Karre et al. (1986) first described the ability of NK cells to preferentially kill tumors that lacked MHC class I, which they termed recognition of "missing self." These seminal observations predicted the existence of inhibitory receptors for MHC class I that dampened or prevented NK cell activation but allowed for a more robust response against virus-infected cells or tumors that had lost or blocked expression of MHC class I in response to selective pressures caused by CD8+ T cells. Subsequently, the Ly49 receptors in mice (Karlhofer et al. 1992) and killer cell Ig-like receptors (KIRs) in humans (Colonna & Samaridis 1995, D'Andrea et al. 1995, Wagtmann et al. 1995) were identified as the inhibitory receptors recognizing polymorphic MHC class I ligands. Ly49 (Klra) and KIR are multigene families with extensive allelic polymorphisms, and the receptors are expressed on overlapping subsets of NK cells (and some T cells) (Lanier 2005, Orr & Lanier 2010). In humans, the KIR2D subfamily of receptors recognizes polymorphic HLA-C ligands, whereas the KIR3D subfamily of receptors binds to polymorphic HLA-A and HLA-B ligands. Blocking these ITIM-bearing inhibitory receptors with mAbs can disrupt interactions with MHC class I on tumors, allowing the tumors to be killed and cytokines to be secreted, provided that the tumor displays sufficient activating ligands to trigger the activating receptors on the NK cell. This has been used as the basis for the development of a blocking antibody against KIR2D (lirilumab) for therapeutic use in patients with acute myeloid leukemia (AML) and multiple myeloma (Figure 2) (Benson et al. 2011, 2012, 2015; Romagne et al. 2009; Vey et al. 2012). Initial results using lirilumab as a monotherapy in AML and multiple myeloma have not indicated significant efficacy, and in a phase II trial, NK cells from treated patients appeared to be hyporesponsive; in vitro experiments suggested the possibility of KIR stripping from the cell surface by a mechanism of Fc-mediated trogocytosis (Carlsten et al. 2016). While the combination in recent studies of lirilumab with anti-PD1 (Opdivo§R ) gave encouraging hints of clinical benefit in head and neck cancer patients, subsequent phase II trials failed to confirm efficiency beyond anti-PD1 monotherapy. Further studies are underway to evaluate KIR blockade in other cancers and with other agents. These negative results might reflect that the tumors in these patients had already been immune edited by NK cells and thus lack expression of the relevant ligands for the stimulatory receptors on NK cells to initiate a response, or that the NK cells may be suppressed by other redundant evasion mechanisms to prevent NK cell attack.
Фигура 4. Ингибирующие рецепторы естественных киллерных клеток. NK клетки обладают многочисленными ингибирующими рецепторами, часть из которых характеризуются наличием ITIM в их цитоплазматических доменах. При связывании лиганда ITIM задействуют тирозинфосфатазы, такие как SHP-1, для противостояния сигналам, переданным активирующими NK рецепторами. Аббревиатуры: ITAM, immunoreceptor tyrosine-based activation motif; ITIM, immunoreceptor tyrosine-based inhibitory motif; ITSM, immunoreceptor tyrosine-based switch motif; KIR, killer immunoglobulin-like receptor; NK, natural killer.
Another inhibitory receptor is the CD94-NKG2A receptor, which recognizes the human HLA-E and mouse Qa-1 MHC molecules (Braud et al. 1998, Lee et al. 1998, Vance et al. 1998). The NKG2A subunit of the receptor contains an ITIM, which is responsible for its inhibitory function. Unlike KIR, CD94-NKG2A and its MHC ligands are not polymorphic, simplifying the generation of reagents to block this receptor. A blocking antibody (monalizumab) has been produced against human NKG2A and is in phase II clinical trials (McWilliams et al. 2016, Ruggeri et al. 2016). CD94-NKG2A, like KIR, is only expressed on a subset of NK cells and T cells; however, prior studies reported that NKG2A can be induced on NK cells by IL-12 (Saez-Borderias et al. 2009) and on activated antigen-specific T cells by IL-15 (Mingari et al. 1998) or by TGFβ (Bertone et al. 1999). These findings suggest that the inhibitory CD94-NKG2A might be upregulated by cytokines in the tumor microenvironment to limit NK cell or T cell responses against tumors; therefore, blocking this receptor may have therapeutic utility. Currently, monaliuzmab is in combination trials with PD-L1-blocking antibodies and with ADCC-inducing antibodies to EGFR (cetuximab) in head and neck carcinomas; preclinical data suggest that monalizumab may augment NK cell–mediated ADCC by cetuximab (Figure 2).
LIRLB1 (also designated as CD85j, LIR1, or ILT2) is an ITIM-bearing inhibitory receptor recognizing MHC class I that is present on a subset of NK cells and T cells, as well as broadly expressed on B cells and myeloid cells (Colonna et al. 1997, Cosman et al. 1997). LILRB1 binds to all human HLA class I proteins, but with the highest affinity for HLA-G (Shiroishi et al. 2006). LILRB1 is expressed at much higher cell surface density and on many more B cells and myeloid cells compared to T cells or NK cells, making it less specific to cell type for potential application in checkpoint blockade applications in cancer.
Initially identified as an ITIM-based inhibitory receptor on mast cells that can suppress IgE Fc receptor signaling (Soto & Pecht 1988), KLRG1 is expressed on mouse and human NK cells, as well as T cells (Corral et al. 2000, Voehringer et al. 2002). In mice, Klrg1 marks the activation and differentiation status of NK cells (Huntington et al. 2007) and has been shown to be stably expressed at high levels on CMV-induced memory NK cells (Sun et al. 2009). KLRG1 binds to cadherins and in vitro has been shown to suppress NK cell lysis of cadherin-bearing tumors (Grundemann et al. 2006, Ito et al. 2006, Tessmer et al. 2007). As cadherins may be abundantly expressed in tumor microenvironments, blockade of KLRG1 may have therapeutic application in some solid tumors.
NK cells express several other inhibitory receptors whose functions are less well understood or have less well-defined ligands. TIM3 is constitutively expressed by all mature human NK cells, and its expression is upregulated by type I IFN and cytokines, including IL-2, IL-12, IL-15, and IL-18 (Ndhlovu et al. 2012). Cross-linking TIM3 with mAbs can suppress NK cell activation triggered by CD16, suggesting that it is an inhibitory receptor; however, TIM3 has no characteristic inhibitory signaling motifs in its cytoplasmic domain (Ndhlovu et al. 2012). TIM3 has been shown to form heterodimers with CEACAM1, which contains conical ITIMs in its cytoplasmic domain, possibly explaining the inhibitory function of TIM3 (Huang et al. 2015b). When expressed on activated human and mouse NK cells, CEACAM1 itself can serve as an inhibitory receptor when CEACAM1 on NK cells binds to CEACAM1 on tumors in a trans-homophilic manner (Hosomi et al. 2013). TIM3 is also expressed on myeloid cells and subsets of T cells, and numerous ligands have been proposed for TIM3, including galectin-9, phosphatidylserine, HMGB1, and CEACAM1 (Das et al. 2017). There is evidence that in some circumstances, TIM3 may serve as an activating receptor on T cells, but the basis for these contrasting functional behaviors has not be resolved (Das et al. 2017). Based on preclinical studies, mAbs against TIM3 are presently in clinical trials in cancer patients.
LAG3 was initially cloned from a human NK cell clone (Triebel et al. 1990) and was shown to bind MHC class II ligands (Baixeras et al. 1992). It is also expressed on activated T cells, B cells, and plasmacytoid dendritic cells. Despite binding to MHC class II, there is no evidence that NK cells are affected by the expression of MHC class II on tumors, in contrast to MHC class I. NK cells in mice deficient in LAG3 were reported to have impaired killing of certain tumor cell lines, which would imply an activating role for LAG3 in NK cells (Miyazaki et al. 1996). The molecular basis for this has not been established, as it does not appear to involve MHC class II. In T cells, it has been suggested that LAG3 has an inhibitory function, and based on preclinical mouse tumor studies blocking mAbs and LAG3-Fc, fusion proteins are being evaluated in the clinic as a checkpoint blockade therapy for cancer, despite not having a mechanism to account for the inhibition (Miyazaki et al. 1996).
The human gene encoding PD1 was originally cloned from the human YT NK-like leukemia cell line (Shinohara et al. 1994). While the expression and function of PD1 have been extensively studied in T cells (Sharpe & Pauken 2018), less is known about the role of PD1 in regulating NK cell responses. Unlike T cells, PD1 is not frequently expressed at significant levels on activated NK cells, although PD1 has been detected on human and mouse NK cells in some circumstances, including on tumor-infiltrating NK cells (Beldi-Ferchiou et al. 2016, Benson et al. 2010, Huang et al. 2015a, Iraolagoitia et al. 2016, Pesce et al. 2017, Wiesmayr et al. 2011). The first report by Benson et al. 2010 of PD1 expression on NK cells in patients with multiple myeloma using the CT-011 clone (pidilizumab) is confounded by the finding that this antibody in fact does not bind PD1, but rather Delta-like ligand. Thus, NK cells may contribute to the efficacy of PD1 checkpoint blockade in some cancer patients, but more research is needed.
