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Wieringa A, Ewoldt TMJ, Gangapersad RN, Gijsen M, Parolya N, Kats CJAR, Spriet I, Endeman H, Haringman JJ, van Hest RM, Koch BCP, Abdulla A. Predicting Beta-Lactam Target Non-Attainment in ICU Patients at Treatment Initiation: Development and External Validation of Three Novel (Machine Learning) Models. Antibiotics (Basel) 2023; 12:1674. [PMID: 38136709 PMCID: PMC10740552 DOI: 10.3390/antibiotics12121674] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
In the intensive care unit (ICU), infection-related mortality is high. Although adequate antibiotic treatment is essential in infections, beta-lactam target non-attainment occurs in up to 45% of ICU patients, which is associated with a lower likelihood of clinical success. To optimize antibiotic treatment, we aimed to develop beta-lactam target non-attainment prediction models in ICU patients. Patients from two multicenter studies were included, with intravenous intermittent beta-lactam antibiotics administered and blood samples drawn within 12-36 h after antibiotic initiation. Beta-lactam target non-attainment models were developed and validated using random forest (RF), logistic regression (LR), and naïve Bayes (NB) models from 376 patients. External validation was performed on 150 ICU patients. We assessed performance by measuring discrimination, calibration, and net benefit at the default threshold probability of 0.20. Age, sex, serum creatinine, and type of beta-lactam antibiotic were found to be predictive of beta-lactam target non-attainment. In the external validation, the RF, LR, and NB models confirmed good discrimination with an area under the curve of 0.79 [95% CI 0.72-0.86], 0.80 [95% CI 0.73-0.87], and 0.75 [95% CI 0.67-0.82], respectively, and net benefit in the RF and LR models. We developed prediction models for beta-lactam target non-attainment within 12-36 h after antibiotic initiation in ICU patients. These online-accessible models use readily available patient variables and help optimize antibiotic treatment. The RF and LR models showed the best performance among the three models tested.
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Affiliation(s)
- André Wieringa
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Clinical Pharmacy, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Tim M. J. Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Ravish N. Gangapersad
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (M.G.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
| | - Nestor Parolya
- Delft Institute of Applied Mathematics, Mekelweg 4, 2628 CD Delft, The Netherlands;
| | - Chantal J. A. R. Kats
- Department of Hospital Pharmacy, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, The Netherlands;
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (M.G.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Jasper J. Haringman
- Department of Intensive Care, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Reinier M. van Hest
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
| | - Birgit C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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Wieringa A, Ter Horst PG, Wagenvoort GH, Koch BC, Haringman JJ. Pharmacokinetics of zanamivir in critically ill patients undergoing continuous venovenous hemofiltration. Antivir Ther 2023; 28:13596535221150746. [PMID: 36609161 DOI: 10.1177/13596535221150746] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Limited data exist for dosing of zanamivir in the setting of CVVH in the intensive care unit (ICU). Our objective is to report the pharmacokinetics and sieving coefficient (Sv) of zanamivir in patients receiving continuous venovenous hemofiltration (CVVH). METHODS In this prospective observational study, patients of ≥18 years admitted to the ICU with a life-threatening Influenza A or B infection, treated with zanamivir i.v. undergoing CVVH were included. Patients received a zanamivir loading dose of 600 mg i.v., 12 h later followed by maintenance dosages two times daily according to the treating physician. Per patient, nine CFT plasma and nine ultrafiltrate samples were drawn on day 2 of treatment and analysed with a validated HPLC-MS/MS method. RESULTS Four patients were included in the study. The zanamivir elimination half-life was prolonged with 5.6-9.9 h, compared to patients with normal renal function. A Sv of approximately 1.0 was identified, with unrestricted transport of zanamivir to the ultrafiltrate. CONCLUSIONS Zanamivir is well cleared by CVVH. In absence of the possibility for therapeutic drug monitoring, the ultrafiltration rate seems as a good surrogate parameter to estimate the CLCVVH and may help guide the dosing of zanamivir.
