>> HELLO EVERYBODY. I'M GLENN NUCKLES, PROGRAM DIRECTOR DIVISION OF NEUROSCIENCE AT NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE. WELCOME TO WEBCAST ON STATE OF THE SCIENCE FOR ACUTE MYLITIS BY THREE OF THE NIH INSTITUTES NINDS NICHD, NIAID, AND IN COLLABORATION WITH THE CDC. SO WE WERE PLANNING FOR A TWO DAY IN PERSON MEETING, THAT WAS CANCELED DUE TO THE COVID-19 PANDEMIC. SO WE DECIDED TO HAVE A SHORT WEBINAR ON NEUROIMMUNE MECHANISMS AND TARGETED THERAPEUTICS. WHEN WE DO RESUME TRAVEL TO CONFERENCES, WE HOPE TO FOLLOW THROUGH WITH AND IN PERSON MEETING IN BETHESDA IN 2021 ON AFM AND GBS AND WE WILL KEEP YOU INFORMED OF THOSE PLANS. NEXT SLIDE. I WOULD LIKE TO THANK OUR CO-CHAIRS FOR THIS WEBINAR, DIANE GRIFFIN AND AVI AND ALSO LIKE TO THEY CAN MEMBERS OF THE ORGANIZING COMMITTEE WHICH INCLUDE PEOPLE FROM THE DIFFERENT NIH INSTITUTES AND FROM CDC. NEXT SLIDE. I WOULD ALSO LIKE TO POINT OUT A COUPLE OF FUNDING OPPORTUNITY ANNOUNCEMENTS ACTIVE RELEVANT TO THIS AREA OF RESEARCH. SO IN 2019 NIAID, NINDS NICHD PUBLISHED SPECIAL INTEREST TO ENCOURAGE GRANT APPLICATIONS THROUGH EXISTING FUNDING ANNOUNCEMENTS OR REQUEST ADDITIONAL FUNDING FOR EXISTING GRANTS ON AFM AND GBS RESEARCH AND MORE RECENTLY COLLECTION OF SPECIAL NIH FUNDING OPPORTUNITIES FOR COVID-19 RELATED RESEARCH INCLUDING NEUROLOGICAL COMPLICATIONS FROM COVID-19 SUCH AS GBS. THIS INCLUDES OPPORTUNITIES FOR ADDITIONAL FUNDING TO EXISTING GRANTS THROUGH NINDS OR NIAID RANDOM SOME OTHER INSTITUTES OR NEW GRANTS NIAID OR NIBIB. SO YESTERDAY I SENT AN EMAIL THAT HAD LINKS TO THESE SPECIAL FUNDING ANNOUNCEMENTS. YOU CAN ALSO GOOGLE NIH COVID FUNDING AND PICK THE FIRST THING ON THE LIST AND SCROLL DOWN AND THERE'S A WHOLE TABLE OF THESE FUNDING OPPORTUNITY ANNOUNCEMENTS. NEXT SLIDE. SO DURING OUR WEBCAST TODAY IF YOU HAVE QUESTIONS FOR THE PRESENTERS YOU CAN EMAIL THEM TO THIS WEB ADDRESS AFM AND GBS@NIH.GOV SO WE'LL READ YOUR QUESTIONS DURING THE WEBCAST. YOU CAN SEND FEEDBACK AFTER THE WEBCAST AND IF YOU NEED SOME GUIDANCE ON TO FINDING APPROPRIATE FUNDING OPPORTUNITIES ANNOUNCEMENTS WE WILL ALSO RESPOND FROM THIS EMAIL ADDRESS. THAT'S ALL I HAVE GOT AND I WILL TURN IT OVER TO DIANE GRIFFIN. >> IF I CAN HAVE ANY FIRST SLIDE. I GUESS MAYBE NOT. MY FIRST SLIDE IS REALLY TO WELCOME YOU TO THIS WEBINAR. IT'S AS MENTIONED WAS ORIGINALLY PLANNED FOR THINK -- SO THE STATE OF THE SCIENCE AND BOTH AFM AND GBS. SO THIS WAS ORIGINALLY PLANNED TO BE A TWO DAY IN PERSON MEETING BUT IT'S BEEN A GOOD IDEA TO FOCUS ON SOME OF THE HIGHLIGHTS AND IMPORTANT TOPICS IN THIS WEBINAR. THE GOAL I THINK SHOULD BE TO THINK ABOUT AND DISCUSS THE BOTH DIRECT AND INDIRECT MECHANISMS WHICH VIRUS INFECTIONS LEAD TO NEUROLOGIC DISEASE. WE ARE TALKING ABOUT TWO DISEASES, AFM AND GBS WHICH CAN BE DEVASTATING AND WHICH WE DO NOT HAVE A COMPLETE UNDERSTANDING CERTAINLY HOW VIRUSES ARE INVOLVED IN THESE DISEASES. AND ONE OF THE REASONS IT'S A GOOD IDEA TO HAVE THIS WEBINAR NOW IS THERE SHALL CURRENT ISSUES COMING UP WITH BOTH OF THESE DISEASES. FIRST OF ALL, WE HAVE A PREDICTED AFM SEASON, EVERY TWO YEARS THERE'S BEEN IN THE PAST, PAST SEVERAL YEARS THERE'S BEEN AN OUTBREAK. THIS IS THE YEAR WE EXPECT THAT TO OCCUR AGAIN. WE WILL SEE. SECONDLY, GBS WHICH IS A CONTINUOUS PROBLEM AND WAS A PROBLEM DURING THE ZIKA OUTBREAK WHICH WE WILL PROBABLY HEAR ABOUT FROM CARLOS AT LEAST, EMERGING VIRUS INFECTIONS HAVE BEEN ASSOCIATED WITH GBS, ZIKA WAS A GOOD EXAMPLE BUT NOW WE HAVE COVID-19 AND ALSO STARTING TO HEAR AND RECOGNIZE GBS IN ASSOCIATION WITH THAT INFECTION. SO THE PLAN IS TO HAVE SIX TALKS, 10 TO 12 MINUTES EACH WITH TIME FOR QUESTIONS AND THE NEXT SLIDE, THOSE SPEAKERS ARE GOING TO BE. IT'S A -- I THINK A EXCELLENT ASSORTMENT OF TOPICS AND EXPERTS IN THESE AREAS TO HELP US FRAME THE SCIENCE ASSOCIATED WITH THESE NEUROLOGIC COMPLICATIONS. SO KEN TYLER, UNIVERSITY OF COLORADO TALKING ABOUT VIRUS 68 AND AFM IN MICE, CARLOS PARDO FROM JOHNS HOPKINS TALKING GBS AND CONNIEBURGMAN, CLEVELAND CLINIC, NEUROINFLAMMATION CORONA VIRUS ENCEPHLITIS IN MICE. INFLAMMATORY NEUROPATHIES IN MICE. THE UNIVERSITY OF HE CAN TECHS HOUSTON, GBS AND IMMUNOTHERAPIES AND THEN JOHN MODLIN FROM DART MOUTH ON VIRUS TREATMENT. SO THIS IS GOING TO GIVE A GREAT OVERVIEW. WE HAVE ENCOURAGED EVERYONE TO STICK TO THEIR TIME SO THERE'S PLENTY OF TIME FOR DISCUSSION AND QUESTIONS WHICH YOU CAN EMAIL IN AS HAS BEEN ALREADY REFERENCED. WITH THAT WE WILL GET START WITH OUR FIRST TALK. KEN TYLER FROM THE UNIVERSITY OF COLORADO. >> THANK YOU VERY MUCH. EMILY IS PUTTING UP THE SLIDE. I WANT TO THANK DIANE AND ABBY FOR ORGANIZING THIS AND EMILY AND GLENN. THE FIRST SLIDE SHOULD BE UP IN A SECOND BUT QUICKLY JUST SHOWS THE PEOPLE INVOLVED IN THIS WORK BEGINNING AT THE TOP WITH ALLISON HIXON M.D. Ph.D. STUDENT WHO DEVELOPED OUR ORIGINAL MOUSE MODEL AND THEN JOSH FROST AND MIKE RUDY, I WANT TO THANK SOME OF THE SPONSORING INSTITUTES BECAUSE WE HAVE BOTH F 30 K 23 AND RO1 SUPPORT FOR PEOPLE WORKING ON THIS, THE ONLY DISCLOSURES ARE SHOWN IN THE CORNER, ONE I'LL MENTION BRIEFLY IS WORK WITH ZAB ON MONTH CLONAL ANTIBODIES. NEXT SLIDE. VERY EARLY AFTER THE OUTBREAK WHEN WE STARTED TO SEE THESE CASES, WE HAD THE OPPORTUNITY TO TAKE A NUMBER OF 2014 ISOLATES BELONGING TO DIFFERENT CLADES OF VIRUS AND STICK THEM INTO NIH SWISS WEBSTER MICE THROUGH IC ROUTE. I WANT YOU TO WALK AWAY FROM THIS SLIDE TO SEE THE TALL BARS THERE AND IT BECAME OBVIOUS A NUMBER OF ISOLATES BELONGING TO DIFFERENT CLADES BUT NOT ALL OF THEM, AND NOT THE ANISES CENTRAL -- NEXT SLIDE. WE CHARACTERIZE THE BASIC MODEL INITIALLY IN SWISS WEBSTER MICE, AND USING THE MISSOURI 14818947 STRAIN AS PROTOTYPE. I WANT YOU TO REALIZE THAT IN THE MOUSE MODEL, THERE IS A DOSE RESPONSE CURVE TO INNOCULATION, SO YOU CAN SEE IN THE TOP OF THE GRAPH THERE IF YOU FOLLOW THE COLORED BARS, THE MORE VIRUS YOU GIVE THE MORE SEVERE THE PARALYSIS ON MOTOR IMPAIRMENT SCORE AND THE QUICKER IT OCCURS. THERE'S DIFFERENT IN INCIDENCE OF PARALYSIS MICE DEVELOP BASED ON ROUTE OF INNOCULATION. THE MOST EFFECTIVE RADIOROUTE OF INDUCING PARALYSIS IS THE INTRAMUSCULAR ROUTE, ALMOST 100% USING THE STRAIN AND LEAST EFFECTIVE ARE INTRANASAL AND INTRAPERITONEAL. WE HAVE AN EXTENSIVELY LOOKED AT THE SUSCEPTIBILITY OF DIFFERENT MOUSE STRAINS, TO PARALYSIS INDUCED BY ANTI-ROW VIRUS D 68 BUT OTHERS HAVE. IT'S CLEAR THERE IS A HIERARCHY AND IT'S WORTH REMEMBERING BECAUSE THAT CERTAINLY SUGGESTS HOST FACTORS ARE GOING TO BE INVOLVE IN THIS ILLNESS. IN THE MOUSE MODEL WE USE THERE'S ALSO A LIKE IN THE HUMANS AGE DEPENDENCE TO THE PARALYSIS, SO AGAIN WITHOUT GOING INTO THIS IN HUGE DETAIL THE HIGHER BARS ARE MORE RECEIVE REAR DISEASE, YOU CAN SEE THERE'S INVERSE RELATIONSHIP, TOP BAR BEING DAY 3 AND ONES TOWARD THE X AXIS AT BOTTOM THERE BEING MICE THAT APPROACH THREE WEEKS OLD. THE YOUNGER THE MICE ARE, THE MORE SUSCEPTIBLE THEY ARE TO PARALYSIS. NEXT SLIDE. HERE IS A MOVIE TO GIVE YOU AN IDEA WHAT THIS MICE LOOKS LIKE HE HAS APPROXIMATE PARAPARSHASIS, 12 DAYS AFTER INNOCULATION WITH THE MISSOURI STRAIN OF ANTI-ROW VIRUS D 68. NEXT SLIDE. IF YOU TAKE THE SPINE CORDS OUT OF THE MICE IT'S EASY TO RECOVER VIRUS BOTH BY RTPCR TO AMPLIFY VIRAL GENOME AND FULLY INFECTIOUS VIRUS BY TCID 50 YOU CAN SEE THERE IN BOTH CASES PEAK IS ABOUT SIX OR SEVEN DAYS FOLLOWING INMOCK RATION VIRUS. IF YOU TAKE THE SPINAL CORDS OUT AND EXAMINE HISTOPATHOLOGICALLY THERE'S WONDERFUL CORRELATION BETWEEN PATTERN OF WEAKNESS THE MICE DEVELOP AND THE LOSS OF MOTOR NEURONS. YOU CAN SEE SOME POOR GUY AT THREE DAYS POST INFECTION, THE ARROW SHOWS PARALYSIS OF HIS LEFT HIND LIMB, THE SPINAL CORD SECTION ON THE RIGHT SIDE OF THE SLIDE, SHOW YOU THE LOSS OF MOTOR NEURONS CORRESPONDING TO THE AREA INOCULATING THE HIND LIMB AND YOU CAN SEE IN THE RIGHT HAND CORNER LOTS OF GREEN WHICH IS THE OPPOSITE UNAFFECTED LEG, LOTS OF GREEN, CHOLINE ACETYLTRANSFERASE POSITIVE NEURONS BUT HE OPPOSITE SIDE OF THE SPINAL CORD CORRESPONDING TO SIDE OF PARALYSIS, THOSE ARE IF YOU STAIN THE FINAL CORDS FOR ANTIGEN USING ANTIBODIES AGAINST THE BP 2 PROTEIN OF ANTIVIRUS D 68 YOU SEE ANTIGEN IN NEURONS. NEXT SLIDE. HERE IS AN EXAMPLE OF THAT SHOWN A LITTLE CLEARER YOU CAN SEE THAT BRIGHT GREEN POSITIVE NEURON CONTAINING ANTI-ROW VIRUS D 68 ANTIGEN. NEXT SLIDE. IF YOU TAKE THE SPINAL CORDS OUT AND DO ELECTRON MICROSCOPY HERE SHOWN INCREASING POWERS UP THROUGH 98,000 YOU CAN SEE VIRAL PARTICLES IN NEURONS THAT ARE QUITE CONSISTENT MORPHOLOGICALLY WITH REFERENCE IMAGES OF ANTI-ROW VIRUS D 68. NEXT SLIDE. WE FOCUSED ON THE DIRECT VIRUS INDUCED INJURY IN THIS MODEL BUT I WOULD BE REMISS IF I DIDN'T SAY THERE WAS AN ASSOCIATED INFLAMMATORY RESPONSE, THOUGH I WOULD ALSO BE REMISS IF I SAID WE STUDIED IT EXTENSIVELY. THE PARALYSIS CORRESPONDS TO LOSS OF MOTOR NEURONS AND PEAK OF VIRAL INFECTION BUT LOOK LATER YOU SEE THINGS LIKE THIS WHICH IS INFILL TRAYTIVE CD 3 POSITIVE T-CELLS SURROUNDING MOTOR NEURON. NEXT SLIDE. AND IF YOU INFECT SLICES OF MOUSE SPINAL CORD CULTURES X VIVO IN A SYSTEM WE AND OTHERS HAVE UTILIZED, YOU CAN SEE THAT THERE IS UPREGULATION OF NUMBER OF CYTOKINES INCLUDING INFLAMMATORY MARKERS. SO AGAIN I WANT TO SAY IN THE MOUSE MODEL THOUGH WE FOCUSED MORE ON THE ACUTE VIRUS HOST TERACTION THERE CLEARLY IS AN INFLAMMATORY RESPONSE AS WELL. NEXT SLIDE. OBVIOUSLY HAVING DEVELOPED THE MODEL LIKE THIS AND STRUGGLING AS CLINICIAN HOW TO TREAT THESE PATIENTS, WE TRIED TO USE THIS TO STUDY BOTH EXISTING AND SOME NOVEL POTENTIAL TREATMENTS. ONE OF THE FIRST WE TRIED TO TEST IN THIS MOUSE MODEL WAS HUMAN INTRAVENOUS IMMUNOGLOBULIN. AGAIN I THINK YOU CAN SEE HERE, HIGHER PARTS OF GRAPH LIKE WHERE PBS IS OR WORSE, LOWER PARTS OF THE GRAPH DOWN BY X AXIS ARE BETTER. AND YOU CAN SEE THAT THERE IS A PROGRESSIVE THERAPEUTIC EFFECT WITH IVIG, THE QUICKER AFTER ONSET OF VIRAL INNOCULATION YOU GIVE IT THE BETTER THE AFFECTS SO DAY ZERO ONE AND TWO DO BETTER THAN DAY FOUR. I DIDN'T PUT DAY SIX THERE BUT THAT WOULD BE INTERMEDIATE BETWEEN DAY FOUR CURVE AND PBS CURVE SO THERE WAS A BENEFIT TOE THIS IN THIS MODEL. NEXT SLIDE. THE BENEFIT CORRELATES PRETTY WELL, WITH DESCRIES IN THE TITLER OF A VIRUS BOTH IN THE MUSCLE WHICH IS THE SITE OF INNOCULATION AND THESE TESTS AND IN THE SPINAL CORD AS YOU CAN SEE THERE. NEXT SLIDE. BECAUSE IVIG EFFECTIVE WE WERE INTRIGUED WHEN THE PAPER IN NATURE MICROBIOLOGY BEGINNING OF LAST YEAR, SHOWING THAT TWO MONOCLONAL ANTIBODIES DIRECTED AGAINST ANTI-ROW VIRUS D 68 SEEMS TO HAVE PROTECTED CAPACITY IN A MOUSE MODEL AGAINST MORTALITY WITH ANTI-ROW VIRUS D 68. YOU CAN SEE THE 15C 51 BIND TO COMPONENT AND VP 2 AND 3 PART OF THE OUTER CAPSID VIRION. NEXT SLIDE. IN COLLABORATION