Phase 1 results of the ODM-208 first-in-human phase 1-2 trial in patients with metastatic castration-resistant prostate cancer (CYPIDES)

18

Background: ODM-208 is a novel, oral, non-steroidal and selective inhibitor of CYP11A1, the first and rate-limiting enzyme of steroid biosynthesis. ODM-208 suppresses the production of all steroid hormones and their precursors that may activate the androgen receptor (AR) signalling pathway. This is particularly relevant in patients with AR ligand binding domain (LBD) activating somatic point mutations, a mechanism of resistance to hormone-based therapies in metastatic castration-resistant prostate cancer (mCRPC). We report the first results of the first-in-man phase I CYPIDES trial. Methods: ODM-208 was examined in a dose finding phase 1 trial with a 3+3 design in patients with progressive mCRPC who had previously received ≥1 line of AR signalling inhibitor and ≥1 line of taxane-based chemotherapy. ODM-208 was administered up to 150 mg/day with glucocorticoid (GC) and mineralocorticoid replacement therapy and androgen deprivation therapy (ADT). The phase 1 endpoints included dose-limiting toxicities (DLTs), adverse events, pharmacokinetics, pharmacodynamics, PSA and RECIST response, and exploratory genetic profiling. Results: By Jan 22 2021, 41 patients (median age 70 yrs.) had received ODM-208. The dose finding was completed and included doses ranging from 10 to 150 mg/day. 22 (54%) patients had previously received both abiraterone and enzalutamide, and 23 (56%) patients both docetaxel and cabazitaxel. Although tolerated by most patients, the main safety finding was adrenal insufficiency (AI). Overall, 15/41 (37%) patients experienced Grade 3 AI requiring short-term high-dose GC treatment. ODM-208 plasma exposure was dose proportional. Serum testosterone was undetectable after 4 weeks of start of ODM-208 in almost all patients, as were serum DHEA sulphate, androstenedione, 11β-hydroxyandrostenedione, 11-ketotestosterone and pregnenolone. Overall 12/36 (33%) evaluable patients achieved a PSA decline of ≥50%. In evaluable patients with AR LBD mutation 10/15 (67%) achieved a PSA decline of ≥50%. Clinical improvement in symptoms such as pain was also observed in some men. Conclusions: Administration of ODM-208 to mCRPC men pretreated with abiraterone/enzalutamide and taxanes was highly effective in blocking the production of steroid hormones and showed promising antitumor activity, especially in men with AR mutation-positive cancers. The phase 2 dose expansion part of CYPIDES is ongoing. Clinical trial information: NCT03436485.

Clinical Pharmacokinetics of the Androgen Receptor Inhibitor Darolutamide in Healthy Subjects and Patients with Hepatic or Renal Impairment

Background

Darolutamide is a second-generation androgen receptor inhibitor approved for the treatment of nonmetastatic castration-resistant prostate cancer at a dosage of 600 mg orally twice daily.

Objective

We aimed to fully characterize the pharmacokinetic profile of darolutamide, its diastereomers, and its main active metabolite, keto-darolutamide.

Methods

Single-dose and multiple-dose pharmacokinetics of ¹⁴C-labeled and non-labeled darolutamide were evaluated in healthy subjects and patients with hepatic or renal impairment.

Results

Following darolutamide oral tablet administration, peak plasma concentrations were reached 4–6 h after dosing. Darolutamide elimination was characterized by a half-life of 13 h. Steady state was reached after approximately 2 days of twice-daily dosing. Pharmacokinetics of the diastereomers and keto-darolutamide followed similar trends to the parent compound. Darolutamide absorption from the tablet was lower than from the oral solution; tablet absolute bioavailability was ~30% in the fasted state but improved to 60–75% when given with food. The unbound fraction of darolutamide in plasma was 7.8%. The administered 1:1 ratio of the diastereomers (S,R)-darolutamide and (S,S)-darolutamide changed to ~1:6 in plasma following multiple dosing. Similar exposure and diastereomer ratios after single and multiple dosing indicate time-independent (no autoinduction) linear pharmacokinetics. Darolutamide exposure increased in patients with moderate hepatic or severe renal impairment vs healthy subjects; dose adaptation at treatment initiation should be considered in these patients.

Conclusions

Darolutamide 600 mg twice daily demonstrates predictable linear pharmacokinetics and sustainably high plasma concentrations, suggesting the potential for constant inhibition of the androgen receptor signaling pathway.

