Scheduled versus Pro Re Nata Dosing in the VIEW Trials

PURPOSE To analyze visual acuity (VA) outcomes before and after preplanned treatment regimen change in the VIEW studies at week 52 (W52). DESIGN Multiple post hoc analyses for retrospectively defined subgroups in 2 multicenter, multinational, double-masked trials. PARTICIPANTS Two thousand four hundred fifty-seven neovascular age-related macular degeneration (AMD) patients. METHODS Patients were randomized to treatment with 0.5 mg ranibizumab given monthly, a 0.5-mg or 2-mg intravitreal aflibercept injection given monthly, or 2 mg intravitreal aflibercept given every other month, after 3 initial monthly doses, up to W52. From W52 through W96, patients received their original dosing assignment using a capped pro re nata (PRN) regimen, with defined retreatment criteria based on VA and morphologic signs of disease activity and mandatory dosing at least every 12 weeks. MAIN OUTCOME MEASURES Best-corrected VA (BCVA) and optical coherence tomography assessments were mandatory at all visits from baseline to W96. Outcomes were changes in BCVA and central retinal thickness. Outcomes were evaluated in all patients who completed 2 years of the VIEW studies using the last observation carried forward method for missing data at interim visits. RESULTS After W52, approximately 20% of patients lost 5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters or more across all treatment arms with PRN treatment. Patients who met the retreatment criterion of loss of 5 ETDRS letters or more in the first quarter of the PRN dosing phase did not recover; mean final VA loss across the 4 study arms was -4.4 to -5.8 letters. Outcomes of these patients up to W52 were indistinguishable from those of the overall population. There were no differences between groups in serious ocular adverse events or Anti-Platelet Trialists' Collaboration arterial thromboembolic events through W96. CONCLUSIONS These analyses suggest that there are subgroups of patients for whom VA outcomes in the second year of the VIEW studies were less stable than in the first year and for whom W52 seems to be an important inflection point. Although alternate reasons specific to the nature of the underlying AMD cannot be fully excluded, the switch in treatment regimen at W52 is a plausible explanation.

Prevention of increased abnormal fundus autofluorescence with blue light-filtering intraocular lenses

PURPOSE To observe changes in fundus autofluorescence 2 years after implantation of blue light-filtering (yellow-tinted) and ultraviolet light-filtering (colorless) intraocular lenses (IOLs). SETTING Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, and the Department of Ophthalmology, University of Bern, Bern, Switzerland. DESIGN Prospective comparative observational study. METHODS Patients were enrolled who had cataract surgery with implantation of a yellow-tinted or colorless IOL and for whom images were obtained on which the fundus autofluorescence was measurable using the Heidelberg Retina Angiogram 2 postoperatively. The fundus autofluorescence in the images was classified into 8 abnormal patterns based on the classification of the International Fundus Autofluorescence Classification Group, The presence of normal fundus autofluorescence, geographic atrophy, and wet age-related macular degeneration (AMD) also was recorded. The fundus findings at baseline and 2 years postoperatively were compared. RESULTS Fifty-two eyes with a yellow-tinted IOL and 79 eyes with a colorless IOL were included. Abnormal fundus autofluorescence did not develop or increase in the yellow-tinted IOL group; however, progressive abnormal fundus autofluorescence developed or increased in 12 eyes (15.2%) in the colorless IOL group (P = .0016). New drusen, geographic atrophy, and choroidal neovascularization were observed mainly in the colorless IOL group. The incidence of AMD was statistically significantly higher in the colorless IOL group (P = .042). CONCLUSIONS Two years after cataract surgery, significant differences were seen in the progression of abnormal fundus autofluorescence between the 2 groups. The incidence of AMD was lower in eyes with a yellow-tinted IOL. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

The role of inducible nitric oxide synthase for interstitial remodeling of alveolar septa in surfactant protein D-deficient mice

