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Toneman M, Groenveld T, Krielen P, Hooker A, de Wilde R, Torres-de la Roche LA, Di Spiezio Sardo A, Koninckx P, Cheong Y, Nap A, van Goor H, Pargmae P, ten Broek R. Risk Factors for Adhesion-Related Readmission and Abdominal Reoperation after Gynecological Surgery: A Nationwide Cohort Study. J Clin Med 2023; 12:jcm12041351. [PMID: 36835887 PMCID: PMC9965311 DOI: 10.3390/jcm12041351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
More than half of women in developed countries undergo surgery during their lifetime, putting them at risk of adhesion-related complications. Adhesion-related complications include small bowel obstruction, chronic (pelvic) pain, subfertility, and complications associated with adhesiolysis during reoperation. The aim of this study is to predict the risk for adhesion-related readmission and reoperation after gynecological surgery. A Scottish nationwide retrospective cohort study was conducted including all women undergoing a gynecological procedure as their initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011, with a five-year follow-up. Prediction models for two- and five-year risk of adhesion-related readmission and reoperation were constructed and visualized using nomograms. To evaluate the reliability of the created prediction model, internal cross-validation was performed using bootstrap methods. During the study period, 18,452 women were operated on, and 2719 (14.7%) of them were readmitted for reasons possibly related to adhesions. A total of 2679 (14.5%) women underwent reoperation. Risk factors for adhesion-related readmission were younger age, malignancy as indication, intra-abdominal infection, previous radiotherapy, application of a mesh, and concomitant inflammatory bowel disease. Transvaginal surgery was associated with a lower risk of adhesion-related complications as compared to laparoscopic or open surgeries. The prediction model for both readmissions and reoperations had moderate predictive reliability (c-statistics 0.711 and 0.651). This study identified risk factors for adhesion-related morbidity. The constructed prediction models can guide the targeted use of adhesion prevention methods and preoperative patient information in decision-making.
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Affiliation(s)
- Masja Toneman
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
- Correspondence:
| | - Tjitske Groenveld
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Pepijn Krielen
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Angelo Hooker
- Department of Obstetrics and Gynecology, Zaans Medical Center (ZMC), 1502 DV Zaandam, The Netherlands
| | - Rudy de Wilde
- University Hospital for Gynecology, Carl von Ossietzky University, 26121 Oldenburg, Germany
| | | | - Atillio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | - Philippe Koninckx
- Department of Gynecology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium
| | - Ying Cheong
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- Complete Fertility Centre, Southampton SO16 5YA, UK
| | - Annemiek Nap
- Department of Gynecology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Pille Pargmae
- Department of Gynecology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Richard ten Broek
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
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Hooker A, Leeuw RA, Twisk J, Brolmann H, Huirne J. O-138 Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial. Hum Reprod 2021. [DOI: 10.1093/humrep/deab126.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
Are the long-term reproductive outcomes following recurrent dilatation and curettage (D&C) for miscarriage in women with identified and treated intrauterine adhesions (IUAs) comparable to women without IUAs.
Summary answer
Reproductive outcomes in women with identified and treated IUAs following recurrent D&C for miscarriage are impaired compared to women without IUAs.
What is known already
The Prevention of Adhesions Post Abortion (PAPA) study showed that application of auto-crosslinked hyaluronic acid (ACP) gel, an absorbable barrier in women undergoing recurrent D&C for miscarriage resulted in a lower rate of IUAs, 13% versus 31% (relative risk 0.43, 95% CI 0.22 to 0.83), lower mean adhesion score and significant less moderate to severe IUAs. It is unclear what the impact is of IUAs on long-term reproductive performance.
Study design, size, duration
This was a follow-up of the PAPA study, a multicenter randomized controlled trial evaluating the application of ACP gel in women undergoing recurrent D&C for miscarriage. All included women received a diagnostic hysteroscopy 8–12 weeks after randomization to evaluate the uterine cavity and for adhesiolysis if IUAs were present. Here, we present the reproductive outcomes in women with identified and treated IUAs versus women without IUAs, 46 months after randomization.
Participants/materials, setting, methods
Between December 2011 and July 2015, 152 women with a first-trimester miscarriage with at least one previous D&C, were randomized for D&C alone or D&C with immediate intrauterine application of ACP gel. Participants were approached at least 30 months after randomization to evaluate reproductive performance, obstetric and neonatal outcomes and cycle characteristics. Main outcome was ongoing pregnancy. Outcomes of subsequent pregnancies, time to conception and time to live birth were also recorded.
