnology companies in collaboration with people at nih and elsewhere in the world have created through molecular biology biologics and other small molecules to try to get at so t cells for instance need not just the t cell receptor get activated but other molecules

that are commented co-stimulators. co-stimulators that have been tried with different diseases is quite an imimportant science. we cured thousands of mice with co-stimulate tree blockade. i can tell you it was developed for rheumatoid arthritis but

thennate works in our il one related inflammatory diseases -- to treat sepsis because -- is an important cytokine in sepsis. co-stimulate tree blockade works in certain diseases. the idea of harnessing regulatory t cells is exciting but it hasn't panned out partly

because of this problem that -- very interesting therapy again developed to treat lymphomas that are b cell lymphomas so people with biotech companies develop drugs to deplete these cells that carry that antigen that are malignant b cells. again that was used in different

autoimmune context and is now remarkably effected the disease where it's become almost the standard of care of vascular lie tice -- pathogenesis and it turns out this antibody doesn't get rid of auto antibodies but gets rid of the b cells at stage before they were antibody

secretion stage. that's a drug that is effective in ra but vascular lie tice as it's been tried in lupus and that's this b cell depletion therapy. finally blocking cytokines have been effective, tnf is one of those cytokines.

rheumatoid arthritis -- the three diseases i showed you at the beginning c this. s blockade. what about effective therapy. our guess underwent, if nothing work, if you're at risk losing is an organ it's worth thinking about we do bone marrow

transplants again -- what about resetting the immune system so the therapy our patient underwent was a therapist that involved b cell depletion, t cell depletion and the drug that we used at higher doses that we use to treat nephritis. stem cells are harvested and a

technology that were developed from the cancer field and then were given back to the periodic after this intensive regimen with the intent essentially with resetting the immune system. and certainly in diseases where there's, this has worked very well and maglinant diseases

immunodeficiencies essentially then you do a transplant from another person. but the idea here is not to have graph versus -- because that can cause complications similar to that's the therapy. i was going to show the out comes but basically five out of

eight patiend for this therapy responded very well ms. avelis is no longer -- such that you went through and to ultimately passed away from those complications. i think i want to even with the idea we need to do better. we have therapies, experimental

therapies that can work in very difficult cases but we clearly want to modify so this protocol really, we're not doing this protocol but ways to do stem cell therapy without imyew suppressants. there are centers around the country doing those kind of

studies right now. anyway i wanted to leave you with that. i hope that's basically just whetting your appetite here in terms of the word of autoimmune and inflammatory diseases. >> thank you very much, richard. introducing us to the brave new

world. i want to bring your attention that all the power points and references and notes i've written are all on our website. not only for this session but for all sessions for the past 11 so all you have to do is google demystifying medicine and you

can see a lot of this which you can't assimilate just looking at the verse but you have a chance to think it over. so now i think we'll hold questions until after abner has talked. okay. >> i'm going to talk today about

antibodies that react with self antigens. auto -- compare antibodies versus poly reactive antibodies. now, you heard a very good presentation about the diseases and emphasis on lupus. what i'm going to talk about is primarily type one diabetes.

and this is a section of the pancreas and this is the cells which make the digestive juices and this is the eyelets and within the eyelets are the beta cells which secrete insulin and insulin of course is required to regulate the blood glucose level in the body.

here is a section of pancreas from a mouse that has autoimmune type one diabetes. what you can see is this massive infiltration of inflammatory cells b and t cells into 9 eyelets which results into the destruction of these beta cells and as a result of that you have

hypo insulin emia -- the question is what are these b cells and t cells seeing. what is the antigen to which they're reacting. and to try to determine this some time ago, we had developed a beta cell subtraction library and succeeded in isolating five

novel genes two of which ia2 and ia2 beta turned out to be major auto amount judges -- antigens in type one diabetes -- and what we call a luminal domain. this is a transmembrane protein on dense core vesicles, and dense core vesicles are the vesicles which contain hormones

such as insulin and neurotrans transmitters. this is protein on the dense core vesicles -- except it has two substitutions in this reajts which makes it essentially -- once we have the sequence of this dpean we then developed a very sensitive radio immunoassay

and screened hundreds of patients with type one diabetes. what you can see is about 70% of these patients developed auto antibodies to ia2 as compared to the control with just several percent. now there are other auto antibodies associated with

diabetes, and one of them is glue tammic acid decarboxylase. this is what i just showed you. antibodies were found at about the same percentage. but what was particularly interesting is that many of these patients had had auto antibodies to ia2, did not have

auto antibodies to gad. and many that had antibodies to gad did not have auto antibodies to ivmentd a2. if you look at antibodies to ivmentd a2 and gad that's 90% of the newly diagnosed patients with type 1 diabetes had one or two of these.