Surfactant protein D (SP-D) modulates the lung's immune system. Its absence leads to NOS2-independent alveolar lipoproteinosis and NOS2-dependent chronic inflammation, which is critical for early emphysematous remodeling. With aging, SP-D knockout mice develop an additional interstitial fibrotic component. We hypothesize that this age-related interstitial septal wall remodeling is mediated by NOS2. Using invasive pulmonary function testing such as the forced oscillation technique and quasistatic pressure-volume perturbation and design-based stereology, we compared 29-wk-old SP-D knockout (Sftpd(-/-)) mice, SP-D/NOS2 double-knockout (DiNOS) mice, and wild-type mice (WT). Structural changes, including alveolar epithelial surface area, distribution of septal wall thickness, and volumes of septal wall components (alveolar epithelium, interstitial tissue, and endothelium) were quantified. Twenty-nine-week-old Sftpd(-/-) mice had preserved lung mechanics at the organ level, whereas elastance was increased in DiNOS. Airspace enlargement and loss of surface area of alveolar epithelium coexist with increased septal wall thickness in Sftpd(-/-) mice. These changes were reduced in DiNOS, and compared with Sftpd(-/-) mice a decrease in volumes of interstitial tissue and alveolar epithelium was found. To understand the effects of lung pathology on measured lung mechanics, structural data were used to inform a computational model, simulating lung mechanics as a function of airspace derecruitment, septal wall destruction (loss of surface area), and septal wall thickening. In conclusion, NOS2 mediates remodeling of septal walls, resulting in deposition of interstitial tissue in Sftpd(-/-). Forward modeling linking structure and lung mechanics describes the complex mechanical properties by parenchymatous destruction (emphysema), interstitial remodeling (septal wall thickening), and altered recruitability of acinar airspaces.

Reduced pro-inflammatory profile of γδT cells in pregnant patients with rheumatoid arthritis

BACKGROUND During pregnancy, many patients with rheumatoid arthritis (RA) experience disease improvement, whereas patients with ankylosing spondylitis often suffer from persistent active disease. Here we investigated whether pregnancy-related changes in disease activity were associated with changes in the proportion and function of γδT cells. METHODS The study population comprised 55 patients with RA, 31 patients with ankylosing spondylitis, and 35 healthy controls. Among these participants, 28 RA patients, 21 ankylosing spondylitis patients, and 23 healthy controls were investigated once before conception when possible, at each trimester of pregnancy, and at 8 weeks postpartum. Data were compared with age-matched non-pregnant patients to obtain disease-related background. In all subjects, peripheral Vδ1 and Vδ2 T cells were analyzed for cell frequencies, the activation marker CD69, the cytotoxicity markers NKG2D and NKG2A, and the intracellular cytokines tumor necrosis factor (TNF)α, interferon (IFN)γ, interleukin (IL)-17 and IL-10. RESULTS Pregnant patients showed a decreased Vδ2/Vδ1 ratio in the third trimester, which resulted from a slightly reduced proportion of Vδ2 cells. Changes in RA disease activity during pregnancy and postpartum were not associated with numerical proportions of γδT cells but with changes of the cell activation marker CD69 on Vδ1 and Vδ2 cells. Only RA patients showed reduced proportions of TNFα-positive Vδ1and Vδ2 cells and IFNγ-positive Vδ2 cells at the third trimester of pregnancy, a finding that was not apparent in the entire population of CD3 T cells. The proportions of IL-17-positive γδT cells and IL-10-positive γδT cells did not differ between pregnant and non-pregnant women of the different groups. CONCLUSIONS Changes of disease activity in pregnant RA patients were associated with functional changes in both γδT cell subsets. This reduced pro-inflammatory profile of γδT cells might contribute to the immunomodulation resulting in pregnancy-induced improvement of RA.

