Attenuation of hepatitis A antibody after immunization with hepatitis A vaccine (Aimmugen) in people living with HIV

AIM

Hepatitis A (HA) is a vaccine-preventable disease. In regions with good sanitation, men who have sex with men (MSM) are the key affected populations. During the 2018-2019 HA outbreak among MSM in Japan, we actively vaccinated MSM living with HIV (MSM-LWHIV) with Aimmugen. As previously reported, their antibody seroconversion rate due to vaccination was lower than that of healthy individuals. However, the durability of Aimmugen in people living with HIV has not yet been reported. We evaluated attenuation after the one-series vaccination (comprising three inoculations) and the factors associated with attenuation.

METHODS

We retrospectively examined anti-HA immunoglobulin G (anti-HA-IgG) titers and other clinical data from our hospital's medical records. Patients with no history of vaccination or HA infection (i.e., negative HA-IgG titers) who received one series of Aimmugen, achieved seropositivity, and anti-HA-IgG antibodies were tested ≥2 years after three doses were included. Fisher's exact test and the Mann-Whitney U-test were performed. p < 0.05 was considered statistically significant.

RESULTS

Fifty-one MSM-LWHIV were included. All were seropositive after the third dose with a median HA-IgG titer of 10.1 (interquartile range, 7.2-12.2) (sample/cut-off values [s/co]). In 45 (40-49) months, seropositivity decreased to 90% (46/51) and was attenuated to a median of 4.4 (2.3-6.5) s/co. Lower baseline B cell counts (p = 0.049), lower anti-HA-IgG levels after the second dose (p = 0.002), and lower anti-HA-IgG levels after the third dose (p = 0.003) were associated with seronegativity.

CONCLUSIONS

Anti-HA-IgG titers of vaccinated MSM-LWHIV may be attenuated; thus, additional immunizations should be considered.

Crisis management for the future: Building a platform to provide information on emerging and re-emerging infectious diseases from normal times in Japan

At the beginning of the mpox (disease caused by monkey pox) epidemic, there was no platform in Japan to provide appropriate information on emerging and re-emerging infectious diseases (EIDs), and the number of accesses to bioterrorism-related information sites increased rapidly. Even though the interest in mpox was much smaller than in coronavirus infectious disease, emerged in late 2019 (COVID-19), the increase in the number of views were much greater than during the COVID-19 epidemic. This may not be because mpox is bioterrorism-related as an analog of smallpox, but rather because there were no other websites providing information on mpox. For future crisis management, there should be a platform to provide information on possible epidemics of EIDs from normal times in Japan.

Favorable Virological Outcome, Characteristics of Injection Site Reactions, Decrease in Renal Function Biomarkers in Asian People with HIV Receiving Long-Acting Cabotegravir Plus Rilpivirine

Long-acting cabotegravir plus rilpivirine has revolutionized the concept of antiretroviral therapy, but as the causes of virological failure and satisfaction can depend on patient background, real-world data are needed. In this single-center study, we reviewed clinical records of people with HIV (PWH) who received injectable cabotegravir plus rilpivirine between June 2022 and January 2023. We assessed virological and safety outcomes, including injection site reactions (ISRs) and changes in serum creatinine and cystatin C. Seventy-four patients were included. There were no virological failures. Approximately 80% of individuals achieved HIV-RNA undetectable in all visits up to 14 months (median 13 months) after switching. Pain upon injection was significantly more common at the rilpivirine injection site, while delayed pain was significantly more common at the cabotegravir injection site. The serum creatinine (mean difference -0.12 mg/dL, p < .0001) and the cystatin C (mean difference -0.077 mg/dL, p < .0001) decreased significantly after switching, and in multivariable regression analysis, baseline characteristics did not affect the decrease in these renal function markers. Long-acting cabotegravir plus rilpivirine showed excellent antiviral efficacy and safety in PWH in Japan. ISRs were characterized differently at the cabotegravir and rilpivirine injection sites. Although cystatin C showed decrease after the regimen switch, further confirmation is needed whether cabotegravir plus rilpivirine can improve renal function.

Brief communications: changes in inflammatory biomarkers and lipid profiles after switching to long-acting cabotegravir plus rilpivirine

We assessed whether the impact of cabotegravir plus rilpivirine on inflammation reduction differs from that of oral antiretrovirals, using real-world data. Inflammatory biomarkers and lipid profiles were followed from baseline to 8 months after switching. Seventy-eight participants were analyzed. The CD4/CD8 ratio and C-reactive protein did not change. There were transient decreases in CD8 and CD4 counts in the group that switched from the dolutegravir-based regimen, but not in the tenofovir alafenamide-based regimen group. High-density lipoprotein (HDL) cholesterol increased, resulting in a decrease in the total-cholesterol to HDL cholesterol ratio, whereas there was no significant change in low-density lipoprotein cholesterol.

Antiviral efficacy against and replicative fitness of an XBB.1.9.1 clinical isolate

The emergence and spread of new SARS-CoV-2 variants with mutations in the spike protein, such as the XBB.1.5 and XBB.1.9.1 sublineages, raise concerns about the efficacy of current COVID-19 vaccines and therapeutic monoclonal antibodies (mAbs). In this study, none of the mAbs we tested neutralized XBB.1.9.1 or XBB.1.5, even at the highest concentration used. We also found that the bivalent mRNA vaccine could enhance humoral immunity against XBB.1.9.1, but that XBB.1.9.1 and XBB.1.5 still evaded humoral immunity induced by vaccination or infection. Moreover, the susceptibility of XBB.1.9.1 to remdesivir, molnupiravir, nirmatrelvir, and ensitrelvir was similar to that of the ancestral strain and the XBB.1.5 isolate in vitro. Finally, we found the replicative fitness of XBB.1.9.1 to be similar to that of XBB.1.5 in hamsters. Our results suggest that XBB.1.9.1 and XBB.1.5 have similar antigenicity and replicative ability, and that the currently available COVID-19 antivirals remain effective against XBB.1.9.1.

