Retinopathy of prematurity (ROP) is an important cause of childhood blindness globally, and the incidence is rising. The disease is characterized by initial arrested retinal vascularization followed by neovascularization and ensuing retinal detachment causing permanent visual loss. Although neovascularization can be effectively treated via retinal laser ablation, it is unknown which children are at risk of entering this vision-threatening phase of the disease. Laser ablation may itself induce visual field deficits, and there is therefore a need to identify targets for novel and less destructive treatments of ROP. Inflammation is considered a key contributor to the pathogenesis of ROP. A large proportion of preterm infants with ROP will have residual visual loss linked to loss of photoreceptor (PR) and the integrity of the retinal pigment epithelium (RPE) in the macular region. Recent studies using animal models of ROP suggest that choroidal degeneration may be associated with a loss of integrity of the outer retina, a phenomenon so far largely undescribed in ROP pathogenesis. In this review, we highlight inflammatory and neuron-derived factors related to ROP progression, as well, potential targets for new treatment strategies. We also introduce choroidal degeneration as a significant cause of residual visual loss following ROP. We propose that ROP should no longer be considered an inner retinal vasculopathy only, but also a disease of choroidal degeneration affecting both retinal pigment epithelium and photoreceptor integrity.

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Glucose and acetate metabolism and the synthesis of amino acid neurotransmitters, anaplerosis, glutamate-glutamine cycling and the pentose phosphate pathway (PPP) have been extensively investigated in the adult, but not the neonatal rat brain. To do this, 7 day postnatal (P7) rats were injected with [1-C]glucose and [1,2-C]acetate and sacrificed 5, 10, 15, 30 and 45 min later. Adult rats were injected and sacrificed after 15 min. To analyse pyruvate carboxylation and PPP activity during development, P7 rats received [1,2-C]glucose and were sacrificed 30 min later. Brain extracts were analysed using Hand C-NMR spectroscopy. The neonatal brain contained lower levels of glutamate, aspartate and N-acetylaspartate but similar levels of GABA and glutamine compared to adults. Metabolism of [1-C]glucose at the acetyl CoA stage was reduced much more than that of [1,2-C]acetate. The transfer of glutamate from neurons to astrocytes was greatly reduced while transfer of glutamine from astrocytes to glutamatergic neurons was relatively higher compared to adults. However, transport of glutamine from astrocytes to GABAergic neurons was lower. Using [1,2-C]glucose it could be shown that despite much lower pyruvate carboxylation, relatively more pyruvate from glycolysis was directed towards anaplerosis than pyruvate dehydrogenation in astrocytes compared to reports from the adult brain. Moreover, the ratio of PPP/glucose metabolism was higher in P7 compared to adult brain. Our findings indicate that only the part of the glutamateglutamine cycle that transfers glutamine from astrocytes to neurons is operating in the After uptake into the cell, glucose (via pyruvate from glycolysis) and acetate can be converted to the TCA cycle substrate acetyl CoA. It has been reported that glucose oxidation is lower and that the average time the metabolites stay in the TCA cycle before conversion to substances such as neurotransmitters glutamate and thereafter γ-amino butyric acid (GABA) is longer in the neonatal compared to the adult brain [7]. This is in part attributed to the low levels of enzymes for pyruvate metabolism and oxidative glucose metabolism in the postnatal period [8].Pyruvate carboxylase, the brain's exclusive anaplerotic enzyme [9], is present in astrocytes only [10], and is of major importance for glial metabolic support of neurotransmission. Pyruvate carboxylase content is low in the neonatal period and increases 15-fold up to young adult age (postnatal day 30-40) when the level reaches a plateau [8].Most of the glutamate in the brain is found in neurons and is released into the synapse after depolarisation [11]. The ability of astrocytes to take up glutamate from the synapse and convert it into glutamine by the astrocyte specific enzyme glutamine synthetase [12] is vital for normal metabolic homeostasis and as a defence mechanism against excitotoxicity [13]. The subsequent transfer of glutamine from astrocytes to neurons for deamidation to glutamate closes the glutamate-