the question is when do these antibodies first appear. this is the subjects at the time of diagnosis. do they appear before the development of a disease? and so what we did was sort of a classic long term perspective retrospective study in

collaboration with noel -- who was then at the university of florida and looked at about i think close to 10,000 subjects in this study. and none of them had diabetes at the onset. blood was drawn and then samples were collected and the subjects

were followed up over about 10 years time. then when an individual came down with type 1 diabetes, we went back and took out these samples and looked to see when these auto antibodies first appeared. what we found is many of them

appeared years before the development of type one and the next study shows what i think is a summary of what we found and what a number of other groups have found doing similar types of studies. if you have one of these auto antibodies, the likelihood of

developing diabetes is 10% or less. if you have two auto antibodies the likelihood of developing type one antibodies is 50%. if you three it's about 60-70% much these auto antibodies appeared years beforehand. they are predictive.

the more antibodies you have, the more predictive it is that you're going to develop the so this type of approach now with type one diabetes is used in clinical research laboratories to identify high risk -- with the ultimate goal of these subjects into

therapeutic intervention trials with hope that you could prevent the development of the disease long before you develop clinical symptoms. now, what about type two type two diabetes is a very different disease. about 90% of subjects in the

patients with diabetes have type two diabetes. we looked at 1200 or so patients with type two diabetes and we found two to three% of these -- other laboratories found a little bit higher percentage, 3-25%. and we found about 5-8% had auto

antibodies. what does this mean because type 2 diabetes is not an autoimmune what it means is that some of these patients have an autoimmune component. if you take a conservative number of say 5% and considering there are 20 million people who

have type 2 diabetes, that would be if it was 5%, that would be one million subjects that have either been misdiagnosed and really have type one diabetes or have some combination of type one and type two diabetes. but these patients who have these auto antibodies are

generally referred to as lata latent immune diabetes of adults or type 1.5 diabetes. the question now is should patients with type two diabetes be screened. now for these auto antibodies. if they are screened, would it change with therapeutic

approach. would you start these patients on insulin sooner than you would otherwise. and so this has a number of pros and cons which i won't go into but it's a subject that has been and is widely debated in the diabetes community.

now here is a list of some of the diseases, about a dozen of the diseases, some which richard mentioned of autoimmune diseases and here are some of the auto ant -- antigens that are known to be associated with these diseases and you somewhere auto antibodies to a number of these

auto antigens. what has been found out is about half a dozen or more of these diseases have been studied is that these auto antibodies appear years before the development of clinical disease just like in type one diabetes. and what this mean is that many

of these diseases are chronic they appear years before there's clinical manifestations of the several of these diseases people have also looked to see whether these auto amount beads were predictive and dr. siegal mentioned lupus for example where they find antibodies five

to ten years before the development of the disease. the number of studies though and the size of the subjects is relatively small compared to what the diabetes communities have done. the question is could these ant beads be used as predictive

markers getting more data on this and if they could be could you enter them into therapeutic intervention trials to try to prevent the development of the now let me switch from auto ant beads to poly reactive a number of years ago we tried to determine whether viruses

could trigger auto anti-viruses so what we did is we took a virus, real virus and we infected mice with this and we found there were a number of auto amount beads or there was auto antibodies in the serum that reacted with a number of perfectly normal tissues.