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Affiliation(s)
- André Wieringa
- Department of Clinical Pharmacy, 8772Isala Hospital, Zwolle, The Netherlands.,Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Peter Gj Ter Horst
- Department of Clinical Pharmacy, 8772Isala Hospital, Zwolle, The Netherlands
| | - GertJan Hj Wagenvoort
- Laboratory of Clinical Microbiology and Infectious Diseases, 8772Isala Hospital, Zwolle, The Netherlands
| | - Birgit Cp Koch
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.,Department of Pharmacy, 6993Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jasper J Haringman
- Department of Clinical Pharmacy, 8772Isala Hospital, Zwolle, The Netherlands
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Wieringa A, Ter Horst PGJ, Wagenvoort GHJ, Dijkstra A, Abdulla A, Haringman JJ, Koch BCP. Target attainment and pharmacokinetics of cefotaxime in critically ill patients undergoing continuous kidney replacement therapy. J Antimicrob Chemother 2022; 77:3421-3426. [PMID: 36210582 DOI: 10.1093/jac/dkac334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Limited data exist about the antimicrobial target attainment and pharmacokinetics of cefotaxime in critically ill patients in the ICU undergoing continuous kidney replacement therapy (CKRT). We conducted a prospective observational study in two large teaching hospitals [Isala Hospital (IH) and Zwolle and Maasstad Hospital (MH)] to investigate target attainment and pharmacokinetics of cefotaxime in patients undergoing CKRT. PATIENTS AND METHODS Patients aged ≥18 years admitted to the ICU treated with IV cefotaxime 1000 mg three times daily (IH) or 4 times daily (MH) were included. Fifteen patients were enrolled in total. Per patient eight cefotaxime plasma and eight ultrafiltrate samples were drawn in IH and four plasma samples in MH on Day 2 of treatment. In ICU patients the recommended antimicrobial target of cefotaxime is a plasma concentration 100% of the time above the MIC. RESULTS In IH 10/11 patients had higher plasma trough concentrations than the MIC breakpoint of Enterobacterales of 1 mg/L (clinical breakpoint for susceptible strains) and 9/11 patients had concentrations above 2 mg/L (clinical breakpoint for resistant strains). All patients (4/4) in MH had higher plasma trough concentrations than 2 mg/L. A sieving coefficient of 0.74 was identified, with a median amount of 40% of cefotaxime eliminated by CKRT. CONCLUSIONS We conclude that cefotaxime 1000 mg 3-4 times daily gives adequate plasma concentrations in patients with anuria or oliguria undergoing CKRT. The 1000 mg four times daily dosage is recommended in patients undergoing CKRT with partially preserved renal function to achieve the target.
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Affiliation(s)
- André Wieringa
- Department of Clinical Pharmacy, Isala Hospital, Zwolle, The Netherlands.,Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | | | - Gertjan H J Wagenvoort
- Laboratory of Clinical Microbiology and Infectious Diseases, Isala Hospital, Zwolle, The Netherlands
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Alan Abdulla
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Birgit C P Koch
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Algera AG, Pisani L, Bergmans DCJ, den Boer S, de Borgie CAJ, Bosch FH, Bruin K, Cherpanath TG, Determann RM, Dondorp AM, Dongelmans DA, Endeman H, Haringman JJ, Horn J, Juffermans NP, van Meenen DM, van der Meer NJ, Merkus MP, Moeniralam HS, Purmer I, Tuinman PR, Slabbekoorn M, Spronk PE, Vlaar APJ, Gama de Abreu M, Pelosi P, Serpa Neto A, Schultz MJ, Paulus F. RELAx - REstricted versus Liberal positive end-expiratory pressure in patients without ARDS: protocol for a randomized controlled trial. Trials 2018; 19:272. [PMID: 29739430 PMCID: PMC5941564 DOI: 10.1186/s13063-018-2640-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 12/05/2017] [Accepted: 04/10/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Evidence for benefit of high positive end-expiratory pressure (PEEP) is largely lacking for invasively ventilated, critically ill patients with uninjured lungs. We hypothesize that ventilation with low PEEP is noninferior to ventilation with high PEEP with regard to the number of ventilator-free days and being alive at day 28 in this population. METHODS/DESIGN: The "REstricted versus Liberal positive end-expiratory pressure in patients without ARDS" trial (RELAx) is a national, multicenter, randomized controlled, noninferiority trial in adult intensive care unit (ICU) patients with uninjured lungs who are expected not to be extubated within 24 h. RELAx will run in 13 ICUs in the Netherlands to enroll 980 patients under invasive ventilation. In all patients, low tidal volumes are used. Patients assigned to ventilation with low PEEP will receive the lowest possible PEEP between 0 and 5 cm H2O, while patients assigned to ventilation with high PEEP will receive PEEP of 8 cm H2O. The primary endpoint is the number of ventilator-free days and being alive at day 28, a composite endpoint for liberation from the ventilator and mortality until day 28, with a noninferiority margin for a difference between groups of 0.5 days. Secondary endpoints are length of stay (LOS), mortality, and occurrence of pulmonary complications, including severe hypoxemia, major atelectasis, need for rescue therapies, pneumonia, pneumothorax, and development of acute respiratory distress syndrome (ARDS). Hemodynamic support and sedation needs will be collected and compared. DISCUSSION RELAx will be the first sufficiently sized randomized controlled trial in invasively ventilated, critically ill patients with uninjured lungs using a clinically relevant and objective endpoint to determine whether invasive, low-tidal-volume ventilation with low PEEP is noninferior to ventilation with high PEEP. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT03167580 . Registered on 23 May 2017.