The first checkpoint blockade therapy for cancer approved by the US Food and Drug Administration (FDA) involved disruption of interactions between the inhibitory CTLA4 receptor and its B7 ligands (CD80 and CD86). The inhibitory function of CTLA4 is considered to be mainly due to its ability to bind to its B7 ligands and prevent the binding of the lower-affinity activating CD28 receptor, as well as its ability to rapidly internalize these ligands, removing them from the surface of the APC by trans-endocytosis (Qureshi et al. 2011). Unlike T cells, human and mouse NK cells do not typically express significant amounts of either the activating CD28 or inhibitory CTLA4 receptors, although in some circumstances, IL-2-activated mouse NK cells have been reported to express CTLA4, and CTLA4 was detected on tumor-infiltrating NK cells in a mouse tumor model (Stojanovic et al. 2014). There are no intrinsic NK cell effects reported in CTLA4-deficient mice, thus it is likely that CTLA4 predominantly regulates T cell activation. Nonetheless, studies examining CTLA4 in tumor-infiltrating NK cells in human cancer patients may provide new insights into this possibility.
Collectively, most of the checkpoint receptors currently in clinical development are expressed both by NK cells and T cells. Studies to determine the mechanisms involved in the success of these drugs should explore the potential contribution of NK cells to these immune therapeutics.
NK cells respond to cytokines to induce differentiation, homeostatic control, and activation. Thus, it is logical to assume that cytokines should support NK cell persistence and expansion to improve cancer therapy. Early direct therapeutic strategies involved the use of IL-2. Based on preclinical studies, Rosenberg and colleagues (Grimm et al. 1982, Lotze et al. 1981, Yron et al. 1980) found that incubation of mouse splenocytes or human peripheral blood mononuclear cells with IL-2 led to the generation of lymphokine-activated killer (LAK) cells that lysed syngeneic or allogeneic tumors. Repeated injections of IL-2 into mice with established tumors induced LAK activity and led to significant tumor regression (Rosenberg et al. 1985). While the antitumor effects of LAK cells and IL-2 in mice were impressive, significant barriers impeded attempts to translate this into human therapy. While limited clinical response was observed in cancer patients treated with IL-2 alone, combination therapy with LAK cells and IL-2 resulted in objective responses in 22% of patients with a variety of advanced metastatic cancers. However, toxicity associated with higher doses of IL-2 (Rosenberg et al. 1987), specifically life-threatening vascular leak syndrome or liver toxicity, limited efficacy (Ettinghausen et al. 1988, Hoffman et al. 1989). As an alternative to direct application of cytokines, cytokines can be manipulated indirectly in vivo. Based on pioneering studies at the National Cancer Institute (NCI), Restifo and colleagues (Dudley et al. 2002) discovered that sublethal radiation in mice induced lymphodepletion to make space, depleted suppressor cells, and, importantly, released a cytokine sink. This finding was translated into human clinical trials in melanoma patients treated with tumor-infiltrating lymphocytes. In these trials, use of high-dose cyclophosphamide with fludarabine resulted in higher response rates.
Because LAK cells represent a mixture of T cells and NK cells, their proportional contributions to antitumor responses remain unclear. Studies in mice suggested that NK cells were the major contributors to antitumor activity. Several groups began manipulating autologous NK cells in the unique setting of recovery after autologous hematopoietic stem cell transplantation. In this circumstance, NK cells are the dominant lymphocytes reconstituting in the first month. Although use of low-dose IL-2 to expand NK cells after autologous transplantation resulted in robust in vivo expansion of NK cells (Miller et al. 1997, Soiffer et al. 1994), analysis of these phase II autologous NK cell studies showed limited efficacy. Although ex vivo activation with high doses of IL-2 improved in vivo function, definitive efficacy was lacking (Burns et al. 2003). This could be a result of inhibitory signals delivered by self-MHC class I and of the fact that even low-dose IL-2 dramatically stimulates a population of suppressive regulatory T cells (Tregs). This finding, consistent with pioneering work by Velardi and colleagues (Ruggeri et al. 2002) showing that NK cell alloreactivity after haploidentical transplantation can control myeloid leukemias, sparked the hypothesis that use of allogenic NK cell therapies from healthy donors might increase the persistence of a population of NK cells in vivo that would not be suppressed by self-MHC of the residual tumor.
We were the first to infuse related HLA-haploidentical NK cells in a nontransplantation setting (Miller et al. 2005). Apheresis products were CD3 depleted and activated with 1,000 IU/mL IL-2 ex vivo overnight. Patients received either low-dose fludarabine for five days (25 mg/m2/day) or high-dose cyclophosphamide for two days (60 mg/kg/day), followed by the same dose of fludarabine (Hi-Cy/Flu) prior to NK cell infusion. This treatment protocol was based on studies from the NCI discussed above. IL-2 was administered daily (1.75 million units/m2) for 14 days [subsequently modified to 6 higher doses (10 million units without m2 correction) over 2 weeks]. Only patients receiving Hi-Cy/Flu had in vivo detectable donor-derived NK cells (defined as 100 donor-derived NK cells per microliter of blood 14 days after adoptive transfer). In some patients, NK cells persisted for up to one month. This outcome was associated with a surge in endogenous IL-15, which was highest in patients receiving Hi-Cy/Flu at the time of NK cell infusion and which diminished as lymphocytes recovered. Fludarabine alone was insufficient to induce this effect. These results are proof-of-concept that human NK cells in some patients could survive for up to one month when infused after lymphodepleting chemotherapy and the administration of IL-2. Infusion of allogeneic NK cells was safe without the risk of graft-versus-host disease (GVHD). In this initial study, 5 out of 19 patients with poor prognosis AML went into complete remission. Clinical efficacy was associated with in vivo expansion of donor NK cells. Thus, the persistence and in vivo expansion of NK cells became a surrogate marker for testing other approaches aimed at increasing the survival of NK cells.
With the application of haploidentical NK cell therapy to treat ovarian cancer, breast cancer, and refractory lymphoma, we found that host Tregs persist after conditioning and expand rapidly when IL-2 is administered after adoptive NK cell transfer (Bachanova et al. 2010, Geller et al. 2011). This is a result of high-affinity IL-2 receptor (IL-2R) alpha chains (CD25) on Tregs driving their proliferation. Tregs can inhibit NK cell function indirectly by limiting the bioavailability of IL-2 (Gasteiger et al. 2013, Sitrin et al. 2013) or directly through their secretion of TGFβ (Ghiringhelli et al. 2005). To overcome the inhibitory effects of Tregs identified in preclinical studies in the mouse (Zhou et al. 2009), we conducted a trial using recombinant IL-2 diphtheria toxin (DT) fusion protein (IL2DT; trade name Ontak§R ). Our objective was to target DT to Tregs through IL-2 binding to CD25. Because IL2DT had a short half-life compared to other methods of Treg depletion using antibodies, it was used in combination with lymphodepletion. Our rationale was that inhibitory effects would be eliminated by the time NK cells, also binding IL-2, were infused. Fifty-seven refractory AML patients were treated with high-dose chemotherapy followed by IL-2 administration. Donor NK cell expansion was observed in 10% (4 of 42) of patients receiving haploidentical NK cell infusions and IL-2 alone, whereas NK cell expansion occurred in 27% (4 of 15) of patients also given IL2DT. Importantly, the addition of IL2DT was associated with higher complete remission rates and improved disease-free survival at 6 months postadoptive NK cell transfer (Bachanova et al. 2014). These results demonstrate that Treg expansion as a result of IL-2 administration limits NK cell expansion in vivo and may limit their therapeutic effects. However, this outcome may be dependent on the immune status of the patient and may vary by disease type.