WITH ZAB BIO WHO I TALKED ABOUT WE CREATED, THEY CREATED, WE USED CHIMERIC ANTIBODIES BASED ON THOSE TWO PUBLISHED ANTIBODIES. SO THEY HAVE THE HUMAN CONSTANT DOMAINS BUT THE MOUSE VARIABLE HEAVY AND VARIABLE LIGHT DOMAINS. IN OUR MODEL THE MORE EFFECTIVE THEIR TWO PUBLISHED ANTIBODIES THAT 115 C 5 CLEARLY HAD AN IMPACT IN REDUCING THE SEVERITY OF PARALYSIS WHEN GIVEN TO MICE A DAY FOLLOWING INNOCULATION OF VIRUS. INTERESTINGLY CONTROL MAP MADE BY THE COMPANY AND THE 11G 1 ANTIBODIES DIDN'T SEEM TO BE EFFECTIVE IN THIS MODEL. NEXT SLIDE. EVEN MORE INTRIGUINGLY WE JUST BEFORE BEING CLOSED DOWN FOR COVID-19 STARTED TO USE A MORE CLINICAL MODEL AND HERE WE DIDN'T ADMINISTER ANTIBODY UNTIL MICE ACTUALLY HAD CLINICAL SCIENCE OF PARALYSIS. SO TREATMENT WAS BEGUN IN MORE LIKE A CLINICAL MODEL. WHERE THE ANIMAL SHOWED SIGNS OF WEAKNESS. AGAIN THERE IS A BENEFICIAL EFFECT. NEXT SLIDE. NOT EVERYTHING WORKS IN THESE MODELS. I WANT TO TELL YOU WE STARTED TO TEST A BUNCH OF ANTI-VIRALS STARTING WITH FLUOXATENE. NO EFFECT, JUST LOOK AT THE RED CURVES VERSUS THE DIFFERENT BLACK CURVES AT DIFFERENT LINES, NO EFFECT OF FLUOXITINE IN VIVO ON PARALYSIS. NEXT SLIDE. WE HAVE BEEN COLLABORATING WITH A GROUP AT THE UNIVERSITY OF ARIZONA INCLUDING WANG ON TALAPAVIR BASED ON INTRIGUING STUDIES THEY PUBLISHED THAT SUGGESTED THIS DRUG WHICH IS USED FOR TREATMENT OF HEPATITIS IN HUMANS MIGHT BE BENEFICIAL. AGAIN WE ARE ABLE TO SEE IN OUR MICE A DOSE RESPONSE CURVE OF BENEFIT WITHIN A DOSING RANGE THAT WOULD BE APPROPRIATE AND PARALLEL TO THAT WHICH WE WOULD USE IN HUMANS. SO AGAIN, RED CURVE IS VIRUS ONLY, THE COLORED CURVE SHOW INCREASING DOSES OF TALAPAVIR. NEXT SLIDE. ONE OF THE THINGS THAT DOESN'T WORK, I HAVE SHOWN YOU SOMETHING THAT WORKS, SOMETHING THAT WILL DOESN'T WORK. A THIRD OUTCOME WE CAN GET IS THINGS WITHIN MADE WORSE. AND WHEN WE USED STEROIDS IN IMMUNOMODULATORY THERAPY, WHETHER WE USE AN EARLY TREATMENT OR LATE TREATMENT MODEL, WE CLEARLY FIND IT WORSENS ILLNESS. IT INDUCES MORTALITY IN A MODEL WE DON'T TYPICALLY SEE MUCH OF THAT. SO THAT'S THE DROP IN SURVIVAL SEEN ON THOSE RED CURVES COMPARED TO THE BLUE AND BLACK ONES AT THE TOP. IF WE USE OUR MOTOR PARALYSIS SCORING SYSTEM, WE SEE WORSE WEAKNESS IN SURVIVING ANIMALS. SO SOME THINGS HELP, SOME DO NOTHING AND SOME THINGS MAKE THINGS WORSE. NEXT SLIDE. JUST LIKE I SHOWED YOU BEFORE, IMPROVEMENT TENDS TO CORRELATE WITH LESS VIRUS IN THE SPINAL CORD AND NO EFFECT WITH NOTHING AND AS YOU CAN SEE HERE THERE IS A SIGNIFICANT BUT SMALL INCREASE IN VIRAL TITER AND SPINAL CORD IN THIS STEROID TREATED ANIMALS. NEXT SLIDE. I THINK I KEPT UNDER MY QUICK TEN MINUTES, I DIDN'T HAVE MY CLOCK GOING BUT I'M HAPPY TO TAKE QUESTIONS THAT EMILY OR GLENN OR THE OTHERS PUT FORWARD AND HOPE I KEPT ON TIME OR AT LEAST CLOSE TO IT. >> YOU DID. YOU WERE GREAT. GLENN P DO YOU HAVE QUESTIONS? >> SO THERE'S ONE QUESTION FROM CAROLYN COIN AT PIT. ANY IDEA WHAT THE AGE RELATED DIFFERENCES RESULT FROM? IS THIS REVERSED IN IFNAR KNOCKOUT MICE FOR EXAMPLE? >> THE QUICK AND HONEST ANSWER IS NO, WE DON'T. WE KNOW MANY OTHER VIRAL INFECTIONS IN THE NERVOUS SYSTEM SHOW DIFFERENT PATTERNS OF AGE RELATED SUSCEPTIBILITY AND DIFFERENT MECHANISM MS.. WE ARE NOT SURE WHAT THE MECHANISM IS HERE BUT WE ARE INTERESTED IN STUDYING IT AND INTERESTINGLY IF YOU WANT TO INDUCE DISEASE IN ADULT MICE, ONE OF THE WAYS OF DOING THAT IS IMPEDING THE INTERFERON SYSTEM. SO THAT INNATE IMMUNITY INCLUDING INTERFERON PLAYS SOME ROLE AT LEAST IN AGE RELATED SUSCEPTIBILITY. >> OTHER QUESTIONS? THAT'S ALL FROM THE EMAIL. >> I HAVE ONE THAT PROBABLY JUST WASN'T LISTENING CLOSELY ENOUGH. THE IVIG THAT YOU USE THAT WORKED HAD WHAT KINDS OF TITERS AGAINST EB 68? >> WE AND OTHERS STEVE AT THE CDC AMONG THEM HAVE SHOWN VIRTUALLY ANY LOTS IN CURRENT USE OF HUMAN IVIG CONTAIN A FAIR AMOUNT OF NEUTRALIZING ANTIBODY TITER AGAINST ANT ROW VIRUS D 68 SO THESE WERE AWFUL THE SHELF LOTS AND WE CONFIRM THEY DO IN FACT HAVE NEUTRALIZING ANTIBODY TITER AGAINST ANT ROW VIRUS D 68. >> SO YOU WOULD CONCLUDE THAT'S THE MECHANISM ADDED TO YOUR MONOCLONAL ANTIBODY DATA? >> YES. I DIDN'T SHOW YOU THAT IF YOU USE IMMUNE SERA FROM MICE THAT YOU ALSO GET A SIMILAR PATTERN OF PROTECTION. WE KNOW IN MICE MONOCLONAL POLYCLONAL AND HUMAN IVIG PROTECT. OF COURSE HUMAN IVIG HAS MORE OPPORTUNITIES THAN THAT -- ACTIVITIES THAN NEUTRALIZING ANTIBODY ACTIVITY SO I CAN'T TELL YOU SOME OF THOSE OTHER FUNCTIONS OF IVIG AREN'T PLAYING A ROLE BUT NEUTRALIZING ANTIBODIES, MONOCLONAL POLYCLONAL OR HUMAN DO SEEM TO BE PROTECTION IN DOSE AND TIME RELATED FASHION. >> GREAT. ANY OTHER QUESTIONS THAT COME UP, GLENN? >> QUESTION FROM TERRY -- SAYS TERRIFIC TALK. DO YOU KNOW ANYTHING HOW EVD 68 KILLS NEURONS? >> WE HAVE DONE SOME STUDIES IN A VARIETY OF DIFFERENT TYPES OF HUMAN NEURONAL CAN BELIEVETURE AND NON-HUMAN NEURONAL CULTURES AND LOOKS LIKE PART OF THE MECHANISM HERE IS GOING TO TURN OUT APOPTOTIC, WHETHER THAT'S EXCLUSIVE OR ONLY MECHANISM I CAN'T TELL YOU, I CAN TELL YOU THE VIRUS SPREADS AND GROWS HAUPTLY IN A VARIETY OF DIFFERENT MOTOR NEURON INCLUDING IPSC DERIVED HUMAN SPINAL MOTOR NEURON LIKE CULTURES. SIZE HELLO TO TERRY AS ON FRIEND. >> WHAT IS THE ROUTE OF VIRAL ENTRY IN >> I THINK WE ARTIFICIALLY WE CAN MAKE IT ANYTHING WE WANT IN A MOUSE BUT I THINK WE ALL BELIEVE IN A HUMAN THAT THIS IS PRIMARILY A RESPIRATORY INFECTION SO THE ENTRY WOULD PRESUMABLY IN THESE CASES BE THROUGH THE UPPER RESPIRATORY TRACK BUT WE DON'T HAVE ANY PATHOLOGIC OR OTHER DOCUMENTATION OF THAT IN PEOPLE. I CAN TELL YOU IT'S PLAUSIBLE IN MICE. >> DO YOU THINK IT'S NEURONAL TRANSPORT? >> I CAN TELL YOU U IN MICE AND IN CULTURES, YOU ABSOLUTELY GET NEURONAL TRANSPORT INCLUDING TRANSSYNAPTIC TRANSPORT OF THE VIRUS. >> OKAY. I THINK IT'S TIME TO MOVE ON TO THE NEXT. THANK YOU. CARLOS PARDO. WHO IS GOING TO BE TALKING ABOUT VIRUS DISEASES AND GPS. >> THANK YOU, DIANE. THANK YOU ORGANIZE RECOGNIZERS FOR THIS INVITATION. I WILL GIVE A BRIEF UPDATE ABOUT GILLIM BARRE AND PATHOGENESIS. IT'S WORK IS ON BEHALF OF LARGE GROUP OF PEOPLE, ALSO PARTICIPATING IN NEUROVIRUS EMERGENCE IN AMERICAN STUDIES. NEXT SLIDE. I ACKNOWLEDGE THE FUNDING PARTICULARLY THE EUROPEAN UNION THAT HAS BEEN A GOOD SUPPORT FOR OUR RESEARCH AS WELL AS THE NIH RESEARCH THAT IS ALLOWING US TO CONTINUE WITH OUR STUDIES IN MANY COLUMBIA. NEXT SLIDE. SO I'M BORROWING THIS SLIDE FROM A VERY NICE REVIEW THAT HAVE PUBLISHED IN LANSETT THAT BASICALLY OUTLINES THE OVERALL VIEW OF GUILLAIN-BARRE AND RELATIONSHIP WITH INFECTIONS. G UILLAIN BARRE IS A DISORDER WHICH THERE'S SEVERAL INFECTIONS VITAL AND BACTERIAL THAT HAS BEEN REALLY ASSOCIATED WITH EMERGENCE OF THESE POST INFECTIOUS DISORDER. UNDER BASICALLY TWO DIFFERENT FORM OF GUILLAIN BARRE AT LEAST FROM NEUROPHYSIOLOGICAL POINT OF VIEW AND PATHOLOGICAL POINT OF VIEW DOMINANT FORM MAIN TARGET IS MYELIN AND MEDIATED BY COMPLIMENT ACTIVATION ANTIBODIES AND THE MODEL AXONAL FORM IN WHICH THERE IS CLEARLY A DAMAGE OF THE AON THAT ULTIMATELY IS GOING TO LEAD TO MAJOR MORE DEVASTATING DISEASE. NEXT SLIDE. ONE THING THAT'S VERY CLEAR IS THAT AMONG INFECTIOUS DISORDERS, THAT HAVE BEEN DESCRIBED TO BE ASSOCIATED WITH GUILLAIN BARE THERE IS A VARIETY OF DISORDERS ASSOCIATED WITH INFLUENZA A OR B, THERE IS ALSO A VERY IMPORTANT ROLE OF HIV AND VITAL ASSOCIATIONS WITH HERPES FAMILY. BUT PERHAPS THE MOST IMPORTANT ELEMENT OF INFECTION THAT HAS BEEN ASSOCIATED WITH GUILLAIN BARRE IS CAMPYLOBACTER. THIS IS A RECENT STUDY IN CHINA WHERE CAMPYLOBACTER PLAYS A ROLE FOR TRIGGERING GUILLAIN BARRE. IN TERMS OF PATHOGENESIS, ACTUALLY AS I MENTION BEFORE, THE TWO MAJOR COMPONENTS OF PATHOGENESIS ARE RELATED WITH THE INVOLVEMENT OF IMMUNOLOGICAL DAMAGE OF AXONAL STRUCTURES, EITHER AT THE -- REGION OR AT THE -- REGION AND CELLS AND MYELIN. MEDIATED MOSTLY BY ANTIBODY MEDIATORS, ANTIBODY MEDIATORS THAT MAY TARGET THOSE STRUCTURES AND THESE ANTIBODIES COMPRISE VERY LARGE GROUP OF IMMUNOLOGICAL REACTTANTS THAT WILL TARGET GANGLIA SITES, THIS HAS BEEN VERY WELL CHARACTERIZED PARTICULARLY AFTER THE STUDIES IN CHINA WITH GUILLAIN BARRE DESCRIBED THERE IN THE '80s AND 90s. SEVERAL OTHER ANTIBODIES THAT APPEAR MEDIATED IN THIS PATHWAY OF INJURY IN AREAS OF THE NORTHERN REGION AS WELL AS THE PARANORMAL REGION. NEXT SLIDE. WHAT I'M GOING TO DESCRIBE IN THE NEXT FEW MINUTES IS IN GUILLAIN BARRE FROM THEPMENTS- EPIDEEM LOGICAL POINT OF VIEW. THE FIRST IS EMERGENCE OF ZIKA OUTBREAK THAT HAPPENED IN AMERICA'S BACK IN 2016, THAT OUTBREAK PRODUCED MAJOR DEVASTATING ILLNESSES IN MANY SUBJECTS IN AREAS OF LATIN AMERICA WHERE THERE WAS NO CURE. IT WAS CLEARLY DISORDER ASSOCIATED AT LEAST ON THE WITH ZIKA INFECTION, AND THIS PRODUCE A VERY DRAMATIC INCREASE IN THE INCIDENCE OF THIS DISORDER IN MANY LATIN AMERICANS IN CARIBBEAN COUNTRIES. MORE RECENTLY ANOTHER OUTBREAK, MAJOR OUTBREAKS OCCUR GUILLANIB BARRE IN THIS TEAM IN PERU IN 2018, 2019 TWO MAJOR OUTBREAKS BUT INTERESTINGLY THIS TIME WAS NOT ASSOCIATED WITH VITALS BUT APPEARS MOSTLY ASSOCIATED WITH SPREADING OF CAMPYLOBACTER JEJEU IN PERU. NEXT SLIDE WHAT IS INTERESTING IN TERMS OF GUILLAIN BARRE AND ZIKA, THE VIRAL DISEASE WAS CLEARLY A -- FOLLOWING A PATTERN OF HEPATIC INFECTION DISORDER. THE TIME FRAME OF NEUROLOGICAL SYMPTOMS WAS VERY COINCIDENCE WITH CLINICALLY INFECTIOUS PROFILE OF THE PATIENT POPULATION. BUT THE OTHER THING VERY INTERESTING IN THE COLUMBIAN AND BRAZILIAN POPULATION AFFECTED BY ZIKA GUILLAIN BARRE, MAJORITY OF PATIENTS HAVE ACUTE INFLAMMATORY MYELINATIONING FORM THAT CONTRASTS WITH WHAT HAD BEEN INITIALLY DESCRIBED BY THE FRENCH RESEARCHERS WHO HAD DESCRIBED ZIKA GUILLAIN BARRE WAS ASSOCIATED WITH AXONAL FORMS. IN IS A VERY INTERESTING -- THIS IS A VERY INTERESTING PARALLEL OBSERVATION BECAUSE THE POLL POLENESIAN STUDY, POINT OF VIEW TO PROVIDE US WITH A GOOD EPIDEEM LOGICAL VIEW OF VITAL INFECTION TRIGGERING NEUROLOGICAL DISORDER, BECAUSE THE CHARACTERISTIC EPIDEMIOLOGY IS VERY CLEAR THAT THIS DISEASE HAS INFECTIOUS DISEASE ZIKA PRODUCE AT LEAST ONE CASE PER FOUR DOZEN INFECTED INDIVIDUALS AND I THINK THIS IS PROBABLY ONE OF THE MOST IMPRESSIVE FORMS OF WAYS FOR DEVELOPING GUILLAN BARRE AMONG INFECTIONS. NEXT SLIDE. ONE OF THE QUESTIONS THAT WE ATTEMPTED TO ANSWER IN THE RESEARCH OF ZIKA GUILLAN BARRE IN COLUMBIA WAS IF THERE WAS ANY SORT OF ZIKA NEUROTROPIC VITALS THAT MAY BE AFFECTING THE PATIENT POPULATION, AND WE WERE VERY INTERESTED IN THE PATHOGENIC MECHANISM ASSOCIATED WITH THE DISORDER. WE PAY ATTENTION OBVIOUSLY TO WHAT HAD BEEN KNOWN ABOUT THE RESPONSE AGAINST GLYCO LIPIDS IN THIS PATIENT POPULATION. NEXT ONE. SO THE FIRST QUESTION IS, IS THERE ANY PARTICULAR VITAL THAT IS