N eonatal hypoxia-ischemia (HI) is a major public health problem, and survivors may exhibit life-long disabilities and cognitive impairments. 1 The stop in delivery of glucose and oxygen compromises mitochondrial oxidative metabolism, causing an immediate fall in energy levels and glutamate release. Subsequent receptor overstimulation initiates an excitooxidative injury cascade, 2 of which many downstream mediators converge on and specifically target mitochondria.3 On re-establishment of cerebral blood flow and oxygen delivery to the tissue, mitochondrial oxidative metabolism resumes, leading to a not only transient recovery in energy levels but also oxidative stress. 4 Because mitochondria are vulnerable to reactive oxygen species, they are not only generators but also targets of such stress.3 Permanent metabolic failure of this organelle probably plays a key role in the secondary decline in energy levels 5 and delayed cell death, 6 which characterize neonatal HI.In normal neurotransmission in the adult brain, astrocytes protect against excitotoxicity through uptake and recycling of extracellular glutamate via conversion to glutamine in the glutamate-glutamine cycle.7 Interestingly, glutamate transfer from neurons to astrocytes is low in the neonatal brain, possibly because of low expression of astrocytic glutamate transporters. 8 It is conceivable that this reduces the capacity of uptake of pathologically increased extracellular glutamate such as after HI. In combination with an abundance 9 of hypersensitive glutamate receptors, 10 this might explain the particular vulnerability to excitotoxicity of the neonatal brain. Mitochondrial oxidative metabolism is also intimately coupled with tricarboxylic acid (TCA) cycling and synthesis of neurotransmitters glutamate, aspartate, and GABA. Astrocytes are essential for the preservation of these neurotransmitter pools through de novo synthesis dependent on Background and Purpose-Increased susceptibility to excitotoxicity of the neonatal brain after hypoxia-ischemia (HI) may be caused by limited capacity of astrocytes for glutamate uptake, and mitochondrial failure probably plays a key role in the delayed injury cascade. Male infants have poorer outcome than females after HI, possibly linked to differential intermediary metabolism. Methods-[1-13 C]glucose and [1,2-13 C]acetate were injected at zero, 6, and 48 hours after unilateral HI in 7-day-old rats. Intermediary metabolism was analyzed with magnetic resonance spectroscopy. Results-Mitochondrial metabolism was generally reduced in the ipsilateral hemisphere for ≤6 hours after HI, whereas contralaterally, it was reduced in neurons but not in astrocytes. Transfer of glutamate from neurons to astrocytes was increased in the contralateral, but not in the ipsilateral hemisphere at 0 hour, and reduced bilaterally at 6 hours after HI. The transfer of glutamine from astrocytes to glutamatergic neurons was unaltered in both hemispheres, whereas the transfer of glutamine to GABAergic neurons was increased ipsilaterally at 0 ...

PurposeTo assess the association between systemic levels of inflammation-associated proteins and severe retinopathy of prematurity (ROP) in extremely preterm infants.MethodsWe collected whole blood on filter paper on postnatal days 1, 7, 14, 21, and 28 from 1205 infants born before the 28th week of gestation, and measured the concentrations of 27 inflammation-associated, angiogenic, and neurotrophic proteins. We calculated odds ratios with 95% confidence intervals for the association between top quartile concentrations of each protein and prethreshold ROP.ResultsDuring the first three weeks after birth, high concentrations of VEGF-R1, myeloperoxidase (MPO), IL-8, intercellular adhesion molecule (ICAM)-1, matrix metalloproteinase 9, erythropoietin, TNF-α, and basic fibroblast growth factor were associated with an increased risk for prethreshold ROP. On day 28, high levels of serum amyloid A, MPO, IL-6, TNF-α, TNF-R1/-R2, IL-8, and ICAM-1 were associated with an increased risk. Top quartile concentrations of the proinflammatory cytokines TNF-α and IL-6 were associated with increased risks of ROP when levels of neuroprotective proteins and growth factors, including BDNF, insulin-like growth factor 1, IGFBP-1, VEGFR-1 and -2, ANG-1 and PlGF, were not in the top quartile. In contrast, high concentrations of NT-4 and BDNF appeared protective only in infants without elevated inflammatory mediators.ConclusionsSystemic inflammation during the first postnatal month was associated with an increased risk of prethreshold ROP. Elevated concentrations of growth factors, angiogenic proteins, and neurotrophins appeared to modulate this risk, and were capable of reducing the risk even in the absence of systemic inflammation.

