ANTIANGIOGENIC ISOFORMS OF VASCULAR ENDOTHELIAL GROWTH FACTOR PREDOMINATE IN SUBRETINAL FLUID OF PATIENTS WITH RHEGMATOGENOUS RETINAL DETACHMENT AND PROLIFERATIVE VITREORETINOPATHY

Clinical therapeutics for proliferative vitreoretinopathy in retinal detachment

Proliferative vitreoretinopathy (PVR) is an abnormal and prolonged healing response to retinal injury (retinal detachment, post retinal detachment surgery) characterised by: pre/subretinal membrane formation; retinal gliosis and retinal shortening, retinal pigment epithelium cell proliferation; and increased glial (mainly Mu¨ller cells), fibroblast and inflammatory cell (macrophage, lymphocyte) activity, leading to tractional retinal holes/breaks and multiple costly eye operations suffered by patients. PVR can cause retinal re-detachment following primary surgical intervention for rhegmatogenous retinal detachment. Vitrectomy and scleral buckling surgery are the main approaches for treating PVR complications of retinal detachment. Patients require many operations to remove the scar tissue but vision results are suboptimal, and do not meet patient expectations. Over the past 40 years, this has been one of the greatest challenges for vitreoretinal surgeons and patients. Despite previous large clinical trials of multiple candidate drug therapeutics, no proven adjunctive treatment currently exists to either prevent, reduce, or treat PVR formation in retinal detachment. Both cellular proliferation and the intraocular inflammatory response are realistic targets for adjunctive treatments in PVR. The cellular components of PVR periretinal membranes (retinal pigment epithelial, glial, inflammatory and fibroblastic cells) proliferate and are thus targets for antiproliferative agents. In recent years, several new therapeutics have been tested, and we present an updated review of the clinical therapeutics for PVR in retinal detachment.

Predictive values of systemic inflammation biomarkers in proliferative vitreoretinopathy associated with primary rhegmatogenous retinal detachment

CLINICAL RELEVANCE

Proliferative vitreoretinopathy (PVR) is still the leading cause of surgical failure after rhegmatogenous retinal detachment (RRD) repair. The factors that can predict the development of PVR remain to be elucidated.

BACKGROUND

This study evaluates the predictive values of the systemic immune-inflammation index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in patients with primary RRD with and without PVR.

METHODS

A total of 150 patients with RRD and 51 age- and sex-matched healthy participants were included in the study. Patients who developed PVR within three months after surgery were enrolled as PVR cases (n = 75, Group 1), and those who did not develop PVR were enrolled in RRD without the PVR group (n = 75, Group 2). Ocular examination findings and medical records of all participants were analysed retrospectively. Peripheral blood samples were collected, and systemic immune-inflammation index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratios were calculated. The systemic immune-inflammation index calculation formula is: (Neutrophil/lymphocyte) × Platelet.

RESULTS

The median neutrophil-to-lymphocyte ratio and systemic immune-inflammation index levels were significantly higher in Group 1 patients compared to Group 2 and the control groups (p = 0.01, for both). However, the groups were similar regarding median platelet-to-lymphocyte ratio (p = 0.917). The optimal cut-off values of neutrophil-to-lymphocyte ratio and systemic immune-inflammation index were calculated as 1.72 (with 72% sensitivity and 48% specificity) and 407.9 (with 72% sensitivity and 49.3% specificity), respectively, for predicting PVR development in patients with RRD.

CONCLUSION

Neutrophil-to-lymphocyte ratio and systemic immune-inflammation index may be useful biomarkers for predicting the risk of PVR development in RRD patients.

Intravitreal Injection of Bevacizumab for the Prevention of Postoperative Proliferative Vitreoretinopathy in High-Risk Patients Selected by Laser Flare Photometry

INTRODUCTION

To evaluate the effect of an intravitreal injection of bevacizumab at the time of rhegmatogenous retinal detachment (RRD) surgery, on postoperative proliferative vitreoretinopathy (PVR) in high-risk patients selected by laser flare photometry.