A Dynamic Analysis: the Smile and Display of Dentition during Speech

The objective of this retrospective study is to follow up on a previous Dynamic Smile Analysis and videographically analyze and develop averages for soft tissue norms with respect to the display of dentition during speech. These values would then be compared cross-sectionally across different age groups to see whether changes attributable to the aging process could be seen. A secondary objective was to compare averages for soft tissue norms in the display of dentition during speech to averages for soft tissue norms in the display of dentition during the smile. Materials and Method: Records from a previous study in which video equipment was used to capture video for 26 1 subjects were re-evaluated to find appropriate frames to analyze for speech. Two frames for each subject were selected; one frame representing the maximal display of maxillary incisors during speech and the second representing the widest transverse display of dentition during speech. After excluding 40 subjects the data for the remaining 221 subjects was analyzed. These averages were then compared to averages attained in the previous study to compare the display of the dentition during speech to the display of the dentition during smile. Results: On average, a difference in 1.29 mm was seen in the display of the maxillary incisors during speech at maximal display and during the smile. An average of 7.23 mm of maxillary incisors is readily visible during maximum display of maxillary incisors during speech, as compared to 8.52 mm during the smile. The constructed smile index was also smaller when measured during the speech when compared to the smile index by an average of 2.58 units. Conclusion: This study helps to establish age-related dynamic norms for the display of dentition during speech. The dynamic measures indicate that the display of dectition is greater, on average, during the smile than at speech.

Barriers to Timely Screening Colonoscopy

Objective: Colorectal cancer (CRC) can be largely prevented or effectively treated in its early stages, yet disparities exist in timely screening. The aim of this study was to explore the disparities in CRC screening on the basis of health insurance status including private, Medicare, Medicaid, and State Administered General Assistance (SAGA). Methods: A retrospective chart review for the period January 2000 to May 2007 (95 records) was conducted at two clinic sites; a private clinic and a university hospital clinic. All individuals at these sites who met study criteria (>50 years old with screening colonoscopy) were included. Age, gender, date of first clinic visit when screening referral was made, and date of completed procedure (screening colonoscopy) were recorded. Groups were dichotomized between individuals with private health insurance and individuals with public health insurance. Individuals with any history of CRC, known pre-cancerous conditions as well as family history of CRC requiring frequent colonoscopy were excluded from the study. Linear model analysis was performed to compare the average waiting time to receiving screening colonoscopy between the groups. T-test was performed to analyze age or gender related differences between the two groups as well as within each group. Results: The average waiting time (33 days) for screening colonoscopy in privately insured individuals was significantly lower than publicly insured individuals (200 days). The time difference between the first clinic visit and the procedure was statistically significant (p < 0.0001) between the two groups. There was no statistical difference (p=0.089) in gender between these groups (public vs. private). There were also no statistically significant gender or age related differences found within each group. Conclusions: Disparities exist in timely screening for CRC and one of the barriers leading to delayed CRC screening includes health insurance status of an individual. Even within the insured group, type of insurance plays major role. There is a negative correlation between public health insurance status and timely screening. Differences in access to medical care and delivery of care experienced by patients who are publicly insured through Medicaid, Medicare, and SAGA, suggests that the State of Connecticut needs to implement changes in health care policies that would provide timely screening colonoscopy. It is evident that health insurance coverage facilitates timely access to healthcare. Therefore, there is a need for increased efforts in advocacy for policy, payment and physician participation in public insurance programs. A state-wide comprehensive program involving multiple components targeting different levels of change such as provider, patients and the community should help reduce some of the observed causes of healthcare disparities based on the insurance status.

Micro-facies and µXRF element scanning data of Dead Sea sediment cores DSEn and 5017-1

Laminated lake sediments from the Dead Sea basin provide high-resolution records of climatic variability in the eastern Mediterranean region, which is especially sensitive to changing climatic conditions. In this study, we aim on detailed reconstruction of climatic fluctuations and related changes in the frequency of flood and dust deposition events at ca. 3300 and especially at 2800 cal. yr BP from high-resolution sediment records of the Dead Sea basin. A ca. 4-m-thick, mostly varved sediment section from the western margin of the Dead Sea (DSEn - Ein Gedi profile) was analysed and correlated to the new International Continental Scientific Drilling Program (ICDP) Dead Sea Deep Drilling Project core 5017-1 from the deep basin. To detect even single event layers, we applied a multi-proxy approach of high-resolution microscopic thin section analyses, micro-X-ray fluorescence (µ-XRF) element scanning and magnetic susceptibility measurements, supported by grain size data and palynological analyses. Based on radiocarbon and varve dating, two pronounced dry periods were detected at ~3500-3300 and ~3000-2400 cal. yr BP which are differently expressed in the sediment records. In the shallow-water core (DSEn), the older dry period is characterised by a thick sand deposit, whereas the sedimentological change at 2800 cal. yr BP is less pronounced and characterised mainly by an enhanced frequency of coarse detrital layers interpreted as erosion events. In the 5017-1 deep-basin core, both dry periods are depicted by halite deposits. The onset of the younger dry period coincides with the Homeric Grand Solar Minimum at ca. 2800 cal. yr BP. Our results suggest that during this period, the Dead Sea region experienced an overall dry climate, superimposed by an increased occurrence of flash floods caused by a change in synoptic weather patterns.