We report on the uptake of MeHg in astrocytes and neurons, as well as specific indicators of neurotoxicity. Cerebellar granule neurons and astrocytes separately and in co-culture were cultured in the presence of MeHg and changes in 3-[4, 5-dimethylthiazol-2-yl]-2, 5 diphenyltetrazolium bromide (MTT)-reduction, lactate dehydrogenase (LDH) leakage, and cellular content of glutathione and amino acids were used as indicators of MeHg toxicity. Mitochondria in cortical astrocytes were slightly more sensitive than those in cerebellar astrocytes to the toxic effects of MeHg; furthermore, cellular integrity was better preserved in cerebellar astrocytes. When neurons and astrocytes from cerebellum were incubated in separable co-cultures using inserts, the astrocytes showed cellular damage at lower exposure to MeHg while neurons showed less changes compared to respective cell types in mono-cultures. Mercury uptake studies at 25 microM MeHg (10% serum present) showed that for neurons in co-culture the uptake was 1/3 compared to mono-cultures. In contrast, for astrocytes in co-culture, uptake was increased by 75%. A MeHg concentration-dependent increase of glutamate content in mono-cultures was noted. When MeHg concentration was increased to 10, 25, or 50 microM, neurons in co-cultures decreased their glutamate content, whereas astrocytes showed an increase. Other amino acids, such as glutamine, serine, valine, isoleucine, taurine, and phenylalanine were unaffected by MeHg. Glutathione content showed MeHg concentration-dependent changes in astrocytes and was increased in neurons in co-culture incubated with 5 microM MeHg. In conclusion, astrocytes appear to increase neuronal resistance, indicating a possible protective role for astrocytes in MeHg neurotoxicity.

The neonatal brain is vulnerable to oxidative stress, and the pentose phosphate pathway (PPP) may be of particular importance to limit the injury. Furthermore, in the neonatal brain, neurons depend on de novo synthesis of neurotransmitters via pyruvate carboxylase (PC) in astrocytes to increase neurotransmitter pools. In the adult brain, PPP activity increases in response to various injuries while pyruvate carboxylation is reduced after ischemia. However, little is known about the response of these pathways after neonatal hypoxia-ischemia (HI). To this end, 7-day-old rats were subjected to unilateral carotid artery ligation followed by hypoxia. Animals were injected with [1,2-(13)C]glucose during the recovery phase and extracts of cerebral hemispheres ipsi- and contralateral to the operation were analyzed using (1)H- and (13)C-NMR (nuclear magnetic resonance) spectroscopy and high-performance liquid chromatography (HPLC). After HI, glucose levels were increased and there was evidence of mitochondrial hypometabolism in both hemispheres. Moreover, metabolism via PPP was reduced bilaterally. Ipsilateral glucose metabolism via PC was reduced, but PC activity was relatively preserved compared with glucose metabolism via pyruvate dehydrogenase. The observed reduction in PPP activity after HI may contribute to the increased susceptibility of the neonatal brain to oxidative stress.

Purpose To test if task shifting of intraocular injections to nurses in a real‐world setting can result in similar visual function outcome with equal safety profile. Method All patients with either age‐related macular degeneration, retinal vein occlusion or diabetic macular oedema remitted to intraocular injections at a tertiary ophthalmology department in Norway between March 2015 and May 2017, were asked to participate. The participants were randomized to either nurse‐ or physician‐administered intraocular injections of anti‐vascular endothelial growth factor. The primary outcome measure was change in best‐corrected visual acuity from baseline to 1‐year follow‐up. The mean difference in the primary outcome between the groups was analysed by a noninferiority test with a margin of three letters in disfavour of the nurse group. Adverse events were recorded. Results Three hundred and forty‐two patients entered the study. Two hundred and fifty‐nine completed the 1‐year follow‐up and were included in the study sample for the analysis of the primary outcome. Nurse‐administered intraocular injections were noninferior to physician‐administered injections with 0.7 and 1.6 letters gained, respectively (95% CI of the mean difference, −2.9 to 1.0; p = 0.019, one‐sided t‐test). Two thousand and seventy‐seven injections and three ocular adverse events were recorded. Conclusion Task shifting of intraocular injections to nurses can be performed without increased risk to visual function. Such a task shift can alleviate the burden of performing intraocular injections in ophthalmology departments. To our knowledge, this is the first RCT on task shifting of a surgical procedure from physicians to nurses in a high‐income country.