the problem was the titer of these antibodies was very low so we decided to make -- and we made a number of them and we found to our great surprise mono clonal hybrid dome awe produces just a single type of amount body that when screened against a variety of tirksz, it react

the with not just a single tissue but a single organelle but this ant body which is a single antibody reacted with all these various organs. and they reacted with different organelles, they were recognized in different antigens. now we're very excited about

this. viruses were really major tiger but then we did the experiment which we should have done six months before we did this experiment and we took normal -- and we did the same thing and we made the hybrid domes from these normal mice and what found is

essentially the same thing that many of these mice produce many hydro domes that are reactive and could act with a variety of turbs and all these were slightly different in terms of the tissue reactivity. in other words what it showed is that these poly reactive

antibodies were part of the normal repertoire the normal b cell repertoire of the animal. what we used is we selected about half a dozen antigens, somewhat randomly, and here's a single monoclonal antibody. what you can see is you can react to varying degrees with

beta single stranded dna insulin cytoglobulin, etcetera. in more contrast to that is a monoclonal antibody we made against beta -- and this with a monoclonalmannal reactive -- it just reacted with beta gad it did not react with any other so this is the fundamental

differences between the poly reactive amount bodies and what i call amannal reactive amount bodies -- being able to react with many different antigens monoclonal and mono reactive with just a single antigen. once we found this and studied in detail the properties of

these antibodies and what we found is these poly reactive antibodies that react with a variety of structurally unrelated antigens, proteins, bacteria, dna, the mono reactive is just a signal -- antigen. the affinities were low, the association constants of 10 to

the minus 4 and 10 to the minus 7. it was high with the normal reactive antibody. of these germline or near germline were hypo mutated. were igm also igg and iga with the mono reactive. when we injected these into

animals the half life was much shorter than the mono reactive presumably because they were reacting with a variety of different organs and tissues. how do antibodies really work? the classic immunochemical idea has been lock and key hypotheses and you have an ant beetd that

has a very specific type of structure and you have an antigen that has a specific structure and the two interact like a lock and key to give a very very specific reaction. well what we think now is and let's set the been antibody -- pockets are more reactive and

these antibodies are more like a pass key. here is the antigen binding pocket for an antibody, the antibody winding pockets. and here are four different antigens, and what you can see is based upon the idea the confirmational hypotheses that

this antigen can recognize these residues, this one recognizes these residues, this one these residues etcetera and it could explain whya poly reactive antibody can bind so many different amount judges but with much lora fibbity than lock and key hypotheses of a mono

reactive type of antibody. now, not only do the antibodies, the purified antibodies bind these antigens but the b cell that make these antibodies can bind a variety of antigens. this shows you, this is a marker just for b cells and you can see here that beta gal insulin both

bound to this. here's the murminger. there's two different antigens binding simultaneously to a single b lymphocyte. this is binding to a single limb tight -- and here is a case where we have three different antigens binding to the same b

lymphocyte at the same time. now i've talked about just about poly reactive antibodies but i'm beginning to think mono reactive antibodies, a class of antibodies may also have a certain degree of poly reactivity or at least oligoreactivity.

so in collaboration with dr. stephen johnson at ears state, he has these chips which have 10,000 peptides on them. there are 13 amino acids long, it's a random type of chip and we took a pile reactive apartment bodies, this is the cut off point.

you can see this poly reactive antibody bound to a whole variety of these peptides. that wasn't a surprise to us. what was more surprising, here was a mono reactive ant body reactive specifically with a particular bacteria. and what you can see it also

could bind to a lower degree but it could bind also to a number of different peptides. and so what this really shows is that, if you screen against enough antigens, 10,000 antigens that classic antibodies so-called mono reactive antibodies can have a sort of

poly reactive type of properties. now let me talk a little bit about the protective value of poly reactive antibodies. but first let me say a first words about natural apartment natural antibodies has been known for over a hundred years.

and they've been an enigma because they're present in newborns, present in german forty three animals and can react with a number of antigens to which the hoe has never been exposed. so how do you explain this? we showed in humans about i

think probably close to 50% of the b cell in the cord blood were going to make poly reactive in the adult circulation, about 15-20% of the b cells could make so poly reactive antibodies are a major component with a natural anti-body repertoire. now, it's also been known for

many years that natural antibodies can react with a variety of different bacteria and viruses to which they've never been exposed. so the hypotheses was that one explanation for these natural apartment bodies with in fact the majority of them were poly

reactive antibodies. and they didn't have to be exposed to a particular antigen, they existed in the rep tar, they can bin to many different things. so to study this, we chose of a dozen, rather half a dozen different bacteria, gram

positive and gram negative bacteria and we used art monoclonal mono reactive you can see here very strong binding to the e coli bacteria. but the same antibody did not bind to any of these other bacteria. been i'm growing to show you a

poly reactive antibody which is just the opposite. here is a single poly reactive antibody and you can see it binds to a very high degree to these bacteria. moderately to these and to a rather low level to these now the next question we asked

is whether complement could bind to these poly reactive for those who aren't immunologists, a complement is a very important component of the natural or innate immune repertoire. it's a collection of several different proteins.