PARTICULARLY NEUROTROPIC PRODUCING GUILLANE BARRE, WE HAD ACCESS TO VITAL ISOLATES IN THE COLUMBIAN POPULATION AND WHEN WE PERFORMED PHYLOGENETIC ANALYSIS WE MANY VITALS WERE SIMILAR TO THE VIRUSES CIRCULATING IN LATIN AMERICA AND THERE WAS NOT NECESSARILY A VERY CHARACTERISTIC DIFFERENCE WITH OTHER VITALS, SO -- WITH OTHER VIRUS SO WE BELIEVE AT THIS POINT WE CAN CONCLUDE THOSE VIRUSES THAT ARE AFFECTED PEOPLE WITH GUILLANE BARRE WERE PARTICULARLY NEUROTROPIC. IN VITRO STUDY IT IS MAJORITY OF ZIKA VIRUS HAVE HIGH DEGREE AND PROBABILITY TO PRODUCE INFECTION IN -- AMONG DIFFERENT TISSUES. NEXT SLIDE. ONE THING THAT WE WERE ABLE TO EVALUATE, BECAUSE OUR GREAT COLLABORATION WITH (INAUDIBLE) SON AND HIS GROUP IN GLASCO LIEU THE ZIKA PLANT WAS TO TEST THE POSSIBILITY THIS PATIENT POPULATION MAY HAVE ALSO THE SIMILAR PATTERNS OF ANTI-GLYCO LIPID ANTIBODY RESPONSE, THE ANTI-ANSWER IS NOT NECESSARILY NO. THERE WAS NOT NECESSARILY GLYCO LIPID RESPONSE. NEXT ONE. BUT ONE OF THE THINGS THAT WAS VERY INTERESTING IS WHEN WE HAVE SOME ACCESS TO PATHOLOGY SPECIMENS AND PATHOLOGICAL ANALYSIS, THE MOST CHARACTERISTIC FINDING IN THIS PATIENT POPULATION WAS OVERWHELPING AMOUNT OF INFLAMMATORY ACTIVITY BY MONOCYTES MACROPHAGES AN T-CELLS, BY STUDYING THE POTENTIAL PRESENCE OF VIRUS IN THIS NERVE TISSUES AND SPINAL CORD TISSUE WE CAN DEMONSTRATE CLEARLY THAT THERE WAS A NEUROTROPIC EVENT GOING ON IN THESE TISSUES BUT MOSTLY ON IMMUNOPATHOLOGICAL PHENOMENON. NEXT SLIDE. ONE THING THAT WE OBSERVE THAT WAS VERY INTERESTED IN H CHARACTERISTIC IS THE MAJORITY OF PATIENTS IN THE COLUMBIAN POPULATION THAT WERE AFFECTED BY GUILLANE BARE APPEAR TO HAVE A HISTORY OF PREVIOUS FLAVI VIRUS INFECTION. THIS WAS VERY WELL SEEN WHEN WE ANALYZE THE PIPELINE FLUID AND SERUM OF PATIENT POPULATION THAT APPEAR TO HAVE ALREADY VERY OVERWHELMING EVIDENCE OF IGG AND IGM RESPONSE DURING EARLY STAGES OF G UILLANE BARRE. WE LIKE TO DISSECT THAT SITUATION AND WE TEAM UP WITH OUR COLLEAGUES WHO HAS DEVELOPED AD VERY GOOD PLATFORM FOR ANALYSIS OF ANTIBODY ANTI-PEPTIDES AGAINST VITAL INFECTION. THE VIRUS TECHNOLOGY WITH BEN AND MATT ROBINSON ALSO AT HOPKINS WE WERE ABLE TO TEST NEWLY DEVELOP SCAN THAT FOCUS ON ASSESSMENT OF THE ANTI-PEPTIDE RESPONSE, SPECIFICALLY TO VIRAL SPECIES PARTICULARLY ZIKA CHICKEN GUNA, KNOWN AS SEQUENCES HARBOR VIRUSES. NEXT ONE. THE -- OF THIS IS VERY EXTENSIVE. YOU SAW IN THE PREVIOUS SLIDE VERY GOOD COVERAGE. ONE OBSERVATION IF YOU PAY ATTENTION THE THE TOP IS BASIS WITH NON-NEUROLOGICAL ZIKA IN THE MIDDLE, THE PATIENT WITH ZIKA GULLIAM BARRE AND WOMEN HAVE AMOUNT OF IMMUNOOGICAL REACTION TO DENGI EPITOPES. WHEN WENDY SECOND THAT RESPONSE WE WERE -- WHEN WE DISSECT THE RESPONSE THIS RESPONSE IS PERMANENTLY AGAINST A SPECIFIC REGION OF THE DENGHI VIRUS. ONE SIDE THE ZIKA PEPTIDE WERE TARGET IN RANDOM APPROACH BUT INTERESTINGLY, THE ANALYSIS OF THE ANTI-PEPTIDE ANTI-DENGHI PEPTIDE DISCLOSE THIS PATIENT ACTUALLY HAD A VERY CHARACTERISTICAL RESPONSE AGAINST ENVELOPE PEPTIDES. NEXT ONE. SO WHAT WE BELIEVE IS THAT IN PATIENTS WITH GILLAIN BARRE WE HAVE A CHARACTERISTIC RESPONSE AGAINST ELEMENTS OF THE ENVELOPE AND AGAINST ENVELOPE PARTICULARLY OF THE NS 2AB REGION OF THE GENOME. WE BELIEVE THAT IN SOME WAY, THIS IS A WORK IN PROGRESS, THAT THESE ANTIBODIES OR THESE REGION CONTAINS POTENTIAL ANTIBODIES THAT MAY HAVE DUTY WITH ELEMENTS OF THE PERIPHERAL NERVOUS SYSTEM. NEXT ONE. FOR THOSE CURIOUS ABOUT THE VIRUS TECHNOLOGY, IT'S VERY POWERFUL TECHNIQUE AND THIS IS ACTUALLY ANALYSIS OF OUR SAMPLE POPULATION WHICH WE ANALYZE ON TOP IS THE ANALYSIS OF THE ANTIBODY PEPTIDE AGAINST OTHER VIRUSES ASSOCIATED WITH GULLAIN BARRE WITHIN INFLUENZA MEG LOW VIRUS. YOU CAN SEE THE BREADTH OF RESPONSE ANTIBODY RESPONSE IS NOT NECESSARILY SIGNIFICANTLY DIFFERENT AMONG THREE GROUPS, ZIKA CONTROLLED AND OTHER CONTROLS. INTERESINGLY FOR THOSE INTERESTING CORONA VIRUS IS ACTUALLY THIS PLATFORM, CONTAINS MANY SEQUENCES FOR CORONA VIRUSES AND WE TESTED RECENTLY OUR POPULATION OF PATIENTS AND SEE WHAT IS THE BREADTH OF IMMUNE RESPONSE AGAINST CORONA VIRUS NOW AND BEFORE COVID 2, YOU CAN SO E THAT IS RELATIVELY MINIMAL AT LEAST IN THE COLUMBIAN POPULATION SO WE ARE WORKING NOW ON DEVELOPING A NEW PLATFORM THAT WILL COVID CORONA VIRUS TO SEE BREADTH OF RESPONSE IN NEW PATIENTS WITH CORONA VIRUS. AND GULLAIN BARRE. NEXT SLIDE. WE CONTINUE DOING OUR WORK WITH SUPPORT OF NIH FOCUSING IN LONGITUDINAL ANALYSIS OF GULLAIN BARRE. IN COLUMBIA, THE SPECTRUM, DECREASE DRAMATICALLY AFTER SECOND SEMESTER IN 2018 BUT WE SEE FLAIR UPS OF GILLAM BARR IN PATIENT POPULATION AN MORE RECENTLY FOUND MANY ARE ASSOCIATED WITH CAMPYLOBACTER JEN UUNE. THERE'S CLEAR DIFFERENCE IN THE CLINICAL EXPRESSION OF THESE PATIENTS OF PATIENTS WITH ZIK A, HAVE CHARACTERISTIC CLINICAL PROFILE, AS COMPARED WITH THE PATIENT THAT WE ARE SEEING MORE RECENTLY WITHOUT EVIDENCE OF INFECTION. SO THE ZIKA PATIENTS HAVE THE CLINICAL CHARACTERISTIC OF ZIKA INCLUDING FEVER AND OTHER CLINICAL FEATURES. NEXT ONE. SO THE CONCLUSION IS ZIKA IS PERHAPS ONE OF THE VIRAL ILLNESSES THAT TRIGGER MORE ACUTE NEUROLOGICAL EVENTS AGAINST PERIPHERAL NERVOUS SYSTEM. AND THEY RAISE OF GILLAM BAR ARERE IS ONE IN 4,000 PEOPLE INFECT WITH THE VIRUS. THIS IS ONE OF THE MOST IMPORTANT REMARKABLE INFECTIONS ASSOCIATED WITH GUILLAM BARRE. NEXT ONE. I WOULD LIKE TO FINISH HEREBY WITH OUR HYPOTHESIS, OUR HYPOTHESIS IS ON TOP IS PATIENTS EXPOSED PREVIOUSLY WITH DENGHI MAY DEVELOP MORE ANTIBODY REACTION PROBABLY THAT AMOUNT OF IMMUNOLOGICAL REACTION IS WHAT IS ASSOCIATED WITH THE DAMAGE OF THE MYELIN IN THESE PATIENTS WITH GULLIAN BARRE AND ASSOCIATED ZIKA. THE LATEST STORY IS COMING FROM PERU AND IN 2018 AND '19 YOU CAN SEE THERE WAS A HUGE PEAK OF GULLAN BARRE IN PERU, OUR COLLEAGUES AND TEAM IN THE AREA DISCLOSED VERY INTERESTINGLY A VERY IMPORTANT OUTBREAK OF GULLAN BARRE, YOU CAN IMAGINE THE WORK THEY HAVE IN 2018 AND '19 WHEN AT LEAST IN FEW WEEKS THEY WERE ABLE TO SEE MORE THAN 400 PATIENTS WITH GUILLANE BARRE ASSOCIATED WITH OUTBREAK OF CAMPYLBACTER. SO IN GENERAL WHAT WE BELIEVE IN LATIN AMERICA WE ARE GOING TO SEE MORE AND MORE CIRCULATION OF CAMPYLOBACTER THAT HAS POTENTIAL FOR GIULLAN BARRE, MT. FUTURE IN FLAVI VIRUS DISEASE AS WELL AS CAMPYLOBACTER MAYBE A VERY IMPORTANT TO APPROACH AND TRY TO CONTROL FROM EPIDEEM LOGICAL POINT OF VIEW. EPIDEEM LOGICAL POINT OF VIEW. ACKNOWLEDGE THAT MANY OF MY COLLEAGUES IN COLUMBIA AND OTHER AREAS OF THE WORLD PARTICIPATED IN THIS STUDIES. AND I ACKNOWLEDGE SUPPORT ALSO BY NIH FOR OUR CONTINUATION OF EPIDEEM LOGICAL STUDIES IN COLUMBIA FOCUS ON GULLAN BARRE MYLITIS AND ENCEPHLITIS. THANK YOU. >> THANK YOU, CARLOS. QUESTIONS. >> CARLOS, CAN I ASK A QUESTION, COULD YOU COMMENT ON THE RECENT REPORTS ASSOCIATED COVID-19 WITH GBS AXONAL AND DEMYELINATIONING IN NEW ENGLAND JOURNAL OF THE FIVE CASES AND THEN SUBSEQUENT INDIVIDUAL CASE REPORTS? ANY THOUGHTS ON POTENTIAL MECHANISMS AND REALITY OF THAT? >> I THIS I THAT IS A VERY CLEAR SIGNAL. I BELIEVE CORNELL IN THE NEXT FEW MINUTE ALSO EXPAND ON THAT BUT MY TAKE AS NEUROLOGIST WORKING WITH THIS PATIENT POPULATION IS THAT THE N MEANING THE NUMBER OF CASES, IS DEFINITELY VERY, VERY SMALL AS COMPARED WITH THE D, THAT IS THE DENOMINATOR OF THE OVERALL AMOUNT OF INFECTION AROUND THE WORLD. AND DIFFERENT COUNTRIES. OUR EXPERIENCE HERE, MANY MARYLAND HAS BEEN WE HAVE SEEN A LOT OF PATIENTS WITH COVID-19 NEUROLOGICAL COMPLICATIONS IS MOSTLY SECONDARY TO HIGH POXEMIA. THE AMOUNT OF PERIPHERAL NERVE DAMAGE IS MINIMAL. SO I BELIEVE THAT THE GULOLAN BARRE ASSOCIATED WITH COVID-19 MAY FOLLOW A SIMILAR PATTERN TO OTHER VITAL ILLNESSES LIKE INFLUENZA, AND OTHER TYPE OF RESPIRATORY VIRUSES THAT MAY TRIGGER OCCASIONAL CASES OF GUILLAN BARRE. HOWEVER THE MAGNITUDE OF DATA FACTORING MONOPATHOGENIC IS NOT AS BIG AS WHAT WE OBSERVE WITH ZIKA GUILLAN BARRE >> IF IT WAS ONE TO 4,000 THINK OF HOW MANY CASES WE WOULD HAVE SEEN. >> THE SAME WITH CAMPYLOBACTER. CAN YOU SEE THE NUMBER ASSOCIATED GUILLAN BARRE IN PERU. IN ONE OR TWO WEEKS THEY SEE 100, 200 PATIENTS SO THE MAGNITUDE OF TRIGGERING FACTOR INFECTIOUS DISEASE THOSE AFFECTED DURING INFECTION. >> GLENN. >> JIM SABOR ASKS WHAT IS KNOWN SPECIFICALLY ANTI-ANTI-GANGLIONCYTE ANTIBODIES IN GBS? >> THIS IS WORK DONE WITH -- AND I SHOW BRIEFLY ONE SLIDE THAT HUGH WILL PROVIDE WITH SAMPLES THAT WE HAVE SHARE FROM OUR STUDIES IN COLUMBIA. THE SIGNAL WE SEE IS THERE IS NOT NECESSARILY PROMINENT. THIS IS AN IMPORTANT OBSERVATION BECAUSE I THINK THE ANTIGUAN GLIOCYTE IS VERY CHARACTERISTIC FOR CAMPYLOBACTER. IT'S NOT NECESSARILY CHARACTERISTIC ZIKA ASSOCIATED GUILLAN BARRE. >> ANY OTHER QUESTIONS? >> SPEAKING OF HUGH, QUESTION FROM HIM. DO YOU THINK THIS AMPLIFIED DENGHE RSPONSE SEEN IN COLUMBIAN ZIKA GBS IS LIKELY TO HAVE OCCURRED IN FRENCH POLYNESIA? >> I BELIEVE SO. I BELIEVE THE FRENCH POLYNESIA PAPER PUBLISHED IN LANSETT SHOWS DATA THAT SUPPORT THAT IDEA AS WELL. OTHER STUDIES HAVE BEEN DONE FOR -- BY OTHER RESEARCHERS WORKING IN DENDHI SHOW MANY PATIENTS WITH ZIKA DEVELOP A STRIKING NEUTRALIZING ANTIBODY RESPONSE AGAINST DENGHE VIRUS, THAT MAY SUGGEST THAT FACTOR IS ALSO AN IMPORTANT FACTOR. >> ANY OTHER QUESTIONS FROM THE -- >> THERE WAS ONE QUESTION FROM SONYA LEONARD. SHE ASKED POSSIBLE ASSOCIATION OF SARS COVID 2 AND GBS. >> CAN I ASK A QUESTION? >> CAN YOU HEAR ME? >> YES. >> THIS IS LANE, I WANTED TO ASK YOU USING YOUR PHAGE IMMUNOPRECIPITATION APPROACH IS IT POSSIBLE YOU CAN SEE EPITOPES THAT MAY OVERLAP WITH NEURONAL OR MYELIN EPITOPES AS WELL? >> YES. THANK YOU FOR THAT QUESTION. YES. WE ARE ABLE TO DO THAT. THE PHAGE ASSAY HAS A PLATFORM DEDICATED TO A HUMAN PEPTIDOME. WE HAVE TWO TARGETS WE AMPLIFY IN OUR STUDY AND WE ARE EVALUATING THOSE OBSERVATIONS SO THE ANSWER IS YES, WE ARE ABLE TO DO THAT. >> I THINK IT'S TIME TO MOVE ON TO THE NEXT TALK. THANKS AGAIN CARLOS. CONNIE WHO HAS BEEN STUDYING CORONA VIRUSES FOR A LONG TIME AND WILL ENLIGHTEN US ABOUT THE CORONA VIRUS ENCEPHALOMYLITIS IN MICE. >> I WANT TO ALSO THANK THE ORGANIZERS FOR INVITING ME. THIS WILL BE MORE AN OVERVIEW OF CORONA VIRUS AND THEIR ABILITY TO INDUCE ENCEPHALOMYLITIS. NEXT SLIDE. SO TO JUST GET EVERYBODY ON THE SAME PLATFORM I WANT TO INTRODUCE THAT WE HAVE BEEN HAVING CIRCULATING CORONA VIRUSES FOR HUNDREDS OF YEARS AND THEY FIRST WERE IDENTIFIED IN THE 1960s. THIS PROMINENT CIRCULATING ONES CAUSE REALLY BENIGN COMMON COLDS. SO 15 TO UP TO 30% THROUGH THE WORLD. OC 43 CAN ALSO INFECT LOWER RESPIRATORY TRACK AND CAUSE MORE SEVERE ILLNESS AND ELDERLY IMMUNE COMPROMISED JUST LIKE THE NEW SARS COVID 2. SO WITH THAT THEN THERE'S ALSO RESEARCH STARTED USING SEVERAL MOUSE HEPATITIS