It may be possible to surmount the obstacle of Treg expansion following administration of IL-2 by using IL-15. IL-15 was originally identified as a T cell growth factor that binds the common beta and gamma chains of IL-2R (Figure 2) (Grabstein et al. 1994). Thus, IL-2 and IL-15 are distinguished by their binding to unique alpha chains, IL-2Ra and IL-15Ra, respectively. IL-15 is physiologically trans-presented by membrane-bound IL-15Ra on dendritic cells or other myeloid cells (Mortier et al. 2008, Prlic et al. 2002). Preclinical studies demonstrated that IL-15 can control homeostasis and stimulate NK cell and antigen-specific CD8+ T cell activity without causing activation-induced cell death or promoting Treg cell function (Waldmann et al. 1998). Recognition of these properties led the 2007 NCI Immunotherapy Workshop to designate IL-15 as the immunotherapeutic with highest potential for clinical development. However, dose escalation was limited by unexpected toxicities encountered in the first-in-human clinical trial of recombinant human (rh) monomeric IL-15 given as an intravenous (IV) bolus infusion (Conlon et al. 2015). Nonhuman primate experiments suggested that subcutaneous (SC) administration should lower peak concentrations and improve clinical tolerance. A recently published trial sought to establish a safe outpatient regimen of IL-15 for cancer patients (Miller et al. 2018). Nineteen patients were treated SC with rhIL-15, Monday through Friday for two weeks at dose levels of 0.25, 0.5, 1, 2, and 3 µg/kg/day, where 2 µg/kg was determined to be the maximal tolerated dose(compared to 0.3 µg/kg when given by IV bolus infusion). The treatment induced a profound expansion of circulating NK cells and a proportional, but less dramatic, increase of circulating CD8+ T cells.
Many IL-15 products are now reaching the clinic. As an example, Altor BioScience Corporation (a NantWorks company in Mirimar, Florida) has developed an IL-15N72D/IL-15Ra-Fc superagonist complex (ALT-803). A major advantage shown in preclinical studies is its substantially increased in vivo half-life compared to rhIL-15 due to the human IgG1 Fc fragment fused to the IL-15Ra in the complex. In addition, studies have shown enhanced NK cell function in vitro and in mouse models after treatment with ALT-803. ALT-803 rescued the functional activity of NK cells derived from ovarian cancer patient ascites (Felices et al. 2017). ALT-803 also enhanced in vivo CD16-triggered NK cell clearance of B cell lymphomas when treated with an anti-CD20 mAb (Liu et al. 2016). In conjunction with the postulated role of gamma chain cytokine–mediated bypass of some checkpoint inhibition pathways (Cheng et al. 2013), the ability of IL-15 to potentiate CD16-mediated functions on NK cells makes this cytokine an attractive immunotherapeutic target. We have recently completed first-in-human testing of ALT-803 in hematologic malignancy patients who relapsed more than 60 days after allogeneic transplantation (Romee et al. 2018). The hypothesis was that stimulating donor immunity would induce a graft-versus-tumor response to treat cancer relapse. ALT-803 was given to 33 patients via IV or SC administration once weekly at four doses (dose levels of 1, 3, 6, and 10 µg/kg). ALT-803 was well tolerated. In this clinical setting, no dose-limiting toxicities or treatment-emergent GVHD requiring systemic therapy was observed. Adverse events following IV administration included constitutional symptoms temporally related to increased amounts of serum IL-6 and IFN?. The SC route was tested to mitigate these effects. SC delivery resulted in self-limited injection site rashes infiltrated with γδ T cells without acute constitutional symptoms. Pharmacokinetic analysis revealed prolonged (>96 h) serum concentrations following SC delivery, but not IV injection. In this setting, SC delivery mimicked a continued infusion lasting nearly a week. ALT-803 stimulated activation, proliferation, and expansion of NK cells and CD8+ T cells without increasing Tregs. Responses were observed in 19% of evaluable patients, including one complete remission lasting 7 months. This immunostimulatory IL-15 superagonist to augment antitumor immunity, both alone and combined with other immunotherapies, warrants further investigation. Another IL-15 product developed by George Pavlakis containing the heterodimer of IL-15/IL-15Ra (Bergamaschi et al. 2018) was recently acquired by Novartis. Clinical development is underway. An alternative to IL-15 is the use of PEG (polyethylene glycol)-ylated IL-2 [developed by Nektar as NKTR-214 (Charych et al. 2016)] or mutant IL-2 proteins that preferentially bind to the IL-2R beta and gamma chains, thereby avoiding stimulation of Tregs. These agents are also currently undergoing evaluation in the clinic.
Priming NK cells with a short ex vivo treatment with a combination of IL-15, IL-12, and IL-18 prior to adoptive transfer is another cytokine-based approach that has shown promise in mouse cancer models. IL-12 synergizes with IL-18 to epigenetically prime NK cells for enhanced IFN? production (Chan et al. 1991, Luetke-Eversloh et al. 2014, Okamura et al. 1995). Cerwenka and colleagues (Ni et al. 2012) tested the in vivo antitumor activity of cytokine preconditioning by incubating syngeneic mouse NK cells with either IL-15 alone or IL-12, IL-15, and IL-18 for 16 hours ex vivo before adoptive transfer into MHC class I–deficient RMA-S tumor-bearing mice. Sustained tumor clearance and NK cell persistence was observed in 22% of the mice that received IL-12/15/18-preactivated NK cells. No beneficial effect was observed in mice that received IL15- or IL-2-preactivated NK cells. These cells are often designated as cytokine induced memorylike (CIML) NK cells. This approach has been translated into human clinical trials based upon favorable preclinical data (Cooper et al. 2009). Fehniger and colleagues (Romee et al. 2012) reported that CIML NK cells exhibit enhanced IFN? production and cytotoxicity against primary AML blasts regardless of KIR/KIR ligand interactions. In a first-in-human trial, NK cells expanded in vivo, and some patients with refractory AML experienced remissions (Romee et al. 2016).
Several groups have promoted the use of cell lines derived from malignant NK cell leukemia or lymphoma (i.e., NK-92, NKL, KYHG-1, YT, and NKG). These transformed NK cell lines maintain cytolytic function and lack the expression of inhibitory KIR. Based on unlimited growth of the NK cell lines, genetic modification introducing CD16 or chimeric antigen receptors (CARs) is accomplished easily. Among the lines, NK-92 cells have been tested in clinical trials that included patients with renal cell carcinoma and malignant melanoma (Arai et al. 2008). In a phase I dose escalation study treating 12 patients, investigators reported only transient toxicities and stable disease in 33% of patients. However, the in vivo activity of the NK-92 cells was difficult to establish (Cheng et al. 2013), and the requirement that the NK-92 cells be irradiated prior to infusion limits their in vivo persistence.
Multiple strategies are under investigation to make off-the-shelf NK cells a reality. These efforts depend upon robust expansion of NK cells. Imai et al. (2005) engineered the MHC class I–negative K562 cell line to express 4-1BBL and membrane-bound IL-15 capable of 1,000-fold expansion of blood NK cells after three weeks in culture. K562 cells expressing membrane-bound IL-21 and 4-1BBL (K562-mb21-4-1BBL) have also been highly successful for ex vivo expansion of NK cells (Denman et al. 2012). These K562-expanded primary NK cells have been tested clinically and found to be safe. They do not induce GVHD. Results have been encouraging in remission maintenance along with allogeneic hematopoietic stem cell transplantation (Ciurea et al. 2017). Another approach involves using particles derived from plasma membranes of the K562-mb214-1BBL cells (PM21 particles). This technique offers the advantage of off-the-shelf feeder cell support without the requirement for live feeder cells (Oyer et al. 2016).
A potential problem with highly expanded NK cells is whether they generate terminally differentiated cells or cells that may be more functionally immature. More attention should be devoted to developing products with defined functional characteristics. Focusing on the functional attributes of adaptive NK cells, Cichocki et al. (2017) discovered that adding a small-molecule inhibitor of glycogen synthase kinase 3 to peripheral blood NK cells from a CMV-seropositive donor expanded ex vivo with IL-15 for one week resulted in an enriched population of adaptive CD57+NKG2C++ NK cells. This outcome was linked to the expression of several transcription factors associated with late-stage NK cell maturation, including T-BET, ZEB2, and BLIMP-1, without affecting cell viability or proliferation. These cells contained high levels of granzyme and were highly functional in mediating potent ADCC, especially in long-term (up to 40 h) killing assays (Cichocki et al. 2017). This discovery has been translated into a phase I clinical trial to investigate systemic administration of these adaptive NK cells for AML and solid tumors, as well as intraperitoneal delivery in ovarian cancer.
Continued improvements in NK cell expansion technology may make off-the-shelf NK cells a reality. Starting material can be from adult peripheral blood or from cord blood progenitors, where hematopoietic progenitors may have more expansion potential and are more amenable to gene transfer (Ciurea et al. 2017, Dolstra et al. 2017, Kang et al. 2013). Recently, Rezvani and colleagues (Liu et al. 2018) initiated a clinical trial using NK-CAR against CD19 with a construct also providing IL-15. However, even progenitor-derived NK cells are heterogeneous in function and not clonal. Potentially, this obstacle may be overcome by deriving NK cells from self-renewing human embryonic stem cells or, alternatively, induced pluripotent stem cells (iPSCs) (Knorr & Kaufman 2010, Woll et al. 2009). These cells have unlimited scale and are easy to genetically modify, and NK cell clones can be selected based on functional attributes. An example of a gene modification is based on the biology that activated NK cells lose CD16 expression and the homing receptor CD62L through proteolytic cleavage by membrane-bound disintegrin and metalloprotease 17 (ADAM17) (Romee et al. 2013). This CD16 receptor shedding is mediated by the ADAM17 cleavage between Ala195 and Val196 at a membrane-proximal site of the CD16 receptor (Lajoie et al. 2013). Pharmacologic inhibition of ADAM17 enhanced NK cell–mediated ADCC function by preserving CD16 on the surface. An alternative approach is to engineer iPSCs with CRISPR technology to express a cleavage-resistant high-affinity CD16. Repurposing CD16 on NK cells with greater specificity by using anticancer antibodies or immune engagers will result in an NK cell product with incredible diversity.