Clinical Trials Registration

NCT02418650, NCT02894385, NCT02671097.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-021-01078-y.

Metabolism and Mass Balance of the Novel Nonsteroidal Androgen Receptor Inhibitor Darolutamide in Humans

The biotransformation and excretion of darolutamide were investigated in a phase I study. Six healthy male volunteers received a single dose of 300 mg ¹⁴C-darolutamide as an oral solution in the fasted state. Plasma, urine, and feces samples were analyzed for mass balance evaluation by liquid scintillation counting (LSC). Metabolite profiling and identification were determined using liquid chromatography mass-spectrometry with off-line radioactivity detection using LSC. Complete mass balance was achieved, with mean radioactivity recovery of 95.9% within 168 hours (63.4% in urine, 32.4% in feces). The administered 1:1 ratio of (S,R)- and (S,S)-darolutamide changed to approximately 1:5, respectively, in plasma. Darolutamide and the oxidation product, keto-darolutamide, were the only components quantifiable by LSC in plasma, accounting for 87.4% of total radioactivity, with a 2.1-fold higher plasma exposure for keto-darolutamide. Aside from darolutamide, the most prominent metabolites in urine were O-glucoronide (M-7a/b) and N-glucuronide (M-15a/b), as well as pyrazole sulfates (M-29, M-24) and glucuronides (M-21, M-22) resulting from oxidative cleavage of the parent. The darolutamide diastereomers were mainly detected in feces. In vitro assays showed that darolutamide metabolism involves a complex interplay between oxidation and reduction, as well as glucuronidation. Interconversion of the diastereomers involves oxidation to keto-darolutamide, primarily mediated by CYP3A4, followed by reduction predominantly catalyzed by cytosolic reductase(s), with aldo-keto reductase 1C3 playing the major role. The latter reaction showed stereoselectivity with preferential formation of (S,S)-darolutamide. SIGNIFICANCE STATEMENT: The metabolism and excretion of darolutamide in humans revealed that oxidation (CYP3A4) and glucuronidation (UGT1A9, UGT1A1) were the main metabolic routes of elimination. Direct excretion also contributed to overall clearance. The two pharmacologically equipotent diastereomers of darolutamide interconvert primarily via oxidation to the active metabolite keto-darolutamide, followed by reduction predominantly by cytosolic reductase(s). The latter reaction showed stereoselectivity with preferential formation of (S,S)-darolutamide. Data indicate a low drug-drug interaction potential of darolutamide with inducers or inhibitors of metabolizing enzymes.

Pharmacokinetics of Darolutamide, its Diastereomers and Active Metabolite in the Mouse: Response to Saini NK et al. (2020)

BACKGROUND

Saini et al. recently investigated the pharmacokinetics of darolutamide and its diastereomers in vitro and in vivo in Balb/c mice, reporting higher levels of (S,S)-darolutamide than (S,R)-darolutamide following intravenous or oral dosing, and interconversion of (S,R)-darolutamide to (S,S)-darolutamide.

OBJECTIVE

To present our in vitro and in vivo studies of darolutamide pharmacokinetics in mice, which contrast with the findings of Saini et al. Methods: Nude male Balb/c mice were orally dosed for 7 days with 25, 50, or 100 mg/kg of darolutamide twice daily. Pharmacokinetic parameters in plasma and tissue samples were assessed by liquid chromatography-tandem mass spectrometry. Metabolism and interconversion of darolutamide and its diastereomers were investigated in cryopreserved Balb/c mouse hepatocytes. Protein binding was determined in plasma samples by equilibrium dialysis.

RESULTS

On day 7, C_max was reached 30 min after the last dose. Rapid formation and greater exposure of keto-darolutamide versus darolutamide were observed. Plasma exposure of (S,R)-darolutamide was 3-5-fold higher than that of (S,S)-darolutamide. The fraction of unbound keto-darolutamide was almost 6-fold lower than for darolutamide. In mouse hepatocytes, the conversion of (S,S)- to (S,R)-darolutamide was observed, but the conversion of (S,R)- to (S,S)-darolutamide was not detectable. Back-formation of keto-darolutamide to both diastereomers occurred at low levels.

CONCLUSION

The darolutamide diastereomer ratio changes upon administration in mice and other species due to interconversion through keto-darolutamide. This is not considered clinically relevant since both diastereomers and keto- darolutamide are pharmacologically similar in vitro. Based on the high protein binding of keto-darolutamide, its contribution in vivo in humans is considered low.