Waning cellular immune responses and predictive factors in maintaining cellular immunity against SARS-CoV-2 six months after BNT162b2 mRNA vaccination

Several clinical trials have shown that the humoral response produced by anti-spike antibodies elicited by coronavirus disease 2019 (COVID-19) vaccines gradually declines. The kinetics, durability and influence of epidemiological and clinical factors on cellular immunity have not been fully elucidated. We analyzed cellular immune responses elicited by BNT162b2 mRNA vaccines in 321 health care workers using whole blood interferon-gamma (IFN-γ) release assays. IFN-γ, induced by CD4 + and CD8 + T cells stimulated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike epitopes (Ag2), levels were highest at 3 weeks after the second vaccination (6 W) and decreased by 37.4% at 3 months (4 M) and 60.0% at 6 months (7 M), the decline of which seemed slower than that of anti-spike antibody levels. Multiple regression analysis revealed that the levels of IFN-γ induced by Ag2 at 7 M were significantly correlated with age, dyslipidemia, focal adverse reactions to full vaccination, lymphocyte and monocyte counts in whole blood, Ag2 levels before the second vaccination, and Ag2 levels at 6 W. We clarified the dynamics and predictive factors for the long-lasting effects of cellular immune responses. The results emphasize the need for a booster vaccine from the perspective of SARS-CoV-2 vaccine-elicited cellular immunity.

Preseptal cellulitis with Streptococcus pyogenes complicated by streptococcal toxic shock syndrome: A case report and review of literature

Preseptal cellulitis, an infection of the eyelid and skin around the eye, can be distinguished from orbital cellulitis. It is common in children and is rarely complicated. Streptococcus pyogenes is one of the major pathogens causing preseptal cellulitis. Here, we report a case of a 46-year-old man with carcinoma of unknown primary presenting preseptal cellulitis of S. pyogenes complicated by streptococcal toxic shock syndrome and multiple metastatic abscesses involving right eyelid, subcutaneous tissue in the scalp, mediastinum, bilateral pleural spaces, pericardial space, and the left knee. Although he required a prolonged hospitalization, antibiotic therapy and multiple courses of debridement led to full recovery. A literature review revealed that there were only four cases of preseptal cellulitis with S. pyogenes in adults and two cases were complicated by streptococcal toxic shock syndrome. The cases had either trauma or immunocompromising factors similar to our patient. All patients survived with antibiotic therapy and debridement, and the functional outcome was favorable. In summary, preseptal cellulitis caused by S. pyogenes can be severe in adult cases where immunocompromising factors and type of strain may play a role in the severity of the disease. Awareness of the risk of severe complications, treatment with appropriate antibiotic therapy, and timely debridement are crucial for favorable prognoses.

Multicenter, single-blind, randomized controlled study of the efficacy and safety of favipiravir and nafamostat mesilate in patients with COVID-19 pneumonia

OBJECTIVES

To evaluate the efficacy and safety of nafamostat combined with favipiravir for the treatment of COVID-19.

METHODS

We conducted a multicenter, randomized, single-blind, placebo-controlled, parallel assignment study in hospitalized patients with mild-to-moderate COVID-19 pneumonia. Patients were randomly assigned to receive favipiravir alone (n = 24) or nafamostat with favipiravir (n = 21). The outcomes included changes in the World Health Organization clinical progression scale score, time to improvement in body temperature, and improvement in oxygen saturation (SpO₂).

RESULTS

There was no significant difference in the changes in the clinical progression scale between nafamostat with favipiravir and favipiravir alone groups (median, -0.444 vs -0.150, respectively; least-squares mean difference, -0.294; P = 0.364). The time to improvement in body temperature was significantly shorter in the combination group (5.0 days; 95% confidence interval, 4.0-7.0) than in the favipiravir group (9.0 days; 95% confidence interval, 7.0-18.0; P =0.009). The changes in SpO₂ were greater in the combination group than in the favipiravir group (0.526% vs -1.304%, respectively; least-squares mean difference, 1.831; P = 0.022). No serious adverse events or deaths were reported, but phlebitis occurred in 57.1% of the patients in the combination group.

CONCLUSION

Although our study showed no differences in clinical progression, earlier defervescence, and recovery of SpO₂ were observed in the combination group.

The association between adverse reactions and immune response against SARS-CoV-2 spike protein after vaccination with BNT162b2 among healthcare workers in a single healthcare system: a prospective observational cohort study

Adverse reactions after vaccination with COVID-19 mRNA vaccines are common; however, the association between adverse reactions and humoral responses is uncertain. To determine whether humoral immune responses after BNT162b2 vaccine administration were associated with local and systemic adverse reactions, we conducted a prospective observational cohort study in a single tertiary referral center. Healthcare workers who received the first dose of BNT162b2 vaccine were recruited. SARS-CoV-2 anti-spike IgG antibody titers were measured three weeks after the second dose and information about adverse reactions after vaccination was collected. Among the 887 participants, 641 (72.3%) were women. The median age was 38 (range, 22–74) years. All but one showed anti-spike IgG levels well above the cutoff, with a median level of 13,600 arbitrary units/mL. Overall, 800 (92.2%) participants reported some reactions after the first dose and 822 (96.3%) after the second dose. Significantly more participants reported systemic reactions after the second dose than after the first dose (P < .01), and 625 (73.6%) reported that reactions were stronger after the second dose. Factors positively associated with elevation of anti-spike IgG levels were history of asthma (24% higher if present, P = .01) and stronger reactions after the second dose (19% higher if experienced, P = .02). The majority of participants showed good humoral responses and reported some adverse reactions after vaccination. Anti-spike IgG levels were significantly higher if adverse reactions after the second dose were stronger than those after the first dose. These findings may help inform current and future vaccine recipients.

