Use of Immunosuppression and the Risk of Subsequent Overall or Cancer Mortality

PURPOSE

To determine the incidence of all-cause and cancer mortality (CM) in association with immunosuppression.

DESIGN

Retrospective cohort study at ocular inflammatory disease (OID) subspecialty centers. We harvested exposure and covariate data retrospectively from clinic inception (earliest in 1979) through 2010 inclusive. Then we ascertained overall and cancer-specific mortalities by National Death Index linkage. We constructed separate Cox models to evaluate overall and CM for each class of immunosuppressant and for each individual immunosuppressant compared with person-time unexposed to any immunosuppression.

PARTICIPANTS

Patients with noninfectious OID, excluding those with human immunodeficiency infection or preexisting cancer.

METHODS

Tumor necrosis factor (TNF) inhibitors (mostly infliximab, adalimumab, and etanercept); antimetabolites (methotrexate, mycophenolate mofetil, azathioprine); calcineurin inhibitors (cyclosporine); and alkylating agents (cyclophosphamide) were given when clinically indicated in this noninterventional cohort study.

MAIN OUTCOME MEASURES

Overall mortality and CM.

RESULTS

Over 187 151 person-years (median follow-up 10.0 years), during which 15 938 patients were at risk for mortality, we observed 1970 deaths, 435 due to cancer. Both patients unexposed to immunosuppressants (standardized mortality ratio [SMR] = 0.95, 95% confidence interval [CI], 0.90-1.01) and those exposed to immunosuppressants but free of systemic inflammatory diseases (SIDs) (SMR = 1.04, 95% CI, 0.95-1.14) had similar mortality risk to the US population. Comparing patients exposed to TNF inhibitors, antimetabolites, calcineurin inhibitors, and alkylating agents with patients not exposed to any of these, we found that overall mortality (adjusted hazard ratio [aHR] = 0.88, 0.89, 0.90, 1.11) and CM (aHR = 1.25, 0.89, 0.86, 1.23) were not significantly increased. These results were stable in sensitivity analyses whether excluding or including patients with SID, across 0-, 3-, or 5-year lags and across quartiles of immunosuppressant dose and duration.

CONCLUSIONS

Our results, in a cohort where the indication for treatment was proven unassociated with mortality risk, found that commonly used immunosuppressants-especially the antimetabolites methotrexate, mycophenolate mofetil, and azathioprine; the TNF inhibitors adalimumab and infliximab, and cyclosporine-were not associated with increased overall and CM over a median cohort follow-up of 10.0 years. These results suggest the safety of these agents with respect to overall and CM for patients treated with immunosuppression for a wide range of inflammatory diseases.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Incidence of and Risk Factors for Cataract in Anterior Uveitis

PURPOSE

To estimate the incidence/risk factors for cataract in noninfectious anterior uveitis.

DESIGN

Retrospective multicenter cohort study (6 US tertiary uveitis sites, 1978-2010).

METHODS

Data were harvested by trained expert reviewers, using protocol-driven review of experts' charts. We studied cataract incidence-newly reduced visual acuity worse than 20/40 attributed to cataract; or incident cataract surgery-in 3923 eyes of 2567 patients with anterior uveitis.

RESULTS

Cataract developed in 507 eyes (54/1000 eye-years, 95% CI 49-59). Time-updated risk factors associated with cataract included older age (≥65 vs <18 years: adjusted hazard ratio [aHR] 5.04, 95% CI 3.04-8.33), higher anterior chamber cell grade (P(trend)=0.001), prior incisional glaucoma surgery (aHR 1.86, 95% CI 1.10-3.14), band keratopathy (aHR 2.23, 95% CI 1.47-3.37), posterior synechiae (aHR 3.71, 95% CI 2.83-4.87), and elevated intraocular pressure ≥30 vs 6-20 mm Hg (aHR 2.57, 95% CI 1.38-4.77). Primary acute (aHR 0.59, 95% CI 0.30-1.15) and recurrent acute (aHR 0.74, 95% CI 0.55-0.98) had lower cataract risk than chronic anterior uveitis. Higher-dose prednisolone acetate 1%-equivalent use (≥2 drops/day) was associated with >2-fold higher cataract risk in eyes with anterior chamber cell grades 0.5+ or lower but was not associated with higher cataract risk in the presence of anterior chamber cells of grade 1+ or higher.