VIRUS MODELS FOR ENCEPHALOMYLITIS, DEMYELINATION BUT DEPENDING ON VAIN CAN ALSO INFECT LUNG AND LIVER. THESE CORONA VIRUSES ARE ALSO INFECT LARGE VARIETY OF ANIMALS AND COMMON AGRICULTURAL BURDEN IN PIG LETS CHICKEN AN CATTLE. THEY CAN INFECT NOT ONLY LUNGS BUT ALSO KIDNEY, AND ENTERIC SYSTEM. SO WITH THE EMERGENCE OF SARS CORONA VIRUS IN 2003 IT BECAME CLEAR THERE CAN BE JUMP FROM BATS THROUGH INTERMEDIATE HOSTS WHICH SARS COR 1 WITHIN BELIEVEDTOR SIV CATS THAT CAUSE SEVERE ACUTE RESPIRATORY DISEASE, ALL THE THESE SARS AND MERS COV 1 ASSOCIATED WITH POTENTIAL NEUROLOGICAL SYMPTOMS. BUT AGAIN JUST TO EMPHASIZE VIRUS -- THESE VIRUSES ARE DERIVED FROM BATS AND HOSTS OF A HUNDRED CORONA VIRUSES BUT WE NEED TO FIND THOSE HOSTS. NEXT SLIDE PLEASE. SO JUST O TO GIVE A BRIEF OVERVIEW OF THE VIRUS ITSELF, IT'S AN ENVELOPED VIRUS. THE SPIKE LIKE PROTEIN IS HEAVILY GLYCOSYLATED. IT ACTUALLY IS REQUIRED FOR ENTRY, IT REQUIRES BINDING TO RECEPTOR AND FUSION PROCESS BUT THEN WE HAVE THE MEMBRANE PROTEIN, THE SMALL SPIKE PROTEIN WHICH SIT IN THE ENVELOPE AND THE NUCLEAR CAPSID PROTEIN IS ACTUALLY THE ONE THAT COVERS THE LONG GENOMIC CAP AND POLYADEN LATED RNA WHICH IS CAPPED BY NORMAL HUMAN RNA SO THESE VIRUS IN GENERAL ARE VERY -- INDUCES TYPE 1 INTERFERON. THE NEXT SLIDE. I WOULD LIKE TO PRESENT THE GENOME BECAUSE THESE VIRUSES AGAIN HIGHLY UNUSUAL IT IS A 30,000 NUCLEOTIDE LONG RNA VIRUS, ENCODES 18 OPEN READING FRAMES. TWO-THIRDS OF THE GENOME AT THE FIVE PRIME END WHICH ENCODE FOR OVERLAPPING POLYPEPTIDES BASICALLY GET PROTEOLYTICALLY CLEAVEDINTO 60 KNOWN STRUCTURAL PROTEINS AND THESE MAKE UP THE REPLICATION COMPLEX AND THEN WE HAVE OPEN READING FRAMES FOR THE STRUCTURAL PROTEINS AS WELL AS VARIETY OF ACCESSORY PROTEINS THAT ARE NOT REQUIRED FOR REPLICATION AND CULTURE BUT ARE DETERMINANTS OF PATHOGENICITY. NEXT SLIDE. SO I'M GIVING A MORE BROAD OVERVIEW, NOT GETTING INTO MUCH SPECIFIC DATA FROM THE LAB AT THE MOMENT BUT JUST RESPIRATORY INFECTIONS THAT ARE COMMONLY CIRCULATING IN THE HUMANS LIKE RESPIRATORY SIN STILL VIRUS FLU, AND CORONA VIRUSES HAVE BEEN LINKED TO NEUROLOGICAL SYMPTOMS. THESE CLINICAL MANIFESTATIONS INCLUDE SEIZURES, STATUS EPILECT CUSS ENCEPHALOPATHIES ENCEPHLITIS. BUT THE EVIDENCE OF VIRUS IN CEREBROSPINAL FLUID IS NOT HARD TO COME BY, IT'S SUPPORTED IN THE VIRUSES MENTIONING SO COULD BE MANIFESTATIONS FROM DIRECT TO CNS. SO THE FIRST LARGER STUDY FROM CHINA REGARDING EVALUATION OF COVID PATIENTS SUGGESTED THAT 6 -- 36% DEVELOP NEUROLOGICAL SYMPTOMS, ESPECIALLY THE PATIENTS THAT ARE MORE SEVERELY AFFLICTED BY COVID-19 ACTUALLY HAVE MORE SEVERE SYMPTOMS LIKE HEADACHE, EPILEPSY AND DISTURBED CONSCIOUSNESS. SO I THINK WHAT NEEDS TO BE DONE IN THE FIELD AND THIS IS HARD TO COME BY BECAUSE EVEN AT THE CLEVELAND CLINIC THEY WON'T DO AUTOPSY MATERIAL IN COVID PATIENTS FOREBRAINS. THOSE ARE THE DANGER OF AEROSOLS. SO I THINK IT REMAINS REALLY UNCLEAR TO WHAT EXTENT THE COVID-19 SYMPTOMS ARE REALLY DUE TO DIRECT CNS INFECTION, THERE IS SOME EVIDENCE IN THE SMALL PATIENT NUMBERS THAT CSF IS POSITIVE FOR VIRAL SEQUENCES. OR IS THIS REALLY DUE I THINK AS CARLOS MENTIONED DUE TO ACUTE SIR BORROW VASCULAR DISEASE, EDEMA, PERIPHERAL SO IS IT A SECONDARY EFFECT. NEXT SLIDE. I WENT BACK TO SOME OF THE STUDIES AND JUST TO SEE WHAT IS OUT THERE WITH HUMAN CORONA VIRUSES AND THERE'S JUST ONLY ONE REPORT OF ACUTE FLASSIS PARALYSIS. THIS IS A 3-YEAR-OLD PEDIATRIC CASE WHICH WAS PUBLISHED IN 2015, CONSIDERING THESE VIRUSES HAVE BEEN WITH US FOR SO LONG I FOUND THAT SORT OF INTERESTING. SO THIS CHILD THAT TESTED POSITIVE FOR CO-INFECTION WITH BOTH BENIGN NORMALLY BENIGN CORONA VIRUSES 229E AND OC 43, SHE WAS HOSPITALIZED DUE TO SHORTNESS OF BREADTH, INABILITY TO WORK FAIRLY EARLY, FEVER AND SYMPTOMS OF COLD, SHE WAS PUT ON MECHANICAL VENTILATION AND SHE GOT DIAGNOSED BASICALLY THERE WAS A LOSS OF MUSCLE STRENGTH, TENDON REFLECTSES. BOTH CHEST RAIDOGRAPHY WAS NORMAL CSF SEEMED NORMAL, NO PACK TIERIAL CULTURES -- BACTERIAL CULTURES. SO THERE WAS NO EVIDENCE EVEN BY MRI THAT THEY WERE ABNORMALITIES IN BRAIN AND SPINAL CORD, SHE DID GET ANTIBIOTIC THERAPY AND INTRAVENOUS GLOBULIN. BASICALLY IMPROVED SIGNIFICANTLY AFTER THREE WEEKS. SO NEXT I WILL DISCUSS IN THE NEXT SLIDE, THERE IS THREE CASES OF GUILLAN BARRE SYNDROME THAT I PICKED OUT THAT ARE YOU CAN P LEARNED BECAUSE -- PUBLISHED BECAUSE I THOUGHT IT WAS INTERESTING THAT THESE CASES ARE ALL FAIRLY DIFFERENT AND AGAIN, DUE TO THE SEVERITY AND MULTI-ORGAN SYMPTOMS OF THIS DISEASE IT IS HARD TO DRAW ANY CONCLUSIONS. BUT THE FIRST ONE IS PUBLICATION WE RAN WHERE MALE PATIENT CAME IN TO THE HOSPITAL WITH (INAUDIBLE) HE HAD HAD COUGH AND FEVER TWO WEEKS BEFORE THAT, HE WAS TESTED POSITIVE FOR SARS COV 2 AND DIAGNOSED AS GBS POSITIVE. REFUSED CSF DRAW BUT IV REAM FOR FIVE DAYS AND THE PATIENT RECOVERED. WHEREAS ANOTHER STUDY OUT OF ITALY, AGAIN, THE PATIENT PRESENTED WITH FLACCID TETROPHORESES, ONLY HAD LOW GRAYED FEVER, NOTHING SEVERE, TESTED POSITIVE FOR SARS COV 2, CSF WAS NEGATIVE FOR VIRUS. THEY PUT HIM ON IV IMMEDIATELY AND ANTI-VIRAL THERAPY BUT THE PATIENT DIED WITHIN 24 HOURS. SO THIS IS REALLY RAPID PROGRESSION OF THE DISEASE. IN ANOTHER CASE I'M HIGHLIGHTING THIS, BECAUSE THIS PERSON CAME IN AGAIN, WITH WEAKNESS IN THE LEGS AND SEVERE FATIGUE, BUT NO OBVIOUS SYMPTOMS OF RESPIRATORY COVID 2 RELATED DISTRESS. SHE DIDN'T HAVE LYMPHOCYTOPENIA WHICH IS COMMON IN COVID 2 PATIENTS AND SHE DID TEST POSITIVE PRETTY MUCH RIGHT AS SHE GOT ADMITTED TO THE HOSPITAL FOR SARS C OV 2 BY CT AND PCR, AGAIN, THE CSF WAS NEGATIVE VIRUS, SHE DID HAVE POSITIVE GBS DIAGNOSIS, AND THIS PATIENT ALSO RECOVERED AFTER IV TREATMENT. GETTING TO THE NEXT SLIDE. I THINK THIS WAS DISCUSSED BEFORE. WHAT ARE THE POTENTIAL ROUTES OF RESPIRATORY VIRUSES TO GET INTO THE CNS AND DO WE REALLY NEED DIRECT CNS INFECTION TO GET THESE DISEASES? AGAIN I THINK FOR COVID-19 WE REALLY DON'T KNOW YET. FROM THE FEW CASES THAT ARE OUT THERE, IT SUGGESTS THAT THE CSF AT LEAST IS RNA NEGATIVE. BUT THE ROUTES ARE ACTUALLY EITHER FROM PERIPHERAL DISSEMINATION, GOING THROUGH THE LUNG MUCOSA, GETTING INTO THE BLOODSTREAM AND DIRECTLY INFECTING THE CNS OR WHICH I THINK FOR THE RESPIRATORY INFECTION HAS GOTTEN SIGNIFICANTLY MORE ATTENTION IN THE LAST FEW YEARS, THAT THESE VIRUSES CAN INFECT NEUROEPITHELIUM AND ULTIMATELY WHEN THEY SPREAD TO NEURONS IN THE OLFACTORY BULB, THAT'S LIKE AN OPEN PATHWAY TO GET INTO THE CNS. TIS IS WHERE THE MURINE CORONA VIRUSES AS WELL AS A ADAPTED OC 43 HUMAN MOUSE MODEL HAS CLEARLY SHOWN YOU CAN GIVE THESE VIRUSES THROUGH THE OLFACTORY BULB OR LIEU THE NASAL CAVITY AND THEY SPREAD THROUGH THE OLFACTORY BULB INTO THE SPINAL CORD. SO NEXT SLIDE. THIS IS JUST A MODEL, I WILL BE VERY BRIEF. WE INFECT THE VIRUS DIRECTLY INTRACRANIALLY, YOU CAN ALSO GIVE IT INTRAMAY SALLY, JUST NEED MORE -- INTRANASALLY, WE GET INFECTIOUS VIRUS, BASICALLY CLEAR FROM THE BRAIN AND FROM THE SPINAL CORDS WITHIN TWO WEEKS, HOWEVER, THESE VIRUSES DO TEND TO PERSIST AND IN THE MOUSE THEY PERSIST IN THE SPINAL CORD FOR UP TO THE LIFETIME AT THE MOUSE, BUT THE VIRAL RNA PANEL SHOWS THEY REALLY PERSISTED VERY, VERY LOW LEVELS. THE VIRUS AGAIN I SAID INDUCES VERY LITTLE INTERFERON ALPHA AND BETA BUT THAT'S REQUIRED TO STEM THE SPREAD INITIALLY AND T-CELLS ARE THE MAJOR EFFECTERS OF VIRUS CLEARANCE PREDOMINANTLY CD8 T-CELLS BY GAMMA INTERFERON. AND ONE THING I WANTED TO BRING UP, AND LIKE ALSO IN THE VIRUS MODEL THE PERSISTING PHASE THAT'S NOT ASSOCIATED WITH INFECTIOUS VIRUS IS CONTROLLED BY LOCAL ANTIBODY SECRETING CELLS, WITHIN THE CNS. SO THESE MICE WE DEVELOP HIND LIMB PARALYSIS, THIS IS A GREAT MODEL TO STUDY BOTH THE SPREAD AND THE IMMUNE EFFECTERS. NEXT SLIDE, SO WHAT -- THE LAB HAS BEEN FOCUSING ON IS REALLY THE ROLE OF TYPE 1 INTERFERON SIGNALING AND BLOCKING CORONA VIRUS VIRAL CNS DISSEMINATION BECAUSE AS LIKE BE ANY CORONA VIRUSES, THERE'S VERY FEW CELLS THAT ARE INFECTED, IT ACTUALLY INDUCED TYPE 1 INTERFERON, IN THE CNS IN THIS MODEL IS MAINLY THE MICROGLIA, ASTROCYTES NEURONAL CULTURE DO NOT INDUCE ANY TYPE 1 INTERFERON. SO OUR QUESTIONS HAVE BECOME HOW IMPORTANT DOES ONE CELL TYPE THAT'S INDUCING INTERFERON AND THEN SIGNALING TO THE OTHERS THAT CAN'T, AND PROVIDING LONG TERM PROTECTION. SO GETTING TO THE NEXT GRAPH. I'M JUST GOING TO SHOW ONE DATA SLIDE, THIS IS LOOKING AT DEPLETION OF TYPE 1 INTERFERON RECEPTOR IN KINASE 2 NEURONS, FOREBRAIN NEURONS, AND THIS IS ONE OF THE FEW MODELS WHERE WE GIVE THE VERY BENIGN HMV 59, CAUSES LOW CLINICAL SCORES, ONLY FOR THAT THESE MICE DEVELOP HIND LIMB PARALYSIS WITHIN SIX DAYS. ABOUT 80%. THAT'S NONE OF THE OTHER MODELS HAVE WE SEEN THAT. THEY ULTIMATELY SUCCUMB TO INFECTION AND THE VIRUS IS NOT CONTROLLED VERY WELL. SO MY SUMMARY SLIDE FOR JUST THE SCIENTIFIC PART, NEXT SLIDE PLEASE. IS THAT THE INTERFERON RESPONSIVENESS ON THE CELL TYPES CAN REGULATE THE DISEASE PHENOTYPE AND SUBSEQUENT ADOPTIVE RESPONSES WHICH I HAVEN'T HAD TIME TO TALK ABOUT BUT IF YOU JUST LOOK AT THE INTERFERON GAMMA RESPONSE BECAUSE WE WERE WONDERING IF T-CELLS RECRUIT IN THESE MODELS, AND THEY ACTUALLY DO BUT THEY JUST CANNOT EFFECT VIRUS CONTROL. WE HAVE NOTICED THAT INTERFERON GAMMA LEVELS ARE FINE BUT THE MICROGLIA JUST DON'T SEEM TO ACTUALLY RESPOND TO THEM. WE ARE LOOKING REALLY AT THE INTERACTION OF TYPE 1 INTERFERON AND GAMMA INTERFERON. REGULATING CONTROL OF THESE INFECTIONS AND ESPECIALLY THE PERSISTING PHASE AND PROGRESSION TO THE SPINAL CORD. WITH THAT I WOULD JUST LIKE TO STOP. JUST TO SAY IT'S NOT ONLY BIG GUYS THAT CAUSE SURPRISES, COVID-19 AND SARS CORONA VIRUS 2 IS DEFINITELY BEEN CHALLENGING. I'LL TAKE QUESTIONS. >> I THINK WE HAVE TIME FOR IS THERE ANYTHING GLENN? >> HERE IS A QUESTION FROM CLINT WRIGHT. YOUR OPINION ANT ENDOTHELIAL INFECTION BY SARS COVE 2? I THINK THAT VIRUS SEEMS TO INFECT SO MANY CELLS AND I THINK THAT'S ONE OF THE MAJOR PROBLEMS WITH SARS COV 2, IT DOES INFECT SO MANY CELL TYPES, I WOULD LIKE TO ADD ONE THING. ALTHOUGH ACE 2 IS KNOWN TO BE RECEPTOR AND WE HAVE ALL THESE COMPLICATIONS WITH AFFECTING HYPERTENSION WITH THAT BALANCE, I THINK THERE ARE ALSO OTHER CELLS THAT IT CAN BE LOW IN AC 2, THERE'S PROTEASES THAT ARE USED NEW DATA COMING OUT EVERY DAY. AND ALL THESE DATA ARE REALLY DONE WITH PSEUDOTYPE VIRUSES. THERE'S REALLY NOT THAT MUCH DONE, AND CELL TYPES THAT REALLY AREN'T THAT RELEVANT IN TERMS OF ENDOTHELIAL CELLS PRIMARY CELL TYPES, THESE ARE REALLY HARD EXPERIMENTS. SO A LOT OF RESEARCH REALLY NEEDS TO BE DONE TO SEE SUSCEPTIBILITY OF SOME OF THESE CELLS, LOOK AT OTHER PARAMETERS IN THE MEMBRANE. ESPECIALLY THE PROTEASES. >> OTHER QUESTIONS? >> THAT'S ALL I HAVE. >> THANK