Plesiomonas shigelloides Septic Shock Following Ingestion of Dojo Nabe (Loach Hotpot)

Plesiomonas shigelloides is a gram-negative bacillus that commonly causes self-limited diarrhea in humans. We present the case of P shigelloides bacteremia in a 49-year-old man with alcoholic cirrhosis who developed septic shock a day after eating Dojo nabe (loach hotpot), a Japanese traditional dish.

Longitudinal analysis of the peripapillary retinal nerve fiber layer thinning in patients with retinitis pigmentosa

PURPOSE

To investigate longitudinal changes in peripapillary retinal nerve fiber layer (RNFL) thickness in patients with retinitis pigmentosa (RP).

METHODS

We re-examined 103 RP patients whose RNFL thickness was previously examined and reported. RNFL thickness was measured using Stratus optical coherence tomography and was compared with the previous measurements. The results were also compared with that of previously reported normal subjects. Association between the decrease rate and visual acuity, and visual field was also investigated.

RESULTS

The mean follow-up period was 56.9 months. After excluding the patients in whom RNFL images were of poor quality, 88 patients were eventually analyzed. The average RNFL thickness decreased from 105.8 to 98.2 μm during the period, with the average rate of decrease being 1.6 μm/year. The decrease in RNFL was more evident in superior and inferior sectors. Cross-sectional linear regression analysis also revealed an age-dependent decrease in RNFL, with the slower rate of decrease being 0.94 μm/year. The decrease in RNFL thickness was significantly faster than that reported in normal subjects. The decrease rate was not associated with visual functions.

CONCLUSION

Age-dependent RNFL thinning occurs at a faster rate in RP patients as compared with that in normal subjects. The result supports the notion that pathologic changes involve inner retina as well as outer retina in eyes with RP. Considering the discrepancy in the rate of RNFL thinning estimated from trend analysis and longitudinal measurement, care should be taken when interpreting the result of cross-sectional analysis.

ARMS2/HTRA1 and CFH polymorphisms are not associated with choroidal neovascularization in highly myopic eyes of the elderly Japanese population

PURPOSE

The purpose of this study was to investigate whether the genetic risk factors of age-related macular degeneration (AMD) are associated with the development of choroidal neovascularization (CNV) in highly myopic eyes of elderly Japanese.

METHODS

Highly myopic elderly Japanese patients with and without CNV were genotyped for three AMD-associated single nucleotide polymorphisms (SNPs), namely rs10490924 (A69S) of ARMS2, rs11200638 of HTRA1, and rs1061170 (Y402H) of complement factor H (CFH), with the TaqMan SNP assay. One hundred and eighty-three unrelated highly myopic (axial lengths>26.00 mm or refractive errors>-6.0 diopters) Japanese patients with CNV who were >or=50 years of age (mean age+/-standard deviation of 62.7+/-6.3 years) and 170 highly myopic patients without CNV who were >or=50 years old (62.3+/-7.1 years) were studied. The differences in the genotypic distributions for the three SNPs between the two groups were tested with the Trend chi2 test, and logistic regression analyses were performed for age and gender adjustment.

RESULTS

No significant difference was detected in the distribution of the three SNPs, rs10490924 (P>0.1), rs11200638 (P>0.1), and rs1061170 (P>0.5), between the two groups even after adjustments for age and gender differences.

CONCLUSION

The genetic risk factors of AMD related to these SNPs do not contribute significantly to the development of CNV in a highly myopic elderly Japanese population.

Photoreceptor integrity and visual acuity in cystoid macular oedema associated with retinitis pigmentosa

AIMS

To assess the correlation between macular morphology and visual acuity in retinitis pigmentosa (RP) patients with cystoid macular oedema (CME).

DESIGN

Retrospective cross-sectional study.

PATIENTS AND METHODS

Forty-one eyes of 25 RP patients with CME. Patients underwent cross-sectional scans with optical coherence tomography (Stratus OCT). Age, total retinal thickness, photoreceptor thickness, and the transverse and vertical lengths of the cystoid space were measured. Correlation between visual acuity and each of the measurements were examined. Additionally, the status of the inner segment/outer segment junction (IS/OS) was classified as being absent, discontinuous, or distinct. Measurements were then compared among the three groups.

RESULTS

Total retinal thickness or photoreceptor thickness was not correlated with visual acuity. There was a correlation between the transverse length of the cystoid space and visual acuity, although the correlation coefficient was weak (r=0.30). The logMAR visual acuity in the IS/OS absent group (0.67+/-0.43) was worse than that seen in the IS/OS discontinuous (0.22+/-0.19) or IS/OS distinct groups (0.07+/-0.16) (P<0.001).

CONCLUSIONS

When monitoring CME associated with RP, the status of IS/OS is the essential parameter that needs to be examined.