CONCLUSIONS

Cataract complicates anterior uveitis in ∼5.4/100 eye-years. Several fixed and modifiable risk factors were identified, yielding a point system to guide cataract risk minimization. Topical corticosteroids only were associated with increased cataract risk when anterior chamber cells were absent or minimally present, suggesting their use to treat active inflammation (which itself is cataractogenic) does not cause a net increase in cataract incidence.

Remission of Non-Infectious Anterior Scleritis: Incidence and Predictive Factors

PURPOSE

To assess how often non-infectious anterior scleritis remits and identify predictive factors.

METHODS

Our retrospective cohort study at four ocular inflammation subspecialty centers collected data for each affected eye/patient at every visit from center inception (1978, 1978, 1984, 2005) until 2010. Remission was defined as inactivity of disease off all suppressive medications at all visits spanning at least three consecutive months or at all visits up to the last visit (to avoid censoring patients stopping follow-up after remission). Factors potentially predictive of remission were assessed using Cox regression models.

RESULTS

During 1,906 years' aggregate follow-up of 832 affected eyes, remission occurred in 214 (170 of 584 patients). Median time-to-remission of scleritis = 7.8 years (95% confidence interval [CI]: 5.7, 9.5). More remissions occurred earlier than later during follow-up. Factors predictive of less scleritis remission included scleritis bilaterality (adjusted hazard ratio [aHR] = 0.46, 95% CI: 0.32-0.65); and diagnosis with any systemic inflammatory disease (aHR = 0.36, 95% CI: 0.23-0.58), or specifically with Rheumatoid Arthritis (aHR = 0.22), or Granulomatosis with Polyangiitis (aHR = 0.08). Statin treatment (aHR = 1.53, 95% CI: 1.03-2.26) within ≤90 days was associated with more remission incidence.

CONCLUSIONS

Our results suggest scleritis remission occurs more slowly in anterior scleritis than in newly diagnosed anterior uveitis or chronic anterior uveitis, suggesting that attempts at tapering suppressive medications is warranted after long intervals of suppression. Remission is less frequently achieved when systemic inflammatory diseases are present. Confirmatory studies of whether adjunctive statin treatment truly can enhance scleritis remission (as suggested here) are needed.

Contemporaneous Risk Factors for Visual Acuity in Non-Infectious Uveitis

INTRODUCTION

We evaluated the associations of clinical and demographic characteristics with visual acuity (VA) with over 5 years in a subspecialty noninfectious uveitis population.

METHODS

Retrospective data from 5,530 noninfectious uveitis patients were abstracted by expert reviewers, and contemporaneous associations of VA with demographic and clinical factors were modeled.

RESULTS

Patients were a median of 41 years old, 65% female, and 73% white. Eyes diagnosed ≥5 years prior to cohort entry had worse VA (-1.2 lines) than those diagnosed <6 months prior, and eyes with cataract surgery performed prior to entry had worse VA (-5.9 lines) than those performed during follow-up. Vitreous haze (-4.2 lines for 3+ vs quiet), hypotony (-2.5 lines for ≤5 mm Hg vs 6-23 mm Hg), and CNV (-1.8 lines) all were strongly associated with reduced VA.

CONCLUSION

Factors associated with reduced VA included well-known structural complications, and lack of subspecialty care during cataract surgery.

Visual Acuity Outcome over Time in Non-Infectious Uveitis

Introduction: We evaluated visual acuity (VA) over 5 years in a subspecialty noninfectious uveitis population.Methods: Retrospective data from 5,530 noninfectious uveitis patients with anterior, intermediate, posterior or panuveitis were abstracted by expert reviewers. Mean VA was calculated using inverse probability of censoring weighting to account for losses to follow-up.Results: Patients were a median of 41 years old, 65% female, and 73% white. Initial mean VA was worse among panuveitis (20/84) than posterior (20/64), intermediate (20/47), and anterior (20/37) uveitides. On average, mean VA improved by 0.62, 0.51, 0.37, and 0.26 logMAR-equivalent lines over 2 years, respectively (each P < .001), then remained stable, except posterior uveitis mean VA worsened to initial levels.Conclusion: Mean VA of uveitic eyes improved and, typically, improvement was sustained under uveitis subspecialty care. Because VA tends to improve under tertiary care, mean VA change appears a better outcome for clinical studies than time-to-loss of VA.

Remission of Intermediate Uveitis: Incidence and Predictive Factors

PURPOSE

To evaluate the incidence of remission among patients with intermediate uveitis; to identify factors potentially predictive of remission.