Predicting the effect of prandial stage and particle size on absorption of ODM-204

The prediction of absorption properties plays a key role in formulation development when the compound under development shows poor solubility and its absorption is therefore presumed to be solubility limited. In our work, we combined and compared data obtained from in vitro dissolution tests, transit intestinal model studies (TIM-1) and physiologically based pharmacokinetic modelling. Our aim was to determine the ability of these methods to predict performance of poorly soluble lipophilic weak base in vivo. The validity of the predictive methods was evaluated against the in vivo clinical pharmacokinetic (PK) data obtained after administration of the first test formulation, T1. The aim of our study was to utilize the models in evaluating absorption properties of the second test formulation, T2, which has not yet been clinically administered. The compound in the studies was ODM-204, which is a novel, orally administered, investigational, nonsteroidal dual inhibitor of CYP17A1 and androgen receptor. Owing to its physicochemical properties ODM-204 is prone to low or variable bioavailability. The models examined provided congruent data on dose dependent absorption, food effect at a dose of 200 mg and on the effect of API (active pharmaceutical ingredient) particle size on absorption. Our study shows that the predictive tools of in vitro dissolution, TIM-1 system and the PBPK (physiologically based pharmacokinetic) simulation, showed predictive power of different mechanisms of bioavailability and together provided valuable information for decision making.

Health Informatics 3.0 and other Increasingly Dispersed Technologies Require Even Greater Trust: Promoting Safe Evidence-based Health Informatics

Healthinformaticsisgenerallylesscommittedtoascientific evidence-basedapproach than any other area of health science, which is an unsound position. Introducing the new Web 3.0 paradigms into health IT applications can unleash a further great potential, able to integrate and distribute data from multiple sources. The counter sideisthatitmakestheuserandthepatientevermoredependentonthe

‘blackbox’ of the system, and the re-use of the data remote from the author and initial context. Thus anticipatory consideration of uses, and proactive analysis of evidenceof effects,are imperative,as only when a clinical technology can be proven to be trustworthy and safe should it be implementedwidely as is the case with other health technologies.

Toargueforpromotingevidence-basedhealthinformatics assystemsbecomemorepowerfulandpro-activeyetmoredispersed andremote;andevaluationasthemeansofgeneratingthenecessaryscientific evidencebase.TopresentongoingIMIAandEFMIinitiativesinthisfield.

Critical overview of recent developments in health informatics evaluation, alongside the precedents of other health technologies, summarising current initiatives and the new challenges presented by Health Informatics 3.0.

Web3.0should betaken asanopportunitytomovehealth informatics from being largely unaccountable to one of being an ethical andresponsiblescience-baseddomain.Recentandplannedactivities ofthe EFMIandIMIAworkinggroupshavesignificantlyprogressedkeyinitiatives.

Concurrent with the emergence of Web 3.0 as a means of new-generation diffuse health information systems comes an increasing need for an evidence-based culture in health informatics.

Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle

Objectives: To present the importance of Evidence-based Health Informatics (EBHI) and the ethical imperative of this approach; to highlight the work of the IMIA Working Group on Technology Assessment and Quality Improvement and the EFMI Working Group on Assessment of Health Information Systems; and to introduce the further important evaluation and evidence aspects being addressed.

Methods: Reviews of IMIA, EFMA and other initiatives, together with literature reviews on evaluation methods and on published systematic reviews.

Results: Presentation of the rationale for the health informatics domain to adopt a scientific approach by assessing impact, avoiding harm, and empirically demonstrating benefit and best use; reporting of the origins and rationale of the IMIA- and EQUATOR-endorsed Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) and of the IMIA WG's Guideline for Good Evaluation Practice in Health Informatics (GEP-HI); presentation of other initiatives for objective evaluation; and outlining of further work in hand on usability and indicators; together with the case for development of relevant evaluation methods in newer applications such as telemedicine. The focus is on scientific evaluation as a reliable source of evidence, and on structured presentation of results to enable easy retrieval of evidence.

Conclusions: EBHI is feasible, necessary for efficiency and safety, and ethically essential. Given the significant impact of health informatics on health systems, care delivery and personal health, it is vital that cultures change to insist on evidence-based policies and investment, and that emergent global moves for this are supported.

eHealth in Europe – Status and Challenges

Objectives: To present European reflections on the concept of eHealth and emerging challenges related to further development of eHealth in Europe.