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Affiliation(s)
- Anna Geke Algera
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Dennis C. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sylvia den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | | | - Frank H. Bosch
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands
| | - Karina Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, The Netherlands
| | - Thomas G. Cherpanath
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Rogier M. Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Arjen M. Dondorp
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Madihol–Oxford Research Unit (MORU), Madihol University, Bangkok, Thailand
| | - Dave A. Dongelmans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - David M. van Meenen
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Hazra S. Moeniralam
- Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Ilse Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, VU Medical Center, Amsterdam, The Netherlands
- REVIVE Research VU Medical Center, VU Medical Center, Amsterdam, The Netherlands
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Haaglanden Medical Center, The Hague, The Netherlands
| | - Peter E. Spronk
- Department of Intensive Care, Gelre Hospital, Apeldoorn, The Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital – IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - for the RELAx Investigators and the PROVE Network Investigators
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands
- Department of Intensive Care, Westfriesgasthuis, Hoorn, The Netherlands
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Madihol–Oxford Research Unit (MORU), Madihol University, Bangkok, Thailand
- Department of Intensive Care, Isala Clinics, Zwolle, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Amphia Hospital, Breda, The Netherlands
- Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
- Department of Intensive Care, VU Medical Center, Amsterdam, The Netherlands
- REVIVE Research VU Medical Center, VU Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Intensive Care, Gelre Hospital, Apeldoorn, The Netherlands
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital – IRCCS for Oncology, University of Genoa, Genoa, Italy
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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van Meenen DMP, van der Hoeven SM, Binnekade JM, de Borgie CAJM, Merkus MP, Bosch FH, Endeman H, Haringman JJ, van der Meer NJM, Moeniralam HS, Slabbekoorn M, Muller MCA, Stilma W, van Silfhout B, Neto AS, ter Haar HFM, Van Vliet J, Wijnhoven JW, Horn J, Juffermans NP, Pelosi P, Gama de Abreu M, Schultz MJ, Paulus F. Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial. JAMA 2018; 319:993-1001. [PMID: 29486489 PMCID: PMC5885882 DOI: 10.1001/jama.2018.0949] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation. OBJECTIVE To determine if a strategy that uses nebulization for clinical indication (on-demand) is noninferior to one that uses preventive (routine) nebulization. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands. INTERVENTIONS On-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for a difference between groups of -0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events. RESULTS Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, -0.00003 to ∞). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, -15.5% [95% CI, -20.7% to -10.3%]; P < .001) were more frequent with routine nebulization and mainly related to tachyarrhythmia (12.5% vs 25.9%; difference, -13.4% [95% CI, -18.4% to -8.4%]; P < .001) and agitation (0.2% vs 4.3%; difference, -4.1% [95% CI, -5.9% to -2.2%]; P < .001). CONCLUSIONS AND RELEVANCE Among ICU patients receiving invasive ventilation who were expected to not be extubated within 24 hours, on-demand compared with routine nebulization of acetylcysteine with salbutamol did not result in an inferior number of ventilator-free days. On-demand nebulization may be a reasonable alternative to routine nebulization. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02159196.
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Affiliation(s)
- David M. P. van Meenen
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Jan M. Binnekade
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Maruschka P. Merkus
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Hazra S. Moeniralam
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands
| | | | - Willemke Stilma
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Bart van Silfhout
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Jan Van Vliet
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | | | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus; Technische Universität Dresden, Dresden, Germany
| | - Marcus J. Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
- Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
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van Noord PT, Gosselink ATM, Haringman JJ. [Resuscitation for myocardial infarction and head injury: first the heart or first the head?]. Ned Tijdschr Geneeskd 2014; 158:A6909. [PMID: 24735807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Loss of circulation in a patient results in collapse and therefore possible head injury. After percutaneous coronary intervention (PCI) including anticoagulation, comatose patients are sedated for mild therapeutic hypothermia. Recognised or unrecognised head trauma may have dramatic clinical consequences. A 42-year-old male with unrecognised head trauma died due to a massive intracranial haemorrhage (ICH) during the hypothermia phase after being treated with PCI. A 76-year-old female, on anticoagulation for atrial fibrillation, with recognised ICH which resulted in an adjusted PCI, died after five days due to a lethal re-bleed. In a 55-year-old male with neurological abnormalities after mild head trauma, the PCI was postponed for a (negative) head CT which might have increased cardiac muscle damage. Nowadays more patients reach hospital after being resuscitated for cardiac arrest and possible head trauma should be considered in all these patients. This could lead to adjustments being made in the treatment protocol.
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Hirdes MMC, Monkelbaan JF, Haringman JJ, van Oijen MGH, Siersema PD, Pullens HJM, Kesecioglu J, Vleggaar FP, Vleggaar FP. Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial. Am J Gastroenterol 2012; 107:1220-7. [PMID: 22751469 DOI: 10.1038/ajg.2012.169] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy. METHODS Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE). RESULTS Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21). CONCLUSIONS Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.