In summary, the use of cytokines, adoptive cell transfer, and a form of antigen-specific off-theshelf NK cells will allow repeated dosing of NK cells as a living drug. The main barrier remaining is how to maintain the persistence and expansion needed to provide a meaningful effector-to-target ratio in vivo and to overcome the rejection of allogeneic NK cells when transferred into immunocompetent patients. While lymphodepleting conditioning has provided a proof-of-concept on the potential of NK cells to expand in vivo and survive for up to one month, the use of Hi-Cy/Flu is too toxic for solid tumor patients who are treated on an outpatient basis, and even in these patients, the immune rejection is still strong. What is needed is more potent transient T cell blunting for one to two weeks that is safe and nontoxic. Some have proposed that conditioning patients with anti-CD3 mAb OKT3 might be appropriate for this purpose, but OKT3 is no longer readily available and can cause a toxic cytokine release syndrome. Optimal immune blunting would need to be specific to T cells without affecting NK cells. Given the similar biology between these cell types, this remains a challenge and an aspiration for future research.
NK cells can broadly recognize stressed malignant targets through a collection of receptors but may be limited therapeutically by a lack of specificity. This assumption is supported by the recent success and FDA approval of genetically engineered CAR-expressing T cells, which are specific for CD19+ B cell malignancies (Glienke et al. 2015, Hermanson & Kaufman 2015). However, these T cell–personalized approaches are expensive (around $500,000) because they require formidable infrastructure to produce individualized cell products. The FDA has approved a bispecific T cell engager named binatumomab, which engages CD3 on T cells and CD19 on B cell malignancies, as a proof-of-concept for an alternative T cell approach. Engaging the CD3 complex on T cells results in both an activation and a proliferation signal, resulting in clinical efficacy in patients with acute lymphocytic leukemia (Topp et al. 2015), and this dual function may be key to efficacy. These outcomes have motivated several groups to develop strategies to engage activating receptors on endogenous and adoptively transferred NK cells (Figure 2).
We have been particularly interested in biand trispecific killer cell engagers (BiKEs and TriKEs) (Figure 2). These molecules are designed to form an antigen-specific immunological synapse between NK cells and tumor cells to trigger antigen-specific NK cell–mediated killing of tumor targets. Unlike full-length bispecific antibodies (300–450 kDa), these constructs (50– 75 kDa) are composed of a single-chain variable fragment (scFv) made up of a variable heavy and variable light chain of an antibody connected by an inert short peptide linker (Holliger & Hudson 2005). This configuration facilitates combination with the scFvs of one (BiKE) or two (TriKE) antibodies of different specificities. As an alternative approach, one of the scFvs can be replaced by a functional cytokine or even added to a TriKE with multiple specificities to create a TetraKE with four function domains.
The mAb-driven low-affinity Fc engagement of CD16 to trigger ADCC has changed the standards of cancer care (Figure 2). Accordingly, the biology of alternative approaches to repurpose the CD16 receptor must be explored. BiKEs and TriKEs were designed with agonistic anti-CD16 scFv components, leading to the hypothesis that an anti-CD16 scFv could bind and trigger CD16 with a stronger interaction than the natural low-affinity binding of CD16 to the Fc of IgG1 antibodies. This concept was demonstrated when comparing the binding affinity of CD16 for the Fc-portion of an anti-HER2 antibody to the binding affinity of the anti-HER2 х anti-CD16 bispecific antibody to CD16, which demonstrated a 3.4-fold increase in binding of the bispecific antibody to CD16 (Moore et al. 2011). Additionally, BiKEs and TriKEs have several potential advantages. These include increased biodistribution compared to mAbs due to their significantly smaller size, their possibly smaller immunogenicity, and their ability to be engineered with great flexibility.
Our group has focused on BiKEs and TriKEs that engage CD16 along with CD19 and CD22 on B cell non-Hodgkin's lymphoma (Gleason et al. 2012); CD33 on AML (Gleason et al. 2014) and myelodysplastic syndrome (Wiernik et al. 2013); EpCAM on prostate, breast, colon, head and neck carcinoma (Vallera et al. 2013); and CD133 on cancer stem cells, as well as a combination of EpCAM and CD133 for a broad-spectrum molecule (Schmohl et al. 2016, 2017). Because CD16 engagement alone does not deliver a proliferative signal, newer-generation TriKEs and TetraKEs all incorporate an IL-15 moiety that substantially induces NK cell proliferation and survival, much like the intracellular CD28 or 4-1BBL domains essential to CAR T constructs that sustain and amplify an immune response. This investigational decision was motivated by clinical studies testing IL-15 against a variety of cancers that found predominant NK cell activation and proliferation without stimulating Treg expansion. The TriKE and TetraKE molecules containing IL-15 demonstrate clear advantages in CD16 engagement over BiKE predecessors by adding a costimulus to cytotoxicity and inducing secondary inflammatory cytokines that may be important to orchestrate a broader immune response. When compared to its BiKE counterpart, one of these molecules, an anti-CD16 х IL-15 х anti-CD33 TriKE, has demonstrated better tumor control and NK cell maintenance and expansion in a preclinical AML xenogeneic mouse model containing human NK cells. It is tempting to speculate that the IL-15 moiety may also enhance a bypass of inhibitory checkpoint signaling. In support of this finding, a recently published study has shown that IL-15/IL-15Ra-Fc superagonist complexes (ALT-803) can augment PD1 blockade therapy in patients with advanced lung cancer (Wrangle et al. 2018). By the end of 2018, the anti-CD16 х IL-15 х anti-CD33 TriKE is scheduled to reach the clinic in a phase I trial at the University of Minnesota for patients with refractory AML and high-risk myelodysplastic syndrome. Other camelid constructs with different agonistic binding to CD16 are currently being tested to generate second-generation TriKEs with higher specific activity. In addition to our own platform, Affimed has clinically tested NK cell engagers with a different tetravalent structure, binding CD16A on NK cells rather than the broader CD16A/CD16B binding using our TriKE approach (Rothe et al. 2015). Constructs binding CD16A/B, as opposed to only CD16A, may also bind to neutrophils in addition to NK cells, leading to a drug sink with unknown clinical consequences. Comparative studies using these NK cell engagers are needed to reconcile this question.
Current TriKEs and TetraKEs trigger NK cell responses via CD16 ligation and cytokine signaling. Additional components can be added to manipulate the immune synapse between NK cells and their targets. Some have suggested that engaging NKG2D through fusion proteins (Smits et al. 2016, von Strandmann et al. 2006) may be more advantageous. In addition, scFvs that block NK cell–specific or broad checkpoints like KIRs, TIGIT, NKG2A, or PD1 may be optimal.
Alternatively, an scFv-neutralizing TGFβ could be included to reduce negative signaling in the tumor microenvironment. Another interesting concept is the incorporation of an scFv functionally blocking ADAM17—a matrix metalloproteinase involved in CD16 shedding to maximize CD16mediated killing. Besides IL-15, several other cytokines such as IL-12 that differentially modulate NK cell biology could be included (Vallera et al. 2016), as it has been shown in mouse model systems that IL-12 is essential to generate memory NK cells specific for CMV (Sun et al. 2012). The choice of options for optimally manipulating the immune synapse will be based on careful studies in NK cell biology.
While the BiKE and TriKE strategies discussed above use an anti-CD16 scFv that binds both CD16A and CD16B, it remains unclear whether CD16B engagement on neutrophils will be clinically important. While BiKEs and TriKEs bind CD16B, which may be a drug sink, thus rendering them biologically unavailable, they do not appear to activate neutrophils or inhibit the ability of BiKEor TriKE-mediated NK cell–mediated killing; however, alternatives to overcome this have been proposed. Constructs that are specific for CD16A engagement are already in the clinic, paired with anti-CD30 for treatment of Hodgkin's lymphoma (Arndt et al. 1999; da Costa et al. 2000; Hartmann et al. 1997, 1998; Hombach et al. 1993; Reiners et al. 2013; Renner & Pfreundschuh 1995; Renner et al. 1997, 2000; Sahin et al. 1996). The future for off-the-shelf immune engagers is exciting. Other types of multispecific antibody constructs have been generated to engage CD16 in conjunction with CD20 and CD19 on B cell non-Hodgkin's lymphoma (Bruenke et al. 2005; Glorius et al. 2013; Johnson et al. 2010; Kellner et al. 2008, 2011; Kipriyanov et al. 2002; Portner et al. 2012; Schlenzka et al. 2004; Schubert et al. 2012), CD19 and CD33 on mixed lineage leukemia (Schubert et al. 2011), CD33 or CD33 and CD123 on AML (Kugler et al. 2010, Silla et al. 1995, Singer et al. 2010), HLA class II on lymphomas (Bruenke et al. 2004), EGFR on EGFR+ tumors (Elsasser et al. 1999, Ferrini et al. 1993), HER2 (neu) on metastatic breast cancer and other HER2-expressing tumors (Moore et al. 2011; Weiner et al. 1995a,b), and MOV19 on ovarian cancer (Ferrini et al. 1991).


