Abstract: Diabeticretinopathy (DR) is a retinal vascular disorder associated with both type 1 and type 2 diabetes mellitus (DM). It is characterized by speci ﬁ c loss of pericytes, which leads to an augmented blood vessel permeability, and development of new blood vessels (retinal neovascularization). Moreover, stiffening of eye membrane, in ﬂ ammation, and apoptosis of endothelial cells also lead to damage of the blood – retinal barrier and blindness in most cases unless it ’ s detected and managed early. Hence, this review was intended to assess the potential roles of Netrin-1 and -4 as new/alternative biomarkers and therapeutic options for DR. Netrin-1 and -4 have been the most known ligands and are well known for their role in neural guidance. DR has both neural and vascular components; therefore, biomarkers used for both neural and vascular retinal tissues are potentially important. According to different experimental and clinical studies, as compared to the normal groups, there was a signi ﬁ cant increment in both retinal Netrin-1 and -4 mRNA and protein levels in the retinopathy groups. In addition, exogenous supplementation of these proteins is also used as a therapeutic agent for DR.
The results of this study are supported by an explora- tory analysis of data from the RIDE/RISE trials, which demonstrated that ranibizumab reduced the risk of worsen- ing of DR severity, with improvement in DR severity seen in many patients. 24,25 Among patients who received rani- bizumab 0.3 or 0.5 mg every 4 weeks (n=468), 13.2% and 14.5% of patients, respectively, had an ≥ 3 Early TreatmentDiabeticRetinopathy Study severity level improvement from baseline at 2 years, compared with 1.3% of sham patients (n=239; P<0.001). Furthermore, 37.2% and 35.9% of patients, respectively, had an ≥ 2 Early TreatmentDiabeticRetinopathy Study severity level improvement over the same period, compared with 5.4% of sham patients (P<0.001). 24 Similar proportions of ranibizumab- treated patients maintained this level of improvement through to 3 years post baseline. 25 Recently, the clinical relevance of these changes has been explored in a post hoc analysis of patients enrolled in the RIDE/RISE trials, showing that improvements in DR severity were asso- ciated with greater VA gains, improved contrast sensitivity, and increased likelihood of resolution of macular edema. 26 In addition, an exploratory analysis by Bressler et al from the DRCR Network Protocol I study of 792 eyes from patients with center-involved DME causing VA impairment suggested that ranibizumab (0.5 mg every 4 weeks for 12 weeks, then as needed with either prompt or deferred [ ≥ 24 weeks] laser) was also associated with a reduced risk of DR worsening in eyes with and without PDR versus sham with prompt laser. 27 Similar ﬁ ndings were noted in uncontrolled case series with ranibizumab 28,29 as well as other anti-VEGF agents used for treatment of DME. 30 Additionally, the 2-year results of the DRCR Network Protocol S study comparing PRP with ranibizumab treatment for PDR demonstrated non- inferiority of ranibizumab (0.5 mg up to every 4 weeks based on a structured re-treatment program) to PRP (com- pleted in 1 – 3 visits, plus ranibizumab for DME); notably, 53% of patients in the PRP group received ranibizumab injections for DME. 8 The ﬁ ndings of this study suggest that anti-VEGF therapy with ranibizumab may have addi- tional utility as a treatmentoption for PDR when it has developed, including preservation of peripheral visual ﬁ eld that occurs following PRP and a marked reduction in the occurrence of macular edema in patients with PDR with- out concurrent macular edema at the time of diagnosis.
PDR, either as monotherapy or, more commonly, as an adjunct to PRP. PRP remains popular because the treatment effect is longer than anti-VEGF and because anti-VEGF therapy requires a high degree of patience compliance for frequent injections. 21 Combination treatment with PRP and anti-VEGF is a popular treatmentoption that allows for more rapid regression of neovascularization via anti-VEGF with more long-term protection against recurrent neovasculariza- tion via PRP. Combination PRP and intravitreal ranibizumab treatment showed less adverse effects on retinal functions than PRP alone, possibly because less intense PRP treatment was required. 22 PRP is typically titrated to ensure regression or stabilization of neovascularization, and the ideal amount of treatment is unknown. In this study, alternations in retinal function after PRP were demonstrated. These ﬁ ndings help quantify the degree of ERG loss after each session of 350 – 400 spots of PRP treatment. A better understanding of the degree of retinal damage following PRP may be helpful in determining the ideal amount of laser treatment that bal- ances regression of retinal neovascularization while mini- mizing reductions in retinal function.