YOU. >> GLENN, WAS THERE ANY OTHER QUESTION? >> THIS IS AVI. SO CONNI SUPERB TALK. WITHIN THE CNS DO YOU FIND EVIDENCE OF NEURONAL INFECTION? AT ALL? WITH SOME THE OTHER HUMAN CORONA VIRUSES, SARS AND OC 43 SEEMS LIKE THERE WAS EVIDENCE OF NEURONAL INFECTION, DO YOU FIND THE MOUSE HEPATITIS VIRUS ALSO? >> DEFINITELY. IT DEPEND, THERE'S SO MANY STRAINS, LIKE THE REALLY SEVERE -- THE ORIGINAL VARIANT SO LETHAL LIKE VERY LOW PFU AND IT SPREADS IMMEDIATELY FROM THE OLFACTORY BULB VIA THOSE NEURONS AND AFFECTS THE SPINAL CORD. WE SEE THIS ACTUALLY, THAT IS WHY I'M SAYING RECEPTORS ARE NOT NECESSARILY -- THEY ARE IMPORTANT BUT I THINK THE TYPE ONE INTERFERON RESPONSE IS EQUALLY IMPORTANT IN DETERMININGTROPE TROPISM, AS& SOON AS YOU TAKE THAT SIGNALING AWAY YOU CAN HAVE TOTALLY LETHAL DISEASE IN DIFFERENT -- THAT'S WHAT I LIKE TO HIGHLIGHT, DIFFERENT PATHOLOGIES. SO THESE VIRUSES DEFINITELY DO INFECT NEURONS. TO KEEP THE ANSWER SHORT. >> IS THAT BECAUSE OF CELL TO CELL SPREAD THAT THE RECEPTOR IS NOT THAT CRITICAL? >> SO ALSO STAN PEARLMAN'S STUDIES LOOKS LIKE THE VIRUS DOES SPREAD ALONG AXONS, THERE'S SO LITTLE RESEARCH DONE IN THAT FIELD THAT HOPEFULLY THEY WILL BE A LITTLE BIT MORE RESEARCH LOOKING AT DIRECT NEURONAL SPREAD. HOW THIS VIRUS -- YOU CAN SEE FROM SOME OF THE SLIDES HOW QUICKLY WITHIN FIVE DAYS I DIDN'T HAVE TIME TO SHOW THE HISTOLOGY BUT BASICALLY THE WHOLE BRAIN IS JUST FULL OF NUCLEAR CAPSID PROTEIN, IT'S FASCINATING, HOW FAST THIS VIRUS CAN SPREAD. >> THANK YOU VERY MUCH. NOW WE WILL MOVE ON TO MAUREEN TSU FROM UCLA LOOKING AT THE PATHOGENESIS. >> THANK YOU SO MUCH, HUE TO GLENN AND ORGANIZING COMMITTEE FOR THE CHANCE TO PRESENT. I'M GOING TO TALK ABOUT MOUSE MODELS AND THEIR ROLE IN HELPING US UNDERSTAND GBS PATHOGENESIS SO AS CARLOS AND CORNELIA ALLUDED TO GBS IS WELL KNOWN TO BE A HETERO GENIUS CONDITION MADE UP OF DIFFERENT SUBTYPES. SOME HAVE DEMYELINATIONING FORM. SOME HAVE ANTI-GANGLIACYTE ANTIBODIES. SOME HAVE ANTI-SEE DENT INFECTION AND OTHERS DON'T. EVEN IF YOU LOOK AT THE INFECTION ASSOCIATED CASES, THERE IS A VERY BROAD NUMBER OF DIFFERENT PATHOGENERALS THAT CAN BE PRECEDING INFECTION SO A VERY HETERO GENIUS CONDITION. NEXT SLIDE. TO TRY TO UNDERSTAND THE SUB STIPES MOUSE MODELS HAVE BEEN DEVELOPED THAT SHARE THE CHARACTERISTICS OF THESE SUBTYPES. AND TODAY I WILL TALK ABOUT SOME OF THE MOUSE MODELS THAT HAVE BEEN DEVELOPED THAT HELPED US UNDERSTAND DEMYELINATIONING GBS. ALSO TOUCH ON MOUSE MODELS TO UNDERSTAND C JEJUNI ASSOCIATED NEUROPATHY AND THEN SPECULATE AT THE END WHAT WE MIGHT BE ABLE TO DO USE MOUSE MODELS TO UNDERSTAND COVID-19 ASSOCIATED GBS. NEXT SLIDE. SO LET'S START FIRST WITH DE MYELINATIONING NEUROPATHY. EAN OR EXPERIMENTAL AUTOIMMUNE NEURORYETIS IS USED TO UNDERSTAND DEMYELINATIONING GBS ANDS IN BEGINNING THESE WERE DONE IN NON-MOUSE SPECIES BUT IN 2000 JOE DESCRIBED EAN IN C 57 BLACK SIX MICE HISTORICALLY CONSISTENT TO AUTO-IMMUNITY AND THEY IMMUNIZED THE MICE WITH P 0 PEPTIDE AND PERTUSSIS ADJUVANT. SO P 0 IS A PROTEIN SPECIFIC TO SWAN CELLS IN THE PERIPHERAL NERVOUS SYSTEM AND WHEN THEY IMMUNIZE THE MICE WITH THE P 0180 TO 199 PEPTIDE THEY COULD SEE IMMUNE CELL INFILTRATION IN THE PERIPHERAL NERVE AS WELL AS DEMYELINATION. YOU CAN SEE THAT IN THE BOTTOM TWO FIGURES. ON THE LEFT IS HNE STAINING SECTION OF PURPLE NERVE AND YOU ONLY SEE NUCLEI FROM THE SWAN CELLS, VERY SPARSE AND YOU CAN SEE AREAS OF DENSE NUCLEAR AGGREGATES, THOSE ARE MACROPHAGES AN T-CELLS IN THE PERIPHERAL NERVE. ON THE RIGHT IS BLUE STAIN, INSTEAD OF SEEING THE HOMOGENOUS THERE'S AREAS OF CLEARING THAT ARE AREAS DEVOID OF MYELIN. NEXT SLIDE. IN ADDITION THERE'S SPONTANEOUS MOUSE MODELS THAT HAVE BEEN DEVELOPED, THAT DON'T REQUIRE THIS IMMUNIZATION WITH THIS STRONG ADJUVANT. THIS MOUSE MODELS SHARE THEIR BACKGROUND WHICH IS INBRED STRAIN CALLED NOD OR NON-OBESE DIABETIC. THIS BACKGROUND HAS MHC HAPLO TYPE THAT PRE-DISPOSE AUTO-IMMUNITY AS WELL AS OTHER GENE POLYMORPHISMS THAT SEEM TO BE INCREASE SUSCEPTIBILITY FOLLOWING IMMUNITY. THESE SPONTANEOUS MOUSE MODELS HAVE MUTATIONS IN KEY IMMUNOREGULATORY GENES. IN 2001 JEFF BLUE STONE DESCRIBED B 72 KNOCK OUT MOUSE PROTECTED FROM DIABETES BUT DEVELOPS NEUROPATHY INSTEAD. WE DESCRIBED A MUTATION IN THE AIRE GENE WHICH ALSO RESULTS IN PERIPHERAL NEUROPATHY AND HORSTE GROUP DESCRIBED ICAM DEFICIENT MODEL IN NOD BACKGROUND THAT DEVELOPS THE NEUROPATHY. ON THE BOTTOM HERE ARE JUST HISTOLOGY FROM THE AIR DEFICIENT MODEL YOU CAN SEE ON THE LEFT IS WILD TYPE NOD NERVE YOU CAN SEE THOSE BLUE DOTS WHICH ARE THE SWAN CELL NUCLEI, IN THE AIRE DEFICIENT NOD MOUSE THERE'S LARGE PATCHES OF BLUE, THOSE ARE INFILTRATING IMMUNE CELLS INSIDE THE NERVES. ON THE RIGHT IS -- YOU CAN SEE THE YOU CAN SEE QUITE A LOT OF DEMYELINATION IN DEFICIENT NOD MICE AS WELL. NEXT SLIDE. MUCH PROGRESS HAS BEEN MADE UNDERSTANDING HOW THE GENES PREVENT THE DEVELOPMENT OF AUTOIMMUNE NEUROPATHY. WE DESCRIBED PATHWAY INSIDE THE THYMUS WHERE THE AIRE GENE UPREGULATES THE EXPRESSION OF THIS SWAN CELL SPECIFIC P 0 PROTEIN. P 0 USUALLY ONLY MADE IN THE SWAN CELLS BUT ALSO AT LEVEL OF MEDULLARY THYMIC EPIHEELIAL CELLS INSIDE THE THYMUS. BY MAKING THE P 0 PROTEIN IT CAN BE PRESENTED TO DEVELOPING T-CELLS AND THOSE THAT ARE REACTIVE, AGAINST THE P 0 PEPTIDE, UNDERGO NEGATIVE SUCTION SO THEY ARE DELETED BEFORE THEY CAN EXIT THE THYMUS. SO IN THE SETTING OFFISHE DEFICIENCY THE P CELL REACTIVE T-CELLS DON'T SEE ANTIGENS THEY CAN ESCAPE TO GO OUT AND CAUSE AUTOIMMUNE DISEASE. ICAM 1 ALSO PLAY AS ROLE IN THE NEGATIVE SELECTION PROCESS FOR P 0 REACTIVE POSITIVE T-CELLS. IT ACTS IN THE PERIPHERY AND SEEMS TO EXPRESS TOLEROGENNIC DENDRITIC CELLS AND BE IMPORTANT SUPPRESSING THIS SPECIFIC IMMUNE RESPONSE SO MANY THE SETTING OF B 2 DEFICIENCY YOU DON'T HAVE THE TOLEROGENNIC SUPPRESSING IMMUNE RESPONSE. NEXT SLIDE. USING THESE MOUSE MODELS THERE HAVE BEEN SOME INSIGHTS INTO THE PATHOGENESIS OF DEMYELINATIONING NEUROPATHY COMMON IN THESE REPLICATING MODELS. THE CD4 T-CELLS ARE SUFFICIENT SO IF WE SORT OUT CD4 T-CELLS FROM AL THREE OF THESE MODELS ACTUALLY, WE CAN TRANSFER DISEASE TO IMMUNODEFICIENT NOD SKID RECIPIENTS. WE ALSO HAVE FOUND INTERFERON GAMMA SEEMS TO BE ESSENTIAL CYTOKINE IN ALL THREE MODELS, IF YOU KNOCK OUT INTERFERON GAMMA, THE MICE ARE PROTECTED FROM NEUROPATHY. SHOWED IL 17 IS AN IMPORTANT CYTOKINE IN HIS ICAM DEFICIENT MODEL SO CD4 T-CELLS SKEWED TO THE TH 17 SUBTYPE WHICH MAKES IL 17 CAN PROVOKE NEUROPATHY EVEN FASTER THAN TH 1 SKEWED POPULATION. THEN WE AND OTHERS HAVE SHOWN IL 10 WHICH IS THOUGHT AS ANTI-INFLAMMATORY CYTOKINE, ACTUALLY ACTS IN PRO-INFLAMMATORY FASHION IN AUTOIMMUNE PERIPHERAL NEUROPATHY BECAUSE IL 10 DEFICIENT MICE ARE PROTECTED FROM NEUROPATHY IN THE AIR DEFICIENT MODEL. WE HAVE ALSO BEEN VERY INTERESTED IN USING THIS MODEL TO UNDERSTAND SWAN CELLS IN DEVELOPMENT OF DISEASE SO WE REPORTED PERIOSTIN IS EXPRESSED BY SWAN CELLS, AND IT'S IMPORTANT FOR MACROPHAGE CHEMO TAXIS, IN COLLABORATION WITH STEVE AT UPEN. SWAN CELLS NOT ONLY EXPRESS MHC CLASS 1 BUT CLASS 2 SUGGESTING IMPORTANT ROLE IN ACTIVATING CD8 AND CD4 IN THE NERVES AND FINALLY WE HAVE SEEN CERTAIN INTEREST GRINS ARE SPECIFICALLY UPREGULATED -- INTEGRINS ARE SPECIFICALLY UP REGULATE BECAUSE BLOCKADE OF INTEGRINS HAVE BEEN EFFECTIVE IN CMS AUTO-IMMUNITY AS WELL AS COLITIS, THIS SUGGESTED THE POSSIBILITY WE CAN POTENTIALLY SPECIFICALLY BLOCK PNS AUTO IMMUNITY BY BLOCKING INTEGRINS. NEXT SLIDE. ADVANCES IN SINGLE CELL RNA SEQ TECHNOLOGY ALLOWS US TO LOOK AT HIGH RESOLUTION NERVE CELLS, IN THESE MODELS. (INDISCERNIBLE) GROUP LOOK IN THE ICAM DEFICIENT MODEL SO IF YOU LOOK AT THE TOP FIGURE HE TOOK SCIATIC NERVES AND BRADY LEXIS NERVE THE MOUSE MODEL TO USE THEM ENZYMATIC SUGGESTION SORTED AND PUT THEM THROUGH THE RAB SEQ PIPELINE. -- RNA SEQ PIPELINE. THE BOTTOM ARE UMAP PROJECTION NOD WILD TYPE MOUSE OR ICAM DEFICIENT NOD MOUSE. THERE'S CLUSTERS OF T-CELLS AND B CELLS AND OTHER IMMUNE CELLS, EVEN IN THE WILD TYPE NOD MOUSE. SO EVEN AT BASELINE THERE SEEMS TO BE SOME RESIDENT IMMUNE CELLS. THESE CLUSTERS GET MORE PROMINENT IN ICAM DEFICIENT MOUSE AND PRIOR TO DISEAS, THESE MICE ARE NOT NEUROPATHIC YET. BUT SEEM TO BE ON THEIR WAY TO DEVELOPING MORE SEVERE DISEASE THEY HAVE EXPANSION OF THESE IMMUNE CELL SUBSETS. NEXT SLIDE. SO WE HAVE DONE THE SAME THING WITH OUR AIR DEFICIENT MODEL. WE LOOK AT MICE NEUROPATHIC AND WE SEE ALSO PROMINENT T-CELLS AS WELL AS B CELLS MACROPHAGES, DENDRITIC CELLS AND OTHER CELL TYPES. NEXT SLIDE. ONE OF THE STRIKING THINGS WE HAVE SEEN WITH SINGLE CELL ANALYSIS, THE PRO INFLAMMATORY CYTOKINE ENVIRONMENT, WE KNEW ABOUT INTERFERON GAMMA, FROM OUR PREVIOUS EXPERIMENTS, BEING& IMPORTANT CYTOKINE, AND IT IS INDEED EXPRESSED BY MANY T-CELLS INSIDE THE NERVE. WE ALSO KNEW ABOUT IL 10 WHICH IS USUALLY AS I TOLD YOU ANTI-INFLAMMATORY CYTOKINE THAT SEEMS TO BE PRO INFLAMMATORY IN THIS MODEL BUT WE ALSO SAW TNF ALPHA BY MACROPHAGES AND T-CELLS, IL 18 AND IL BETA MADE BY MACROPHAGES AND VERY INTERESTING IL 21 IS MADE BY QUITE A FEW T-CELLS WITH THE -- THAT SUGGEST PERHAPS MAY BE PLAYING AN IMPORTANT ROLE AS WELL. THIS IS ALSO EXCITING BECAUSE THERE'S MANY BIOLOGICS DEVELOPED TO BLOCK THESE CYTOKINES AND POTENTIALLY COULD BE USEFUL. TO MOVE TO THE CAMPYLOBACTER JEJUNI. DR. PARDO WENT OVER THIS ALREADY BUT TO SUMMARIZE MIMICRY, ANTIBODIES CROSS THE C JEJUNI OUTER MEMBRANE, ALSO CROSS REACT TO GAIN GAIN GLIOCYTES. USING MOUSE MODELS, HUE WILSON AND OTHERS HAVE SHOWN PATIVE TRANSFER OF ANTI-GANGLIACYTE ANTIBODIES WITH SERUM OR COMPLIMENT RESULT IN AXONAL DAMAGE AND THIS LED TO A MODEL WHERE THE ANTIBODIES PLUS COMPLIMENT WERE IMPORTANT AND ESSENTIAL FOR THIS AXONAL NEUROPATHY. NEXT SLIDE. IN USING THESE MODELS, THREE DIFFERENT PAPERS SUGGESTED THAT BODY BLOCKADE OF C 5 AND C 1Q COULD BE PROTECTIVE FOR THIS DISEASE AND THIS IS INSPIRED MULTIPLE CLINICAL TRIALS AT THIS POINT USING C 1Q AND C 5 INHIBITORS FOR GBS AND I THINK DR. -- WILL BE TALKING ABOUT THAT IN THE NEXT TALK. SO JUST IN THE LAST PART OF THE TOPIC I WANTED TO TALK A LITTLE BIT HOW WE CAN USE MOUSE MODELS TO UNDERSTAND COVID-19 ASSOCIATED GBS. NEXT SLIDE. SO DR.BURGMAN ALLUDED TO SOME CASE REPORTS OF CNS ASSOCIATED SARS COV 2, THERE'S ALSO THIS RECENT PAILER FROM APRIL 17 IN NEW ENGLAND JOURNAL, FIVE PATIENTS IN ITALY WHO WERE HOSPITALIZED IN THREE HOSPITALS CASES BETWEEN FEBRUARY 28 AND MARCH 21ST. DURING THIS TIME THESE THREE HOSPITALS SAW APPROXIMATELY 1,000 TO 1200 COVID-19 CASES. THESE FIVE CASES ASSOCIATED WITH DEVELOPMENT OF GBS, WERE DIAGNOSED USING RTPCA AND SEROLOGY. NEXT SLIDE. IF YOU DO THE MATH, THIS IS FIVE CASES AMONG 1200 WHICH SUGGESTS INCIDENCE APPROXIMATELY 1 PER 240 