METHODS

This single-center observational retrospective cohort study included 137 consecutive patients who underwent pars plana vitrectomy and gas tamponade for primary RRD with increased aqueous flare between July 2016 and June 2021. From June 2019, an intravitreal injection of bevacizumab was administered as an adjunct to RRD repair. Patients who underwent surgery before this time and who did not receive intravitreal bevacizumab served as controls. The main outcome was the rate of retinal redetachment due to PVR.

RESULTS

The median flare value was 22.0 (16.5-36.5) pc/ms in the control group and 28.2 (19.7-41.0) pc/ms in the bevacizumab group (p = 0.063). Eyes treated with bevacizumab were more likely to have macula-off RRD (p = 0.003), grade B PVR (p = 0.038), and worse visual acuity (p = 0.004) than controls. The rate of PVR redetachment was significantly lower in the bevacizumab group (11.1%) than in the control (30.1%) (p = 0.012). This difference was more pronounced after adjusting for potential confounding factors (p = 0.005); the risk of developing PVR was 4.5-fold higher in controls (95% CI, 1.6-12.8). After adjustment, the final median visual acuity was also significantly higher in eyes treated with bevacizumab (p = 0.025).

CONCLUSION

This pilot study provides preliminary evidence that bevacizumab may reduce the risk of PVR-related recurrent RRD and improve visual outcomes in high-risk patients selected by laser flare photometry.

Vitreal Concentrations of Vascular Endothelial Growth Factor in Patients with Rhegmatogenous Retinal Detachment

The purpose of this study is to evaluate the concentration of vascular endothelial growth factor (VEGF) in the vitreous humor of patients with primary rhegmatogenous retinal detachment (RRD). This is a prospective case control study. Eighteen patients with primary RRD without proliferative vitreoretinopathy C (PVR C) were enrolled as cases, and twenty-two non-diabetic retinopathy patients who were candidates for complete pars plana vitrectomy due to Macular Hole or Epiretinal Membrane were included as the control group. Undiluted vitreal samples were collected during the initiation of Pars Plana Vitrectomy (PPV) prior to any infusion into the posterior cavity. Vitreous samples were also collected from 21 fresh cadaveric globes. The vitreous concentration of VEGF was measured by enzyme-linked immunosorbent assay (ELISA) technique and compared between these two groups. The vitreal concentration of VEGF was 0.643 ± 0.088 ng/mL in the RRD group. Measured concentrations of VEGF in controls were 0.043 ± 0.104 ng/mL, and in cadaveric eyes they were 0.033 ± 0.058 ng/mL. The mean VEGF concentration in the RRD group was statistically higher than in the control group (p < 0.0001) and cadaveric eyes (p < 0.0001). Our study shows that vitreal VEGF concentrations significantly increase in patients with RRD.

Vitreous humor proteome: unraveling the molecular mechanisms underlying proliferative and neovascular vitreoretinal diseases

Proliferative diabetic retinopathy (PDR), proliferative vitreoretinopathy (PVR), and neovascular age-related macular degeneration (nAMD) are among the leading causes of blindness. Due to the multifactorial nature of these vitreoretinal diseases, omics approaches are essential for a deeper understanding of the pathophysiologic processes underlying the evolution to a proliferative or neovascular etiology, in which patients suffer from an abrupt loss of vision. For many years, it was thought that the function of the vitreous was merely structural, supporting and protecting the surrounding ocular tissues. Proteomics studies proved that vitreous is more complex and biologically active than initially thought, and its changes reflect the physiological and pathological state of the eye. The vitreous is the scenario of a complex interplay between inflammation, fibrosis, oxidative stress, neurodegeneration, and extracellular matrix remodeling. Vitreous proteome not only reflects the pathological events that occur in the retina, but the changes in the vitreous itself play a central role in the onset and progression of vitreoretinal diseases. Therefore, this review offers an overview of the studies on the vitreous proteome that could help to elucidate some of the pathological mechanisms underlying proliferative and/or neovascular vitreoretinal diseases and to find new potential pharmaceutical targets.