Dust flux records from the Subarctic North Pacific

We present a new record of eolian dust flux to the western Subarctic North Pacific (SNP) covering the past 27000 years based on a core from the Detroit Seamount. Comparing the SNP dust record to the NGRIP ice core record shows significant differences in the amplitude of dust changes to the two regions during the last deglaciation, while the timing of abrupt changes is synchronous. If dust deposition in the SNP faithfully records its mobilization in East Asian source regions, then the difference in the relative amplitude must reflect climate-related changes in atmospheric dust transport to Greenland. Based on the synchronicity in the timing of dust changes in the SNP and Greenland, we tie abrupt deglacial transitions in the 230Th-normalized 4He flux record to corresponding transitions in the well-dated NGRIP dust flux record to provide a new chronostratigraphic technique for marine sediments from the SNP. Results from this technique are complemented by radiocarbon dating, which allows us to independently constrain radiocarbon paleoreservoir ages. We find paleoreservoir ages of 745 ± 140 yr at 11653 yr BP, 680 ± 228 yr at 14630 yr BP and 790 ± 498 yr at 23290 yr BP. Our reconstructed paleoreservoir ages are consistent with modern surface water reservoir ages in the western SNP. Good temporal synchronicity between eolian dust records from the Subantarctic Atlantic and equatorial Pacific and the ice core record from Antarctica supports the reliability of the proposed dust tuning method to be used more widely in other global ocean regions.

Benthic foraminiferal faunas of Miocene to Holocene sediments of ODP Site 184-1143 from the southern South China Sea

Deep-sea benthic foraminiferal assemblages from Ocean Drilling Program (ODP) Site 1143 located in the southern South China Sea (SCS) were investigated to evaluate the relationship between faunal composition patterns and paleoceanographic changes during the last 6 million years (late Miocene to Holocene). We used multivariate statistics (correspondence analysis) to analyze carbon-flux-related changes in assemblage composition of benthic foraminifers. Additional proxies for carbon flux and deep-water ventilation include delta13C records of epifaunal Cibicidoides wuellerstorfi and infaunal Uvigerina peregrina var. dirupta and Melonis pompilioides, benthic foraminiferal accumulation rates (BFARs), diversity indices, and relative abundances of indicator species. We observe three significant benthic faunal changes in the southern South China Sea during the last 6 million years. Strong fluctuations in BFAR and relative abundance of productivity indicator species between glacial and interglacial stages after the mid-Pleistocene revolution (MPR) at approximately 0.9 Ma, indicating stronger seasonal carbon flux fluctuations, are accompanied by the extinction of such species as Stilostomella spp. Increases in carbon flux indicator species are coupled with an overall decrease in benthic foraminifer diversity around 3.0 Ma in the late Pliocene. This may indicate increasing carbon flux in a period of productivity maximum caused by enhanced offshore upwelling from intensified winter monsoon wind strength.

Radioisotopes and He accumulation in deep sea sediments of the Ontong Java Plateau

The accumulation of extraterrestrial 3He, a tracer for interplanetary dust particles (IDPs), in sediments from the Ontong Java Plateau (OJP; western equatorial Pacific Ocean) has been shown previously to exhibit a regular cyclicity during the late Pleistocene, with a period of ~100 ka. Those results have been interpreted to reflect periodic variability in the global accretion of IDPs that, in turn, has been linked to changes in the inclination of Earth's orbit with respect to the invariable plane of the solar system. Here we show that the accumulation in OJP sediments of authigenic 230Th, produced by radioactive decay of 234U in seawater, exhibits a 100-ka cyclicity similar in phase and amplitude to that evident in the 3He record. We interpret the similar patterns of 230Th and 3He accumulation to reflect a common origin within the ocean-climate system. Comparing spatial and temporal patterns of sediment accumulation against regional patterns of biological productivity and against the well-established pattern of CaCO3 dissolution in the deep Pacific Ocean leads to the further conclusion that a common 100-ka cycle in accumulation of biogenic, authigenic and extraterrestrial constituents in OJP sediments reflects the influence of climate-related changes in sediment focusing, rather than changes in the rate of production or supply of sedimentary constituents.

