Real-World Vision in Age-Related Macular Degeneration Patients Treated with Single Anti-VEGF Drug Type for 1 Year in the IRIS Registry.

PURPOSE: The purpose of this study is to compare real-world visual acuity (VA) in patients with neovascular age-related macular degeneration (nAMD) treated with a single anti-vascular endothelial growth factor (VEGF) drug monotherapy for 1 year from the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) Registry. DESIGN: Retrospective, nonrandomized, comparative study. PARTICIPANTS: IRIS Registry patients with nAMD who received bevacizumab, ranibizumab, or aflibercept only for 1 year between 2013-2016. METHODS: Participants were divided into 3 groups based on monotherapy type. Multivariate analysis of covariance models (ANCOVA) was constructed in a stepwise fashion. MAIN OUTCOME MEASURES: The logarithm of the minimum angle of resolution (logMAR) VA at 1 year and mean change in logMAR VA between baseline and 1 year were compared between drug types. RESULTS: Of 13 859 patients, 6723 received bevacizumab, 2749 received ranibizumab, and 4387 received aflibercept only for 1 year. A total of 84 828 injections were performed. The mean number of injections (standard deviation) at 1 year was higher in the ranibizumab (6.4 [±2.4]) and aflibercept groups (6.2 [±2.4]) compared to bevacizumab group (5.9 [±2.4]; P < 0.0001). In the age-adjusted model, both ranibizumab and aflibercept achieved better logMAR VA at 1 year compared with bevacizumab (0.50 [±0.49], 0.49 [±0.44], 0.55 [±0.57]; P < 0.0001). However, this difference was not significant after multivariate adjustment (age, baseline VA, diabetes, posterior vitreous detachment, number of injections, race, insurance). There was no statistical difference in the age-adjusted or multivariate-adjusted mean logMAR VA change (standard deviation) at 1 year among treatment groups (-0.048 [0.44] bevacizumab, -0.053 [0.46] ranibizumab, -0.040 [0.39] aflibercept; P = 0.46). A higher percentage of patients achieved a ≥3-line VA improvement at 1 year in the bevacizumab group (22.7%) compared with ranibizumab (20.1%; P = 0.0093) and aflibercept (17.8%; P < 0.0001). However, after multivariate adjustment, aflibercept exhibited a greater log odds of a ≥3-line VA loss compared with bevacizumab only (1.25 log odds ratio; P < 0.0016). CONCLUSIONS: This study suggests that all 3 drugs improve VA similarly over 1 year of monotherapy.

Right and left ventricular myocardial perfusion reserves correlate with right ventricular function and pulmonary hemodynamics in patients with pulmonary arterial hypertension.

PURPOSE: To evaluate the relationships of right ventricular (RV) and left ventricular (LV) myocardial perfusion reserves with ventricular function and pulmonary hemodynamics in patients with pulmonary arterial hypertension (PAH) by using adenosine stress perfusion cardiac magnetic resonance (MR) imaging. MATERIALS AND METHODS: This HIPAA-compliant study was institutional review board approved. Twenty-five patients known or suspected to have PAH underwent right heart catheterization and adenosine stress MR imaging on the same day. Sixteen matched healthy control subjects underwent cardiac MR imaging only. RV and LV perfusion values at rest and at adenosine-induced stress were calculated by using the Fermi function model. The MR imaging-derived RV and LV functional data were calculated by using dedicated software. Statistical testing included Kruskal-Wallis tests for continuous data, Spearman rank correlation tests, and multiple linear regression analyses. RESULTS: Seventeen of the 25 patients had PAH: 11 with scleroderma-associated PAH, and six with idiopathic PAH. The remaining eight patients had scleroderma without PAH. The myocardial perfusion reserve indexes (MPRIs) in the PAH group (median RV MPRI, 1.7 [25th-75th percentile range, 1.3-2.0]; median LV MPRI, 1.8 [25th-75th percentile range, 1.6-2.1]) were significantly lower than those in the scleroderma non-PAH (median RV MPRI, 2.5 [25th-75th percentile range, 1.8-3.9] [P = .03]; median LV MPRI, 4.1 [25th-75th percentile range, 2.6-4.8] [P = .0003]) and control (median RV MPRI, 2.9 [25th-75th percentile range, 2.6-3.6] [P < .01]; median LV MPRI, 3.6 [25th-75th percentile range, 2.7-4.1] [P < .01]) groups. There were significant correlations between biventricular MPRI and both mean pulmonary arterial pressure (mPAP) (RV MPRI: ρ = -0.59, Bonferroni P = .036; LV MPRI: ρ = -0.79, Bonferroni P < .002) and RV stroke work index (RV MPRI: ρ = -0.63, Bonferroni P = .01; LV MPRI: ρ = -0.75, Bonferroni P < .002). In linear regression analysis, mPAP and RV ejection fraction were independent predictors of RV MPRI. mPAP was an independent predictor of LV MPRI. CONCLUSION: Biventricular vasoreactivity is significantly reduced with PAH and inversely correlated with RV workload and ejection fraction, suggesting that reduced myocardial perfusion reserve may contribute to RV dysfunction in patients with PAH.