Comparison between Vascular Endothelial Growth Factor and Platelet-Derived Growth Factor Levels in Rhegmatogenous Retinal Detachment

Introduction

This study aimed to assess vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) levels within vitreous and blood serum samples of patients with rhegmatogenous retinal detachment (RRD) and their relationship to the development of proliferative vitreoretinopathy (PVR).

Methods

Seventeen eyes of patients with RRD were included in the RRD group and divided into three subgroups: RRD without PVR, RRD with PVR grades A and B, and RRD with PVR grade C. Five control eyes (nucleus and intraocular lens drop) were included in this study. Blood serum and vitreous samples were collected during vitrectomy. VEGF-A and PDGF-AA levels were determined by enzyme-linked immunosorbent assay.

Results

The mean vitreous VEGF-A level in the RRD group was 131.71 ± 58.25 pg/mL, and the mean vitreous PDGF-AA level was 174.62 ± 65.17 pg/mL. Both levels were significantly higher in the RRD group compared with the control group (p < 0.05). Vitreous VEGF-A and PDGF-AA levels were the highest in RRD with PVR grade C subgroup, with mean levels of 179.87 ± 21.02 pg/mL and 229.44 ± 14.09 pg/mL, respectively (p < 0.05). The vitreous VEGF-A/PDGF-AA ratios in the RRD subgroups were completely different.

Conclusion

Based on the tendency of VEGF-A and PDGF-AA levels, RRD surgery has to be performed as soon as possible prior to retinal cell death and membrane proliferative formation.

Determining the effect of low-dose isotretinoin on proliferative vitreoretinopathy: the DELIVER trial

PURPOSE

To examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair.

METHODS

Prospective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery.

RESULTS

The single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%).

CONCLUSION

The management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.

EFFICACY OF INTRAVITREAL INJECTION OF BEVACIZUMAB IN VITRECTOMY FOR PATIENTS WITH PROLIFERATIVE VITREORETINOPATHY RETINAL DETACHMENT: A Meta-analysis of Prospective Studies

PURPOSE

To evaluate the effect of intravitreal injection of bevacizumab in vitrectomy for patients with proliferative vitreoretinopathy (PVR)-related retinal detachment.

METHODS

The PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from their earliest entries through October, 2016, to identify the studies that had evaluated the effects of intravitreal injection of bevacizumab in vitrectomy for eyes with PVR-related retinal detachment. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. The relevant data were analyzed using Stata 12.0 software. The weighted mean difference, relative risk, and their 95% confidence intervals were used to assess the strength of the association.

RESULTS

The authors' search yielded 133 records from which 3 studies that have examined the effects of intravitreal injection of bevacizumab (120 eyes with PVR-related retinal detachment) were included for review and analysis. Their meta-analyses showed that neither the best-corrected visual acuity nor retinal redetachment rate showed any clinically or statistically important difference between the nonbevacizumab and bevacizumab groups (P > 0.05). In addition, bevacizumab did not influence the interval between vitrectomy and retinal redetachment (P > 0.05).

CONCLUSION

Based on the available evidence, intravitreal injection of bevacizumab in vitrectomy for patients with PVR-related retinal detachment did not decrease retinal redetachment rate or improve visual acuity. Better-designed studies with larger simple sizes and longer follow-up periods are required to reach valid conclusions regarding benefits and harms. Moreover, evaluation of anti-vascular endothelial growth factor therapy on surgical outcomes in eyes with milder subtypes of PVR or no PVR, but deemed at high risk of PVR, may be worthy of future consideration.

Intravitreal Injection of Bevacizumab in Primary Vitrectomy to Decrease the Rate of Retinal Redetachment: A Randomized Pilot Study

Purpose:

To evaluate the effect of intravitreal bevacizumab (IVB) as a surgical adjunct in prevention of proliferative vitreoretinopathy (PVR) after retinal detachment surgery.