COVID INFECTED PATIENTS WORLDWIDE INDENSE IS ONE IN 100,000. SO MAYBE THERE IS A CAUSAL ASSOCIATION NOT JUST COINCIDENCE BUT THAT HAS NOT BEEN PROVEN YET. THE CASES SEEM TO BE HETERO GENIUS. THERE WERE TWO DEMYELINATIONING CASES SUBTYPES AND THREE AXONAL SUBTYPES REPORTED. NONE OF THE PATIENTS HAD ANTI-GANGLIACYTE ANTIBODIES PRESENT. AND THIS BEGS THE QUESTION, IS IT POSSIBLE TO TRY TO MODEL THIS IN MICE. OUR MOUSE MODEL IS AVAILABLE FOR COVID-19 INFECTION, IT DOES NOT INFECT WILD TYPE MOUSE BECAUSE THE MOUSE ACE THE ENTRY PROTEIN IS DIFFERENT FROM HUMAN ACE 2 PROTEIN. SO SAM PEARLMAN'S GROUP DEVELOPED A MOUSE THAT DEVELOPED -- THAT EXPRESSES A HUMANIZED -- THE HUMAN ACE 2 UNDER THE CYTOCORE TIN PROMOTER ON D 7 BLACK 6 BACKGROUND. THERE'S A PAPER IN ARCHIVES WHERE THEY INFECT THIRD DEGREE MOUSE WITH COVID 19 AND REPORTED THE MOUSE DEVELOPED WEIGHT LOSS AND PNEUMONIA. BUT THE MOUSE DOES NOT GET NEUROPATHY. SO SUGGESTING THIS IS NOT GOING TO NECESSARILY BE EASY GBS MODEL. NEXT SLIDE. WHAT POTENTIAL APPROACHES WORK FOR MODELED MYELINATIONING ASSOCIATED GBS? ONE IS PASSIVE TRANSFER OF PATIENT SERUM FROM PATIENTS WHO HAVE GBS ASSOCIATED WITH COVID-19 INFECTION. ANOTHER IS TO POTENTIALLY MAKE N OF D MOUSE WHICH WE DISCUSSED EARLIER HAS A GENETIC PRE-DISPOSITION TO AUTO-IMMUNITY, THAT ALSO CARRIES THIS TRANSGENE THAT EXPRESSES THE HUMAN ACE 2 UNDER CORE TIN PROMOTER OR JUST TO CHANGE TO MOUSE ACE 2 TO BE MORE HUMAN ACE 2 IN NOD MOUSE. THERE'S SOME INFECTIONS IN THE NOD BACKGROUND LEAD TO AUTOIMMUNE PERIPHERAL NEUROPATHY. IN 2016 SAINT CHARLES ET AL DESCRIBED C JEJENI INFECTION IN MICE AN DID REPORT THEY DEVELOP ANTIBODIES IN MICE AND NEUROPATHIES SO THIS SUGGESTS THAT PERHAPS THIS MIGHT BE ONE WAY TO REPLICATE THE COVID-19 ASSOCIATED GBS AND THE OTHER POSSIBILITY IS TO CROSS MUTATION OR ICAM MUTATION ON TO THE MICE TO GENETICALLY PRE-DISPOSE TO GBS. NEXT SLIGHTED. SO JUST TO SUMMARIZE THEN, MOUSE MODELS OF DIFFERENT GBS SUBTYPE HAVE BEEN REVEALING A DIFFERENT PATHOGENIC MECHANISMS. WE NOW HAVE IDENTIFIED KEY GENES THAT ARE IMPORTANT IN IMMUNE REGULATION AND THIS IS POINTED TO SOME NEW THERAPEUTIC TARGETS. AND THEN WE THINK MOUSE MODEL COVID IS IT MAYBE HELPFUL FOR DESIGNING PATHOGENESIS. >> THANK YOU VERY MUCH. GOT YOUR ACKNOWLEDGMENTS HERE. >> NO WORRIES. >> A QUESTION THAT CAME UP ON THE CHAT, WHAT IS PERCENT -- PHENOTYPES OF THE B CELLS IN THE NERVE? >> GREAT, GREAT QUESTION. SO WE'VE JUST STARTED DOING THE MOUSE ESPECIALLY WITH THE SINGLE CELL SEQUENCE TRANSCRIPTOMIC DATA THAT WE HAVE. AND WE ARE HOPING TO KNOW MORE ABOUT THAT. I DON'T THINK MUCH IS KNOWN ABOUT WHAT THE B CELLS IN THE NERVES LOOK LIKE, I THINK THERE IS A QUESTION OF WHETHER OR NOT THE IL 21 COMING FROM T-CELLS MIGHT BE HELPING THE B CELLS BECOME MORE ACTIVATED, MATURE AND WHETHER OR NOT THERE'S FORWARD STRCTURES OF THAT. >> I ASK THE QUESTION BECAUSE WE WERE LOOKING AT MENINGES AND SINCE I HAVE B CELL PROJECT LOOKING AT DEVELOPMENT BECAUSE WE NEVER FIND ECTOPIC FOLLICLES IN OUR MODEL. BUT WHAT WE DO FIND IS THAT IGG POSITIVE IGM DOUBLE POSITIVE B CELLS SHOW UP IN THE MENINGES FAIRLY EARLY ON DURING THE INFECTION LIKE DAY THREE ALREADY. AND PROGRESSIVELY THAT PHENOTYPE CHANGES BUT WE DON'T KNOW THE ROLE OF THOSE CELLS. THAT IS WHY I WAS INTERESTED IF YOU KNEW IN THE INFLAMED VERSUS NON-INFLAMED NERVES WHETHER YOU HAVE A DISTINCT PHENOTYPE. >> WE HAVE MULTIPLE PEOPLE STAYING HOME AND ANALYZING THE DATA SET RIGHT NOW TO MAKE THAT A TO DO ON OUR LIST HIGH UP ON OUR LIST OF THINGS TO DO. >> YEAH. THANKS. >> THANK YOU VERY MUCH, NO QUESTIONS FROM THE EMAILS. WE'LL MOVE -- >> WE JUST GOT ONE QUESTION FROM HUGH WILLIS. HOW IMPORTANT DO YOU THINK IT IS TO EXPLORE WHETHER P 0 SPECIFIC T OR B CELL RESPONSES ARE RELEVANT TO HUMAN GBS OR CIDP? BEFORE PURSUING BASIC RESEARCH IN THOSE MODELS? >> THAT IS A REALLY GREAT QUESTION. THERE'S BEEN HISTORICALLY MANY PAPERS WRITTEN THAT ANTIBODY RESPONSES IN PATIENTS WITH GBS AND CIDP, THEY HAVE BEEN FRUSTRATING, IN SEEMS LIKE VERY FEW ANTIGEN SPECIFIC ANTIBODIES AGAINST PERIPHERAL NERVES HAVE BEEN IDENTIFIED, IT'S ALWAYS A MINORITY OF PATIENT WHOSE SEEM TO HAVE THEM. OF THE ONE WHOSE HAVE THEM IT DOES SEEM TO BE AGAINST P 0 SO THAT DOES CORRELATE WITH OUR MOUSE MODELS. THE T-CELL RESPONSES ARE -- HAVE BEEN HARDER TO EVALUATE IN THE PATIENTS, I THINK WE HAVEN'T DONE AS GOOD OF A JOB LOOKING IN T-CELLS OF PATIENTS AS -- THAT NEEDS -- WHAT NEEDS TO BE DONE. SO THAT'S DEFINITELY SOMETHING THAT NEEDS TO BE DONE STILL. >> MAY ASK QUICKLY. IMPORTANT FEATURE IN GBS IS SPINAL FLUID WITH INCREASED PROTEIN WITHOUT ANY INCREASE IN CELLS. SO DO YOU KNOW IF THERE IS ANY EVIDENCE OF INTRATHREECAL SYNTHESIS OF THESE ANTIBODIES AND WHAT IS HAPPENING IN THAT SPACE AND WHAT ROLE DOES IT PLAY IN PATHOPHYSIOLOGY? >> REALLY GOOD QUESTION BECAUSE WHEN I WAS READING HISTORICALLY AGAIN G UILLAME AND BARRE WERE WHAT IMPORTANT IN WHAT IS THE IMMUNOGLOBULIN, CYTOKINES, SOMETHING ELSE, COMPLIMENT? I DON'T KNOW THE ANSWER TO IT. I'M NOT SURE. I HAVEN'T LOOKED IN OUR MOUSE MODELS TO KNOW IF THEY HAVE THE SAME FINDING. >> OKAY. THINK WE'LL MOVE ON TO OUR NEXT TO THE LAST TIME WHICH IS IMMUNOTHERAPIES FOR G UILLAN BARRE. UNMUTE YOURSELF. >> I AM UNMUTED. >> NOW WE CAN HEAR YOU. >> GREAT. THANK YOU. THANK YOU TO THE ORGANIZING COMMITTEE FOR INCLUDING ME IN THE PROGRAM. I WILL BRIEFLY DISCUSS EMERGING IMMUNOTHERAPIES THAN ARE IN CLINICAL DEVELOPMENT FOR GUILLANE-BARRE SYNDROME OR CROSS-EXAMINATIONIPD AND HAVE POTENTIAL TO BE EFFICACIOUS FOR GUILLANE-BARRE SYNDROME. THE CURRENT THERAPIES ARE IVIG AND PLASMA EXCHANGE WHICH DO NOT WORK FOR A SUBSTANTIAL PROPORTION OF PATIENTS. THESE PATIENTS -- POSE A DIFFICULT CHALLENGE, THEY HAVE NO EVIDENCE BASED RECOMMENDATIONS FOR THEM. EXCEPT SUPPORTIVE CARE. NEEDLESS TO SAY, THERE IS URGENT NEED FOR NEW IMMUNOTHERAPIES IN THIS DISEASE. NEXT SLIDE PLEASE. AS A BACKGROUND I WILL SHOW YOU REALLY LAND MARK PATH LOGICAL STUDIES THAT WERE DONE IN JACK GRIFFIN'S LAB. THAT SHOW SHARED ELEMENTS OF END NEURAL INFLAMMATION THAT MEDIATE NERVE INJURY IN DEMYELINATIONING AND AXONAL FORMS OF THE DISEASE. AS YOU CAN SEE IN THIS CASE FROM A DEMYELINATIONING PATIENT IN THE UP PER LEFT HAND CORNER, THERE IS DEPOSITION OF COMPLIMENT PRODUCTS OUTSIDE MYELINATED NERVE FIBER, IT IMPLY THERE'S ANTIBODY MEDIATED ATTACK AGAINST SWAN CELL AND MYELINATED ANTIGENS AND COMPLIMENT PATHWAY. WE ALSO SEE THAT THERE IS MACROPHAGE MEDIATED CONTACT DEPENDENT DEMYELINATION. YOU CAN SEE VARIOUS CASES OF THIS PROCESS OCCURRING IN THE ELECTRON MICROGRAPHS. NEXT SLIDE PLEASE. IN CONTRAST IN AXONAL GBS YOU CAN SEE THE SAME ELEMENTS OF INTRANEURAL INFLAMMATION I.E. ANTIBODIES, COMPLIMENT, AND ACTIVATED MACROPHAGES, BUT HERE THEY ARE REALLY ATTACKING AXONS RATHER THAN MYELIN. NEXT SLIDE PLEASE. THIS IS AN OVERSIMPLIFIED CARTOON BASED ON PATHOLOGICAL STUDIES AND A LARGE BODY OF RESEARCH WORK WHICH SHOWS THAT COMMON ELEMENTS OF ENDONEURAL INFLAMMATION THAT MEDIATE NERVE INJURY IN AFTER THE ACCIDENTONNAL AND DEMYELINATIONING FORM OF GBS. IT HIGHLIGHT IT IS ROLE OF AUTOANTIBODIES IN IMMUNE EFFECTER SUCH AS COMPLIMENT PATHWAY AND ACTIVATING FC GAMMA RECEPTORS AND MACROPHAGE LINEAGE CELLS. IN THIS CONTEXT, I WILL BRIEFLY DISCUSS TREATMENTS THAT TARGET COMPLIMENT PATHWAY INHIBITORS OF NEONATAL RECEPTOR THAT INHIBIT FCRN RECEPTOR AND ENHANCE THE DEGRADATION OF IGG AUTOANTIBODIES AND HYPERSYLATED IMMUNOGLOBULIN THAT HAS POTENTIAL TO ALTER FC GAMMA RECEPTORS, IN MACROPHAGE LINEAGE CELLS. NEXT SLIDE PLEASE. DO YOU HAVE THE NEXT SLIDE? I CAN'T SEE MY LAP TOP. DO YOU HAVE THE NEXT SLIDE UP? >> YES, IT'S UP. >> OKAY. SO THERE ARE TWO COMPLIMENT INHIBITORS THAT ARE IN CLINICAL DEVELOPMENT. FIRST OF THEM IS MONOCLONAL ANTIBODY AGAINST C 5 COMPONENT OF THE COMPLIMENTMENT, IT PREVENTS FORMATION OF TERMINAL COMPLIMENT COMPLEX. AND THIS HAS BEEN STUDIES IN A PHASE 2 TRIAL IN COMBINATION THERAPY WITH IVIG. THESE SAFETY AND EFFICACY STUDIES INDICATE THAT THIS TREATMENT IS RELATIVELY SAFE. THERE WAS ONE PATIENT THAT DEVELOPED CEREBRAL HEMORRHAGE IN THE ECULIZUMAB GROUP CONSIDERED NOT TO BE RELATED TO THIS MEDICATION. 61% OF THE PATIENTS IN ECULIZUMAB TREATED GROUP MET PRIMARY END POINT COMPARED TO 45% IN THE PLACEBO GROUP. THE DIFFERENCE WAS NOT SIGNIFICANT IN THIS SMALL STUDY. NOTABLY, A SECONDARY OUTCOME MEASURE ABILITY TO RUN WAS SIGNIFICANTLY DIFFERENT AND THERE WAS MORE PATIENTS ABLE TO RUN AT SIX MONTHS IN E, CULIZUMAB GROUP COMPARED TO PLACEBO. I'M NOT SURE WHAT IS THE STATUS OF THIS DRUG IN TERMS OF MOVING TO PHASE 3 CLINICAL TRALS AT THIS POINT. THIS STUDY WAS PUBLISHED COUPLE OF YEARS AGO. NEXT SLIDE PLEASE. NEXT SLIDE. >> WE HAVE IT. THE OTHER COMPLIMENT INHIBITOR IS NXO 5 WHICH IS A HUMANIZED THAT NEUTRALIZING C 1Q, FIRST COMPONENT OF COMPLIMENT PATHWAY THAT BINDS TO IMMUNE COMPLEXES TO INITIATE ACTIVATION OF CLASSICAL PATHWAY. THIS WAS STUDIED IN PLACEBO CONTROLLED FASHION, FOR SAFETY AS A MONOTHERAPY IN BANGLADESH, INITIAL STUDIES IN BANGLADESH INDICATE THIS IS SAFE AS A MONOTHERAPY, THERE WAS NO DEATHS OR TREATMENT RELATED SEVERE ADVERSE EVENTS. IT WAS ALSO NOTICED THAT ANX 005 TREATED GROUP HAD EARLY REDUCTION IN SERUM LEVELS ASSOCIATED IMPROVEMENT IN MRC SUM SCORES COMPARED TO PLACEBO, INDICATING LOWER DISEASE BURDEN IN THE TREATMENT GROUP. THERE IS ONGOING DRUG-DRUG INTERACTION STUDY OF ANX 005 IN COMBINATION WITH IVIG AND THIS STUDY IS ONGOING AND ACTIVELY RECRUITING PATIENTS IN U.S.. GIVEN THE INITIAL SAFETY SIGNAL IT IS LIKELY THAT THIS DRUG WILL MOVE TO PHASE 2, 3 EFFICACY STUDIES IN FUTURE. NEXT SLIDE. THE SECOND GROUP OF DRUGS THAT ARE ENTERING CLINICAL TRIALS FOR CIBP ARE INHIBITORS OF SGRN RECEPTORS. AS YOU KNOW CRN RECEPTORSES IN VASCULAR ENDOTHELIAL CELLS FUNCTION TO PROTECT IGG AND ALBUMIN FROM DEGRADATION. EXPLAIN IT IS PROLONGED HALF LIFE OF THESE MOLECULES. IGG ON AUTOANTIBODIES ALSO RECYCLE THROUGH THESE RECEPTORS. CONCEPTUALLY INHIBITION OF THESE RECEPTORS SHOULD ENHANCE THE DEGRADATION OF IGG AUTOANTIBODIES WHICH IS THE BASIS TO STUDY THESE DRUGS IN IMMUNE NEUROPATHIES SUCH AS CIPD AND GUILLANE-BARRE SYNDROME. NEXT SLIDE PLEASE. THERE ARE SIX DIFFERENT FCRN INHIBITORS IN CLINICAL ANTIBODIES, ONE IS A SMALLCLONAL- ANTIBODY MEMATIC FRAGMENT AND ONE IS FC FRAGMENT OF HUMANIZED IGG 1. TWO PRODUCTS, THE UCB 7665 AND ARGX 113 ARE MORE ADVANCED STAGES OF CLINICAL DEVELOPMENT. THEY ARE CURRENTLY INCREASE THREE TRIALS IN MICE XENOGRAPHS AND PHASE 2 TRIAL IN CIP WITH THE AGENTS ABOUT TO BEGIN. NEXT SLIDE PLEASE. THESE DATA ARE FROM PHASE 2 STUDY WITH ARGX 113 IN MIASENA GRAVIS, SHOWING THIS TREATMENT SUBSTANTIALLY REDUCES TOTAL IGG LEVELS AND ACETYLCHOLINE SPECIFIC ANTIBODIES IN YELLOW AN