Circulating hematopoietic stem cells in patients with choroidal neovascularization secondary to pathologic myopia

BACKGROUND

Emerging evidences suggest that circulating hematopoietic stem cells (HSCs) affect the pathogenesis of choroidal neovascularization (CNV), however, the roles of HSCs in CNV remain unclear in human population. The current study was designed to investigate the role of HSCs in the pathogenesis of CNV secondary to pathologic myopia (PM).

METHODS

We clinically documented 78 patients with CNV in PM, and 35 of 78 patients and 28 age-matched controls were experimentally analysed. Functional analyses of HSCs were performed using an ex vivo culture system.

RESULTS

We disclosed colony-forming units of endothelial cell (CFU-EC) were markedly lower in patients with bilateral CNV compared to those with unilateral CNV (13.8+/-3.7 vs 45.9+/-7.8, P<0.001). Systemic characteristics between both groups showed no significant difference. To identify local ocular factors that may affect the occurrence of CNV, clinical parameters were compared with the following groups in all enrolled subjects: eyes with CNV vs without CNV in unilateral affected patients, and primary affected eyes vs secondary affected eyes in patients with bilateral CNV. However, no statistically significant factors were identified in any of the groups.

CONCLUSIONS

Circulating HSCs may play a role in the bilateral involvement of CNV in PM patients as one of the systemic factors. Further prospective and longitudinal studies are required.

Retinal nerve fiber layer thickness in patients with retinitis pigmentosa

PURPOSE

To study retinal nerve fiber layer (RNFL) thickness in patients with retinitis pigmentosa (RP).

DESIGN

Cross-sectional observational study.

METHODS

One hundred and thirty-seven eyes of 137 patients with RP were examined. The effect of age, gender, laterality, inheritance trait, spherical equivalent refractive error, visual acuity, and the extent of visual field defect on RNFL thickness measured with optical coherence tomography were analyzed by a multiple linear regression model.

RESULTS

The average RNFL thickness was 104.1+/-21.7 microm. The multiple R(2) for the model was 0.349. Among the variables studied, ageing and being male were significant risk factors for thinner RNFL thickness. RNFL thickness was not correlated with inheritance trait, laterality, refractive error, visual acuity, or the extent of visual field defect.

CONCLUSION

RNFL thickness in RP patients was not correlated with visual function but ageing as in the normal subjects. Currently proposed therapies, including photoreceptor rescue/transplantation and visual prosthesis, are based on the premise that the inner retinal structures are relatively retained despite the profound loss of photoreceptors. The present result supports this notion.

Angiotensin II induces expression of the Tie2 receptor ligand, angiopoietin-2, in bovine retinal endothelial cells

Recent studies have shown that angiopoietins (Angs) and their receptor, Tie2, play a role in vascular integrity and neovascularization. The renin-angiotensin system has been hypothesized to contribute to the development of diabetic retinopathy. In this study, we investigated the effect of angiotensin II (AII) on Ang1 and Ang2 expression in cultured bovine retinal endothelial cells (BRECs). AII stimulated Ang2 but not Ang1 mRNA expression in a dose- and time-dependent manner. This response was inhibited completely by angiotensin type 1 receptor (AT1) antagonist. AII increased the transcription of Ang2 mRNA, but did not change the half-life. Protein kinase C (PKC) inhibitor completely inhibited AII-induced Ang2 expression, and the mitogen-activated protein kinase (MAPK) inhibitor also inhibited it by 69.4+/-15.6%. In addition, we confirmed the upregulation of Ang2 in an AII-induced in vivo rat corneal neovascularization model. These data suggest that AII stimulates Ang2 expression through AT1 receptor-mediated PKC and MAPK pathways in BREC, and AII may play a novel role in retinal neovascularization.

Angiotensin II-stimulated vascular endothelial growth factor expression in bovine retinal pericytes

PURPOSE

Angiotensin II (AII) has been shown to play a role in many vascular diseases. In the study described, the effect of AII on vascular endothelial growth factor (VEGF) expression and related intracellular signaling mechanism was investigated in bovine retinal microcapillary pericytes.

METHODS

Cultured bovine retinal microvascular endothelial cells and pericytes were prepared. VEGF expression was determined by Northern blot analysis and immunoprecipitation assay. Cell proliferation was assessed by DNA content growth assay. Reporter gene studies were performed to identify the AII responsible transcription-activating region of VEGF gene.

RESULTS

Angiotensin II induced a significant increase in VEGF mRNA in a time- and dose-dependent manner. Angiotensin II type I receptor antagonist inhibited this effect. Angiotensin II activates the transcription of VEGF gene without changing the mRNA half-life, and the AII responsible region was found in the 5'-flanking region of the VEGF gene. Angiotensin II also increased the expression of c-fos and c-jun mRNA, and antisense oligonucleotides against c-Fos blocked the AII-induced VEGF mRNA expression. The conditioned media of AII-stimulated pericyte cultures had a growth-promoting effect on endothelial cells, and this effect was inhibited almost completely by VEGF neutralizing antibody.

CONCLUSIONS

These findings suggest that AII might induce angiogenic activity through a paracrine function of VEGF in retinal microvascular cells.

17 Beta-estradiol increases VEGF receptor-2 and promotes DNA synthesis in retinal microvascular endothelial cells

PURPOSE

Estrogen is known to promote angiogenesis in gonads. The presence of estrogen receptors in the vascular endothelium of organs other than gonads has been reported. The goal of this study was to determine whether estrogen promotes the proliferation of retinal microvascular endothelial cells and to explore the mechanism of it.