Methods:

In this controlled, randomized pilot study, 27 patients with primary retinal detachment undergoing pars plana deep vitrectomy were included. Of these, 12 received IVB at the end of procedure. The anatomic success and best corrected visual acuity (BCVA) were compared to the control group at months 3 and 6 postoperatively.

Results:

At three month follow-up, 3 of 11 eyes (27.3%) had detached retinas in the IVB group versus 6 of 12 (50.0%) in the control group (P = 0.40). At six-month follow-up, 3 of 10 eyes (30%) had detached retinas in the IVB group versus 3 in 8 (37.5%) in the control group (P > 0.99). Mean logMAR BCVA improved significantly in both groups relative to baseline, but did not show a significant difference at three-and six-month follow-ups between the two groups.

Conclusion:

Our preliminary results show neither a benefit nor any harm from intervention in both anatomic and visual outcomes. Our results support conducting additional studies to evaluate the effect of intravitreal bevacizumab on postoperative PVR.

Expression of Total Vascular Endothelial Growth Factor and the Anti-angiogenic VEGF 165 b Isoform in the Vitreous of Patients with Retinopathy of Prematurity

Background:

This study was to examine the expression of total vascular endothelial growth factor (VEGF) and the anti-angiogenic VEGF₁₆₅b isoform in the vitreous body of retinopathy of prematurity (ROP) patients, and to further study the role of the VEGF splicing in the development of ROP.

Methods:

This was a prospective clinical laboratory investigation study. All patients enrolled received standard ophthalmic examination with stage 4 ROP that required vitrectomy to collect the vitreous samples. The control samples were from congenital cataract patients. The expression of total VEGF and the anti-angiogenic VEGF₁₆₅b were measured by enzyme-linked immunosorbent assay. Results were analyzed statistically using nonparametric tests.

Results:

The total VEGF level was markedly elevated in ROP samples while VEGF₁₆₅b was markedly decreased compared to control group. The relative protein expression level of VEGF₁₆₅b isoform was significantly decreased in ROP patients which were correlated with the ischemia-induced neovascularization.

Conclusions:

There was a switch of VEGF splicing from anti-angiogenic to pro-angiogenic family in ROP patients. A specific inhibitor that more selectively targets VEGF₁₆₅and controls the VEGF splicing between pro- and anti-angiogenic families might be a more effective therapy for ROP.

Effect of Serial Intrasilicone Oil Bevacizumab Injections in Eyes With Recurrent Proliferative Vitreoretinopathy Retinal Detachment

PURPOSE

To investigate the effect of serial intrasilicone oil bevacizumab injections (1.25 mg/0.05 mL) on visual acuity (VA) and anatomic outcomes in eyes undergoing proliferative vitreoretinopathy (PVR)-related retinal detachment (RD) repair.

DESIGN

Prospective, nonrandomized, historical-control pilot study.

METHODS

setting: Tertiary care center.

STUDY POPULATION

Nondiabetic eyes undergoing pars plana vitrectomy (PPV) and silicone oil tamponade with or without scleral buckling procedure (SBP) for recurrent RD due to PVR.

INTERVENTION

Intrasilicone oil injection of 1.25 mg bevacizumab was performed intraoperatively and at postoperative months 1, 2, and 3.

OUTCOMES

Retinal reattachment rate, final VA, and rate of epiretinal membrane (ERM) formation at month 6.

RESULTS

Twenty eyes of 20 patients were enrolled and compared to a historical control group composed of 35 age- and sex-matched controls. In the study group, logMAR VA improved from mean 1.78 ± 0.43 (Snellen 20/1205) to 1.43 ± 0.70 (Snellen 20/538, P = .04), retinal reattachment was achieved in 14 of 20 eyes (70%), and ERM formation was observed in 7 of 20 eyes (35%) at 6 months. In the control group, logMAR VA improved from mean 1.50 ± 0.74 (Snellen 20/632) to 1.43 ± 0.58 (Snellen 20/538, P = .64), retinal reattachment was achieved in 25 of 35 eyes (71%), and ERM formation was observed in 7 of 35 eyes (20%) at 6 months. No significant difference in final VA (P = .96), retinal reattachment rate (P = .75), or ERM formation (P = .33) was observed between groups. No intrasilicone oil injection-related adverse events occurred.