GREEN LINES WHICH CORRELATES WITH CLINICAL EFFICACY AS ASSESSED BY DIFFERENT SCALES SHOWN ON THE GRAPH. THESE STUDIES PROVIDE PROOF OF CONCEPT THAT FCR INHIBITORS BY REDUCING IGG AUTOANTIBODIES, PROVIDE CLINICAL EFFICACY IN IMMUNE DISEASE SUCH AS MIASTHENIA GRAVIS. NEXT SLIDE PLEASE. DR. (INDISCERNIBLE) WHO WAS AT UT SOUTH WESTERN PRODUCED A NUMBER OF IGG MOLECULES THAT BOUND TO FCRN RECEPTOR THROUGH FC PORTIONS, THEY WERE CALLED ABDAGS. ABDAG STANDS FOR ANTIBODIES THAT ENHANCE THE DEGRADATION OF IGG. SHE GRACIOUSLY SHARED AN ABDAG WITH US WHICH WAS THE PARENT COMPOUND FOR THE ARGX 113 AND WE HAVE EXAMINED IT IN ANTIGUAN FLY OWECYTE ANTIBODY MEDIATED NERVE INJURY MODEL IN WHICH GANGLIOCYTE ANTIBODIES INHIBIT AXON REGENERATION. AS YOU CAN SEE IN THE PLOT ON THE LEFT, A SINGLE DOSE OF THE ABDAG SUBSTANTIALLY REDUCES CIRCULATING LEVELS OF ANTI-GANGLIACYTE ANTIBODIES. THE AREA OF THE CURVE REDUCED BY ALMOST 50% WITH THE SINGLE DOSE. COMPARED TO CONTROL ISOTYPE MAST ANTIBODY CALLED HULYS 10, THIS IS CORRELATE WITH REDUCE NERVE INJURY AS REFLECTED BY INCREASE NUMBER OF REGENERATING AXONS AND IS SHOWN IN THE PLOT ON THE RIGHT. THESE STUDIES PROVIDE RATIONALE OF USING FCRN INHIBITORS IN IMMUNE NEUROPATHIES SUCH AS CIDP, AND GUILLANE-BARRE SYNDROME. NEXT SLIDE PLEASE. MOVING ON TO HYPERSYLATED IGG. THESE ARE GLYCO MODIFIED TETRA SYLATED FORM OF IBID WHICH IS CONSIDERED MORE IMPORTANT ANTED INFLAMMATORY THAN IVIG. THE FIGURE ON THE RIGHT SIDE OF GLYCAN CHAIN WITH TWO TERMINAL SIGHIAL LICK ACIDS. EACH MOLECULE HAS TWO GLYCAN CHAINS ATTACHED TO THE PORTION OF THE IGG MOLECULE SO FULLY GLEE KATEED IGG MOLECULE CAN BE TETRA SYLATED. THERE'S TREMENDOUS HETEROGENEITY IN THE LENGTH OF THIS GLYCAN CHAIN, AND NUMBER OF SILIC ACID. 10% OF THE IGG MOLECULES IN THE CURRENTLY USED IVIG FORMULATIONS ARE SYLATED. AND LESS THAN ONE PERCENT ARE TETRA SYLATED. WHY IS SYLATION IMPORTANT? ABOUT 15 YEARS AGO JEFFREY, AN INVESTIGATOR AT ROCKEFELLAR PROPOSED THAT ANTI-INFLAMMATORY ACTIVITY OF IVIG RESIDES IN SYLATED FRACTIONS. SOME OF-TO BE SURE SYLATED WERE TEN TIMES MORE POTENT THAN REGULAR IVIG. SUFFICE TO SAY THIS IDEA IS HIGHLY CONTENTIOUS IN IVIG FIELD. PHARMACEUTICAL NOW HAS COME UP WITH A GLYCO TECHNOLOGY ALLOWS THEM TO TAKE REGULAR IVIG AND TETRA SIALATE MORE THAN 90% OF THE PRODUCT. THEY HAVE SHOWN THAT THIS HYPERSIALYLATED IGG IS TENFOLD MORE POTENT THAN IVIG IN A NUMBER OF PRE-CLINICAL AUTOIMMUNE MODELS. INITIAL STUDIES IN NORMAL INDICATE ANTI-IGIF IS SAFE AND PHARMACOKINETICS IS SIMILAR TO IVIG AND CURRENTLY BEING STUDIED IN A SAFETY AND EFFICACY TRIAL IN ITP. THE COMPANY HAS PLANNED TO STUDY THIS DRUG FOR CIDP AND GBS INDICATIONS. NEXT SLIDE PLEASE. JEFFREY'S GROUP IN SERIES OF STUDIES CHARACTERIZED THE SIALIC ACID MEDIATED PATHWAY CALLED PH 2 PATHWAY. THIS MAYBE RELEVANT TO SOME AUTOIMMUNE DISORDERS BUT NOT TO ALL. ACCORDING TO THIS PATHWAY, SIALATED IGG BIND TO LECTIN LIKE RECEPTOR CALLED DC SIGN 2 EXPRESSED BY MACROPHAGE LINEAGE CELLS, IN SPLENIC MARGINAL ZONES THIS TRIGGER AS TH 2 RESPONSE WHICH LEADS TO PRODUCTION OF TH 2 CYTOKINES WHICH UPREGULATE INHIBITOR OF C GAMMA RECEPTORS PLAYLY ON EFFECTIVE MACROPHAGE LINEAGE CELLS. SO WRITTEN THESE EFFECTER MACROPHAGES ARE IN AN EFFECTIVE TISSUE AND COME ACROSS IMMUNE COMPLEXES, THEY REMAIN DORMANT AND BECOME PROINFLAMMATORY IN THEIR PHENOTYPE THAT'S HOW IT REDUCES OR PREVENTS INFLAMMATION IN TISSUES THAT IS THEIR HYPOTHESIS. NEXT SLIDE PLEASE. WE HAVE STUDIED SIV IG IN OUR MODEL OF ANTI-GANGLIACYTE ANTIBODY MEDIATED NERVE INJURY. THIS MODEL IS DEPENDENT ON EXPRESSION OF ACTIVATING FC GAMMA RECEPTORS PARTICULARLY IN MACROPHAGE LINEAGE CELLS. THESE STUDIES ARE FRACTIONATED WHOLE IVIG INTO SIALIC ACID ENRICH FRACTIONS LABELED SIVIG AND SIALIC ACID DEFICIT FRACTIONS UIVID SHOWN IN THE IMMUNOBLOT ON THE LEFT. WE COMPARED THESE FRACKS WITH WHOLE IVID IN OUR MODEL AND FOUND THAT WHOLE IVIG WAS PROTECTIVE IN OUR MODEL. AND WE COULD USE TENFOLD SIALATED IVIG IN THIS MODEL AND GET EQUAL EFFICACY. THE UNSIALATED FRACTIONS WERE NOT EFFICACIOUS IN OUR MODEL. OVERALL, THESE STUDIES AGAIN SUPPORT THE RATIONALE OF AT LEAST TRYING THE HYPERSIALATED IMMUNOGLOBULINS IN IMMUNE NEUROPATHIES SUCH AS CIPD AND GUILLANE-BARRE SYNDROME AND IMPLICATION IS THAT HUMAN STUDIES INDICATE THAT HYPERSIALATED IMMUNOGLOBULINS ARE MORE IMPORTANT THAN ONE COULD USE LESS OF THESE INSTEAD OF IVIG, AND IN PATIENTS WHO CURRENTLY DO NOT RESPOND TO THE MAXIMALLY USES OF IVIG MAY BECOME RESPONSIVE TO THE SAME AMOUNT OF MORE POTENT HYPERSIALATED PRODUCT. NEXT SLIDE PLEASE. SO IN SUMMARY, THE PROGRESS IN GBS THERAPEUTICS HAS BEEN EXCEPTIONALLY SLOW, NEW IMMUNOTHERAPIES ARE ENTERING FOR CLINICAL DEVELOPMENT FOR THIS DISEASE AFTER A HIATUS OF 30 YEARS. IT REMAINS TO BE SEEN IF THESE TREATMENTS ARE EFFICACIOUS FOR THIS CONDITION AND IF SO, IF THEY ARE MORE POTENT THAN THE CURRENT TREATMENT EITHER ALONE OR IN COMBINATION. I'LL STOP HERE AND TAKE ANY QUESTIONS IF THERE IS TIME. THANK YOU. >> UNFORTUNATELY IF WE'RE GOING TO HAVE TIME FOR JOHN TO GIVE HIS TALK I THINK WE BETTER MOVE ON. JOHN. >> OKAY. THANKS. >> ANTI-ROW VIRUSES IS WHERE WE STARTED. CAN YOU HEAR ME? >> YES. >> GOOD AFTERNOON, EVERYONE. THANK YOU FOR HAVING ME. I HAVE BEEN ASKED TO GIVE AN OVERVIEW OF ANTERO VIRUS INFECTIONS AND TREATMENT THEREOF. THIS IS A MORE A CLINICAL PRESENTATIONS HAVE BEEN. SINCE THE TIME IS SHORT, I'M GOING TO LIMIT THIS TO JUST SMALL MOLECULE ANTI-VIRAL DRUGS WHICH HAVE BEEN TESTD IN CLINIC. AT THE SAME TIME, OF COURSE TECHNOLOGY AND OTHER APPROACHES, INCLUDING IMMUNOGLOBULIN AND IMMUNE MODIFIERS WITH CORTICOSTEROIDS. REGARDING IMMUNOGLOBULINS THE THING I WILL SAY TALKED QUITE A BIT ABOUT IMMUNOGLOBULIN WITH EARLIER PRESENTATIONS. INTERVIRUS. THERE'S CERTAINLY ARE ANIMAL MODELS THAT SUGGEST AFFECT AGAINST SPECIFIC ENTERO VIRUS LIKE KEN SHOWED EARLIER. THERE IS A RECENT NON-HUMAN PRIMATE MODEL DEMONSTRATING EFFICACY OF HIGH TITER POLIO VIRUS IMMUNOGLOBULIN. I'M SORRY, MONOCLONAL ANTIBODY AGAINST POLIO VIRUS TYPE ONE. BUT FOR THE MOST PART, IT'S BEEN DIFFICULT TO DEMONSTRATE CLINICAL BENEFIT IN PATIENTS THAT HAVE SERIOUS CLINICAL INTERO VIRUS SYNDROME SUCH AS SEPSIS AND MYOCARDITIS. THE REASON FOR THAT, THESE ARE SYNDROMES THAT INVOLVE A MORE HETERO GENIUS ETIOLOGY THAN A SINGLE SEROTYPE. AND THAT MAY VERY WELL PLAY INTO THE FACT THAT IT IS MORE DIFFICULT TO DEMONSTRATE STATISTICALLY SIGNIFICANT AFFECTS OF IMMUNE GLOBULIN. NEXT SLIDE. THIS IS A SHORT LIST OF ANY CORONA VIRUSES STUDIED IN THE CLINIC. IT'S PROBABLY NOT COMPREHENSIVE, BUT I HAVE CAPTURED MOST MAJOR AGENTS, I CLEARLY NEED TO ADD TALAPOVIR AFTER HEARING KEN'S PRESENTATION EARLIER. STUDIED CLINICALLY FALL INTO SEVERAL CLASSES. FIRST MAJOR CLASS OF THE CAPSID BINDING AGENTS, POCONORIL AND POCAPAVIR ARE GOOD ONES, THEY IMPAIR ATTACHMENT TO RECEPTOR AND VIRAL ENCODING. AND IS PRIMARY MECHANISM OF ACTION, I WILL SHOW ABOUT THAT MORE IN THE NEXT SLIDE. THEY HAVE A MODERATE SPECTRUM OF ACTIVITY AGAINST MANY BUT NOT ALL ENTEROVIRUS SUB STIPES, GENERALLY FAVORABLE PHARMACOKINETIC PROPERTIES, WITH GOOD ORAL ABSORPTION, GOOD TEST AND DISTRIBUTION INCLUDING GOOD PENETRATION INTO CENTRAL NERVOUS SYSTEM. BUT CONSIDERABLE LIMITATION IS THAT THESE VIRUSES HAVE A LOW BARRIER TO DEVELOPMENT OF RESISTANCE. ANOTHER LARGE CLASS ARE THE ACE INHIBITORS THAT INHIBIT THE THREE C PROTEASE CORONA VIRUSES, THEY IN GENERAL HAVE VERY BROAD SPECK RUM ACTIVITY AND AT LEAST IN VITRO THIS ACTIVITY IS IRREVERSIBLE. SO IT'S POTENT ANTI-VIRAL ACTIVITY AT CONCENTRATIONS THAT ARE READILY ACHIEVABLE AGAINST MOST ENTEROVIRUS STEREOTYPES. THE MAJOR LIMITATION OF THIS CLASS OF COMPOUNDS, IS THEY ARE ORAL BIOAVAILABILITY IS LIMITED BY HEPATIC ESTERASE ACTIVITIES. ACTIVITY. WHICH IS ASSOCIATED WITH HIGH DEGREE OF PAST METABOLISM IN THE LIVER AND REDUCE BIOAVAILABILITY FOR THESE AGENTS. SO THAT'S BEEN A MAJOR FOCUS OF INVESTIGATION BY THE DRUG DEVELOPERS. THERE'S THREE OTHER CLASSES I LISTED ON THE SLIDE, I WON'T FOCUS OR DRILL DOWN INTO ANY OF THEM, ONLY TO SAY THAT EVEN THOUGH THEY ALL HAVE EARLY STAGE OF HUMAN TRIAL, FOR THE MOST PART THEY ARE LESS ACTIVE AGAINST CAPSID BINDING AGENTS AND PROTEASE INHIBITORS. SECONDLY AT LEAST IN SOME CASES, ARE LIMITED SOMEWHAT HAVE A LIMITED THERAPEUTIC INDEX THAT ARE SOMEWHAT LIMITED LEAST BY CYTOTOXICITY. SO I'LL SKIP OVER WITH THAT AND GO TO THE NEXT SLIDE. IF I MIGHT. THIS IS PACONORIL DEMONSTRATING MECHANISM OF ACT, IT BIND WITHIN THE POCKET SHOWN HERE AT THE TIP OF THE YELLOW ARROW. THIS POCKET SITS JUST BELOW THE SURROUNDS A FIVE FOLD AXIS OF SYMMETRY, WITHIN THE VIRION AND IT'S A CANYON THAT SERVES AS RECEPTOR BINDING SITE WHERE THE PICORA VIRUS IS. NEXT SLIDE. PLECONARIL IS A DRUG THAT'S AROUND A WHILE. DEVELOPED BACK IN THE 1990s BY A SMALL COMPANY CALLED VIRAL PHARMA. IT WAS DEVELOPED TO PRIMARILY TO TREAT VIRAL URIs UPPER RESPIRATORY TRACT INFECTION DUE TO RHINO VIRUSES AND TO ENTERO VIRUSES. VIRAL PHARMA DID TWO LARGE PHASE 3 TRIALS, THIS FIGURE SHOWS THE OUTCOME OF THE TWO TRIALS WITH DATA ACTUALLY COMBINED BETWEEN TWO TRIALS. AND WHAT THE CURVES SHOW IS A REDUCTION IN WHAT IS CALLED TOTAL VIRAL SCORE USED AS PRINCIPLE -- MEASURE IN THESE TWO TRIALS. THE DRUG WAS ADMINISTERED ORALLY OVER FIVE DAY PERIOD. ONE THING I WANT TO POINT OUT IS THAT THE CURVES DIVERGE EARLY ON WITHIN ONE TO TWO DAYS OF STARTING THERAPY. SO SUGGEST VERY EARLY ONSET OF A CLINICAL EFFECT BUT ALSO PROGRESSIVE DIFFERENCE BETWEEN THE TWO GROUPS PLACEBO TREATED AND PICSCONO TREATED PATIENTS IS RELATIVELY SMALL, RELATIVELY MODEST DIFFERENCE. SO IT SUGGESTS IF THIS IS GOING TO HAVE CLINICAL ACTIVITY IT WILL NOT BE BLOCKBUSTER TYPE ACTIVITY THAT YOU WOULD BE LOOKING FOR AT LEAST IN A ANTI-RHINO VIRUS DRUG. THIS DRUG DID MAKE IT ALL THE WAY TO THE ANTI-VIRAL ADVISORY COMMITTEE AT THE FDA. AND ULTIMATELY WAS TURNED DOWN, THE COMMITTEE VOTED AGAINST LICENSURE OF THE DRUG. DID SO NUMBER ONE BECAUSE OF THIS RELATIVELY MODEST BENEFIT THOUGH IT WAS STATISTICALLY SIGNIFICANT. BUT ALSO PICONORIL SEEMED TO HAVE EFFECTS ON HEPATIC METABOLISM ORAL CONTRACEPTIVES. WHICH WAS CREATED A BIT OF A PROBLEM IN WOMEN. TAKING ORAL CONTRACEPTIVES SMALL NUMBER OF THEM ACTUALLY HAD BREAK THROUGH BLEEDING DURING THE TRIAL. IT WAS A VERY SMALL NUMBER BUT IT WAS ENOUGH OF A PROBLEM TO SUGGEST THAT THE FDA DID NOT WANT TO LICENSE THIS DRUG FOR URIs. PICONORIL HAS HAD A LIFE THOUGH NOT LICENSED. NEXT SLIDE SHOWS STUDIES THAT WAS DONE BY THE COLLABORATIVE ANTI-VIRAL STUDY GROUP. THIS IS A LARGE TRIAL, IN PLACEBO CONTROL IN NEONATES WITH SUSPECTED OR PROVEN SERIOUS EMTERO VIRUS INFECTION. THE STUDY WAS A MULTI-INSTITUTIONAL STUDY, IT TOOK TEN YEARS, TO COMPLETE AND EVEN THEN