METHODS

DNA was quantitated using primary cultures of bovine retinal endothelial cells that were incubated with different doses of 17 beta-estradiol (E2), VEGF, or both. The changes in expression level of VEGF and VEGF receptor-2 (VEGFR2) were measured using northern blot analysis after treatment with E2. The presence of estrogen receptors in the endothelial cells was studied by immunohistochemistry and western blot analysis.

RESULTS

17 Beta-estradiol (E2) increased the DNA level in bovine retinal capillary endothelial cells (BRECs) by 177% at 1 nM (P < 0.05) and 150% at 10 nM (P < 0.05) by comparison with unstimulated BREC. One hundred nanomole tamoxifen completely blocked the E2-induced DNA synthesis in BRECs. Ten nanomole E2 augmented vascular endothelial growth factor (VEGF)-induced DNA synthesis in BRECs significantly (160%, P < 0.01). Ten nanomole E2 also increased VEGF mRNA expression, which peaked after 24 hours (6.7 times, P < 0.05), and VEGF receptor-2 (VEGFR2) mRNA expression, which peaked after 9 hours (2.4 times, P < 0.05). The mRNA expression level of VEGFR2 peaked with 10 nM E2 (P < 0.05) and that of VEGF reached maximum with 1 nM E2 (15 times, P < 0.001). VEGFR2 and VEGF proteins increased in parallel with their mRNA levels. Immunocytochemistry showed estrogen receptor expression in BRECs, and western blot analysis indicated the presence of a 67-kDa protein that was compatible with the estrogen receptor.

CONCLUSIONS

These findings suggest that E2 may stimulate BREC growth by the receptor-mediated pathway and that E2 may augment the VEGF-dependent angiogenesis partly through the upregulation of VEGFR2.

Expressions of angiopoietins and Tie2 in human choroidal neovascular membranes

PURPOSE

To elucidate the potential role of angiopoietins and the Tie2 system in choroidal neovascularization.

METHODS

Surgically excised choroidal neovascular membranes (CNVMs) were obtained at vitrectomy from five eyes with age-related macular degeneration, three eyes with idiopathic neovascular maculopathy, and two eyes had degenerative myopia and two eyes had angioid streaks. Light microscopic immunohistochemistry was performed to detect cytokines such as vascular endothelial growth factor (VEGF), Ang1, and Ang2 and cellular components such as retinal pigment epithelial (RPE) cells, macrophages, and endothelial cells. Immunofluorescent double staining using confocal microscopy was performed to identify the cell types that secrete specific cytokines.

RESULTS

Ang1 and Ang2 were positive in all surgically excised CNVMs, regardless of the primary disease. Double staining revealed that many of the cytokeratin, CD68 and factor VIII positive cells also had Ang1 and Ang2 immunoreactivities. In contrast to Ang1, Ang2 immunoreactivity tends to be higher in the highly vascularized regions of many CNVMs, and the localization was very similar to that of VEGF staining. Almost all vascular structures had prominent immunoreactivity for Tie2, which was confirmed by double staining for Tie2 and factor VIII. Tie2 immunoreactivity was also observed in the RPE monolayer and in pigmented, polygonal, and fibroblast-like cells in the stroma.

CONCLUSIONS

Present findings that Ang2 and VEGF are co-upregulated and that Tie2 is expressed in a variety of cell types in CNVMs further support a crucial role of the interaction between VEGF and Ang2 in pathologic angiogenesis of CNVM formation.

The potential angiogenic role of macrophages in the formation of choroidal neovascular membranes

PURPOSE

To investigate the distribution of inflammatory mediators such as interleukin (IL)-1beta and tumor necrosis factor (TNF)-alpha and angiogenic cytokines such as vascular endothelial growth factor (VEGF) and to identify their cellular source in surgically excised choroidal neovascular membranes (CNVMs) of various origins.

METHODS

Immunoperoxidase staining was performed on paraffin-embedded sections of 11 surgically excised CNVMs to identify cellular distribution and localization of cytokines. Immunofluorescent double staining was performed to detect the cellular source of cytokines.

RESULTS

Cytokeratin-positive cells were detected in the RPE layer, in stromal cells, and around neovascular vessels. Macrophages identified by their cellular marker CD68 showed almost the same distribution as cytokeratin-positive cells, although they were most prominent in the stroma. A substantial number of neovascular vessels were also immunoreactive to IL-1beta and TNF-alpha. Immunofluorescent double staining revealed that the RPE layers immunopositive for cytokeratin were also immunopositive for all cytokines, whereas stromal cells immunostained for CD68 were positive for IL-1beta and TNF-alpha, but not for VEGF.

CONCLUSIONS

These results indicate that IL-1beta and TNF-alpha secreted by macrophages may promote, at least in part, angiogenesis in CNVMs by stimulating VEGF production in RPE cells.