Magnesium/calcium and stable isotope ratios of planktonic foraminifera from the Timor Sea

We present sea surface and upper thermocline temperature records (60-100 yr temporal resolution) spanning Marine Isotope Stage 3 (~24-62 kyr BP) from IMAGES Core MD01-2378 (121°47.27'E and 13°04.95'S; 1783 m water depth) located in the outflow area of the Indonesian Throughflow within the Timor Sea. Stable isotopes and Mg/Ca of the near surface dwelling planktonic foraminifer Globigerinoides ruber (white) and the upper thermocline dwelling Pulleniatina obliquiloculata reveal rapid changes in the thermal structure of the upper ocean during Heinrich Events. Thermocline warming and increased delta18Oseawater (P. obliquiloculata record) during Heinrich Events 3, 4, and 5 reflect weakening of the relatively cool and fresh thermocline flow and reduced export of less saline water from the North Pacific and Indonesian Seas to the tropical Indian Ocean. Three main factors influenced Indonesian Throughflow variability during Marine Isotope Stage 3: (1) global slow-down in thermohaline circulation during Heinrich Events triggered by northern hemisphere cooling; (2) increased freshwater export from the Java Sea into the Indonesian Throughflow controlled by rising sea level from ~60 to 47 ka and (3) insolation related changes in Australasian monsoon with associated migration of hydrological fronts between Indian Ocean and Indonesian Throughflow derived water masses at ~46-40 ka.