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Affiliation(s)
- Meike M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
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Wijbrandts CA, Vergunst CE, Haringman JJ, Gerlag DM, Smeets TJM, Tak PP. Absence of changes in the number of synovial sublining macrophages after ineffective treatment for rheumatoid arthritis: Implications for use of synovial sublining macrophages as a biomarker. ACTA ACUST UNITED AC 2007; 56:3869-71. [PMID: 17968928 DOI: 10.1002/art.22964] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Carla A Wijbrandts
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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9
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Haringman JJ, Gerlag DM, Smeets TJM, Baeten D, van den Bosch F, Bresnihan B, Breedveld FC, Dinant HJ, Legay F, Gram H, Loetscher P, Schmouder R, Woodworth T, Tak PP. A randomized controlled trial with an anti-CCL2 (anti–monocyte chemotactic protein 1) monoclonal antibody in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2006; 54:2387-92. [PMID: 16869001 DOI: 10.1002/art.21975] [Citation(s) in RCA: 197] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Chemokines such as CCL2/monocyte chemotactic protein 1 (MCP-1) play a key role in leukocyte migration and are potential targets in the treatment of chronic inflammatory disorders. The objective of this study was to evaluate the effects of human anti-CCL2/MCP-1 monoclonal antibody (ABN912) treatment in patients with rheumatoid arthritis (RA). METHODS Patients with active RA were enrolled in a randomized, placebo-controlled, dose-escalation study of ABN912. Infusions were administered on day 1 and day 15. In the dose-escalation phase, 4 cohorts of 8 patients each underwent serial arthroscopic biopsy of synovial tissue. Immunohistochemistry and digital image analysis were used to characterize biomarkers in synovial tissue. Laboratory evaluation included pharmacokinetic analysis and immunotypic studies of peripheral blood mononuclear cells. To assess the clinical effects of treatment with ABN912, an additional 21 patients were treated with the highest dose tolerated. RESULTS The total study population comprised 45 patients: 33 patients received ABN912, and 12 patients received placebo. ABN912 treatment was well tolerated. Unexpectedly, there was a dose-related increase in ABN912-complexed total CCL2/MCP-1 levels in peripheral blood, up to 2,000-fold. There was no detectable clinical benefit of ABN912 compared with placebo, nor did treatment with the study drug result in a significant change in the levels of biomarkers in synovial tissue and peripheral blood. CONCLUSION ABN912 treatment did not result in clinical or immunohistologic improvement and may have been associated with worsening of RA in patients treated with the highest dose. The results might be related to the greatly increased level of total CCL2/MCP-1 in serum that was observed following treatment with ABN912. This observation may be relevant for a variety of antibody-based therapies.
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Affiliation(s)
- Jasper J Haringman
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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10
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Bresnihan B, Baeten D, Firestein GS, Fitzgerald OM, Gerlag DM, Haringman JJ, McInnes IB, Reece RJ, Smith MD, Ulfgren AK, Veale DJ, Tak PP. Synovial tissue analysis in clinical trials. J Rheumatol 2005; 32:2481-4. [PMID: 16331792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Synovial tissue analysis has considerable potential for future randomized controlled trials (RCT). The synovial membrane is the target tissue in treatment strategies of rheumatoid arthritis and other arthropathies. Effective modulation of synovitis is critical when attempting to control symptoms and signs, to prevent joint damage, and to maintain function. In RCT, the systematic evaluation of changes in synovial tissue after commencing treatment enables identification of an early therapeutic effect, using relatively small numbers of patients. This special interest group is working on establishing the evidence to have this endpoint meet the OMERACT filter criteria.
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Affiliation(s)
- Barry Bresnihan
- Department of Rheumatology, St. Vincent's University Hospital, Dublin, Ireland.
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11
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Haringman JJ, Smeets TJM, Reinders-Blankert P, Tak PP. Chemokine and chemokine receptor expression in paired peripheral blood mononuclear cells and synovial tissue of patients with rheumatoid arthritis, osteoarthritis, and reactive arthritis. Ann Rheum Dis 2005; 65:294-300. [PMID: 16107514 PMCID: PMC1798063 DOI: 10.1136/ard.2005.037176] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chemokine receptors and chemokines have a crucial role in leucocyte recruitment into inflamed tissue. OBJECTIVE To examine the expression of an extensive number of chemokines and receptors in a unique bank of paired samples of synovial tissue (ST) and peripheral blood (PB) from patients with different forms of arthritis to assist in identifying suitable targets for therapeutic intervention. METHODS Synovial biopsy specimens were obtained from 23 patients with rheumatoid arthritis (RA), 16 with osteoarthritis, and 8 with reactive arthritis. ST chemokine (CCL2/MCP-1, CCL5/RANTES, CCL7/MCP-3, CCL8/MCP-2, CCL14/HCC-1, CCL15/HCC-2, CCL16/HCC-4), chemokine receptor (CCR1, CCR2b, CCR5, CXCR4), and CD13 expression was analysed by immunohistochemistry and two colour immunofluorescence. Chemokine receptor expression (CCR1, CCR3, CCR5, CCR6, CCR7) on PB cells was studied by flow cytometry. Non-parametric tests were used for statistical analysis. RESULTS Abundant expression of CCR1, CXCR4, and CCR5 was found in all forms of arthritis, with a specific increase of CCL5 and CCL15 in RA. CCL7, CCL8, CCL14, CCL15, and CCL16 were detected for the first time in ST. The results for PB analysis were comparable among different arthritides. Interestingly, compared with healthy controls, significantly lower expression of CCR1 (p<0.005) and CCR5 (p<0.05) by PB monocytes in the patient groups was seen. DISCUSSION A variety of chemokines and receptors might have an important role in several inflammatory joint disorders. Although other receptors are involved as well, migration of CCR1(+) and CCR5(+) cells towards the synovial compartment may play a part in the effector phase of various forms of arthritis.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Arthritis/blood
- Arthritis/metabolism
- Arthritis, Reactive/blood
- Arthritis, Reactive/metabolism
- Arthritis, Rheumatoid/blood
- Arthritis, Rheumatoid/metabolism