Hypoxia and vascular endothelial growth factor selectively up-regulate angiopoietin-2 in bovine microvascular endothelial cells

Recent studies have shown that the angiopoietin-Tie2 system is a predominant regulator of vascular integrity. In this study, we investigated the effect of two known angiogenic stimuli, hypoxia and vascular endothelial growth factor (VEGF), on these molecules. VEGF induced both a time- and concentration-dependent increase in angiopoietin-2 (Ang2) mRNA expression in bovine microvascular endothelial cells. This up-regulation was derived primarily from an increased transcription rate as evidenced by nuclear run-on assay and mRNA decay study. The increased Ang2 expression upon VEGF treatment was almost totally abolished by inhibition of tyrosine kinase or mitogen-activated protein kinase and partially by suppression of protein kinase C. Hypoxia also directly increased Ang2 mRNA expression. In contrast, Ang1 and Tie2 responded to neither of these stimuli. The enhanced Ang2 expression following VEGF stimulation and hypoxia was accompanied by de novo protein synthesis as detected by immunoprecipitation. In a mouse model of ischemia-induced retinal neovascularization, Ang2 mRNA was up-regulated in the ischemic inner retinal layer, and remarkable expression was observed in neovascular vessels. These data suggest that both hypoxia- and VEGF-induced neovascularization might be facilitated by selective induction of Ang2, which deteriorates the integrity of preexisting vasculature.

Expression of thrombospondin-1 in ischemia-induced retinal neovascularization

Thrombospondin-1 is an extracellular matrix protein that inhibits endothelial cell proliferation, migration, and angiogenesis. This study was performed to investigate the role of thrombospondin-1 in ischemic retinal neovascularization. In a murine model of retinal neovascularization, thrombospondin-1 mRNA was increased from postnatal day 13 (P13), with a threefold peak response observed on P15, corresponding to the time of development of retinal neovascularization. Prominent expression of thrombospondin-1 was observed in neovascular cells, specifically, cells adjacent to the area of nonperfusion. It has been suggested that vascular endothelial growth factor (VEGF) plays a major role in ischemia-induced retinal neovascularization of this model, so we studied the effects of VEGF on thrombospondin-1 expression. In bovine retinal microcapillary endothelial cells, VEGF induced a biphasic response of thrombospondin-1 expression; VEGF decreased thrombospondin-1 mRNA 0.41-fold after 4 hours, whereas it increased, with a threefold peak response, after 24 hours. VEGF-induced endothelial cell proliferation was completely inhibited by exogenous thrombospondin-1 and increased by 37.5% with anti-thrombospondin-1 antibody. The present findings suggest that, in the ischemic retina, retinal neovascular cells increase thrombospondin-1 expression, and VEGF may stimulate endogenous thrombospondin-1 induction, which inhibits endothelial cell growth. VEGF-mediated thrombospondin-1 induction in ischemia-induced angiogenesis may be a negative feedback mechanism.

New surgical approach for removing massive foveal hard exudates in diabetic macular edema

OBJECTIVE

To examine the efficacy of surgical removal of foveal hard exudates in diabetic macular edema and to determine the expression of vascular endothelial growth factor (VEGF) in the excised specimens.

DESIGN

Cohort study.

PARTICIPANTS

Seven eyes of six patients with massive subfoveal hard exudate due to diabetic macular edema were examined. The average age of the patient was 56 years (range, 46-60 years).

INTERVENTION

Pars plana vitrectomy for removal of massive foveal exudates was performed.

MAIN OUTCOME MEASURES

Preoperative and postoperative visual acuity and complications were recorded; immunohistochemical staining for VEGF and other cell markers for macrophage and pigment epithelial cells in excised specimens was performed.

RESULTS

Postoperative best-corrected visual acuity improved by two or more lines of Snellen equivalent in five eyes (71%) (P = 0.0061). VEGF, identified by anticytokeratin and CD68 antibodies, was expressed in pigment epithelial cells and macrophages invading the hard exudates.

CONCLUSION

Surgical removal of foveal hard exudates might be effective in low-vision patients with diabetic maculopathy. VEGF might play a role in the formation and persistence of foveal hard exudates in diabetic macular edema.

Increased expression of KDR/Flk-1 (VEGFR-2) in murine model of ischemia-induced retinal neovascularization

Although the vascular endothelial growth factor (VEGF)/VEGF receptor system plays a critical role in the pathogenesis of ischemic retinal neovascular diseases such as diabetic retinopathy, regulation of VEGF receptor expression in ischemic retina has not been fully investigated in vivo. Accordingly, we studied the regulation of Flt-1 (VEGFR-1) and KDR/Flk-1 (VEGFR-2) expression in a mouse model of ischemia-induced retinal neovascularization. Immunohistochemistry for Flt-1 and KDR/Flk-1 revealed that, in hypoxic retina, the immunoreactivity of KDR/Flk-1 was increased in both intensity and extent of involvement in the vessels near the avascular area, particularly at the neovascular tufts, but that the pattern of Flt-1 expression in hypoxic retina was almost the same as that of control animals. The number of KDR/Flk-1-positive vessels was significantly increased in hypoxic retina (P < 0.01). In addition, expression of both Flt-1 and KDR/Flk-1 was observed in nonvascular cells of the neural retina. Northern blot analysis demonstrated that the mRNA levels of KDR/Flk-1 were greater in the neovascular retina of hypoxic animals than in control animals. We suggest that the increased expression of KDR/Flk-1 in vascular cells might potentiate the VEGF-mediated angiogenesis that accompanies many ischemic retinal diseases.

Hypoxia and vascular endothelial growth factor stimulate angiogenic integrin expression in bovine retinal microvascular endothelial cells

PURPOSE

Integrins alphavbeta3 and alphavbeta5 are cell-to-matrix adhesion molecules that have been reported to mediate vascular cell proliferation and migration. The authors investigated the regulation of expression of these angiogenic integrins by hypoxia and vascular endothelial growth factor (VEGF) in retinal microvascular endothelial cells in culture.