it binds to apartment body interaction and binds to certain product that could have chemo toxic effects or can actually lice cells. the poly reactive antibodies strong enough when it binds to an antigen to fix complement. and the answer is yes.

and here we show the bindings to a particular bacteria and you can see there's about 90% binding of the complement to this particular bacteria versus the control. so clearly complement could bind. now if that was the case, we

asked what effect would it have on the growth of the bacteria because i said when you have an active antibody interact shurch complement which can have analytic effect, what effect will this have on the growth of this bacteria. so we labeled -- and here is pbs

over time. and this is our monoclonal mono reactive anti-viral, did not inhibit the growth but here is our poly reactive act body and you can see it markedly inhibited. growth of the carrier. so it has a protective effect.

if you heat and activate the complement you lose this effect so you need the poly reactive antibody and you need the complement. and the complement also general rates a number of these factors i mentioned chemo -- one called c5a, different bacteria and you

can see when you have the poly reactive antibody versus -- it generated this factor. and these factors then can play a role in phagocytosis. and so here we took bacteria, labeled them green, took imagine phages labeled them red and what you can see is there is a very

strong uptake. here, this is the poly reactive and here is our mono reactive and you find very very little uptake. so the poly reactive apartment bodies now can enhance phagocytosis. this is an antibody that reacts

with self antigens. now what about in human serum. can we idea poly reactive what we do is we take purified humanoid gm, we pass it through beta -- collect the pass through and in the loose that's there, if it's poly reactive it should bind to a globulin column, did

the same thing, collected -- pass it down to a single stranded dna closm and what we thought was it passed through all these three columns it must be -- so we took the pass through and concentrated to the same, tent as the poly reactive igm and then asked will it bind

to bacteria. and what you see is that the poly reactive found very well while the poly reactive depleaftd serum human serum did not. and as a result of that, it could poly reactive enrich could lice bacteria while the poly

reactive heated could not. to summarize what i've said so far the poly reactive antibodies bind to a variety of bacteria. they fix complement, they inhibit bacteria -- class of the complement pathway and they enhance phagocytosis bacteria by macrophages and i didn't go into

this but they neutralize toxins. the conclusion is poly reactive antibodies is a major component with a natural anti-body repertoire and provide an explanation at least in part for the anti-bacterial activity of normal serum. i want to show you one more set

of slides. the we've recently found another protective effect of these poly reactive antibodies and that is the ability of them to bind to and clear phagoize the cells. about a human body a billion cells a day undergo it's to be very important to --

will clear these cells otherwise they're thought to play a role in trigger certain autoimmune diseases and thought to play a role if they're not cleared properly in lupus. now we therefore hypothesize it may be the poly reactive apartment bodies playing a major

role in the clearances of think apoptotic cells. it's a little bit more complicated. this is new data and i haven't put together slides yet. what we did was took these cells, human t lymphosides and we treated them with uv light

and that induces even -- even toasts -- what you can see at so row time only 12 percent of the cells were apoptotic but 90% of the cells were apoptotic. what you see here is that the poly reactive antibodies bind to the apoptotic cells but the mono reactive antibodies do not.

the antibodies are binding to these cells. what we did with what we call gating these cells into live cells early apoptotic and lay apoptotic. this is a normal situation in live cell. we can see early in epi toasts

and the index of permeability. then we ask what happens to the binding of a mono reactive antibody versus three poly what did you see with the live cells nothing bound then you look at -- you got a small amount of binding of the poly reactive.

look what happens in late apoptosis. mono reactive doesn't bind whether you get anywhere from 40 to 80% binding of the poly this shows where in the cell it's binding. this is the marker for the membrane.