- Chemokines/blood
- Chemokines/metabolism
- Female
- Fluorescent Antibody Technique
- Humans
- Immunoenzyme Techniques
- Leukocytes, Mononuclear/metabolism
- Male
- Middle Aged
- Osteoarthritis/blood
- Osteoarthritis/metabolism
- Receptors, CCR1
- Receptors, CCR5/metabolism
- Receptors, Chemokine/blood
- Receptors, Chemokine/metabolism
- Synovial Membrane/metabolism
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Affiliation(s)
- J J Haringman
- Division of Clinical Immunology and Rheumatology F4-218, Department of Internal Medicine, Academic Medical Centre/University of Amsterdam, Meibergdreef 9, NL-1105 AZ Amsterdam, The Netherlands
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12
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Haringman JJ, Vinkenoog M, Gerlag DM, Smeets TJM, Zwinderman AH, Tak PP. Reliability of computerized image analysis for the evaluation of serial synovial biopsies in randomized controlled trials in rheumatoid arthritis. Arthritis Res Ther 2005; 7:R862-7. [PMID: 15987488 PMCID: PMC1175038 DOI: 10.1186/ar1757] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Revised: 04/13/2005] [Accepted: 04/14/2005] [Indexed: 11/16/2022] Open
Abstract
Analysis of biomarkers in synovial tissue is increasingly used in the evaluation of new targeted therapies for patients with rheumatoid arthritis (RA). This study determined the intrarater and inter-rater reliability of digital image analysis (DIA) of synovial biopsies from RA patients participating in clinical trials. Arthroscopic synovial biopsies were obtained before and after treatment from 19 RA patients participating in a randomized controlled trial with prednisolone. Immunohistochemistry was used to detect CD3+ T cells, CD38+ plasma cells and CD68+ macrophages. The mean change in positive cells per square millimetre for each marker was determined by different operators and at different times using DIA. Nonparametric tests were used to determine differences between observers and assessments, and to determine changes after treatment. The intraclass correlations (ICCs) were calculated to determine the intrarater and inter-rater reliability. Intrarater ICCs showed good reliability for measuring changes in T lymphocytes (R = 0.87), plasma cells (R = 0.62) and macrophages (R = 0.73). Analysis by Bland–Altman plots showed no systemic differences between measurements. The smallest detectable changes were calculated and their discriminatory power revealed good response in the prednisolone group compared with the placebo group. Similarly, inter-rater ICCs also revealed good reliability for measuring T lymphocytes (R = 0.68), plasma cells (R = 0.69) and macrophages (R = 0.72). All measurements identified the same cell types as changing significantly in the treated patients compared with the placebo group. The measurement of change in total positive cell numbers in synovial tissue can be determined reproducibly for various cell types by DIA in RA clinical trials.
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Affiliation(s)
- Jasper J Haringman
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, The Netherlands
| | - Marjolein Vinkenoog
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, The Netherlands
| | - Danielle M Gerlag
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, The Netherlands
| | - Tom JM Smeets
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center/University of Amsterdam, The Netherlands
| | - Paul P Tak
- Division of Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, The Netherlands
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Abstract
The development of specific targeted therapies, such as anti-TNF-alpha treatment, for chronic inflammatory disorders such as rheumatoid arthritis, has significantly improved treatment, although not all patients respond. Targeting cellular adhesion molecules and chemokines/chemokine receptors as regulators of the extravasation and migration of leukocytes may provide a novel approach for the treatment of these diseases. Moreover, the possibility of developing small-molecule antagonists offers an excellent method for the oral delivery of compounds with a short half-life.
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Affiliation(s)
- Jasper J Haringman
- Division of Clinical Immunology and Rheumatology F4-218, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, NL-1105 AZ, Amsterdam, The Netherlands
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Gerlag DM, Haringman JJ, Smeets TJM, Zwinderman AH, Kraan MC, Laud PJ, Morgan S, Nash AFP, Tak PP. Effects of oral prednisolone on biomarkers in synovial tissue and clinical improvement in rheumatoid arthritis. ACTA ACUST UNITED AC 2005; 50:3783-91. [PMID: 15593225 DOI: 10.1002/art.20664] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To create greater understanding of the changes in synovial tissue parameters that occur in conjunction with clinical response by using an effective therapy, in order to facilitate the planning of future studies with therapeutic agents for rheumatoid arthritis (RA). METHODS Twenty-one patients with active RA were randomized to receive either oral prednisolone (n = 10) or placebo (n = 11) for 2 weeks. In all patients, synovial tissue biopsy specimens were obtained by arthroscopy directly before treatment and after 14 days of treatment. Immunohistochemical analysis was performed to characterize the cell infiltrate and vascularity. Stained tissue sections were analyzed by digital imaging. Statistical analysis was performed using an analysis of covariance model. RESULTS After treatment, the mean Disease Activity Score in 28 joints (DAS28) was 2.0 units lower (95% confidence interval [95% CI] 1.0-3.0) in patients who received prednisolone than in those who received placebo. In the prednisolone group, the mean (+/-SD) DAS28 decreased from 6.27 +/- 0.95 to 4.11 +/- 1.43 after therapy; minimal change was observed in the placebo group. For macrophages, the estimated effect of prednisolone was large. Patients receiving active treatment had fewer (mean 628 cells/mm(2) [95% CI 328-927]) macrophages after therapy compared with those receiving placebo. A reduction in the total number of CD68+ macrophages, from 1,038 +/- 283 cells/mm(2) before treatment to 533 +/- 248 cells/mm(2) after treatment, was observed in the prednisolone group. There were clear trends toward decreased infiltration by T cells, plasma cells, and fibroblast-like synoviocytes after active treatment. We observed a trend toward a reduction in alphavbeta3+ newly formed blood vessels and expression of vascular growth factors after prednisolone therapy. CONCLUSION Prednisolone therapy in RA is associated with a marked reduction in macrophage infiltration in synovial tissue, suggesting that synovial macrophage numbers could be used as a biomarker for clinical efficacy.