Main results and the role of chance
In women pursuing a pregnancy, 14/24 (58%) ongoing pregnancies were recorded in women with identified and treated IUAs versus 80/89 (90%) ongoing pregnancies in women without IUAs odds ratio (OR) 0.18 (95% CI 0.06 to 0.50, P-value <0.001). Documented live birth was also lower in women with IUAs; 13/24 (54%) with versus 75/89 (84%) without IUAs, OR 0.22 (95% CI: 0.08 to-0.59, P-value 0.004). The median time to conception was 7 months in women with identified and treated IUAs versus 5 months in women without IUAs (hazard ratio (HR) 0.84 (95% CI 0.54 to 1.33)) and time to conception leading to a live birth 15 months versus 5.0 months (HR 0.54 (95% CI: 0.30 to 0.97)). In women with identified and treated IUAs, premature deliveries were recorded in 3/16 (19%) versus 4/88 (5%) in women without IUAs, P-value 0.01. Complications were recorded in respectively 12/16 (75%) versus 26/88 (30%), P-value 0.001. No differences were recorded in mean birth weight between the groups.
Limitations, reasons for caution
In the original PAPA study, randomization was applied for ACP gel application. Comparing women with and without IUAs is not in line with the randomization and therefore confounding of the results cannot be excluded. IUAs, if visible during routine hysteroscopy after randomization were removed as part of the study protocol.
Wider implications of the findings
As IUAs have an impact on reproductive performance, even after hysteroscopic adhesiolysis, primary prevention is essential. Expectative and medical management should therefore be considered as serious alternatives for D&C in women with a miscarriage. In case D&C is necessary, application of ACP gel should be considered.
Trial registration number
Netherlands Trial Register NTR 3120.
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Affiliation(s)
- A Hooker
- Zaans Medical Center ZMC, Department of Obstetrics and Gynaecology, Zaandam, The Netherlands
| | - R A Leeuw
- Amsterdam UMC- Location VU University Medical Center- Amsterdam- the Netherlands, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
| | - J Twisk
- Amsterdam UMC- Location VU University Medical Center- Amsterdam- the Netherlands, Department of Epidemiology and Biostatistics-, Amsterdam, The Netherlands
| | - H Brolmann
- Amsterdam UMC- Location VU University Medical Center- Amsterdam- the Netherlands, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
| | - J Huirne
- Amsterdam UMC- Location VU University Medical Center- Amsterdam- the Netherlands, Department of Obstetrics and Gynecology, Amsterdam, The Netherlands
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Gitsels-van der Wal JT, Gitsels LA, Hooker A, Scholing P, Martin L, Feijen-de Jong EI. Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:269. [PMID: 32375734 PMCID: PMC7201569 DOI: 10.1186/s12884-020-02957-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/20/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes. METHODS A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief. RESULTS The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death. CONCLUSION In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.
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Affiliation(s)
- Janneke T. Gitsels-van der Wal
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Lisanne A. Gitsels
- ESRC funded Business and Local Government Data Research Centre (BLG DRC), School of Computing Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ UK
- University College London, London, UK
| | - Angelo Hooker
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117 Amsterdam, Netherlands
- Zaans Medical Center, Department of Obstetrics and Gynecology, Koningin Julianaplein 58, Zaandam, Netherlands
| | - Paula Scholing
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Linda Martin
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Esther I. Feijen-de Jong
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
- Department of General Practice & Elderly Medicine, University of Groningen, University Medical Center Groningen, POBox 30001, 9700 RB Groningen, the Netherlands