this is our antibody. this is a marker for the nucleus. here's a single cell and what you can see is in this cell it's binding to the nucleus. we fine that in a about 8% of the situations. we see the body binding to the

here you can see it's binding to the cytoplasm of the cell. the antibodies are getting into the cells when they become permeable and combine to a variety of antigens. and also generates as you would expect as i showed you -- fixes and it enhances phagocytosis.

the quadrant to look at is the upper right hand quadrant. a percent of the cells are phago site here and paulo react -- poly reactive to complement. if you put complement in there's a four to five fold increase in the phagocytosis. then what i just want to show

you is that package so cytosis can be induced by a number of things, by viral infections and other types of infections. and here for example we infected cells with hiv and what you can see here is that the poly reactive antibodies, the three paul pee reactives all bound to

the hiv infected cells. nothing bounds to the uninfected cells. and then it enhanced the phagocytosis of these cells. let me show you how we do that. it's a nice technique called image stream. it's a flow through sigh

cometary but what it does is take a picture of every cell and with a powerful software program it's able to tell how far apart these cells are. here's a t cell which we will make apoptotic. we want to know will it be phago sitized.

here now is an example of full you can see the difference between these colors is very small and here is phagocytosis. here the distance is greater and the software program can give you absolute numbers and tell you to what degree phagocytosis has taken place.

and here is an example of that. with our hiv infected t cells. this again is a single cell, and what you see is the macrophages in red, t cells in green. and what you can see you have full phagocytosis. they found this in about 41% of the cells that are phagocytes.

here you have partial and here you have what we call adherence and so by this method, you can really quantitate the degree of phagocytosis that's taking place. so to summarize now poly reactive ant body is a major component of an antibody

the natural antibody repertoire is largely due to poly reactive and poly reactive antibodies bind to apoptotic cells and accelerate the phagocytosis by macrophages and complement and poly reactive antibodies have protective properties against floor invaders and against the

hosts own damaged cells. now, why did i go into so much date about poly reactive i want to compare them that combine to self antigens with so what is the difference? between the auto antibody and a poly reactive antibody? they both bind to self antigens.

there isn't any real difference because antibodies are defined by the fact they bind with self amount journals. what we're saying here is there are million of apartment bodies in the body that combine to self amount jens. so what is the real difference.

i think by analogy sort of like the color red and red has a number of different shades and it has a number of different flavors and so it is with anti-bodies that react with self so auto antibodies are associated with disease. poly reactive antibodies are not

associated with disease even they are they bind to self the auto antibodies have a high affinity where the poly reactive apartment bodies have lower affinities. -- near germline -- primarily igg poly reactive mainly igm but also igg.

and the auto antibodies are part of the adoptive immune system which dr. siegal talked b the reason we say that is because we think it's antigen driven because they have so many schematic mutations. so we think that these real auto antibodies are antigen driven

antibodies are part of the natural antibody repertoire or the innate repertoire. finally the auto antibodies may be pathogenic. part of the majority of the disease do not a known patted owe genic role. they're there but we don't know

what they do in contrast to what dr. siegal mentioned the antibody for example in mystein yeah graphic which is a pathogenic anti-virus. so what i would say is that the term auto antibody should be used in very restrictive way. it should be used by a medical

sense, it should be used only when associated with disease. i would not use the term auto antibodies to describe any antibody that simply reacts with self antigens. i do not define was an auto body. and i think es clearer then that

there are now minutes of ant borders that can react with reantigens but just like the color red with different plaifers to it, the auto amount beads and wally reactive apartment bodies differ from each other in terms of where they're associated and their

properties and their actual functions. so i think we need a redefining or clarification of the term optoantibodies and i would use that term in a specific sense and not apply to all these other antibodies that can react with self ant antigens.

this was carried out by other colleagues -- who is sitting out there, joe, raise your hand. if you have any questions i'll try to answer them. [applause] >> i have some questions -- inner not polar reactive to summarize.

they are not polar ring aive antibodies? u.s.-russia we just showed us the polar active antibodies so the antibodies that can't be polar reactive is that right? >> what is the word you're using?