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Affiliation(s)
- Danielle M Gerlag
- Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands.
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15
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Haringman JJ, Gerlag DM, Zwinderman AH, Smeets TJM, Kraan MC, Baeten D, McInnes IB, Bresnihan B, Tak PP. Synovial tissue macrophages: a sensitive biomarker for response to treatment in patients with rheumatoid arthritis. Ann Rheum Dis 2004; 64:834-8. [PMID: 15576415 PMCID: PMC1755544 DOI: 10.1136/ard.2004.029751] [Citation(s) in RCA: 314] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous work identified synovial sublining macrophage numbers as a potential biomarker for clinical efficacy in rheumatoid arthritis. OBJECTIVE To investigate the association between changes in infiltration of synovial macrophages and clinical improvement after antirheumatic treatment. METHODS 88 patients who participated in various clinical trials were studied. All patients underwent serial arthroscopy before initiation of treatment and after different time intervals. Immunohistochemical and digital image analysis were performed according to standardised procedures to detect changes in CD68+ synovial sublining macrophages in relationship to changes in the 28 joint count Disease Activity Score (DAS28). Statistical analysis was performed using one way analysis of variance, the independent samples t test, linear regression, and the standardised response mean (SRM). RESULTS For good, moderate, and non-responders, according to the DAS28 response criteria, there was a significant difference in the change in sublining macrophages (mean (SEM) cells/mm(2) -643 (124), -270 (64), and -95 (60), respectively; p<0.0003). There was a significant correlation between the change in the number of macrophages and the change in DAS28 (Pearson correlation 0.874, p<0.01). The change in sublining macrophages explained 76% of the variation in the change in DAS28 (p<0.02). The sensitivity to change of the biomarker was high in patients treated actively (SRM >0.8), whereas the ability to detect changes in placebo treated patients was weak (SRM <0.3). CONCLUSION The results suggest that changes in synovial sublining macrophages can be used to predict possible efficacy of antirheumatic treatment.
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Affiliation(s)
- J J Haringman
- Division of Clinical Immunology and Rheumatology, F4-218, Academic Medical Centre/University of Amsterdam, Meibergdreef 9, NL-1105 AZ Amsterdam, The Netherlands
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16
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Haringman JJ, Tak PP. [Blockade of chemokines in chronic inflammatory diseases]. Ned Tijdschr Geneeskd 2004; 148:1760-4. [PMID: 15495938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Chemokines form a relatively new family of chemotactic cytokines that seem to play a central role in the migration and activation of leukocytes in a wide variety of immune-mediated disorders. Specific therapy targeted against these proteins may well become an effective treatment in many of these disorders. The efficacy and safety of chemokine blockade is currently being investigated in clinical trials on patients with HIV infection, multiple sclerosis, rheumatoid arthritis and other chronic inflammatory disorders. The first results have been reported in patients with rheumatoid arthritis and these seem to confirm the potency of this treatment.
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Affiliation(s)
- J J Haringman
- Academisch Medisch Centrum/Universiteit van Amsterdam, afd. Klinische Immunologie en Reumatologie, F4-218, Meibergdreef 9, 1105 AZ Amsterdam.