METHODS

Cultured bovine retinal capillary endothelial cells were exposed to human recombinant VEGF under normoxic (95% air, 5% CO2) conditions to assess the effects of VEGF. Hypoxia studies were performed under lower oxygen concentration (0.5%-1.5% O2) induced by nitrogen replacement in constant 5% CO2 conditions. Integrin family mRNA and protein expression were assessed by northern blot analysis and immunoprecipitation.

RESULTS

VEGF (25 ng/ml) increased integrin alphav, beta3, and 35 mRNA after 24 hours 6.1+/-0.8-fold (P < 0.001), 5.9+/-1.1-fold (P < 0.001), and 1.9+/-0.2-fold (P < 0.01), respectively. Similarly, hypoxia stimulated gene expression of integrin alphav and beta3 after 24 hours by 5.1+/-1.7-fold (P < 0.01) and 3.0+/-0.5-fold (P < 0.01), respectively, and integrin beta5 after 9 hours 1.4+/-0.2-fold (P < 0.05). This hypoxia-induced, integrin alphav mRNA elevation was inhibited significantly by anti-VEGF neutralizing antibody. Also, a conditioned medium from confluent endothelial cells maintained under hypoxic conditions for 24 hours produced a 7.1+/-1.1-fold increase (P < 0.001) in integrin alphav mRNA expression after 24 hours, which was reversed by anti-VEGF neutralizing antibody. Induction of integrin alphav by VEGF and hypoxia was confirmed in the protein level.

CONCLUSIONS

These data suggest that hypoxia stimulates expression of vascular integrins alphavbeta3 and alphavbeta5 in retinal microvascular endothelial cells partially through autocrine-paracrine action of VEGF induced by the hypoxic state.

Angiotensin II potentiates vascular endothelial growth factor-induced angiogenic activity in retinal microcapillary endothelial cells

Angiotensin II (Ang II) plays a role in the development of many vascular diseases. In the present study, we have investigated the effect of Ang II on vascular endothelial growth factor (VEGF) receptor expression and VEGF-induced angiogenic activity in bovine retinal microcapillary endothelial cells (BRECs). Ang II induced a significant increase of kinase domain-containing receptor/total liver kinase (KDR/Flk-1) mRNA in a time- and dose-dependent manner, with a maximal 4.3+/-0.8-fold increase after a 4-hour stimulation. Ang II increased the rate of KDR gene transcription by 5.4-fold, whereas the half-life of KDR mRNA was not increased significantly. The increase depended partially on new protein synthesis. The Ang II-induced KDR mRNA increase was inhibited by either [Sar1,Ile8]angiotensin or angiotensin type 1 receptor antagonists but was not significantly altered by angiotensin type 2 receptor antagonists. The PKC inhibitor reduced Ang II-induced KDR mRNA expression by 70+/-15%. The tyrosine kinase inhibitor reduced the Ang II- and phorbol 12-myristate 13-acetate-induced KDR mRNA increases by 35+/-8% and 44+/-26%, respectively. Ang II increased by 3.1-fold the 35S-labeled KDR/Flk-1 immunoprecipitated by a specific antibody to KDR/Flk-1. Scatchard analysis demonstrated that Ang II induced a significant increase of binding sites without changing binding affinity. Ang II enhanced VEGF-induced cell growth and tube formation. Ang II itself had no effect on cell growth, tube formation, or mRNA levels of VEGF and tms-like tyrosine kinase (Flt-1) in BRECs. These findings suggest that Ang II might potentiate VEGF-induced angiogenic activity through an increase of the VEGF receptor KDR/Flk-1.

Long-term prognosis of extracapsular cataract extraction and intraocular lens implantation in diabetic patients

Although cataract extraction with intraocular lens implantation (IOL) is being used for increasing numbers of patients, there is still insufficient information regarding the long-term outcome for these patients. In this retrospective study of 140 eyes of 102 patients, 97 eyes (69%) achieved a best visual acuity of 20/40 or better. After a minimum 6-month postoperative period, 26 eyes (19%) had developed retinopathy: eight eyes progressed from nonproliferative to proliferative retinopathy. Glycosylated hemoglobin levels and fasting blood glucose were significantly higher at time of surgery in the eight that progressed than in those who did not (P = 0.002, P = 0.034). There were 65 unilateral IOL implantations; in 10 (15%) of these eyes, retinopathy progressed. Retinopathy also progressed in 70% of the fellow eyes of these patients. In patients whose retinopathy did not progress, 95% of the fellow eyes also showed no progression. Also, patients with progression in the pseudophakic eye frequently had progression in the fellow unoperated eye. Postoperative progression was symmetrical (P = 0.0001). Our analysis suggests that progression of diabetic retinopathy following IOL implantation can be correlated to diabetic control at the time of surgery.

[Long-term prognosis of intraocular lens implantation in diabetic patients]

We retrospectively studied 255 eyes of 190 diabetic patients who underwent cataract extraction with posterior chamber intraocular lens (IOL) implantation. One hundred forty-six eyes (57.3%) achieved the best visual acuity of 20/30 or better and 221 eyes (86.7%) achieved the acuity of 20/100 or better. Among 161 eyes that were followed up over 6 months, 26 eyes (16%) showed a progression of the retinopathy. Eight eyes developed proliferative retinopathy from non-proliferative retinopathy. The level of glycosylated hemoglobin of the progression group at the time of surgery was significantly higher than that of the non-progression group (8.0 +/- 2.4% vs 6.8 +/- 1.6%, p < 0.05). Sixty-five patients received IOL implantation in one eye. Of these patients, 10 eyes (15%) showed progression of the retinopathy. Seventy percent of the fellow eyes also showed the progression, where as 95% of the non-progression group did not show progression in the fellow eyes. The results suggested that the progression of diabetic retinopathy after IOL implantation was correlated with diabetic control at the time of surgery. Additionally, patients who developed the progression of the retinopathy in pseudophakic eyes frequently showed the progression in the fellow unoperated eyes.