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Gitsels-van der Wal JT, Gitsels LA, Hooker A, van Weert B, Martin L, Feijen-de Jong EI. Determinants and underlying causes of frequent attendance in midwife-led care: an exploratory cross-sectional study. BMC Pregnancy Childbirth 2019; 19:203. [PMID: 31208355 PMCID: PMC6580473 DOI: 10.1186/s12884-019-2316-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/25/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND An adequate number of prenatal consultations is beneficial to the health of the mother and fetus. Guidelines recommend an average of 5-14 consultations. Daily practice, however, shows that some women attend the midwifery practice more frequently. This study examined factors associated with frequent attendance in midwifery-led care. METHODS We conducted a cross-sectional study in a large midwifery practice in the Netherlands among low-risk women who started prenatal care in 2015 and 2016. Based on Andersen's behavioral model, we collected data on potential determinants from the digital midwifery's practice database. Prenatal healthcare utilization was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and numbers of visits. Logistic regression models were fitted to estimate the likelihood of frequent attendance compared to the recommended number of visits, adjusted for all relevant factors. Separate models were fitted on the non-referred and the referred group of obstetric-led care, as referral was found to be an effect modifier. RESULTS The prevalence of frequent attendance was 23% (243/1053), mainly caused by worries and/or vague complaints (44%; 106/243). Among non-referred women, 53% (560/1053), frequent attendance was associated with consultation with an obstetrician (OR = 3.99 (2.35-6.77)) and exposure to sexual violence (OR = 2.17 (1.11-4.24)). Among the referred participants, 47% (493/1053), frequent attendance was associated with a consultation with an obstetrician (OR = 2.75 (1.66-4.57)), psychosocial problems in the past or present (OR = 1.85 (1.02-3.35) or OR = 2.99 (1.43-6.25)), overweight (OR = 1.88 (1.09-3.24)), and deprived area (OR = 0.50 (0.27-0.92)). CONCLUSION Our exploratory study indicates that the determinants of frequent attendance in midwifery-led care differs between non-referred and referred women. Underlying causes for frequent attendance was mainly because of non-medical reasons. IMPLICATION FOR PRACTICE A trustful midwife-client relationship is known to be needed for clients such as frequent attenders to share more detailed, personal stories in case of vague complaints or worries, which is necessary to identify their implicit needs.
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Affiliation(s)
- Janneke T Gitsels-van der Wal
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands.
| | - Lisanne A Gitsels
- ESRC funded Business and Local Government Data Research Centre (BLG DRC), School of Computing Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, England, UK
| | - Angelo Hooker
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands.,Department of Obstetrics and Gynecology, Zaans Medical Center, Koningin Julianaplein 58, Zaandam, Netherlands
| | - Britte van Weert
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Linda Martin
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Esther I Feijen-de Jong
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands.,Department of General Practice & Elderly Care Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB, Groningen, the Netherlands
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Torres-De La Roche LA, Campo R, Devassy R, Di Spiezio Sardo A, Hooker A, Koninckx P, Urman B, Wallwiener M, De Wilde RL. Adhesions and Anti-Adhesion Systems Highlights. Facts Views Vis Obgyn 2019; 11:137-149. [PMID: 31824635 PMCID: PMC6897521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The peritoneal and intrauterine cavities are lined by fragile membranes with a high-wound healing capacity, e.g. repairing the endometrium in its cyclical "injury and scar-free repair process" during menstruation. However, peritoneal and intrauterine fibrosis and adhesions can develop after surgical trauma through activation of molecular, immune and genetic mechanisms. During procedures with a high-risk of adhesions, the use of new peritoneal and intrauterine conditions in combination with anti-adhesion substances are promising measures to preserve peritoneal and endometrial function and avoid the most common complication of gynecological surgery. Highlights of adhesions and anti-adhesion prevention techniques in laparoscopic, laparotomic and hysteroscopic surgeries are discussed in this paper. Unfortunately, evidence is lacking to prove the superiority of one technique over its counterparts in terms of postoperative adhesions, such as instrumentation, type of energy, distending media, and intracavitary pressure. Additionally, there is limited evidence about the efficacy and outcomes of techniques and adjuvant measures used during adhesiolysis. The definition of a universal intrauterine adhesions classification scheme as well as a prognostic scoring system to identify women at high risk of postoperative adhesions are necessary for advising those who could benefit the most of the use of antiadhesion barriers.