PDR as often as previously thought, although screening also serves the purpose of detecting DME. 26 Only 2.3-8.6% of patient eyes that had no DR or very mild NPDR and had not required anti-VEGF treatment progressed to PDR in 5 years. Similarly, the 4-year incidence of PDR in patients with no baseline DR was 2.8% (33/1164) in a meta-analysis that included 14 studies conducted during 1986 and 2008. 24 Nevertheless, 0.3-0.8% of these eyes progressed to PDR in 1 year, suggesting that more specific, feature-based criteria would be advantageous in determining the appropriate frequency of follow-up. Our study findings need to be replicated and validated in future studies prior to recommending different
UNC5H2-Ig chimera, thereby preventing both from binding endogenous ligand or receptors and from poten- tially masking endogenous netrin-1 gradients. For all measures before and after treatment, neurons from tad- poles co-treated with netrin + UNC5H2-Ig were similar to controls. After injection, tadpoles were imaged every 2 h for 4 h and then again at 24 h. Only neurons that were accessible to imaging and intact 8 h after initial im- aging were included in the analysis. Images were ac- quired using LSM 5 Pascal confocal microscope with a × 63/0.95 water immersion objective. Optical sections were collected at 1.2-μm intervals. Diffusion of injected proteins was confirmed by immunohistochemistry on groups of non-imaged animals fixed immediately after treatment. Diffusion of recombinant netrin was analyzed using MetaMorph. A quantitative measure of the relative intensity of the immunofluorescent signals was obtained from confocal images acquired with identical laser cap- ture settings from brains of untreated, vehicle-injected, and netrin-1-injected tadpoles. The average pixel inten- sity values (gray level, 255 maximum) in 20-pixel-wide line scans along the medial to lateral axis of the tectum (from the ventricle to the lateral-most side of the tec- tum, excluding pia and skin) were measured with Meta- Morph; pixel intensity values were averaged for every 5 μm and normalized to those at the highest intensity value for each group.
Although PEX together with corticosteroids are the back- bone of the upfront management of patients with aTTP with successful outcomes, patients may remain refractory and/or relapse following an initial response to this treatment. There are some therapeutic options, which can be used among these patients and help in improving outcomes of aTTP. Caplacizumab has recently been approved in adult patients experiencing an episode of aTTP in the EU. The drug mainly has a protective effect in the acute phase aTTP; however, it does not modify the underlying immune pathophysiology of aTTP and patients still need to use it in combination with immunosuppression. Future studies are needed, which will focus on the risk factors for relapse including ADAMTS13 activity and anti-ADAMTS13 autoantibodies, which can stop caplacizumab activity and to evaluate whether these tests can be used to guide the duration of therapy, together with the potential role of caplacizumab in refractory aTTP.
Following an acclimation period, thirty-two, 24-day-old rats were randomly divided into four groups (each consisting of eight animals). The first group (control group) received 0.2 mL of subcutaneous saline for 6 consecutive days (days 25–30) and no further intervention. Subcutaneous injections of 10 IU recombinant FSH (Gonal-f; Darmstadt, Germany) were administered to the remaining 24 rats on 5 consecutive days (on a daily basis from day 25 to day 29). Then, on day 6, 30 IU of hCG (Pregnyl; N.V. Organon, Schiphol-Rijk, the Netherlands) was administered for induction of ovarian hyperstimulation. After OHSS induction (on a daily basis till day 30), the rats were randomly divided into three equal groups, resulting in a total of four groups. Group 2 (OHSS group) received no intervention after hCG was administered and OHSS was established. After OHSS induction, group 3 (cabergoline group) received 100 mg/kg of cabergoline (Dostinex; Pfizer, New York, NY, USA) orally for 6 days, and group 4 (celecoxib group) received 25 mg/kg of celecoxib (Celebrex; Pfizer) orally for 6 days. All groups were evaluated in terms of weight, hematocrit, VEGF, ET-1, and IL-2 levels on the initial day of the study (day 0), on day 6 (pretreatment), and on day 12 (after treatment following decapitation on day 36). Decapitation was performed under general anesthesia following administration of intraperitoneal ketamine (75 mg/kg, Ketalar 500 mg injectable vial; Pfizer) and xylazine (10 mg/kg, Xylased 100 mg ampule; Bioveta, Ivanovice na Hank, Czechoslovakia). All hormones were administered subcutaneously. Increased weight and hema- tocrit values were the criteria for successful establishment of OHSS as previously described by Ohba et al. 16
More recently, dual inhibition of MDM2/MDMX as a therapeutic strategy is undergoing clinical evaluation. MDMX similar to MDM2 also represses TP53 transcriptional activity. It is hypothesized that targeting TP53 interac- tions with MDM2 and MDMx will have a more significant impact than MDM2 inhibition alone. ALRN-6924 is a novel “stapled peptide”, which has been structurally stabilized in an α -helical configuration, to mimic the inhibitor binding region of TP53. By mimicking this region, ALRN-6924 can bind the 2 most important endogenous inhibitors of p53, MDM2 and MDMX. In Phase I/Ib study, ALRN-6924 was evaluated alone and in combination with cytarabine in AML patients. 73
were made according to the International Classi ﬁ cation of Headache Disorders, 3rd edition (beta version). 6 Only those who met the inclusion criteria were enrolled for this study. The inclusion criteria were: 1) no blindness; 2) no deafness; 3) can participate in normal communica- tion; 4) can read and ﬁ ll out the questionnaire; and 5) has signed the informed consent. Exclusion criteria were: 1) pregnant women; 2) with severe gastrointestinal diseases; 3) with metabolic diseases; 4) with mental illnesses; 5) with malignant tumors; 6) with severe heart diseases; 7) with hematological diseases; 8) with severe liver and kid- ney diseases; and 9) refused to sign informed consent. VM patients were assigned as the derivation cohort, and non- VM patients were assigned as controls.