THE TRIAL WAS TERMINATED JUST BEFORE THE PLANNED ACCRUAL WAS FULL. THESE ARE THE DATA THAT HAVE BEEN PUBLISHED. THE FIGURE ON THE LEFT SHOWS THE -- WHICH IS A PRIMARY OUTCOME, ISOLATION OF VIRUS FROM THE UPPER RESPIRATORY TRACK. NOT ALL SUBJECTS WERE ABLE TO EVALUATE THIS INPUT, WHICH IS AN INTERESTING PROBLEM HERE. BUT YOU CAN SEE FROM THIS FIGURE, THERE WAS AN ANTI-VIRAL RESPONSE, DEMONSTRATED BY DIMINUTION OF RESPIRATORY VIRUS SHEDDING, AND AGAIN, LIKE WITH PRIOR STUDY, THE CURVES MERGED EARLY ON WITHIN THE FIRST ONE TO TWO DAYS OF TREATMENT. BUT SO THERE IS A PRETTY CLEAR ANTI-VIRAL EFFECT. THE PAPER HERE ON THE RIGHT, UP PER PANEL, FIGURE ON THE RIGHT, ACTUALLY THEY ARE BOTH MORTALITY FIGURES. THE UPPER PANEL INVOLVES ALL SUBJECTS IN THE TRIAL AND THERE WAS A STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN PICONORIL AND PLACEBO IN TERMS OF MORTALITY IN THAT OUTCOME. AND THE LOWER FIGURE SHOWS PRETTY MUCH THE SAME THING, CURVES DIVERGING IN THE SAME WAY AND SMALLER NUMBER OF SUBJECTS THAT WERE PCR POSITIVE AND THEREFORE THIS PARTICULAR ANALYSIS DIDN'T QUITE MEET STATISTICAL SIGNIFICANCE PROBABLY BECAUSE OF THE SMALL NUMBER. NEXT SLIDE. MOVING ON TO POCAPAVIR, ANOTHER VIRAL CAPSID INHIBITOR. THESE STUDIES THAT HAVE COME OUT OF THE ANTI-VIRAL INITIATIVE PROGRAM, THAT UNDER AUSPICES OF TASK FORCE FOR GLOBAL HEALTH IN ATLANTA HABITUDING ANTI-VIRAL -- HAS BEEN STUDYING ANTI-VIRAL AGENTS FOR PURPOSES OF TREATING IMMUNODEFICIENT POLIO VIRUS EXCREERS. THIS IS A STUDY THAT WAS CONDUCTED NOW SIX OR SEVEN YEARS AGO AND ADULT VOLUNTEERS IN SWEDEN WHO WERE ADMINISTERED PICAPOVIR AND THEN AFTER ONE TO THREE DAYS OF AFTER AN ORAL IV -- I'M SORRY, GO BACK HERE. ALL THESE VOLUNTEERS WERE CLINICAL CHALLENGED WITH TYPE 1 POLIO VIRUS STRAIN VACCINE AND THEN BEGINNING ONE TO THREE DAYS AFTER THE VIRAL CHALLENGE, BEGAN A 14 DAY TREATMENT COURSE WITH POCAPAVIR. THE END POINT IN THIS TRIAL WAS FECAL SHEDDING OF VIRUS BUT ONE THING THAT POPPED UP SOMEWHAT UNEXPECTED DEGREE WHICH RESISTANCE THE POCAPOVIR DEVELOPED IN THESE SUBJECTS. THAT'S WHY YOU SEE TWO DIFFERENT FIGURES THERE, FIGURE ON THE LEFT FIGURE ON THE LEFT IS ENTIRE STUDY POPULATION WITH POCAPAVIR VERSUS PLACEBO AND THERE IS SUBSTANTIAL DIFFERENCE BETWEEN TWO TREATMENT ARMS WITH DIVERGENCE FAIRLY EARLY ON. BUT THAT DIMINISHED OVER TIME AND THE REASON FOR THAT DIFFERENCE BETWEEN THE TWO STUDY ARMS DIMINISHING WAS DEVELOPMENT OF RESISTANCE. THERE IS A SECOND ANALYSIS THAT WAS DONE SHOWN ON THE RIGHT HAND FIGURE HERE. THESE ARE THE SUBJECTS IN THE TRIAL THAT REMAINED -- THE VIRUS REMAINS SUSCEPTIBLE TO POCAPAVIR. AGAIN YOU CAN SEE SUBSTANTIAL DIFFERENCE IN THE TYPE CLEARANCE OF VIRUS FROM STOOL. AND ALSO THERE WAS SUBSTANTIAL DIFFERENCE IN THE VIRAL LOAD MEASURED BY THE AREA UNDER THE CURVE. OKAY. NEXT SLIDE. THIS IS COMPOUND ONE, USED TO BE KNOWN, NOW CALLED B 7404, A PROTEASE INHIBITOR UNDER ACTIVE DEVELOPMENT BY THE POLIO ANTI-VIRAL INITIATIVE. IT'S A PROTEASE INHIBITOR SIMILAR TO OTHER PROTEASE INHIBITORS LIKE WE HAVE FOR HIV AND FOR HEPATITIS C. IN THIS CASE THE DRUG INHIBITS THE THREE C PROTEASE FOR POLIO VIRUS AND BASICALLY INTERRUPTING PROCESSING OF THIS POLYPROTEIN, THIS TRANSLATED FROM THE RNA MESSAGE. MENTIONED BEFORE, THESE DRUGS HAVE QUITE POTENT ACTIVITY IN VITRO, THE NEXT SLIDE SHOWS THE SPECTRUM OF ACTIVITY AGAINST B 7404 AGAINST THE FAIRLY LARGE NUMBER OF CLINICAL ISOLATES FROM DIFFERENT ANTIVIRUS SEROTYPES. YOU CAN SEE HERE THAT MOST OF THESE ARE SUSCEPTIBLE, EASILY ACHIEVED CLINICAL EASILY ACHIEVED CONCENTRATIONS CLINICALLY AND THAT THEY ARE ALL PRETTY MUCH ALL SUSCEPTIBLE AT SUB ONE MICROMOLAR CONCENTRATIONS INCLUDING ANTIVIRUS D 68 WHICH YOU CAN SEE DOWN THERE ON THE LOWER RIGHT HAND SIDE OF THE FIGURE. NEXT SLIDE PLEASE. THIS SLIDE SHOWS WHAT I MENTIONED BEFORE ABOUT BIOAVAILABILITY BEING AN ISSUE WITH THIS CLASS OF DRUG. THIS FIGURE COMES FROM A SINGLE ASCENDING DOSE STUDY THAT WAS CONDUCTED BY PFIZER USING ORAL TABLETS AT FOUR DOSE LEVELS. EVEN THE HIGHEST DOSE HERE WHICH IS TWO GRAMS ORALLY, RESULTED IN CONCENTRATIONS THAT REMAIN ABOVE THE EC 90 FOR POLIO VIRUS, FOR ONLY A SHORT PERIOD OF TIME, ONLY TWO OR THREE HOURS. THE COMPANY THAT IS DEVELOPING THIS DRUG AGAIN WORKING WITH ANTI-VIRAL INITIATIVE, HAS WORKED TO MAKE IMPROVEMENTS IN THE FORMULATION AND WE THINK THESE IMPROVEMENTS WILL PROVIDE SOME ENHANCEMENT OF BIOAVAILABILITY, THAT WORK IS UNDERWAY RIGHT NOW. WITH PHASE 1 DOSE RANGING STUDIES UNDERWY AT VIRAL DEFENSE. ULTIMATELY, PLAN IS TO USE THESE TWO DRUGS POCAPAVIR AND B 7404 PROTEASE INHIBITOR, TO USE THEM TOGETHER, TO TREAT IMMUNE DEFICIENT POLIO VIRUS PATIENTS MUCH IN THE SAME WAY THAT WE NOW USE COMBINATIONS OF DRUG AGAIN FOR HIV AND FOR HEPATITIS C. AND FOR OTHER RNA VIRUS INFECTIONS. THIS IS WORK WITH POLIO BUT IT SHOULD BE CLEAR THERE COULD BE APPLICABILITY TO OTHER ANTIVIRUS SEROTYPES AS WELL. THERE'S HOPE FOR THIS STRATEGY, THERE'S DEMONSTRATED IN THE LAST SLIDE, WHICH SHOWS SYNERGY IN VITRO. THIS IS WORK DONE BY STEVEN AND ERIC AGAIN AT CDC, THEY ARE TESTING THE TWO COMBINATIONS OF TWO DRUGS AGAINST THE THREE OPD STRAINS. IN THE INTEREST OF TIME I'LL POINT OUT THAT QUICKLY THESE ARE THREE DIMENSIONAL GRAPHS, AND THAT THE VOLUME ABOVE THE PLAIN BASELINE IS MEASURE OF THE FUNCTION OF THE SYNERGISTIC ACTIVITY BETWEEN THE TWO DRUGS. YOU CAN SEE FOR ALL THREE TYPES THERE'S CONSIDERABLE SYNERGY DEMONSTRATED OR ILLUSTRATED IN THESE TWO -- IN THIS SLIDE. SO THE LAST SLIDE, I'D LEAVE EVERYBODY WITH AN OBSERVATIONS -- SOME OBSERVATIONS WE HAVE ALL MADE, ABOUT DRUG DEVELOPMENT PROGRAM SO FAR IS THAT WITH CAPSID INHIBITORS, THERE IS RAPID ONSET OF ACTIVITY WHICH CAN BE A GOOD THING CLINICALLY. THERE APPEARS TO BE RELATIVELY LOW BARRIER OF RESISTANCE THAT'S BEEN DEMONSTRATED IN VITRO AND NOW IN THE CLINIC. WITH POCAPAVIR. PROTEASE ACTIVATES HAVE A BROAD SPECTRUM OF ACTIVITY THAT RAPIDLY METABOLISM, PARDON ME, MAY LIMIT CLINICAL EFFECTIVENESS. EFFECTIVE THERAPY MAY REQUIRE COMBINATION OF THESE DRUGS, JUST POINTED OUT, AND FINALLY, NOT THE LEAST IS THAT THE CLINICAL TRIALS FOR ANTIVIRUS INFECTIONS ARE VERY DIFFICULT TO DO. SO THAT'S IT. I'LL LEAVE YOU WITH THAT. WITH THOSE OBSERVATIONS AND BE HAPPY TO ADDRESS ANY QUESTIONS. >> THANK YOU VERY MUCH. WE'VE OFFICIALLY RUN OUT OF TIME. I'M GOING TO TURN IT OVER TO AVI. >> HE CAN O. >> OKAY. >> >> THE ONE MINUTE SUMMARY HERE. I DID SEND GLENN COUPLE OF SLIDES, IS IT POSSIBLE TO GET THEM UP? OTHERWISE I CAN READ OFF THEM RIGHT HERE. >> I THINK EMILY IS WORKING ON IT. >> OKAY. I'LL GIVE HER 20 SECONDS MAYBE THEN I'LL TALK FOR 40 SECONDS. SO WHILE SHE IS GETTING UP THE SLIDES, MIGHT I JUST GO AHEAD. BUT I DID IS PRODUCE A ONE -- THERE WE GO. SO LET'S GO TO THE FIRST SLIDE. SO THAT'S A ONE SLIDE SUMMARY OF EACH OF THE TALKS. KEN TALKED ABOUT THE -- YOU CAN GO TO NEXT SLIDE. PATHOPHYSIOLOGY OF AFM, AND HE POINTED OUT THAT EVERYTHING MATTERS THE AGE, THE MOUSE VAIN, ROUTE OF INFECTION. AND THAT THE PATHOLOGY INCLUDES BOTH IMMUNE MEDIATED PARTS OF THE T-CELLS AND CHEMOKINES AS WELL AS VIRUS INFECTION OF THE NEURONS. NEXT. AND THEN CORRESPOND -- AS POINTED OUT A LOT OF VIRUSES ARE ASSOCIATED WITH GBS AND CERTAINLY VERY STRONG ASSOCIATION WITH ZIKA, ESPECIALLY PRIOR INFECTION WITH DENGHI AND CAMPYLOBACTER INFECTION WHICH IS ASSOCIATED WITH ANTIGUAN GLEE OWECYTE ANTIBODIES. CO IN,NI SHOWED ALL CORONA VIRUSES CAN CAUSE NEUROLOGICAL INFECTIONS, WITH HUMAN CORONA VIRUSES IT'S MA RARE. FEW CASE REPORTS OF GBS, WE NEED AUTOPSY STUDIES TO SOLVE THESE OUT. INTERFERON AND BETA INTERFERON SEEM CRITICAL AND COV 2 IS THIS UNIQUE ABILITY TO INFECT A LOT OF DIFFERENT CELLS, THOUGH TRANSSYNAPTIC SPREAD WITH THE MOUSE MODEL HAS BEEN SHOWN BY OTHER CORONA VIRUSES. THEN PATHOPHYSIOLOGY OF GBS USING MOUSE MODELS, VERY INTERESTING HERE, GAMMA INTERFERON, IL 17 AND IL 10 SEEM TO BE MEDIATING THE AFFECTS. AS WELL AS INTEGRINS ON SWAN CELLS, ASSOCIATION OF ANTI-GANGLIACYTE ANTIBODIES AND CMPLIMENT CAMPYLOBACTER AND HERE WHICH IS NICE SHE POINTED OUT THERE IS AN INCREASE INCIDENCE OF GBS, WITH COV 2, HOWEVER, IT IS DIFFERENT FROM OTHERS WHERE THERE IS NO GANGLIACYTE ANTIBODIES. MENTION A NUMBER OF APPROACH HOW TO STUDY THESE THINGS AND QUESTIONS THAT STILL NEED TO BE ANSWERED. TALKED IMMUNOTHERAPIES AND TALKED ABOUT THIS COMPLIMENT INHIBITORS THAT ARE BEING DEVELOPED FOR OTHER DISEASES AND COULD POTENTIALLY BE USEFUL HERE. AND THEN THIS VERY EXCITING ROLE OF THE FCRN RECEPTOR INHIBITORS THAT DEGRADE ANTIBODIES. AND THE POTENTIAL ROLE OF HYPERSIALANATEG IGG, I WAS NOT AWARE OF THAT AND THAT SOUNDS VERY FASCINATING TO ME, HOW IVIG FINALLY WORKS. NEXT ONE. THEN JOHN TALKED ABOUT ANTI-VIRAL THERAPIES BOTH DIRECTLY AGAINST CAPSID AND PROTEASE, EACH ONE OF THEM HAVE VERY BIG ADVANTAGES AN DISADVANTAGES. BOTTOM LINE IS COMBINATION THERAPY IS GOING TO BE THE ANSWER ND NO ONE TREATMENT ALONE IS GOING TO WORK. I'LL STOP HERE. THAT IS MY MINUTE SUMMARY. SO ANY FINAL WORDS, DIANE OR -- THAT YOU MIGHT HAVE? >> NOT FROM ME, OTHERWISE THAN IT WAS A GREAT CONFERENCE. I'LL LET GLENN WRAP UP. >> SO I HAD ONE LATE QUESTION THAT CAME IN FOR DR. TYLER. AS I RECALL TELEPOVIR IS HARD TO TOLERATE AND WE THOUGHT THERE WERE ISSUES IN DOSING IN THE CLINICAL WORLD. ARE THERE EASIER TO TOLERATE SIMILAR ANTI-VIRALS TO TEST IN THE MOUSE? >> THE ANSWER IS YES. WE ARE ACTUALLY WORKING WITH THE PERSON THAT DESCRIBED THE ORIGINAL EFFICACY IN VITRO OF TELAPOVIR ON SOME OF ITS DERIVATIVES. THERE MAY VERY WELL BE BETTER AGENTS. THIS ONE HAS OF COURSE THE ADVANTAGE OF BEING ALREADY FDA APPROVED, AND WITH AWFUL LOT KNOWN ABOUT DOSING REGIMEN AND PHARMACOKINETICS SO THAT'S A WAY OF GETTING THINGS QUICKER INTO CLINICAL USE, THE NEW DRUG DEVELOPMENT. >> ANY OF THE NEW DRUGS APPROACHING CLINICAL TRIALS? USED IN PATIENTS ANY TIME SOON? >> YOU ARE ON MUTE. FROM >> SORRY. >> CAN YOU HEAR ME NOW? >> YES. >> WE CERTAINLY SAW WITH FLUOXETIN THERE WAS RAPID PROGRESSION FROM A IDEA AND IN VITRO EFFICACY INTO THE CLINIC SO OF COURSE SINCE THERE ISN'T ANY PROVEN THERAPY YET, FOR AFM, SOMETHING THAT'S FDA APPROVED COULD GET INTO A USE PRETTY QUICKLY. THE PROBLEM IS, JUST AS WE SEE WITH COVID-19, REALLY PROVING IN MULTI-CENTER CONTROL TRIALS THAT SOMETHING WORKS AND IS THAT GOING TO BE POSSIBLE WHEN YOU HAVE A SMALL AND SPORADIC EVERY OTHER YEAR SEASONAL DISEASE LIKE AFM. >> OKAY. THANKS, EVERYBODY FOR JOINING US, THANKS TO DIANE AND AVI FOR CHAIRING, ALSO WANT TO THANK EMILY FOR SLIDE WRANGLING AND LOTS OF OTHER HELP ON PUTTING THIS TOGETHER. IF ANYBODY HAS ANY FEEDBACK ABOUT PLANS FOR FUTURE IN PERSON MEETING ON THIS OR ANYTHING RELATED TO THE TOPIC, PLEASE SEND IT TO OUR EMAIL ADDRESS AT AFNANDGBS@NIH.GOV.