text:
import CONFIGS from './configs';
import { extendShorthandOptions } from './options';
import { extend } from '../../_modules/helpers';
import * as DOM from '../../_modules/dom';
import * as media from '../../_modules/matchmedia';
import breadcrumbs from './navbar.breadcrumbs';
import close from './navbar.close';
import prev from './navbar.prev';
import searchfield from './navbar.searchfield';
import title from './navbar.title';
import tabs from './navbar.tabs';
Navbars.navbarContents = {
    breadcrumbs,
    close,
    prev,
    searchfield,
    title,
};
Navbars.navbarTypes = {
    tabs,
};
export default function Navbars() {
    this.opts.navbars = this.opts.navbars || [];
    this.conf.navbars = this.conf.navbars || {};
    //	Extend options.
    extend(this.conf.navbars, CONFIGS);
    let navs = this.opts.navbars;
    if (typeof navs == 'undefined') {
        return;
    }
    if (!(navs instanceof Array)) {
        navs = [navs];
    }
    if (!navs.length) {
        return;
    }
    var navbars = {};
    navs.forEach((options) => {
        options = extendShorthandOptions(options);
        if (!options.use) {
            return;
        }
        //	Create the navbar element.
        const navbar = DOM.create('div.mm-navbar');
        //	Get the position for the navbar.
        let { position } = options;
        //	Restrict the position to either "bottom" or "top" (default).
        if (position !== 'bottom') {
            position = 'top';
        }
        //	Create the wrapper for the navbar position.
        if (!navbars[position]) {
            navbars[position] = DOM.create('div.mm-navbars.mm-navbars--' + position);
        }
        navbars[position].append(navbar);
        //	Add content to the navbar.
        for (let c = 0, l = options.content.length; c < l; c++) {
            const ctnt = options.content[c];
            //	The content is a string.
            if (typeof ctnt == 'string') {
                const func = Navbars.navbarContents[ctnt];
                //	The content refers to one of the navbar-presets ("prev", "title", etc).
                if (typeof func == 'function') {
                    //	Call the preset function.
                    func.call(this, navbar);
                    //	The content is just HTML.
                }
                else {
                    //	Add the HTML.
                    //  Wrap the HTML in a single node
                    let node = DOM.create('span');
                    node.innerHTML = ctnt;
                    //  If there was only a single node, use that.
                    const children = DOM.children(node);
                    if (children.length == 1) {
                        node = children[0];
                    }
                    navbar.append(node);
                }
                //	The content is not a string, it must be an element.
            }
            else {
                navbar.append(ctnt);
            }
        }
        //	The type option is set.
        if (typeof options.type == 'string') {
            //	The function refers to one of the navbar-presets ("tabs").
            const func = Navbars.navbarTypes[options.type];
            if (typeof func == 'function') {
                //	Call the preset function.
                func.call(this, navbar);
            }
        }
        //	En-/disable the navbar.
        let enable = () => {
            navbar.classList.remove('mm-hidden');
        };
        let disable = () => {
            navbar.classList.add('mm-hidden');
        };
        if (typeof options.use == 'boolean') {
            this.bind('initMenu:after', enable);
        }
        else {
            media.add(options.use, enable, disable);
        }
    });
    //	Add to menu.
    this.bind('initMenu:after', () => {
        for (let position in navbars) {
            this.node.pnls[position == 'bottom' ? 'after' : 'before'](navbars[position]);
        }
    });
}

redpajama_set_name: RedPajamaGithub


Friends and family aren't always the best place to turn when life gets difficult. That's where we come in. No matter what might be going on in your life, call us and we'll connect you to a caring mental health professional Or, if you'd prefer, fill out our Client Contact Form, and one of our staff will contact you by the end of the next business day.


text:
President U.Khurelsukh: Mongolia should lead the world in Chinggis Khaan studies
Address by President of Mongolia H.E. Ukhnaagiin Khurelsukh at the special session of the State Great Khural dedicated to the 860th Anniversary of the birth of the Great Chinggis Khaan.
"My fellow Mongolians – the guardians of hearth and home of the Great Mongolian State under the Eternal Blue Sky,
My fellow countrymen, living all over the world, from where the sun rises to where it sets,
Esteemed Speaker of the State Great Hural and Prime Minister,
Honorable state officials and friends,
I wish to extend my greetings to you on the occasion of the 860th Anniversary of the birth of the Great Chinggis Khaan - the great leader in the history of the humankind, the founder of the modern world, the Man of the Millennium and the source of the lasting pride of the Mongolian people.
We, the Mongolians, are blessed people.
The Eternal Blue Sky bestowed upon us the Great Chinggis Khaan – the King of Kings of great genius.
Eight centuries ago the Great Chinggis Khaan was born as Temuujin, the eldest son of the Mongolian nobleman and warrior Yesukhei, and the wise queen Oelun at the chest of the sacred mountain Burkhan Khaldun, at the basin of the three rivers of eternal spring water.
Temuujin unified the scattered Mongolian tribes and established the Great Mongolian State, strengthened the golden tether of statehood dating back to the Hun dynasty, rekindled the hearth of the Mongolian state, and was exalted as the Great Chinggis Khaan recognized all over the world.
Chinggis Khaan is the guardian of the independence and the very being and existence of the Mongolian nation, the source of our people's pride, and the great emperor of today and forever.
Consolidating the traditions of statehood of our forefathers, inheriting the wisdom to govern the state and the people, winning the hearts of its people and honing their trust and confidence, aware of the past, sensible of the present and discerning about the future, this man was a genius who made invaluable contributions to the shaping of the history of the world.
The thirty years of struggle for unity, of quest for peace, of crafting the rule of law, and of eventually emerging as a Great Khaan of heavenly might from a humble young man wasn't easy.
Abandoned by relatives and kinfolk, knowing the pain of loss at young age, Chinggis Khaan unified the scattered nomadic tribes and founded the Great Mongol State thanks to perseverance, courage, fortitude of mind, wisdom and the power of his will.
Chinggis Khaan's founding of the Great Mongol State was an event of unprecedented and unparalleled nature in the world history where the peoples of the world enjoyed harmony and accord peacefully co-existing under the Eternal Blue Sky.
The Great Mongolian State, built by Chinggis Khan, marked two centuries in the history of humankind as "Mongolian centuries".
The Great Mongolian State strengthened its unity, enhanced its statehood, promoted the rule of law, put an end to wars and conflicts across Asia and Europe, established peace in the world, and expanded into an empire that was admired by the world for its greatness.
Encyclopedia Britannica notes that the territory of the Mongol Empire accounted for 23 million square kilometers from the Pacific Ocean in the east to the Persian Gulf and the Danube River in the west, representing the largest land area in the history of the world.
Even today, the world continues to study with interest how the Mongols of Chinggis, numbered so few, with a nomadic civilization, were able for two centuries to keep the people unified and govern millions of people of different languages, cultures and religions, dispersed throughout a vast territory.
We, Mongols, take profound pride in the fact that the entire humankind, including the global leaders have constantly studied and learned from the genius, history, ideals and causes of the Supreme Khaan of the Mongols.
The first Prime Minister of India, Jawaharlal Nehru, praised Chinggis Khaan as "undoubtedly a military genius and leader, on par with Alexander of Macedonia and Julius Caesar in the history of the world", and as "a man who valued peace, rather than war, despite his military superiority."
Indeed, the empire he established was unparalleled in military science, might and the art of warfare, yet, it had always sought and honored law, peace and harmony in ruling its huge empire of a multitude of nations.
In 1995, the Washington Post named Chinggis Khaan as the "Man of the Millennium", in recognition of the contributions Chinggis Khaan and his successors made eight centuries ago in overcoming political, economic, religious, and civilizational wars and conflicts and proclaiming the "Pax Mongolica".
The establishment of the "Pax Mongolica", enabled the people of Eurasia to focus more on creating, building, construing, developing and studying. Hence, many areas of science, culture and education were developed, including mathematics, medicine, philosophy, astronomy, history, geography, literature, music, visual arts and architecture. In addition, land and water maps were made, and new advanced methods and technologies of military warfare, animal husbandry, and agriculture were developed.