High-sensitivity C-reactive protein as an associate of clinical subsets and organ damage in systemic lupus erythematosus.

OBJECTIVE: C-reactive protein (CRP) may play an anti-inflammatory role during the acute phase of inflammation and is also used as a marker of inflammation associated with cardiovascular disease. In the present study, we investigated the association between high-sensitivity CRP (hsCRP) and systemic lupus erythematosus (SLE) manifestations, autoantibodies, and organ damage. METHODS: In this cross-sectional study, 610 SLE patients from a prospective cohort had more than 1 hsCRP measurement. Organ damage was assessed using the Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology Damage Index. Multiple linear regression models were used to adjust for age, gender, ethnicity, disease duration, body mass index, education, disease activity, current prednisone dose, statin use, and estrogen use. RESULTS: After adjusting for confounders, hsCRP was associated with myocarditis, cardiac murmur, interstitial pulmonary fibrosis, pulmonary hypertension, gastrointestinal lupus manifestations, and anemia. Anti-dsDNA antibodies and lupus anticoagulant were associated with hsCRP in unadjusted models, and these associations remained significant after adjustment for confounders. hsCRP levels were significantly higher in patients with pulmonary, musculoskeletal, and endocrine damage, and a total SLICC Damage Index score>or=1. After adjustment, hsCRP was associated with pulmonary, musculoskeletal, and total damage, but no longer with endocrine damage. CONCLUSIONS: hsCRP is associated with a broad range of clinical features and organ damage in SLE, particularly in the pulmonary and musculoskeletal systems. This association holds true independent of sociodemographic, disease activity, and treatment factors and may be useful to identify high-risk SLE patients who would benefit from additional screening and surveillance studies.

Superior Recess Access of the Lumbar Facet Joint.

STUDY DESIGN: Descriptive approach to accessing the lumbar facet joint by superior recess. OBJECTIVE: This study is aimed to describe an approach to accessing the lumbar facet joint through targeting the superior recess during lumbar facet joint injections. SUMMARY OF BACKGROUND DATA: Lumbar facet joint injections are routinely performed for both the diagnosis and treatment of chronic low back pain. Previous studies either did not specify which part of the joint to target, or recommended targeting the inferior aspect of the joint to access the inferior recess. One study did mention the superior recess as an alternative to injecting the inferior recess, but none has focused on description of the technique. This is the first time this technique has been described. MATERIALS AND METHODS: The records and fluoroscopic images were reviewed for all patients over a period of 9 months (January-September 2012) using the proposed technique. This resulted in a total of 48 patients; 15 men, 29 women, and a total of 117 facet joint intra-articular injections. Among these 48 patients, injections were repeated in total of 4 cases. The average time of injections among 4 repeat cases was 121 days. The success of the procedure was confirmed with an arthrogram demonstrating contrast flowing from the superior recess inferiorly through the joint space. RESULTS: Successful access of the lumbar facet joint through puncture of the superior recess was seen in 114 cases, with 3 unsuccessful attempts to enter facet joints due to osteophytes at involved levels. There were no complications observed during the procedure. CONCLUSIONS: We find this approach to be highly successful, safe, and well tolerated by the patient and recommend it as a technique for access of the lumbar facet joint in those patients in whom direct puncture of the inferior recess is difficult.