The superficial neurovasculature of the head and neck

The majority of dermatologic procedures are performed in the sun-damaged regions of the head and neck. These regions have special cosmetic and functional importance, and dermatologists should become familiar with the underlying structures. Even though all the major nerves and vessels arborize below the superficial fascia, cutaneous atrophy and fibrosis from previous surgeries can make these neurovascular structures susceptible to damage from superficial procedures. Hence, it is advisable to utilize blunt dissection whenever possible, and to identify vital structures when working in their vicinity.

Cross validation of the Hypnotic Induction Profile factor structure: simultaneous confirmatory factor analysis of two published samples

This study cross-validated factor structure and psychometric characteristics of the Hypnotic Induction Profile (HIP). Earlier studies identified two constructs of the HIP, but their methodology did not allow empirical confirmation of the number of factors. I have used a new methodology, confirmatory factor analysis, and submitted the data from the previous studies to a simultaneous, multisample, factor analysis. The results showed that the HIP indeed consists of two factors. Although the HIP two-factor model is statistically adequate, 7 of the 10 scales have very low item reliability. Issues of measurement error and clinical implications of the study are also discussed in relation to the current findings.

The dialogue technique of hypnotic induction

In this paper we describe a technique of hypnotic induction, using a dialogue between two hypnotists. It combines, in principle, the utilization of the patient's unconscious resources (utilization principle) and verbal confusion (confusion principle) to evoke hypnotic responses. The process of the trance induction in the dialogue technique comprises four major stages: (1) preinduction verbal set, (2) unconscious access and utilization, (3) trance ratification and deepening, and (4) trance termination. Clinical experience suggests that the dialogue technique can "mask" the effect of confusion and produce trance states "spontaneously" for patients. Following the theoretical and methodological description of the technique, we also discuss appropriate clinical applications and a case example using the dialogue technique.

Contextual roles in clinical hypnosis and hypnotherapy: theory and applications

Context is a cognitive psychological term that has relevance to hypnosis and hypnotherapy. This paper has three purposes: (a) to review five major characteristics of contexts in light of contemporary experimental cognitive psychological findings, (b) to examine the role of contexts in hypnosis theories, and (c) to discuss applications of contexts in clinical situations. As a heuristic concept, the contextual theory can offer new insights into the understanding of various hypnotherapeutic techniques. Clinicians are encouraged to understand and apply contextual functions to their practice of hypnotherapy.

Characteristics of change in Ericksonian hypnotherapy: a cognitive-psychological perspective

Milton H. Erickson's approach to hypnosis and psychotherapy has established itself as a therapeutic paradigm in recent years. As its popularity grows, however, myths and misconceptions about his approach have also emerged. Some of them claim falsely that Erickson's therapy consists of nothing more than a set of quick, symptom-management formulae. To understand Erickson's hypnotic psychotherapy in a proper context, a systematic review is warranted. In this article I have examined, from a cognitive-psychological perspective, four of the major characteristics of therapeutic change underlying Erickson's work: (a) self-efficacy, (b) spontaneous compliance, (c) cognitive/experiential reorganization, and (d) global distribution of information. Drawing on Erickson's original writing, this paper integrates his published cases into an existing theoretical and empirical framework. Clinical implications are also discussed.

The confusion technique untangled: its theoretical rationale and preliminary classification

This article examines the historical development of Milton H. Erickson's theoretical approach to hypnosis using confusion. Review of the literature suggests that the Confusion Technique, in principle, consists of a two-stage "confusion-restructuring" process. The article also attempts to categorize several examples of confusion suggestions by seven linguistic characteristics: (1) antonyms, (2) homonyms, (3) synonyms, (4) elaboration, (5) interruption, (6) echoing, and (7) uncommon words. The Confusion Technique is an important yet little studied strategy developed by Erickson. More work is urged to investigate its nature and properties.

Leukocyte chemotaxis: a new in vivo testing technique

A new and sensitive technique is introduced for evaluating in vivo leukocyte chemotaxis. A small, disposable plastic chamber is used for holding the test solution, and an electric ink eraser for controlled abrasion of the skin test site. Another innovation is the use of capturing micropore membranes that, when placed between the test solution and the skin, collect cells for a permanent record. The small size of the chamber, the ease of application and immobilization, and the short time needed for cell collection permit experimentation with laboratory animals as well as with human volunteers. The accumulation of leukocytes in the chambers containing previously frozen or complement-activated autologous serum was 20 to 40-fold greater than in buffer controls after 3 h. Cell counts of approximately (1--2) x 10(3) leukocytes per mm3 were obtained in 3 h when serum diluted 1:1 with Hank's solution was applied to human or rabbit skin. Although predominantly polymorphonuclear leukocytes were detected in the chambers after just 3 h, prolonged incubations of 6--12 h found mononuclear cells also invading the chambers. These results clearly simulate the sequences of cellular emigration commonly observed in local inflammation.

Lupus erythematosus hypertrophicus et profundus

A patient with a sudden onset of severe lupus erythematosus hypertrophicus et profundus was noted to have extensive serological abnormalities; in addition to antinuclear antibody, leukopenia, anaemia, decreased serum complement, abnormal renal function, and positive immunofluorescence, she also had antibodies against clotting factors.