Benthic foraminifera in Tertiary sediments of DSDP Leg 90 holes

Eocene through Pliocene benthic foraminifers were examined from seven sites located at middle and lower bathyal depths on the Lord Howe Rise in the Tasman Sea, from another site at lower bathyal depths in the Coral Sea, and from a site in the intermediate-depth, hemipelagic province of the Chatham Rise, east of southern New Zealand. Age-related, depth-related, and bioprovincial faunal variations are documented in this chapter. One new species, Rectuvigerina tasmana, is named. The paleoecologic indications of several key groups, including the miliolids, uvigerinids, nuttallitids, and cibicidids, are combined with sedimentologic and stable isotopic tracers to interpret paleoceanographic changes in the Tasman Sea. Because the total stratigraphic ranges of many bathyal benthic foraminifers are not yet known, most endpoints in the Tasman Sea are considered ecologically controlled events. The disappearances of Uvigerina rippensis and Cibicidoidesparki and the first appearances of U. pigmaea, Sphaeroidina bulloides, and Rotaliatina sulcigera at the Eocene/Oligocene boundary can be considered evolutionary events, as also can the first appearance of Cibicides wuellerstorfi in Zone NN5. Species which are restricted to the lower bathyal zone except during discrete pulses, most of which are related to the development of glacial conditions, include Melonis pompilioides, M. sphaeroides, Pullenia quinqueloba, Nuttallides umbonifera, and U. hispido-costata. Middle bathyal indigenes include U. spinulosa, U. gemmaeformis, Ehrenbergina marwicki, R. sulcigera, and all rectuvigerinids except Rectuvigerina spinea. Although the miliolids first occurred at lower bathyal depths, they were more common in the middle bathyal zone. Although the Neogene hispido-costate uvigerinids first developed at lower bathyal depths and at higher middle latitude sites, in the later Neogene this group migrated to shallower depths and became predominant also in the middle bathyal zone. Despite the relatively similar sedimentologic settings at the six middle bathyal Tasman sites, there was extensive intrageneric and intraspecific geographic variation. Mililiolids, strongly ornamented brizalinids, bolivinitids, Bulimina aculeata, Osangularia culter, and strongly porous morphotypes were more common at higher latitudes. Osangularia bengalensis, striate brizalinids such as Brizalina subaenariensis, Gaudryina solida, osangularids in general, and finely porous morphotypes were more common in the subtropics. There was strong covariance between faunas at lower middle latitude, lower bathyal Site 591, and higher middle latitude, middle bathyal Site 593. The following oceanographic history of the Tasman Sea is proposed; using the stable isotopic record as evidence for glacials and examining the ecologic correlations between (1) miliolids and carbonate saturation, (2) nuttallitids and undersaturated, cooled, or "new" water masses, (3) uvigerinids with high organic carbon in the sediment and high rates of sediment accumulation, and (4) cibicidids and terrestrial organic carbon. The glacial located near the Eocene/Oligocene boundary is characterized by the penetration of cooler, more corrosive waters at intermediate depths in high southern latitudes. This may have caused overturn, upwelling pulses, in other Tasman areas. The development of Neogenelike conditions began in the late Oligocene (Zone NP24/NP25) with the evolution of several common Neogene species. A large number of Paleogene benthics disappeared gradually through the course of the early Miocene, which was not well preserved at any Tasman site. Corrosive conditions shallowed into the middle bathyal zone in several pulses during the early Miocene. The development of glacial conditions in the middle Miocene was accompanied by major changes throughout the Tasman Sea. Sediment accumulation rates increased and high-productivity faunas and corrosive conditions developed at all but the lowest-latitude Site 588. This increase in productivity and accumulation rate is attributed to the eutrophication of Antarctic water masses feeding Tasman current systems, as well as to invigorated circulation in general. It overlaps with the beginning of the Pacific High-productivity Episode (10-5 Ma). During the latest Miocene glacial episode, corrosive conditions developed at lower bathyal depths, while cooler water and lower nutrient levels shallowed to middle bathyal depths. Lower input of terrestrial organic carbon may be related to the lower nutrient levels of this time and to the termination of the Pacific High-productivity Episode. The moderate glacial episode during the mid-Pliocene (Zone NN15/NN16, ~3.2 Ma) corresponds to a decline in sediment accumulation rates and a reorganization of faunas unlike that of all other times. New genera proliferate and indices for cool, noncorrosive conditions and high organic carbon expand throughout the middle bathyal zone coeval with the sedimentation rate decreases. By the latest Pliocene (about 2.5 Ma), however, during another glacial episode, faunal patterns typical of this and later glacials develop throughout the Tasman Sea. Benthic foraminiferal patterns suggest increased input of terrestrial organic matter to Tasman Sea sediments during this episode and during later glacials.

Stable isotope record and trace element ratios of Eocene and Oligocene foraminifers from ODP Site 120-748

Stable carbon and oxygen isotope analyses were conducted on well-preserved planktonic and benthic foraminifers from a continuous middle Eocene to Oligocene sequence at Ocean Drilling Program (ODP) Site 748 on the Kerguelen Plateau. Benthic foraminifer d18O values show a 1.0 per mil increase through the middle and upper Eocene, followed by a rapid 1.2 per mil increase in the lowermost Oligocene (35.5 Ma). Surface-dwelling planktonic foraminifer d18O values increase in the lowermost Oligocene, but only by 0.6 per mil whereas intermediate-depth planktonic foraminifers show an increase of about l.0 per mil. Benthic foraminifer d13C values increase by 0.9 per mil in the lowermost Oligocene at precisely the same time as the large d18O increase, whereas planktonic foraminifer d13C values show little or no change. Site 748 oxygen isotope and paleontological records suggest that southern Indian Ocean surface and intermediate waters underwent significant cooling from the early to late Eocene. The rapid 1.2 per mil oxygen isotope increase recorded by benthic foraminifers just above the Eocene/Oligocene boundary represents the ubiquitous early Oligocene d18O event. The shift here is unique, however, as it coincided with the sudden appearance of ice-rafted debris (IRD), providing the first direct link between Antarctic glacial activity and the earliest Oligocene d18O increase. The d18O increase caused by the ice-volume change in the early Oligocene is constrained by (1) related changes in the planktonic to benthic foraminifer d18O gradient at Site 748 and (2) comparisons of late Eocene and early Oligocene planktonic foraminifer d18Ovalues from various latitudes. Both of these records indicate that 0.3 per mil to 0.4 per mil of the early Oligocene d18O increase was ice-volume related.