Aflibercept: a novel VEGF targeted agent to explore the future perspectives of anti-angiogenic therapy for the treatment of multiple tumors.

Angiogenesis is the process of formation of new blood vessels due to over expression of VEGF (vascular endothelial growth factor) which plays a critical role in the growth and development of all solid tumor types. With the advancement in understanding of tumor angiogenesis and VEGF, there have been a number of agents developed to target VEGF for the treatment of cancer. These targeted agents can affect downstream VEGF signal transduction by unique mechanisms at different cellular and extracellular levels. FDA has recently approved Aflibercept or VEGF-Trap in August 2012 for the treatment of colorectal cancer. It is a recombinant, decoy receptor fusion protein, rationally designed to block angiogenesis by targeting VEGF-A, VEGF-B and placental growth factor. VEGF-Trap exerts its antiangiogenic effects through regression of tumor vasculature, remodelling or normalization of surviving vasculature and inhibition of new tumor vessel growth. In this review, pre-clinical and clinical data have been summarized for aflibercept alone and in combination with chemotherapy to explore its efficacy and benefits in ovarian cancer, breast cancer, non-small cell lung cancer, pancreatic cancer, glioblastoma, adenocarcinoma and renal cell cancer xenograft models.

Linaclotide-a novel secretagogue in the treatment of irritable bowel syndrome with constipation and chronic idiopathic constipation.

Irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are highly prevalent gastrointestinal disorders. Traditional symptoms based therapies had somewhat limited success and efficacy in addressing the disorders. Recently, linaclotide emerged as novel peptide capable of improving abdominal symptoms in patients suffering from IBS-C and CIC. Guanylate cyclase C (GC-C) receptor a multi domain protein, found to be molecular target for linaclotide which acts by activating GC-C receptor on the apical surface of intestinal epithelial cells. Binding of linaclotide to GC-C receptor triggers the elevation of second messenger cGMP that elicits fluid secretion into intestinal cells which play a critical role in maintaining homeostasis through cystic fibrosis transmembrane conductance regulator (CFTR). Data from Phase II and III clinical trials demonstrated that linaclotide seems to produce a statistically significant increase in stool frequency, improved straining, decreased abdominal pain and discomfort.

Enzalutamide: a novel anti-androgen with prolonged survival rate in CRPC patients.

Prostate cancer is the most common malignancy among men found to be the second leading cause of male cancer-related mortality due to development of resistance against androgen deprivation therapy (ADT). With the advancement in understanding of prostate cancer, numbers of agents have been emerged to target Androgen-Receptor (AR) signaling for the treatment of castration resistant prostate cancer (CRPC). Food and Drug Administration (FDA) has recently approved enzalutamide (XTANDI) for the treatment of CRPC. Androgen receptor promotes the prostate cancer progression after transformation. Androgen receptor signaling leads to CRPC when cellular nucleus binds to DNA and increases pro cancer gene expression. In phase ΙΙΙ clinical trial, enzalutamide showed that 160 mg once daily oral administration is well tolerated and significantly enhanced overall survival in men with CRPC after chemotherapy, demonstrated by reduction in the serum prostate specific antigen (PSA) level and increased survival rate by 4.8 months.

Increased right ventricular Septomarginal trabeculation mass is a novel marker for pulmonary hypertension: comparison with ventricular mass index and right ventricular mass.

OBJECTIVE: : To prospectively evaluate the cardiac magnetic resonance (MR) imaging-derived measurement of right ventricular (RV) septomarginal trabeculation (SMT) mass as a noninvasive marker for pulmonary hypertension (PH), compared with the ventricular mass index (VMI = RV mass/left ventricular mass) and RV mass. MATERIALS AND METHODS: : A total of 49 patients (60 ± 12 years; 35 female) with suspected PH underwent cardiac MR and right heart catheterization on the same day. Eighteen normal volunteers were also included. The performance of SMT mass, VMI and RV mass measurement, with regard to PH detection, was analyzed using receiver operating characteristic curves. Logistic regression analysis was used to assess the association between SMT mass, RV mass, VMI, and PH. RESULTS: : The area under the receiver operating characteristic curve for SMT mass/body surface area (BSA), VMI, and RV mass/BSA in diagnosing the presence or absence of PH was 0.88, 0.87, and 0.73 respectively. In multivariable models, both SMT mass/BSA (P = 0.005, odds ratio: 8.6) and VMI (P = 0. 012, odds ratio: 1.1) were found to be significant, independent predictors of PH. CONCLUSION: : Compared with right heart catheterization measurement, SMT mass and VMI are reproducible and noninvasive MR imaging markers for the diagnosis of PH.