CONCLUSIONS

Serial intrasilicone oil injections of bevacizumab did not improve retinal reattachment rate, improve final VA, or reduce ERM formation in patients undergoing PVR-related RD surgery.

Defining the seriousness of proliferative vitreoretinopathy by aspiration of cytokines from the anterior chamber

AIM

Proliferative vitreoretinopathy is the major cause of retinal detachment surgery failure. Our prospective cohort study of 27 eyes aimed to determine intraocular levels of growth factors and cytokines in patients with retinal detachment with various degrees of severity of proliferative vitreoretinopathy using multiplex xMAP(®) Technology.

PATIENTS & METHODS

The concentrations of 12 proangiogenic, antiangiogenic, inflammatory and neurotrophic factors were measured from 0.05-ml samples of intraocular fluid using multiplex xMAP Technology. The results were compared with levels of various factors, which were measured in samples from the control group of 31 eyes prior to senile cataract surgery.

RESULTS

The concentration of the MCP-1 cytokine was found to be higher in eyes with retinal detachment compared with the control group. The concentration of VEGF was found to be higher in eyes with retinal detachment complicated with proliferative vitreoretinopathy compared with the uncomplicated retinal detachment group and the control group.

CONCLUSION

MCP-1 and VEGF may participate in pathogenesis of retinal detachment and proliferative vitreoretinopathy. Biomarkers in disease detection and management have become important tools in modern clinical medicine, and their application to retinal disease should be no exception.

Intrasilicone oil injection of bevacizumab at the end of retinal reattachment surgery for severe proliferative vitreoretinopathy

PURPOSE

To evaluate the role of bevacizumab injected into the silicone oil at the end of retinal reattachment surgery for rhegmatogenous retinal detachment (RRD) associated with severe proliferative vitreoretinopathy (PVR) for prevention of postoperative PVR and compare the results with those without intrasilicone injection.

METHODS

In this prospective comparative interventional study, eyes with RRD with grade C PVR were included. Standard 20 gauge pars plana vitrectomy, and retinal reattachment was performed. In case group, 1.25 mg bevacizumab was injected into the silicone oil at the end of surgery. The rate of retinal redetachment associated with PVR was assessed.

RESULTS

In all 38 eyes of 38 patients (19 cases and 19 controls) with a mean age of 46.6 ± 18.3 years were studied. The two groups were matched for age, sex, preoperative visual acuity, presence of anterior and posterior PVR, extent of PVR, and history of previous retinal detachment surgery. Retinal redetachment with PVR occurred in nine (47.3%) and seven (36.8%) eyes in case and control groups, respectively (P=0.5). Extensive subretinal fibrous proliferations in addition to preretinal membranes occurred more in the case group (55.5 vs 14.3%). At final visit, visual acuity was similar between the two groups (1.6 ± 0.8 and 1.6 ± 0.6, respectively, P=0.9).

CONCLUSION

Intrasilicone injection of bevacizumab at the end of vitrectomy for RRD with severe PVR does not eliminate the risk of postoperative PVR.

Expression of IGFBP‑6 in proliferative vitreoretinopathy rat models and its effects on retinal pigment epithelial‑J cells