DESIGN

Retrospective cohort study.

METHODS

Involved eyes of patients with primary noninfectious intermediate uveitis at 4 academic ocular inflammation subspecialty practices, followed sufficiently long to meet the remission outcome definition, were studied retrospectively by standardized chart review data. Remission of intermediate uveitis was defined as a lack of inflammatory activity at ≥2 visits spanning ≥90 days in the absence of any corticosteroid or immunosuppressant medications. Factors potentially predictive of intermediate uveitis remission were evaluated using survival analysis.

RESULTS

Among 849 eyes (of 510 patients) with intermediate uveitis followed over 1934 eye-years, the incidence of intermediate uveitis remission was 8.6/100 eye-years (95% confidence interval [CI], 7.4-10.1). Factors predictive of disease remission included prior pars plana vitrectomy (PPV) (hazard ratio [HR] [vs no PPV] = 2.39; 95% CI, 1.42-4.00), diagnosis of intermediate uveitis within the last year (HR [vs diagnosis >5 years ago] =3.82; 95% CI, 1.91-7.63), age ≥45 years (HR [vs age <45 years] = 1.79; 95% CI, 1.03-3.11), female sex (HR = 1.61; 95% CI, 1.04-2.49), and Hispanic race/ethnicity (HR [vs white race] = 2.81; 95% CI, 1.23-6.41). Presence/absence of a systemic inflammatory disease, laterality of uveitis, and smoking status were not associated with differential incidence.

CONCLUSIONS

Our results suggest that intermediate uveitis is a chronic disease with an overall low rate of remission. Recently diagnosed patients and older, female, and Hispanic patients were more likely to remit. With regard to management, pars plana vitrectomy was associated with increased probability of remission.

Site of secretion of the trail marker of the eastern tent caterpillar

A new site of secretion of a chemical trail marker was found on the sternum at the tip of the last abdominal segment of the larva of the eastern tent caterpillarMalacosoma americanum. Larvae marked from this site by drawing their sterna along the substrate when they extended existing trails in search of food and again when they established recruitment trails to food-finds. Differences in the quantity or quality of the marker deposited by exploring and recruiting caterpillars may account for the greater activity of the recruitment trails.

Identification of trail pheromone of larva of eastern tent caterpillarMalacosoma americanum (Lepidoptera: Lasiocampidae)

Previous studies have shown that larvae of the eastern tent caterpillar (Malacosoma americanum F.) mark trails, leading from their tent to feeding sites on host trees, with a pheromone secreted from the posterior tip of the abdominal sternum. 5β-Cholestane-3,24-dione (1) has been identified as an active component of the trail. The larvae have a threshold sensitivity to the pheromone of 10(-11) g/mm of trail. Several related compounds elicit the trail-following response. Two other species of tent caterpillars also responded positively to the pheromone in preliminary laboratory tests.

REVIEW paper: mare reproductive loss syndrome

An epidemic of early fetal loss (EFL), late fetal loss (LFL), fibrinous pericarditis, and unilateral uveitis which occurred during the spring of 2001, are together now known as the mare reproductive loss syndrome (MRLS). A similar epidemic with less intensity was reported during the same period of time from southern Ohio, West Virginia, and Tennessee. The same syndrome with lesser intensity recurred in 2002. The estimated economic loss from the syndrome in 2001 and 2002 together was approximately $500 million. Both EFL and LFL were characterized by the absence of specific clinical signs in aborting mares. Nonhemolytic Streptococcus spp. and Actinobacillus spp. accounted for 65% of the organisms isolated from fetuses submitted for a postmortem during the MRLS period in 2001 and 2002. The pathologic findings in fetoplacental units of LFL included bronchopneumonia and funisitis, and there were no findings in EFL. Epidemiologic studies conducted in 2001 suggested an association between the presences of eastern tent caterpillars (ETC) in pastures with MRLS. Experimental studies in pregnant mares by exposure to ETC, or administration by stomach tube or with feed material, reproduced EFL and LFL. Similar experimental studies in mouse, rats, and goats with ETC were unsuccessful. Currently, 2 hypotheses are proposed for MRLS. One hypothesis proposes that an ETC-related toxin with secondary opportunistic bacterial invasion of the fetus leads to MRLS. The second hypothesis suggests that a breach of gastrointestinal mucosal integrity by hairs of ETC leads to a bacteremia and results in MRLS. In 2004, a similar equine abortion storm was reported from Australia and caterpillar exposure was identified as a risk factor for the abortion. In 2006, the syndrome was observed in Florida and New Jersey.