Prevalence of flare and influence of demographic and serologic factors on flare risk in systemic lupus erythematosus: a prospective study.

OBJECTIVE: We determined the prevalence of and risk factors for British Isles Lupus Activity Group (BILAG) flare in patients with systemic lupus erythematosus (SLE). METHODS: We followed 299 patients for 1 year with the BILAG scores calculated using British Lupus Integrated Prospective System software and confirmed with manual calculation. RESULTS: "A" flares occurred at a rate of 0.254/year, "B" flares 1.637/year, and A or B flares 1.765/year. The most common A flares were renal and mucocutaneous. The most common B flares were hematologic, renal, mucocutaneous, and musculoskeletal. Risk factors for a later A or B flare in the hematological system included: low C3 (p < 0.0001), low C4 (p = 0.0004), and positive anti-double-stranded (ds)DNA (p = 0.003); in the mucocutaneous system: low C3 (p = 0.02) and low C4 (p = 0.0004); and in the renal system: low C3 (p = 0.02) and low C4 (p = 0.02). In a stepwise regression model, only ethnicity (p = 0.02) and low C4 (p = 0.0002) remained as independent predictors of later A or 2B flares. CONCLUSION: The organ system distribution of A and B flares is very different, with A flares more common in renal and mucocutaneous, and B flares more common in hematologic and renal systems. A or 2B flares are significantly more common in African Americans and in patients with abnormal serologies (low C3, low C4, or high anti-dsDNA). If flare is an outcome in an SLE clinical trial, these factors must be balanced by taking them into account at baseline in terms of randomization, or by statistical adjustment in final analyses.

Urine osteoprotegerin and monocyte chemoattractant protein-1 in lupus nephritis.

OBJECTIVE: Renal biopsy is the "gold standard" to determine renal activity in systemic lupus erythematosus (SLE), but it is expensive, invasive, and carries risk. Osteoprotegerin (OPG) is produced by the heart, lungs, kidney, and bone. Monocyte chemoattractant protein-1 (MCP-1), a chemotactic cytokine, is involved in the progression of glomerular and tubulointerstitial injury. We investigated both urine OPG and MCP-1 as potential biomarkers for lupus nephritis. METHODS: Our subjects, 87 patients with SLE (88% women; 48% African American, 41% Caucasian, 11% other), mean age 44 years, were followed monthly to quarterly. Urinary OPG (pg/ml) and MCP-1 (pg/ml) were measured (Luminex MAP bead assay). RESULTS: OPG concentrations were strongly associated with global disease activity and with both renal activity on a visual analog scale (VAS) (p = 0.0006) and renal disease activity descriptors of the SELENA SLEDAI, including hematuria (p = 0.001) and a positive anti-dsDNA (p = 0.013). MCP-1 was also associated with the renal VAS (p = 0.032), renal disease activity descriptors of SELENA SLEDAI, including hematuria (p = 0.027), and with a positive anti-dsDNA (p = 0.016). We also examined the relationship between the biomarkers and having a urine protein to creatinine ratio (pr/cr) > or = 0.5. Among patients with medium or high OPG, 46% had urine pr/cr > or = 0.5, compared to only 23% among those with low OPG (p = 0.032). The 2 biomarkers were strongly correlated with each other (Spearman correlation coefficient 0.77, p < 0.0001). CONCLUSION: The lack of availability of urine biomarkers has hampered development of new therapies for lupus nephritis. Urine MCP-1 and OPG were both associated with measures of lupus renal disease activity. Medium or high levels of OPG were predictive of a urine protein/creatinine ratio of > or = 0.5. Further study, including longitudinal assessment and correlation with concurrent renal biopsies, is necessary before this assay can be used in the routine clinic setting.