Also, the transportation and communication system of that time got a tremendous boost by connecting vast areas by Urtoo, the horse relay stations.
Chinggis Khaan and his successors developed the Silk Road and ensured its security, thus boosting trade and commerce to flourish in vast areas from the Korean Peninsula to the Mediterranean Sea, introduced paper money into circulation and made significant contributions to the development of world economy.
Historians and researchers view that the Great Mongol State was the political and economic center of the world at that time. The City of Kharkhorum stands out as a historical and cultural heritage to testify this assertion.
In 1220, Chinggis Khaan issued a decree to establish the city of Kharkhorum and to move the capital of the Great Mongol State.
Kharkhorum was the center of many religions and civilizations, where scholars, artists, artisans, merchants, and envoys of kings and nobles from many countries lived or sojourned on a visit.
Democratic ideals and values flourished under the patronage of the Mongol Empire.
When Eurasian countries came under the rule of the Mongol state in terms of land, politics, economy and social structure, the walls of civilization and ideology that divided countries and regions fell down, and it was for the first time that many peoples and nations experienced comfortable and peaceful co-existance with each other with mutual respect and understanding.
Although the Great Mongol State at that time was a monarchy with unlimited power, it embraced and upheld the principles of democracy.
A clear example of that was the city of Kharkhorum, the capital city, where 12 temples, churches and mosques of various religions, including Buddhist, Christian and Muslim, coexisted and freely functioned, and representatives of various religions met and debated. That occurred for the first time in world history.
This was made possible due to the fact that the diversity of worldviews, beliefs, and religions of various peoples of that time was not banned or infringed upon, but rather their values were treated with respect, which was preserved in the history of humankind and passed down as one of fundamental principles of the modern civilization.
My fellow Mongolians,
Since the Great Chinggis Khan was a man of the world who founded the Eurasian Empire, his biographies have been written and printed in many languages in various countries since the 13th century.
Therefore, leaders of many countries, renowned scholars and religious leaders recognize that the history of Chinggis Khan is not only the history of Mongols, but also the history of the world.
In the famous book entitled "Genghis Khan and the Making of the Modern World" written in 2004, Jack Weatherford, renowned American scholar, emphasized that "Genghis Khan is the great king who laid the groundwork of the ideals and foundation of the modern world."
This famous work attracted the world's attention and re-acquainted humanity with the great story of Genghis Khan, and was selected as a bestseller of the New York Times.
Also, Jack Weatherford wrote, "P. Carpini and V. Rubruk, who visited Mongolia in the 13th century, applauded how the laws, enforced by Chinggis Khaan, were adhered to, and they wrote on a number of occasions how Mongolians respected and followed the laws established by Emperor Chinggis Khan."
J. Chaucer, an English writer of the 14th century, called Chinggis Khaan the "Great King" of the law. According to him, Chinggis Khaan was a leader who was loyal to the law he had sworn to. He wrote that the most extraordinary thing was the fact that powerful kings of that time put themselves above the law, whereas Chinggis Khaan obeyed the law equally.
Paul Pelliot, a French scientist and a well-known Orientalist, concluded the period of Chinggis Khaan's conquest as "the unprecedented great miracle."
Furthermore, on the 800th anniversary of founding the Great Mongolian State, the President of the Republic of Korea and Nobel Peace Prize Laureate Kim Dae-jung wrote: "Chinggis Khaan's achievements have the following historical significance: First, he created land and sea routes connecting East and West. Second, he had played an important role in the spread of Christianity and Islamic religion to the East. Third, he influenced the spread of geography, astronomy, mathematics, and mapping technology to the West. Fourth, by intensifying the cultural and economic exchange between East and West, he changed the future development course of the world".
The XIV Dalai Lama underscored that "The renowned Great Mongol Empire was founded in 1206 after the various Mongolian tribes gathered together and proclaimed Chinggis Khaan their leader. What he went on to achieve, he did through a determined exercise of courage and physical strength. Today, it is fitting to remember with pride what he accomplished for Mongolian independence, unity and freedom. Taking inspiration from his example, I urge you to apply a similar determination in extending education in your country, in furthering not only material progress, but also in fostering the important values of inner development."
Pope Benedict XVI wrote in 2006, "Through his personality Chinggis Khaan made a marvelous contribution to the recognition by the world of the political, social and cultural specificities of the Mongolian people. From 1206 to the present, there have been significant changes in human development, yet it is beyond doubt that Chinggis Khaan's contribution to the Great Mongolian State and its relations with other civilizations will remain significant. It is critical not only to study this important achievement, but also to duly mingle the rightful national pride as a model in relations with civilizations of other peoples".
The President of the Russian Federation, Vladimir Putin, stressed that, "The Mongolian State, founded by Chinggis Khaan, had a great impact on the course of the world history."
Japanese Prime Minister Junichiro Koizumi cited the conclusion of scholar Okada Hidehiro to the effect that "During the time of the Mongol Empire, which ruled the lands of Eurasia, a general concept of the "world" had originated leading to the creation of the world history," and further stressed that "Also, considering Chinggis Khaan's policies such as appointing talented and learned foreigners to high positions, introducing a common currency, and exercising freedom of religion, the Mongolian Empire was a pioneer of globalization. Junichiro Koizumi further concluded that "even from a historical viewpoint, the reality of Chinggis Khaan, who started a new era in history, would reveal much more about the world at that time".
Hosni Mubarak, President of the Arab Republic of Egypt, mentioned that "The historical role of this great leader was not confined only to the unification of Mongol tribes and the establishment of the Great Mongol State, he had a profound influence on the change of the world map to be redrawn during the late Middle Ages.
Moreover, historians unanimously agree that Chinggis Khaan was a great political thinker, brilliant military leader, and possessed strong leadership skills, which are all reflected in the advanced civil and military systems he established during his rule as well as the law and order that continued long after him.
Chinggis Khan was able to establish the Mongol Empire, one of the greatest empires in history, within a few years. As his fame spread throughout the world, historians have included his name in the list of the world's greatest leaders along with Ramses II, Thutmose III, Alexander the Great and Caesar. His empire stretched from the Pacific Ocean to the Black Sea and from Siberia to the northern border of Southeast Asia.
Despite the prevailing perception of Chinggis Khaan and his successors as great leaders in Egypt and the region, in some parts of Islamic world, he is remembered as a usurper who overthrew the Khwarazmian Empire and captured Khwarasm, Samarkand, and Bukhara, as well as occupied Khorasan, Afghanistan, Iran, Iraq, and Al Mashreq.
Nevertheless, it is more appropriate to assess such a leader not by the prevailing criteria of today, but of that time. By the criteria of his time, Chinggis Khaan was renowned as a great leader and conqueror.
He unified his nation, transforming a few scattered tribes into a powerful state and then a great empire on vast territories. Even after his death, his successors continued to expand the empire. Their military forces crossed the Danube River and reached the borders of present-day Germany."
Recep Erdoğan, President of the Republic of Turkey, "The Mongol Empire founded in 1206 was the largest contiguous land empire that the world has known, a well-established fact that will no doubt continue to feature prominently in the annals of the history of mankind. The great Chinggis Khaan went into history not only as the leader that founded this vast Empire, but also as the greatest military mastermind of all time that extended the territories of that State to infinite greatness.
In 1206 Chinggis Khaan gained the stature of the founder and the sovereign of a worldwide empire, thus leaving behind the era of tribal chieftainship.
Chinggis Khaan left a vast State stretching from the Black Sea to the Pacific Ocean as legacy when he died in 1227.
The Mongol Empire thus owed a lot to its founder, the great Chinggis Khan, who made inroads in histories of many nations, be it a friend or foe, with his reputation of being a great commander who could project force to wherever he pleased.
Modern Mongolia is destined to prosper as an active member of the contemporary world, given its vast territory of more than 1.5 million sq. km., its young and dynamic population, and its rapidly evolving reform process launched in 1990s.
Mongolia has managed to preserve its distinctive place in world history and world cultural heritage."
Bill Clinton, Former President of the United States, also noted that "Since the unification of the Mongol State by Chinggis Khaan in 1206, Mongolians have always deeply cherished their independence and freedom."
Jacques Chirac, President of France, describing Chinggis Khaan and his deeds, said, "I have not yet fully explored and learned about the great conqueror, who shook the world, a highly cultured visionary and a shaper of his society."
Chinggis Khaan dismantled the tribal system, created national unity, and laid the foundations of the Mongolian nation that will last for generations.
He established peace, ensured the security of the Silk Road, and provided an opportunity to develop trade as well as intellectual and cultural exchanges.
According to historians, one of Chinggis Khaan's important legacies, the Pax Mongolica, allowed relations between Europe and Asia to flourish for centuries.
It was concluded that "Chinggis Khaan has become a modern legendary hero, and his power and legacy continue to be immortalized in a combination of fear and admiration from generation to generation."