Proliferative vitreoretinopathy (PVR) is one of the most common causes for failed retinal detachment surgeries. The aim of the present study was to investigate the role of insulin‑like growth factor‑binding protein‑6 (IGFBP‑6) in PVR using rat models and its effects on retinal pigment epithelial‑J (RPE‑J) cells. PVR Wistar rat models were administered intravitreal injection of RPE‑J cells (1x106/5 µl) combined with platelet‑rich plasma (1x107/5 µl). The concentration of IGFBP‑6 in the vitreous and serum of rats was tested by an enzyme‑linked immunosorbent assay and the expression of IGFBP‑6 mRNA in the liver and retina of rats was determined by quantitative polymerase chain reaction (qPCR). The expression of IGFBP‑6 mRNA in the RPE‑J cells stimulated by vitreous or serum from PVR patients or normal volunteers was also determined by qPCR. The proliferation of RPE‑J cells was evaluated by the 3‑(4,5‑dimethylthiazol‑2‑yl)‑5‑(3‑carboxymethoxyphenyl)‑2‑(4‑sulfophenyl)‑2H‑tetrazolium, inner salt (MTS) method. The success rate of PVR rat model induction at the 8th week was 89.5% (34/38). The concentration of IGFBP‑6 in the vitreous and serum of PVR rats was significantly higher than that of the control group (P<0.05). The expression of IGFBP‑6 mRNA in the retina of PVR rats was also significantly higher compared with the control group (P<0.05). The vitreous from PVR patients and donors significantly stimulated the expression of IGFBP‑6 mRNA in the RPE‑J cells (P<0.05). IGFBP‑6 only inhibited IGF‑II‑stimulated proliferation but not the basal level of proliferation or the PDGF/VEGF‑stimulated RPE‑J cell proliferation. Thus, the trends and effects of IGFBP‑6 provide the possibility of PVR therapeutic targets, with the vitreous representing a significant environmental factor in the progression of PVR.

Increased intravitreal angiopoietin-2 levels associated with rhegmatogenous retinal detachment

PURPOSE

To explore factors related to pathogenesis of rhegmatogenous retinal detachment (RRD) and development of proliferative vitreoretinopathy (PVR), vitreous levels of angiopoietin-1 and -2 (Ang-1 and -2), previously undefined in RRD, transforming growth factor-(TGF) β1, vascular endothelial growth factor (VEGF), erythropoietin (EPO) and proteolytic mediators of extracellular matrix remodelling (MMP-2 and -9) were compared in eyes with RRD and eyes with idiopathic macular hole or pucker.

METHODS

Vitreous samples were collected from 117 eyes with RRD (study group) and 40 eyes with macular hole or pucker (control group). Growth factors were measured by ELISA and matrix metalloproteinases (MMPs) by gelatin zymography.

RESULTS

The mean vitreous concentrations of Ang-2, MMP-2, and MMP-9 were higher (all p < 0.01), whereas concentration of VEGF was lower (p = 0.01) in eyes with RRD relative to controls. Logistic regression analysis identified Ang-2 concentration as a novel marker of RRD (p = 0.0001, OR 48.7). Ang-1, EPO, and total TGF-β1 levels were not significantly different between the groups. However, TGF-β1 and MMP-2 were increased in eyes with total RRD compared to those with local RRD (p ≤ 0.05). In eyes with PVR, no differences were observed in any studied marker as compared with non-PVR eyes.

CONCLUSIONS

Current results reveal Ang-2 as a key factor upregulated in RRD. It may co-operate with fibrosis-associated factors and contribute to vascular complications such as breakdown of blood-eye barrier and PVR development.

Mechanisms of inflammation in proliferative vitreoretinopathy: from bench to bedside

Proliferative vitreoretinopathy (PVR) is a vision-threatening disease and a common complication of surgery to correct rhegmatogenous retinal detachment (RRD). Several models of the pathogenesis of this disease have been described with some of these models focusing on the role of inflammatory cells and other models focusing on the role of growth factors and cytokines in the vitreous which come into contact with intraretinal and retinal pigment epithelial cells. New experiments have shed light on the pathogenesis of PVR and offer promising avenues for clinical intervention before PVR develops. One such target is the indirect pathway of activation of platelet-derived growth factor receptor alpha (PDGRα), which plays an important role in PVR. Clinical trials assessing the efficacy of 5-fluorouracil (5-FU) and low-molecular-weight heparin (LMWH), daunorubicin, and 13-cis-retinoic acid, among other therapies, have yielded mixed results. Here we review inflammatory and other mechanisms involved in the pathogenesis of PVR, we highlight important clinical trials, and we discuss how findings at the bench have the potential to be translated to the bedside.