In the global DR study, longer duration of T2DM, higher level of HbA1c, and poorer blood pressure control were strongly associated with DR. 3,35 In the present study, we showed a similar result, in that, diabetic duration, HbA1c, SBP, and DBP were signi ﬁ cantly associated with DR in the univariate analysis. It has been previously reported that dysli- pidemia was associated with DR. 36 While the relationship between DR and plasma lipid levels was not signi ﬁ cant in our study. Lee 37 did not ﬁ nd a signi ﬁ cant correlation between the TG/HDL-C ratio and DR. They have hypothesized that serum lipids were involved more in the later stages of DR than the early stages. Unexpectedly, we found there was positive correlation between increased CAVI and carotid plaque with HDL-C. Many large cohort studies and randomized trails have showed that HDL-C is a strong, independent, inverse predictor
Abstract: To report a treatment of radiation retinopathy in a patient exposed to ionizing radiation for a period of 2 years. A 26-year-old female patient with no comorbidities diagnosed with myelodysplasia con ﬁ rmed by bone marrow biopsy. She presented a com- plaint of bilateral progressive visual acuity reduction. At the ophthalmologic examination, she presented alterations suggestive of radiation retinopathy as well as macular thickness to optical coherence tomography (OCT) of over 500 µm. The patient underwent intravitreal injection (0.05 mL) of ranibizumab (Lucentis ® ) monthly in both eyes and follow-up through visual acuity and OCT examination. She presented reduction of macular edema as well as a slight improvement of visual acuity. In this case, the treatment of radiation retinopathy with intravitreal injection of ranibizumab (Lucentis) was relatively useful, with a slight improve- ment of visual acuity, due to the regression of macular edema, not being curative.
variable regarding neurodevelopmental outcomes in infants with ROP receiving anti-VEGF therapy. Morin et al 20 noted that, in 125 infants treated for ROP, the odds of having a severe neurodevelopmental disability (severe cerebral palsy, hearing aids, or bilateral blindness) were 3.1 times higher with bevacizumab versus laser treatment. However, the authors acknowledged the study was limited by being retro- spective, nonrandomized and because infants treated with bevacizumab tended to be sicker with more severe health problems. In contrast, Araz-Ersan et al 21 evaluated series of 13 infants treated with combination intravitreal bevacizumab and laser therapy for ROP, compared with an age-matched control group of children who had received laser treatment for ROP, and found no difference in the mean cognitive, language, or motor scores based on the Bayley Scales of Infant Development (BSID) test. Lien et al 22 reported no difference in mental or psychomotor impairment when com- paring bevacizumab monotherapy to laser monotherapy, but patients with combination therapy of laser and bevacizumab had higher incidence of mental or psychomotor impairment.