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Affiliation(s)
- LA Torres-De La Roche
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, Carl von Ossietzky University Oldenburg, 26121, Germany
| | - R Campo
- Leuven Institute for Fertility and Embryology, Tiensevest, 3000, Leuven
| | - R Devassy
- Dubai London Clinic and Speciality Hospital, Dubai, 3371500, UAE
| | | | - A Hooker
- Zaans Medical Centre, Zaandam, 1502, Netherlands
| | - P Koninckx
- UZ Leuven Campus Gasthuisberg, Leuven, 3000, Belgium
| | - B Urman
- Koç University Faculty of Medicine, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34330, Turkey
| | - M Wallwiener
- Heidelberg University Women's Hospital, Heidelberg, 69115, Germany
| | - RL De Wilde
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, Carl von Ossietzky University Oldenburg, 26121, Germany
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Abstract
OBJECTIVES Termination of pregnancy (TOP) is one of the most performed interventions in women worldwide: approximately one in three women will have at least one TOP in their reproductive life. Intrauterine adhesions (IUAs) have been reported as a possible complication after TOP, but their prevalence has not been established, as women are not routinely evaluated. IUAs are associated with menstrual disturbances, infertility and obstetric complications. METHODS We searched Ovid MEDLINE, Ovid EMBASE and CENTRAL from inception until November 2015 for studies evaluating women following TOP. We selected studies in which women were evaluated consecutively, independently of symptoms, by hysteroscopy or hysterosalpingography (HSG), for the presence of IUAs. RESULTS After an extensive review of the literature, no studies were found that evaluated women after medical TOP and no randomised trials following surgical TOP. Only two prospective cohort studies were identified. In the first, IUAs were detected in 21.2% of women evaluated by hysteroscopy following first trimester surgical TOP; adhesions were moderate to severe in 48%. In the second, IUAs were detected in 16.2% of women evaluated by HSG after second trimester TOP by intra-amniotic prostaglandin induction followed by D&C; a pathologically wide internal cervical os was observed in 12%. CONCLUSIONS This systematic review suggests a link between TOP and adhesion formation, but, according to the scientific literature and despite new diagnostic facilities, the relationship between the methods of TOP and IUA formation remains unclear. Nevertheless, the reported frequency is in accordance with that found in women following D&C for miscarriage. Further research is required.
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Affiliation(s)
- Angelo Hooker
- a Department of Obstetrics and Gynaecology , Zaans Medical Centre , Zaandam , The Netherlands ;,b Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
| | - Donachienne Fraenk
- a Department of Obstetrics and Gynaecology , Zaans Medical Centre , Zaandam , The Netherlands ;,c Department of Obstetrics , Haaglanden Medical Centre , The Hague , The Netherlands
| | - Hans Brölmann
- b Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
| | - Judith Huirne
- b Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
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Abstract
Several software tools are available that facilitate the use of the NONMEM software and extend its functionality. This tutorial shows how three commonly used and freely available tools, Pirana, PsN, and Xpose, form a tightly integrated workbench for modeling and simulation with NONMEM. During the tutorial, we provide some guidance on what diagnostics we consider most useful in pharmacokinetic model development and how to construct them using these tools.
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Affiliation(s)
- R J Keizer
- Department of Pharmaceutical Biosciences, Pharmacometrics research Group, Uppsala University, Uppsala, Sweden
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Mentré F, Chenel M, Comets E, Grevel J, Hooker A, Karlsson MO, Lavielle M, Gueorguieva I. Current Use and Developments Needed for Optimal Design in Pharmacometrics: A Study Performed Among DDMoRe's European Federation of Pharmaceutical Industries and Associations Members. CPT Pharmacometrics Syst Pharmacol 2013; 2:e46. [PMID: 23887744 PMCID: PMC3697035 DOI: 10.1038/psp.2013.19] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 03/13/2013] [Indexed: 01/07/2023]
Affiliation(s)
- F Mentré
- UMR 738, INSERM, University Paris Diderot, Paris, France
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Abstract
The cloning of the cDNA for human interferon-gamma (IFN-gamma) has resulted in its expression in Escherichia coli, baculovirus-infected insect cells, Chinese hamster ovary (CHO) cells, and the mammary gland of transgenic mice. Large quantities of highly purified recombinant IFN-gamma have been generated, aided by the use of highly specific neutralizing monoclonal antibodies, with a view to its production as a human therapeutic protein. The primary source of structural heterogeneity for IFN-gamma during its production in mammalian expression systems is glycosylation, which can profoundly affect the three-dimensional structure of a glycoprotein and its biological function. A number of analytical approaches have been developed recently to allow a detailed analysis of the carbohydrate structures associated with IFN-gamma, the principal advances being in the areas of capillary electrophoresis and mass spectrometry. The implementation of these high-resolution analytical tools to determine the glycosylation profile of IFN-gamma makes it one of the best characterized recombinant glycoproteins. Recombinant human IFN-gamma acts as a model secretory glycoprotein, typifying the intrinsic glycosylation processing events associated with production of a potential therapeutic glycoprotein.
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Affiliation(s)
- A Hooker
- Oxford GlycoSciences (UK) Plc, Abingdon Science Park, United Kingdom.
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Affiliation(s)
- A R Ready
- Renal Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, England
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