In 2005, on the occasion of the 800th anniversary of the establishment of the Great Mongol Empire, the General Assembly of the United Nations adopted a resolution urging its member countries to celebrate the contribution of Mongolians to the history of mankind.
In this resolution, the General Assembly recognized that "The Great Mongol State influenced, inter alia, societies across Asia and Europe and, in turn, absorbed influences from both East and West in a true interchange of human values; played important role in the development of extensive trade networks and the creation of large administrative, cultural, religious and commercial centers; and promoted dialogue and interaction among all forms of civilization." It also emphasized "the ever-increasing significance and relevance of a culture of living in harmony with nature, which is inherent in nomadic civilization, in today's world."
It is evident from the speeches, researches and literature written by these well-known individuals that Chinggis Khaan and his successors deeply valued peace, ensured harmony under the rule of law, spread democratic ideals that fostered religion and equality, promoted development in many fields, including trade, communications, culture and science, and created the initial concept of diplomatic service and exchange of envoys. They laid the foundation for the values and ideals that we uphold today and have planted the root for modern-day globalization.
The Great Chinggis Khaan always kept the history and legacy of his ancestors in his heart, when he led his country. He was a visionary emperor and a father who shared his wisdom with his children and people.
Penelope Aubin, a famous English writer and interpreter of the 18th century, translated a book about Chinggis Khaan and presented it to the Prince of Wales, where she described Chinggis Khaan "not only as a pious, just and humble king, but also a wonderful husband, a good father, a loyal friend, a kind lord, and a wise general".
He was a great man and emperor who treated his fellow people like his own children, respected the soldiers and scholars as brothers, and provided shelters to orphans and the poor. He was generous and distributed his wealth, placed his people, the state, and mothers above all, and deeply valued honesty.
The Great Chinggis Khaan taught us not to entrust state affairs to anyone who does not admit what he said, a shameless person who can't control himself, let alone others, and a sly, cruel, dishonest person with greed for wealth and power.
These teachings should continue to be the basic principle and practice of public service.
Honorable citizens, descendants of our Great Emperor,
The Great Khaan ignited our national pride, that has the ability to unite all the hearts that beat for Mongolia, with his power and glory.
The admirable merits and proud deeds of the emperor in the history of Mongolia is immeasurable, and it is a value that strengthens the intellectual immunity of the Mongolian people and unites the Mongolian nation.
We, Mongolians, are aware of our responsible and sacred duty in guarding the birthplace of our Great Chinggis Khaan and the hearth of all Mongolians around the world, and shall remember and pass on to the future generations that we must spare no effort in preserving, studying, researching and spreading the great heritage of our Great Khaan.
Therefore, the President of Mongolia issued a decree, urging every Mongolian to be aware that they are the guardians of the Great Mongol Empire's hearth and home, and for Mongolian government, every household and organizations to honor the Chinggis Khaan's portrait, to honor and follow Chinggis Khan's teachings, deeds, and wisdom, to pass on the state's values and heritage to his successors, to maintain harmony, and to contribute to the prosperity of the country.
Chinggis Khaan accomplished more than thousands of leaders could ever accomplish in a lifetime and he left behind a vast and rich heritage for mankind.
It is a pleasure to note and celebrate on this historic day, today, the strides and achievements made by the government, heads of state, presidents, scholars, citizens, and relevant organizations in terms of promoting, disseminating, and reporting on the legacy and deeds of Great Chinggis Khaan abroad and domestically.
This year, on the occasion of the 860th anniversary of the birth of our Great Khaan, we, Mongolians, have successfully built and opened the Chinggis Khaan Museum & Cultural Center, which showcases history of Great Chinggis Khaan, his ancestors and successors, despite the difficult times of the pandemic.
Also, the international scientific conference entitled "The World of Chinggis Khaan and Mongolian Studies" was organized in Ulaanbaatar and the International Association of Chinggis Khaan Studies was established this year.
This international association and the Chinggis Khaan museum aim to scientifically study, disseminate and publicize the great Khaan's contribution to the development of humanity, his state ethics, historical and cultural heritage, expand the scope of Chinggis Khaan studies, activate the cooperation of scientists from many countries of the world and implement joint projects and programs.
Mongolia should lead the world in Chinggis Khaan studies.
World renowned individuals, intellectuals, scholars, and writers have spent several centuries learning and studying all the great deeds and accomplishments achieved by the Great Khaan since his birth.
Therefore, it is important to train and prepare specialized research scholars who will work on the study of Chinggis Khaan and the Mongol Empire at the international level through government policy.
As Chinggis Khaan studies develop, scholars and scribes of many countries will recognize, appreciate and acknowledge the great contribution of the Great Khaan to the development of mankind and the history of the world, and the true story about the Emperor and the Mongols will spread to the world.
The more we aspire to build a strong and developed country, the more we should strive to learn from our history, the knowledge and wisdom of our ancestors, and strengthen the golden bond of the past, present, and future.
The future generations of Mongolia should never forget that our independent country, freedom, vast territory, people, pride, history and culture are inextricably linked with the glory of the Great Khaan, honor and follow the teachings of our Emperor.
The Great Chinggis Khaan was able to establish the Great Mongol Empire and brought world peace. He made history by following his teachings to "Aim for the high mountains, cross the wide ocean, do not despair because it is far, you will reach it, do not get discouraged because it is big, you can cross it, do not be scared because it is heavy, you can lift it."
Today, Mongolians can author great deeds and build a strong nation, if we cherish and strictly follow this wisdom of our Supreme Khaan, work hard for our country and become the masters of our destiny.
I encourage every Mongolian to respect and worship our great Khaan, to protect, from the bottom of our hearts, our freedom, independence and unity – the apple of our eyes, and remember every morning, strive every day, and contemplate every night that we are the continuation of the Great Khaan's great legacy.
On behalf of the people of Mongolia, the descendants of the Great Khaan, we would like to extend our greetings to the world on the anniversary of the birth of Chinggis Khaan, the Man of the Millennium, one of the founders of modern world, and the King of Kings.
May the power and glory of the Great Emperor bless us, Mongolians, forever under the power of the eternal sky!"

redpajama_set_name: RedPajamaCommonCrawl


Mammograms, biopsies, and lumpectomies: Are these "life-saving" procedures actually making things worse?
Of course, none of this semi-accolade applies to the Chinese bureaucracy: Because of the Chinese government's desperate attempt to cover up the SARS epidemic when it started there, the disease advanced perilously around the world before the rest of the world even became aware of it. Basically, China didn't give us a chance to stop SARS before it spun out of control.
But even though we've got a handle on it now, it's important to know a bit about what caused this outbreak and to be prepared in case something similar ever happens again–which it undoubtedly will. As I mentioned in the April 22 edition of Daily Dose (subject line: "A SARS is born"), SARS appears to be either a new strain of the virus that causes the common cold or a mutated version of the virus responsible for measles and mumps. And it also appears to be frighteningly similar to the killer influenza of 1918 that killed millions of people worldwide. We don't know for sure that SARS is similar to the 1918 monster, because we don't know for sure what the original virus was. Today's epidemiologists just got a little lucky since SARS isn't quite as infectious as the original 1918 influenza. In 1918, it seemed that if someone just looked at you, you caught it. SARS takes a good sneeze in the face to infect you (or so they say).
But SARS isn't the only deadly microorganism out there: There are plenty more lurking just beneath our radar, waiting for the perfect opportunity to strike. For example, there's the Nipah virus, a killer you've probably never heard of. (I hadn't either until I read about it in a financial report! These weird and deadly diseases are good for the biomedical industry since every one of them "requires" its own vaccine.) This virus is characterized by the all-too-familiar flu-like symptoms of high fever and muscle pain, but it can also lead to swelling of the brain, convulsions, and coma. The death rate is roughly 50 percent. Nipah killed a few Chinese farmers in the late '90s and disappeared. But I can assure you it's still out there somewhere.
But even though the psychos out there may have gotten their hands on the black plague–and even though you've heard me say this numerous times–I still have to ask: why would the terrorists of the world bother making more weapons of mass destruction when they already have one of the greatest killers of all time sitting in vials on the shelf, all ready to go? Smallpox is easily transportable, highly contagious, and has a dynamite, ghastly death finale right out of a Hollywood horror flick: blood from every pore and orifice; hideous, scabby sores; blindness; insanity; and death. What more could a lunatic want? Russia has hundreds of gallons of this stuff, but, of course, they're our friends now, right? They wouldn't do that to us, would they? They've inoculated the entire Russian population–but that was only because the Russian people LOVE to be stuck with needles, right?
Anyway, whether we come under attack from man (as in the case of weaponized smallpox) or nature (as in the case of super viruses like SARS), the point is, these diseases are here to stay. They cannot be eradicated from the face of the earth as the World Health Organization (WHO) proclaims. Although our response and protective methods have improved impressively, nothing can completely stop marauders like smallpox and influenza: All we can do is prepare ourselves to fight them.