>> [indiscernible] >> yes, there's a great debate where these auto antibodies originate whether some of them can originate from these poly reactive antibodies or not and there's no clear answer to this right now -- can originate from these poly reactive antibodies

but there are other papers suggest that isn't absolutely necessary and explain it in other ways. >> but you didn't check that for yourself. you can't really say that. you have to, that's a very different type of experiments to

be able to do, to see where these antibodies came from. most of these antibodies are mutated. in other words genes are different than the poly reactive antibodies so you would have to be able to show that the poly reactive antibodies became

mutated and would have to show the gene sequence as in these so that's not easy to do. >> did you check those adherent to phagocytosis -- why do they escape this phagocytosis. do you know what the mechanism is now? >>

>> we think that's one of the normal mechanisms by which it does. in the most people descbed it in terms of just natural antibody aids in the clearches of these cells. what we're saying is it's not just natural antibodies it's the

poly reactive antibodies in the so-called natural antibody repertoire that are one of the main factors. >> okay, thank you. >> while we're getting another question, so abner, do people who have auto ant body real disease, do they express poly

reactive antibodies? >> sure. i mean in poly reactive antibodies are again part of a normal repertoire. they express one of the things we're looking at now is to see if there is a higher increase or not of pauly reactive antibodies

in people who have various autoimmune diseases and we're just beginning to look at that are the terms environmental factors and i'm genetics used simultaneously. this might induce an even genetic alteration. >> the first speaker mentioned

environmental factors such as viruses and medication but how broad are environmental factors with respect to how they work on gene and how this affect gene behavior. >> in terms of diseases you've heard there's an enormous amount of speculation that may trigger

the auto antibodies like in the viruses expliek the bacteria and molecular mimicry and other techniques. you're asking did does that spriermal trigger whatever it is affect the epi genetic aspect of the gene and i don't think that's known in connection with

autoimmune diseases at this i'm not sure what the triggers are. >> [indiscernible] >> i still don't get the difference between environmental and epi genetic. >> do you have any idea why these [indiscernible] are patho

genic -- >> as i mentioned and i think this was mention also that perhaps the majority of these auto antibodies that are associated with disease, it's not none what role they actually play in the pathogenesis. for example ih2 which we've

researched extensively is a marker for type one diabetes but what role plays in the pathogenesis of the season, how it contribute to the pathogenesis is unclear. we know quite a bit now about the function of that particular gene, but we don't know how the

antibody interacts in any way to cause the disease itself. so many of these are what i call biomarkers, these antibodies. they don't know -- with miocene gravis and several others they don't know if it binds to receptors say acetyl choline -- >> what about the question of

bacterial mimetic. is that the word? the papers that appeared recently? >> no, no. the concept that auto antibodies bear relationship to bacterial proteins on this expression. >> do you mean molecular mimicrc

type of things. there's a whole consent called mimicky. those act body can cross react with host amount job or host tissues. there are -- harder to prove at the human level. >> i don't know if there's any

that one would absolutely say is due to molecular mimicry. they're able to show the antibodies to some of these viruses can cross repack with normal human tissue. but again, whether it's involved in the pathogenesis is not clear.

>> hi. a basic question but for example when you talked about the rheumatoid factor earlier, it is an ign antibody it is associated with disease but not pathogenic for the disease but do i still call it an auto -- >> by my definition, which i'm

not sure most of the immunologists would agree with, but because most of thing, anything that reacts with self should be called an auto antibody. i do not think that's the case anymore based upon all the evidence we have with these poly

it's an igm antibody. we don't know what role it plays in the pathogenesis of the the point is i think rich said they clearly would have, there's no definite evidence in terms of its pathogenic role. people looked at this for the longest time.

it is perhaps a useful marker as a predictor over not a particularly good one because a lot of patients have rheumatoid factors but don't have rheumatoid arthritis. >> so these poly reactive antibodies when they enhance phagocytosis, i'm not an

immunologist so maybe this is an innate -- do those digested bacterial products, are they now presented to the adaptive immune response or do they bypass that and get digested complete legal. >> i'm not sure if i can get you a direct answer but clearly what

you need is both the adaptive immune response and the innate immune response. the innate immune response or alone don't seem to be capable of eliminating a disease you need the adaptive immune response that would be much more specific to a particular

bacteria or a virus but i think it's clear that these poly reactive antibodies can help and contribute to the process. >> all right, well thank you very much abner, that was wonderful insight. >> i remind you about the