However, a research based on Chinese population illu- strated that patients with diabetic foot and compound con- ditions expressed a higher serum CA125 level. 18 While the relationship between DR and CA125 has not been explored till now. Pathological angiogenesis is the com- mon characteristic of cancer and retinopathy. 12 Our study illustrated that CA125 level was signi ﬁ cantly higher in patients with DR, especially VTDR and the independent association was further con ﬁ rmed. Consequently, the actual relationship between CA125 and the diabetic micro- vascular complication DR has not been explained funda- mentally. Pathological angiogenesis is the common characteristic of cancer and retinopathy. 26 Previous studies have discussed the potential mechanisms of serum CA125 elevation in cardiovascular diseases including chronic heart failure, atrial ﬁ brillation, aortic stenosis, coronary heart disease, etc, 27 and CA125 were produced from mesothelial cells mainly in response to in ﬂ ammatory sti- muli and ﬂ uid overload. 25 Considering DR is a kind of hyperplastic lesion of micro-vessels, we put forward the theory that proliferative vessels might undergo similar process with above-mentioned cardiovascular diseases, such as vascular wall expansion and congestion, leading Table 4 Associations Between Quartiles of CA125 and Various Stages of DR After Controlling for Confounding Factors
The network was constructed by using the graph theore- tical network analysis toolbox GRETNA (http://www. nitrc.org/projects/gretna/). 51 Node de ﬁ nition: each sub- ject ’ s brain was divided into 90 cortical and subcortical regions of interest, based on the automated anatomic label- ing (AAL) atlas 52 (Table S1). To de ﬁ ne the edges of the network, the mean time series of each region was acquired. Pearson ’ s correlation coef ﬁ cients between the regional mean time series of all possible pairs of the 90 brain regions were then calculated as edges in the network, resulting in a 90×90 Pearson ’ s correlation. Then, this matrix was converted into a binary matrix, where the entry aij equaled 1 if the absolute Pearson correlation between regions i and j exceeded the threshold, and equaled 0 otherwise. 53 All individual correlation maps were z-transformed with Fisher ’ s r-to-z transformation to reduce the in ﬂ uence of individual variation for group statistical comparisons.
Few studies have investigated the effect of PRP laser in proliferative diabeticretinopathy patients on visual evoked potential parameters. Shenoy et al 19 assessed PRVEP para- meters prior to and 4 weeks after PRP in patients with uncontrolled diabetes mellitus and reported a signi ﬁ cant decrease in VEP amplitudes in 48% and increase in latency in 75% of eyes. Consistent with Shenoy ’ s 19 study, reduction in P100 amplitude and delay in P100 latency was observed in the patients with proliferative diabeticretinopathy in the current study. However, the relative recovery of P100 amplitude and latency were observed after 1.5 months of ﬁ nal laser therapy. Perhaps the reason for the differences in the results of these two studies is related to the number of patients, the method of measuring VEP parameters, the laser treatment method and the duration of the evaluation after the PRP. In fact, most studies have assessed the changes of visual evoked potential components in diabetes without any medical intervention in eye structures or even prior to the onset of vascular abnormalities. The results of various studies about changes in visual evoked potential components due to diabetes pointed to a delay in latency, especially P100 wave, in patients with different types of diabetes, as well as with or without retinopathy. 20 – 25 In fact, the high varia- bility of P100 latency changes ranging from 9% to 77% were found in these studies. However, in the present study, changes in PRVEP parameters after laser therapy were evaluated and, contrary to the mentioned studies, changes were not only considered in diabetes but in all of the patient ’ s therapeutic procedures including three laser ther- apy sessions.
The present analysis also found that a 2-step or greater DR improvement at month 6 was more common among eyes with DME resolution by month 3 than in those who still had DME at month 3. Corresponding data, consistent with the results of our new predictive analysis, were reported by Ip et al, 24 who found that resolution of DME and signi ﬁ cant improvement in best-corrected visual acuity (BCVA) is more common in eyes with an at least 2- or 3-step DR improvement at month 24. In fact, addi- tional analyses on RIDE/RISE data demonstrated that among eyes that had both resolution of DME and a 2-step or greater DR improvement at month 3, only 17.5% experienced an additional 2-step or greater DR improvement between months 3 and 24 (unpublished data). This is expected because most of these eyes had improved to the point that they no longer had room to improve by an additional 2 or more steps in DR severity. These data are in accord with and supportive of the RIDE/ RISE analyses published by Ip et al, 24 which show that DR step improvements in patients with DME correlate with BCVA letter improvements, indicating the clinical impor- tance of DR severity regression. Together, these ﬁ ndings show that there is a correlation between DME and DR responses to ranibizumab; this is consistent with the fact that both are associated with a VEGF-driven pathophysiol- ogy and that DME occurs as a complication of DR. Based on the existing data, we hypothesize that eyes that have early resolution of DME accompanied by early improve- ments in DR could be potentially good candidates for less frequent (less-than-monthly) ranibizumab treatment, while some eyes that do not have early resolution of DR and DME may bene ﬁ t from continued treatment with anti- VEGF therapy for up to 12 – 18 months (when the plateau of the population response is reached; Figure 1).