My reason for writing this article is to warn you not to depend on the U.S. government to give you a solution to the SARS problem, or any other epidemic. There are two simple, safe, and effective methods to treat deadly viral diseases, but you won't hear about either of them from public health authorities.
At the first sign of infection–sore throat, malaise, sniffles, or cough–start taking a homeopathic influenza formula. Homeopathy involves using formulations made from diluted strains of viruses and bacteria to build the body's resistance. The concept has met with its share of flak from the medical establishment, but don't underestimate the power of this form of treatment. If you have doubts, read the May issue of Dr. Douglass' Real Health Breakthroughs. You'll be amazed at how effective homeopathy can be. And if it works for a disease as serious as smallpox, I'm sure it can tackle influenza, too.
My second recommendation is photoluminescence. This treatment involves withdrawing a small amount of blood from your body, exposing it to UV irradiation, then re-injecting back into the body, where it carries the UV light's antiviral and antibacterial power with it. It isn't painful, and each session only takes about 20 minutes. Photoluminescence is our No.1 hope against all biological agents.
(1) Find a homeopathic doctor who can help you determine your options for fighting deadly strains of flu. To locate one in your area, contact the National Center for Homeopathy at (703)548-7790 or visit their website at www.homeopathic.org.


text:
Cargo plane carrying four goes missing in Indonesia
Timika (Indonesia): An Indonesian cargo plane with four people on board lost contact with air traffic control yesterday, an official said, the latest incident to hit the country's poor aviation record.
The Twin Otter DHC6-400, set off from the city of Timika at 10.39am and was headed to Ilaga, a mountainous region in the remote eastern province of Papua and was scheduled to arrive 50 minutes after taking off.
"After 2.5 hours, there has been no information from the nearest airport on the plane's whereabouts, we decided to announce the plane has lost contact, " local transportation agency head, Yan Purba told Metro TV.
The aircraft was carrying three crew members and one passenger as well as 1.7 tonnes of rice.
Search and rescue have been assembled for the missing plane which was flying in a good weather condition, Purba said.
Indonesia relies heavily on air transport to connect its thousands of islands, but mountainous Papua is a particularly difficult area to reach.
The country has a poor aviation safety record and Papua is a particularly problematic place to fly due to its mountainous terrain and frequent poor weather. — AFP


text:
Tepee, Temporary Exhibition Tent
In 1992, this "tepee" was designed as a reception pavilion for a major Toulouse-Lautrec exhibition held in the Grand Palais in Paris, The form and the structure were based on the requirements of the initial location. The entrance situation was to be inviting and at the same time have a striking appaerance. The outcome was a much-acclaimed temporary structure intended for subsequent use in other locations.
In 1993, the tepee was erected in front of the Bibliothèque de France - still under construction at that time - where it served as an information centre for two years.
In the course of time, the structure acquired an emblematic quality and became a sign of special events in Paris. In 1997, it was moved to the open square of the Beaubourg, where it will stand until the year 2000, accomodating various activities and serving as an information centre during the period in which the Centre Georges Pompidou is closed.
The tepee was conceived as a temporary yet enduring structure. A period of three weeks is required for its transport to a new site and its re-erection. In considering the use, therefore , the duration of a particular event has to be balanced against the assembly time.
Outwardly, the tepee has the form of a large white opaque cone during the day. Seen from the inside, it is translucent and brightly lit, and its load-bearing construction is clearly visible. In the evening, the metal structure supporting the illuminated cone is also visble from the outside.
The load-bearing framework consists of 12 tiers that taper towards the top. Each tier is divided along its perimeter into 12 bays of equal size. The sloping steel legs of the triangulated framework diminish in length from tier to tier upwards. At right angles to the node points of the triangles are compression members that serve to tension the outer membrane. Metal plates welded to the ends of the compression members protect the skin from damage. The 700 g/m² fabric membrane has no load-bearing function. It is manufactured as a single element, which is hoisted to the tip of the cone by crane, lowered over the supporting framework and finally tensioned by pressing the compression members outwards at the node points.
[Detail 8/1998, Mobile Structures, p 1411]
General comments, links
An Itinerant Building Temporary Exhibition Tent
Convertible or mobile
Convertible and mobile
Philippe Chaix, Jean-Paul Morel and Partners
Malinowsky Marc
Marijke M. Mollaert


text:
lovely and grateful
Slow living in a city
Follow lovely and grateful on WordPress.com
Search the Archives Select Month Jan 2022 (2) Dec 2021 (3) Nov 2021 (3) Oct 2021 (5) Sep 2021 (3) Aug 2021 (5) Jul 2021 (4) Jun 2021 (3) May 2021 (3) Apr 2021 (3) Mar 2021 (4) Feb 2021 (1) Jan 2021 (5) Dec 2020 (4) Nov 2020 (5) Oct 2020 (4) Sep 2020 (4) Aug 2020 (5) Jul 2020 (4) Jun 2020 (4) May 2020 (5) Apr 2020 (4) Mar 2020 (5) Feb 2020 (4) Jan 2020 (4) Dec 2019 (4) Nov 2019 (4) Oct 2019 (4) Sep 2019 (4) Aug 2019 (2) Jul 2019 (3) Jun 2019 (2) May 2019 (3) Apr 2019 (3) Mar 2019 (3) Feb 2019 (3) Jan 2019 (4) Dec 2018 (4) Nov 2018 (4) Oct 2018 (4) Sep 2018 (4) Aug 2018 (4) Jul 2018 (4) Jun 2018 (3) May 2018 (4) Apr 2018 (3) Mar 2018 (3) Feb 2018 (3) Jan 2018 (3) Dec 2017 (4) Nov 2017 (3) Oct 2017 (5) Sep 2017 (4) Aug 2017 (3) Jul 2017 (3) Jun 2017 (2) May 2017 (3) Apr 2017 (4) Mar 2017 (4) Feb 2017 (4) Jan 2017 (5) Dec 2016 (3) Nov 2016 (5) Oct 2016 (3) Sep 2016 (4) Aug 2016 (4) Jul 2016 (1)
📚 Review 📖
I truly fell back in love with reading last year, and it was the first time in my life I've ever reached my goal of reading 52 books. My final tally was 66 books, and this little selection was my Top 10 of 2021. I read so many wonderful books but these are the stories I haven't been able to stop thinking about.
Reading fell by the wayside last month as work and Christmas preparations took up most of my time and concentration. Finally enjoying a few quiet days at home after the festivities have finished, and trying to get a head start on my reading goal for 2022.
I will undoubtedly be asleep before midnight, but wishing everyone the very happiest New Year. 🥂🎆 See you in 2022! 😘
Goodreads: Currently Reading
lovelyandgrateful	in Reading	 Jul 15, 2020 Jul 16, 2020 322 Words
Why I'm No Longer Talking to White People About Race by Reni Eddo-Lodge
Following the Black Lives Matter protests around the world, Why I'm No Longer Talking to White People About Race was widely recommended, and I was drawn to it because it offers a British perspective on race relations.
The book starts with history, describing the British role in the slave trade, the whitewashing of the World Wars, decades of police brutality and racial profiling, the election of the first black MPs in 1987 (including Diane Abbot), the Brixton riots and many other significant events leading up to the present day. It's as fascinating as it is disturbing, British history is often ugly and violent but necessary to understanding racism and discrimination in the U.K.
Eddo-Lodge argues that racism is more insidious than abusive language or flag waving nationalist mobs marching, it's the influence of people (predominantly white male) in positions of power to impact the life chances and circumstances of others. Very few white people will openly admit to being racist, yet many become defensive when confronted with evidence of white privilege.
It's uncomfortable reading in places, the way that readers and viewers assume fictional characters are white unless otherwise described (as the furore caused when a black actress was cast as Hermoine Granger in the play Harry Potter and the Cursed Child, or when there was a rumour that a black actor was being considered as the new James Bond demonstrate), the backlash against intersectional feminism (black women are doubly discriminated against by being both black and female), how racism and class intersect with the idea that "white working class" are a marginalised minority that deserve support and special consideration, and how many white people ignore or accept discrimination and racism instead of challenging it.
Why I'm No Longer Talking to White People About Race is well-researched, thought-provoking, and a great place to start learning about systemic racism and how to be actively anti-racist. Take care, and have a lovely week. X
Summer Walks, Slugs and Sprinkles
Stories, Music and Swans
One thought on "Why I'm No Longer Talking to White People About Race by Reni Eddo-Lodge"
Throw in ageism too, and even more problems.


These presentations are classified and categorized, so you will always find everything clearly laid out and in context. You are watching Global and china coconut oil acyl glutamic acid sodium industry 2014 market research report presentation right now. We are staying up to date!