Larvae of the fall webworm, Hyphantria cunea, inhibit cyanogenesis in Prunus serotina

The larvae of the fall webworm, Hyphantria cunea (Dru.), though vulnerable to cyanide poisoning, consume the cyanogenic leaves of black cherry, Prunus serotina, without apparent harm. The cyanide contents of leaves, defensive regurgitant, the bolus, and frass were assayed by ion chromatography to determine the fate of the toxin in the caterpillar. Leaves collected in September, when the caterpillars were feeding, contained 1592+/-276 p.p.m. cyanide. Samples of dried frass obtained from caterpillars fed these leaves yielded 2868+/-552 p.p.m. cyanide. Frass extracted directly in NaOH yielded approximately five percent of the cyanide obtained from frass ground in buffer and distilled in Warburg flasks, indicating that cyanogenesis is largely inhibited as the bolus traverses the gut. This inhibition is attributable to the ability of the caterpillar to maintain a foregut environment in the presence of the bolus that is sufficiently alkaline to suppress the conversion of the plant cyanogen to cyanide. Although a number of caterpillars feed without harm on cyanogenic plants, this it the first shown to inhibit cyanogenesis in this manner.

Role of trail pheromone in foraging and processionary behavior of pine processionary caterpillars Thaumetopoea pityocampa

Although caterpillars of Thaumetopoea pityocamnpa may mark their pathways with silk, this study shows that the material is essential to neither the elicitation nor maintenance of trail-following or processionary behavior. Trail following is dependent upon a pheromone the caterpillars deposit by brushing the ventral surfaces of the tips of their abdomens against the substate. Earlier instars are strongly bound to their trail system; in the laboratory, caterpillars followed circular trails continuously for as long as 12 hr before breaking away from them. The trail pheromone is long-lived and soluble in nonpolar solvents, but its volatilization or degradation allows the caterpillars to distinguish new from aged trails. In contrast to trail following, processionary behavior, the head-to-tail, single-file movement of the caterpillars is dependent on neither silk nor the trail pheromone. Stimuli associated with setae found on the tip of the abdomen of the precedent caterpillar serve to hold processions together, and such stimuli take priority over those associated with either the trail pheromone or silk. Although the caterpillars discern trail strength and choose stronger over weaker trails, the trail marking system of the processionary caterpillar appears less sophisticated than those of other, previously studied species of social caterpillars, and colonies are relatively inefficient in abandoning exhausted feeding sites in favor of new food finds. In laboratory studies, females were more likely to lead processions than males, and leaders, regardless of gender, expended more energy in locomotion than followers.

Depletion of host-derived cyanide in the gut of the eastern tent caterpillar, Malacosoma americanum

Using a colorimetric procedure, we assessed the HCN-p of black cherry leaves (Prunus serotina) ingested by the eastern tent caterpillar, Malacosoma americanum, and the cyanide content of the bolus as it passed thorough the caterpillar's digestive tract and into the detritus pool. The mean HCN-p of leaves in our study area was 1902 +/- 174 (SE) ppm. Young leaves found at the tips of growing branches, which the caterpillars preferred, had a significantly higher HCN-p (3032 +/- 258 ppm) than older leaves found at the middle (1542 +/- 243 ppm) or base of the shoot (1131 +/- 159 ppm). Following a bout of overnight feeding on young leaves, the cyanide content of the foregut and midgut boluses of early sixth-instar caterpillars averaged 631 +/- 161 ppm, and 14 +/- 3 ppm, respectively, indicating that host-derived cyanide is rapidly depleted as the bolus transits the gut. Some cyanide, however, remains. In three studies, the mean cyanide content of fresh fecal pellets ranged from approximately 20 to 38 ppm, while the dried, compacted pellets ranged from 63 to 85 ppm. Food in the foreguts of mature caterpillars dispersing over the ground in search of pupation sites had 417 +/- 99 ppm cyanide. The potential impact of this egested and caterpillar-transported cyanide on the consumer and detritivore communities is discussed.

Trail marking by larvae of the eastern tent caterpillar

Eastern tent caterpillars that are successful foragers deposit trails as they return to the tent that are more attractive than the exploratory trails of the unfed larvae. The trails of these fed returning larvae attract unfed tentmates to food finds anre chemical factors account for the attractiveness of these trails.