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17
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Kraan MC, Haringman JJ, Weedon H, Barg EC, Smith MD, Ahern MJ, Smeets TJM, Breedveld FC, Tak PP. T cells, fibroblast-like synoviocytes, and granzyme B+ cytotoxic cells are associated with joint damage in patients with recent onset rheumatoid arthritis. Ann Rheum Dis 2004; 63:483-8. [PMID: 15082476 PMCID: PMC1755001 DOI: 10.1136/ard.2003.009225] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine immunohistological markers in synovial tissue of patients with early rheumatoid arthritis (RA) which are associated with unfavourable disease outcome. METHODS Synovial tissue was obtained from 36 patients with RA within 1 year after the initial symptoms and before starting disease modifying antirheumatic drug treatment. Clinical, laboratory, and radiological assessments (Larsen score) were performed at the time of the biopsy and at the end of follow up (mean 58 months, range 38-72). Immunohistological analysis was performed to detect T cells, B cells, plasma cells, fibroblast-like synoviocytes (FLS), macrophages, and granzyme B+ cytotoxic cells. The sections were evaluated by digital image analysis. RESULTS Patients were divided into two groups based upon the radiological progression per year of follow up: group I with mild progression (n = 20; Larsen <2 points/year); group II with more severe progression (n = 16; Larsen > or =2 points/year). Regression analysis with a univariate model showed that the numbers of granzyme B+ cytotoxic cells (relative risk (RR) = 12, p = 0.003), T cells (RR = 11, p = 0.013), and FLS (RR = 10, p = 0.020) discriminated between groups I and II. A multivariate model demonstrated that the numbers of T cells (RR = 1.2, p = 0.015) and FLS (RR = 1.4, p = 0.013) were independent discriminators between groups I and II. CONCLUSION The numbers of granzyme B+ cytotoxic cells, T cells, and FLS in synovial tissue of patients with RA are related to the severity of joint damage. The data suggest a pathogenetic role for these cells in the process of joint damage.
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Affiliation(s)
- M C Kraan
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University of Amsterdam/Academic Medical Centre, Amsterdam, The Netherlands
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18
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Abstract
Targeting chemokines and/or chemokine receptors appears to be an intriguing new approach to treating chronic inflammatory disorders like rheumatoid arthritis, inflammatory bowel diseases, multiple sclerosis, and transplant rejections. The involvement of chemokines and chemokine receptors in inflammatory joint diseases, the in vitro and in vivo characteristics of the chemokine family in inflammatory joint disease, and initial clinical data on chemokine blockade in patients with rheumatoid arthritis suggest that targeting the chemokine and chemokine receptor family might provide a new, promising antirheumatic strategy.
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Affiliation(s)
- J J Haringman
- Division of Clinical Immunology and Rheumatology, F4-218, Department of Internal Medicine, Academic Medical Centre/University of Amsterdam, Meibergdreef 9, NL-1105 AZ Amsterdam, The Netherlands
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19
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Abstract
Blockade of chemokines or chemokine receptors is emerging as a new potential treatment for various immune-mediated conditions. This review focuses on the therapeutic potential in rheumatoid arthritis, based on studies in animal models and patients. Several knockout models as well as in vivo use of chemokine antagonists are discussed. Review of these data suggests that this approach might lead to novel therapeutic strategies in rheumatoid arthritis and other chronic inflammatory disorders.
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Affiliation(s)
- Jasper J Haringman
- Division of Clinical Immunology and Rheumatology, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands
| | - Paul P Tak
- Division of Clinical Immunology and Rheumatology, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands
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21
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Haringman JJ, Kraan MC, Smeets TJM, Zwinderman KH, Tak PP. Chemokine blockade and chronic inflammatory disease: proof of concept in patients with rheumatoid arthritis. Ann Rheum Dis 2003; 62:715-21. [PMID: 12860725 PMCID: PMC1754636 DOI: 10.1136/ard.62.8.715] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Chemokines and their receptors are considered important contributors in cell migration and inflammation in chronic inflammatory disorders. Chemokines affecting monocytes/macrophages are considered potential therapeutic targets, but no studies of the effects of blocking the chemokine repertoire in humans with a chronic inflammatory disease have been reported. OBJECTIVE To carry out a double blind, placebo controlled, phase Ib clinical trial with a specific, oral CCR1 antagonist. METHODS 16 patients with active rheumatoid arthritis (RA) were randomised 3:1 to active:placebo treatment for 14 days. Synovial biopsy specimens were obtained on days 1 and 15. Immunohistochemistry was used to detect the presence of various cell types before and after treatment and the results measured by digital image analysis. Results before and after treatment were compared by paired t test, and a two sample t test was used to compare the changes from baseline in the two groups. RESULTS All patients completed the study. A significant reduction in the number of macrophages (p=0.016), intimal macrophages (p=0.026), and CCR1+cells (p=0.049) in patients treated with the chemokine antagonist compared with the placebo group occurred in the synovium. Significant decreases in overall cellularity, intimal lining layer cellularity, CD4+ T cells, and CD8+ T cells also occurred in treated patients. Cells lacking CCR1 were not affected. Trends towards clinical improvement were seen in the treated patients but not in the placebo group. Severe side effects were not reported. CONCLUSION Specific chemokine receptor blockade can result in relevant biological effects in patients with active RA.