stages as non-proliferative diabeticretinopathy (NPDR) and proliferative diabeticretinopathy (PDR). NPDR can be subdivided into mild, moderate and severe. Mild NPDR is an early stage with microaneurysm (MA) and dot/blot hemorrhage (HA) occurring. Flame-shaped hemorrhages (FSHs), hard exudates (HEs) and cotton-wool spots (CWSs) occur in moderate NPDR stage as the disease progresses. In the severe NPDR stage, many more MAs, HAs or venous beading (VB) occurs. The PDR stage is the advanced stage of DR. The significant pathologies are new abnormal blood vessels that called neovascularization (NV), pre-retinal hemorrhages (PHs), vitreous hemorrhage (VH), and fibrous proliferation (FP), which is the cause of tractional retinal detachment. Screening and diagnosing DR early can prevent visual loss and blindness in these diabetic patients. In distant rural area, however, there is no ophthalmologist available. Therefore, we developed automation software that can screen and diagnose
serin proteases are considered key mediators of the in- nate immune response [11,12] and can activate specific receptors named protease-activated receptors (PARs) on the membrane of immune cells such as neutrophils, eo- sinophils and macrophages. PARs are a family of four re- ceptors (PAR1-4) involved in the intracellular signaling cascade and PAR-1 and PAR-4 appear to be essential during inflammatory responses . In neutrophils, cell activation is accompanied by Akt (also known as protein kinase B) phosphorylation, rise of intracellular Ca +2 and for- mation of actin filaments, leading to better cell motility . The crucial role of PARs activation during disease pro- gression was revealed in animal models of inflammation such as gastrointestinal diseases, neuroinflammatory and neurodegenerative processes, skin, or allergic responses  and insulin-deficient murine type 1 diabetes models . Moreover, the expression of mRNA of the four mem- bers of PARs was found in the postnatal eye and in the ret- ina of adult rat . PAR-2 is expressed in a variety of cells, including neuronal tissue, leukocytes, and vascular endothe- lial cells  and it was found involved in neovascularization processes of proliferative retinopathies . Furthermore, PAR-2 has a link between pro-inflammatory and pro- angiogenic effects mediated by TNF-α, via MEK/EK1/2 pathway in the retina . In summary, the inhibition of serine proteases that activate PARs could contribute to de- creasing the inflammatory and pro-angiogenic process.
Truncated netrin-1 isoforms are present in the vitreous humor of patients with DME. To assess the potential involvement of netrin-1 in DR, we first investigated protein levels in vitreous humor from patients with DME, selected according to their macular thickness as determined by spectral-domain optical coherence tomogra- phy (SD-OCT) (>250 μm) (Table 1). Representative SD-OCT 3D retinal maps and cross sections are shown in Figure 1, A and B. Full-length netrin-1 is a 604-aa protein comprising the N-termi- nal to the C-terminal of one laminin domain (domain VI), 3 lami- nin EGF-like domains (domains V 1 , V 2 , and V 3 ), and a netrin-like domain (NTR) module also called the C domain (Figure 1C). We used a netrin-1 Ab with specificity to sequences within domain V for Western blot analysis (Figure 1C). Western blot analysis of equal volumes of vitreous (Figure 1D) revealed a major band at 72 kDa corresponding to full-length netrin-1 (Figure 1D) and an increase in a 55-kDa fragment of netrin-1 in patients with DME. According to their mass and prospective fragmentation profiles, netrin-1 bands at 55 kDa were consistent with the proteolytic processing of full-length netrin-1 to remove one of its domains (Figure 1E). Densitometric analysis revealed the 55-kDa truncat- ed form of netrin-1 to be significantly increased by approximate- ly 8-fold in patients with DME (healthy patients 1.000 ± 0.053, DME patients 8.433 ± 3.038, P = 0.0270) (Figure 1F), coincident with a nonsignificant drop in the amount of full-length netrin-1 (healthy patients 1.000 ± 0.2474, DME patients 0.443 ± 0.1476) (Figure 1G). Importantly, higher levels of the truncated 55-kDa form of netrin-1 correlated with increased retinal edema as deter- mined by SD-OCT (r 2 = 0.5235, P < 0.05) (Figure 1H), whereas
Notes: (A) Computerized software determination of Zone 1 in retinopathy of prematurity (ROP) (yellow circle). Notice the image processing capabilities (change brightness, contrast, and color saturation), which can aid in the modification of the original photo to allow a more accurate review. (B) Fundus image of the left eye of an infant with a heavily pigmented fundus obtained with a wide-field contact fundus camera (RetCam; Clarity Medical Systems, Pleasanton, CA, USA) and type 1 ROP requiring laser treatment. Media opacity is due to vitreous hemorrhage, which renders the retinal vessels difficult to discern.