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Affiliation(s)
- J J Haringman
- Division of Clinical Immunology and Rheumatology, Academic Medical Centre/University of Amsterdam, The Netherlands
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Haringman JJ, Smeets TJM, Kraan MC, Tak PP. Expression of chemokines and their receptors in synovial tissue of patients with rheumatoid arthritis, osteoarthritis and reactive arthritis. Arthritis Res Ther 2003. [PMCID: PMC2833606 DOI: 10.1186/ar669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- JJ Haringman
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - TJM Smeets
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - MC Kraan
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - PP Tak
- Clinical Immunology and Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
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23
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Kraan MC, Patel DD, Haringman JJ, Smith MD, Weedon H, Ahern MJ, Breedveld FC, Tak PP. The development of clinical signs of rheumatoid synovial inflammation is associated with increased synthesis of the chemokine CXCL8 (interleukin-8). Arthritis Res 2001; 3:65-71. [PMID: 11178128 PMCID: PMC17826 DOI: 10.1186/ar141] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [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] [Subscribe] [Scholar Register] [Received: 07/18/2000] [Revised: 09/22/2000] [Accepted: 10/12/2000] [Indexed: 11/10/2022]
Abstract
Paired synovial tissue samples were obtained from both clinically uninvolved (CU) and clinically involved (CI) knee joints of eight rheumatoid arthritis (RA) patients. In addition, biopsies were taken from five control subjects. We observed the expression of the chemokines CXCL8, CXCL9, CXCL10, CCL2 and CCL4 in CI and CU joints of RA patients. In particular, CXCL8 protein levels were specifically increased in CI joints compared with CU joints, which was confirmed by immunohistochemistry and in situ hybridization.
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Affiliation(s)
- M C Kraan
- Division of Clinical Immunology and Rheumatology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands.
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Kraan MC, Haringman JJ, Ahern MJ, Breedveld FC, Smith MD, Tak PP. Quantification of the cell infiltrate in synovial tissue by digital image analysis. Rheumatology (Oxford) 2000; 39:43-9. [PMID: 10662872 DOI: 10.1093/rheumatology/39.1.43] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The experience with digital image analysis (DIA) in the assessment of synovial inflammation is limited. In this study we compared DIA with two currently applied methods for the evaluation of the synovium. METHODS Synovial tissue (ST) specimens were obtained by arthroscopy from knee joints of rheumatoid arthritis (RA) patients with variable disease expression and in control subjects. CD68+ macrophages and CD3+ T-cells were detected by immunohistochemical staining using two different labelling techniques. The labelled ST sections were quantified using three different analysis techniques: manual cell counting (MC), semi-quantitative analysis (SQA) and DIA. RESULTS We observed strongly positive correlations between the three methods when examining T-cell infiltration: between MC and SQA: sigma=0.91 (P<0. 0001), between MC and DIA: sigma=0.95 (P<0.0001), and between SQA and DIA: sigma=0.83 (P<0.0001). Similarly, for the analysis of synovial intimal macrophages, positive correlations were noted between MC and SQA (sigma=0.62; P=0.002), MC and DIA (sigma=0.56; P<0.01), and SQA and DIA (sigma=0.79; P<0.0001). Finally, the analysis of synovial sublining macrophages revealed positive correlations between MC and SQA (sigma=0.95; P<0.0001), MC and DIA (sigma=0.64; P=0.001) and SQA and DIA (sigma=0.69; P<0.0001). CONCLUSION These three different methods generated similar results. DIA offers the opportunity of a reliable and time-efficient analysis of the synovial infiltrate.
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Affiliation(s)
- M C Kraan
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
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25
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Kraan MC, Haringman JJ, Post WJ, Versendaal J, Breedveld FC, Tak PP. Immunohistological analysis of synovial tissue for differential diagnosis in early arthritis. Rheumatology (Oxford) 1999; 38:1074-80. [PMID: 10556258 DOI: 10.1093/rheumatology/38.11.1074] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE An early diagnosis in patients presenting with arthritis is important to provide information about prognosis and to initiate treatment. The objective of this study was to determine which markers applied in immunohistological analysis of synovial tissue (ST) specimens could be used to differentiate rheumatoid arthritis (RA) from other forms of arthritis. METHODS Synovial biopsies were obtained by blind needle techniques from 95 patients with early arthritis. After follow-up of at least 2 yr to verify the diagnosis, the patients could be classified as follows: RA (n=36), undifferentiated arthritis (UA; n=21), osteoarthritis (OA; n=17), reactive arthritis (ReA; n=10), ankylosing spondylitis (AS; n=3), psoriatic arthritis (PsA; n=2) and crystal-induced arthritis (CA; n=6). ST sections were analysed by immunohistochemistry using monoclonal antibodies against CD3, CD4, CD8, CD22 (B cells), CD38 (plasma cells), CD68 (macrophages) and CD55 (fibroblast-like synoviocytes). RESULTS Logistic regression analysis revealed that the higher scores for the numbers of CD38+ plasma cells and CD22+ B cells in RA were the best discriminating markers comparing RA to non-RA patients (CD38: P=0.0001; CD22: P<0.05). Polychotomous regression analysis comparing three diagnostic categories (1: RA; 2: UA, ReA, AS and PsA; 3: OA and CA) also identified the score for the number of CD38+ plasma cells (P<0.0001) as well as the numbers of CD68+ macrophages in the synovial sublining (P=0.05) as discriminating markers. CONCLUSION The results suggest that immunohistochemical analysis of ST specimens from early arthritis patients can be used to differentiate RA from non-RA patients. The numbers of plasma cells, B cells and macrophages are especially increased in ST of patients with RA. Future studies in early arthritis patients with clinical features which do not allow an immediate confident diagnosis may clarify the role of this test system in differential diagnosis.
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Affiliation(s)
- M C Kraan
- Division of Clinical Immunology, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
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