Methods: A survey with 10 questions was distributed to representatives of the national member associations of the European Federation of Medical Informatics (EFMI).

Results: The results document a shift from a constricting ICT-orientation to development of the entire health system where eHealth strategies, organizational change, and appropriate technological infrastructure are singled out as important aspects.

Conclusion: There are urgent needs to ensure that eHealth strategies and policies for further design and deployment of eHealth applications support sociable services and innovations in health care.

Success and Failure Factors in the Regional Health Information System Design Process

Objectives: To identify success and failure factors in the design process of a regional health information system.

Methods: A constructive evaluation study including interviews, observations, usability study and document analysis.

Results: Modelling was found to be a key element for the successful implementation of a health information system. The developed service chain model helped to define use cases and to implement seamless service chains. User participation in the design process was a success factor resulting in good user acceptance and signs of positive impacts on work practices. Evaluation study also helped system developers to guide the system’s further development. An important failure factor identified was the lack of semantic interoperability of the system components.

Conclusions: The results emphasize the socio-technical nature of health information systems. The starting point for development should be thorough insight into the health care work practices where the information systems are to be used. Successful system design should start from modelling of work processes, data and information flows and definition of concepts and their relations. Health informatics as a scientific discipline provides theories and models for the design and development process.

Factors Influencing Success and Failure of Health Informatics Systems

Objectives: The aim is to gain information on factors influencing success and failure for Health Informatics applications from a group of medical informaticians.

Methods: Based on the presentations at a special topic conference on success and failure in Health ICT and analysis of the proceedings, we conducted a Delphi study on success and failure aspects.

Results: A total of 110 success factors and 27 failure criteria were identified, distributed on categories like functional, organizational, behavioral, technical, managerial, political, cultural, legal, strategy, economy, education and user acceptance. These factors and criteria were rated for six different system types. Unanimously it was agreed that “collaboration and co-operation” and “setting goals and courses” are “essential for the success” of clinical systems, and “user acceptance” for educational systems. Similarly, the score “essential in order to avoid a failure” were given unanimously on clinical systems for “response rate and other performance measures” and on administrative systems for “not understanding the organizational context” with “not understanding or foreseeing the extent to which the new IT-system affects the organization, its structure and/or work procedures” as the highest scoring sub-item.

Conclusions: All success factors and failure criteria were considered relevant by the Delphi expert panel. There is no small set of relevant factors or indicators, but success or failure of a Health ICT depends on a large set of issues. Further, clinical systems and decision support systems depend on more factors than other systems.

National Health IT Services in Finland

Objectives: In 2002 a decision was reached to set up a nation-wide electronic health record system in Finland. The legal framework of actors with the necessary mandate was approved in the parliament in December 2006. A set of standards and norms have been selected that all health care actors need to follow. Functional specifications of the services were completed in 2006. Setting up the centralized health IT services begins in 2007.

Centralization of patient record data allows the reorganization of health service providers to take place at local and regional levels according to need. The services allow users to access patient records securely from anywhere with the provision that they have the right to access private patient data.

Methods: The functionality of the services and the necessary infrastructure has been agreed to in projects and working groups involving users, experts, key stakeholders and vendors.

Results: The legal framework was approved in the parliament in December 2006. The functional specifications of thecentralized health IT services were finalized in 2006.

Conclusions: The implementation of the services will start in 2007.

Evaluation Considerations for Secondary Uses of Clinical Data: Principles for an Evidence-based Approach to Policy and Implementation of Secondary Analysis

Objectives: To set the scientific context and then suggest principles for an evidence-based approach to secondary uses of clinical data, covering both evaluation of the secondary uses of data and evaluation of health systems and services based upon secondary uses of data. Method: Working Group review of selected literature and policy approaches. Results: We present important considerations in the evaluation of secondary uses of clinical data from the angles of governance and trust, theory, semantics, and policy. We make the case for a multi-level and multi-factorial approach to the evaluation of secondary uses of clinical data and describe a methodological framework for best practice. We emphasise the importance of evaluating the governance of secondary uses of health data in maintaining trust, which is essential for such uses. We also offer examples of the re-use of routine health data to demonstrate how it can support evaluation of clinical performance and optimize health IT system design. Conclusions: Great expectations are resting upon "Big Data" and innovative analytics. However, to build and maintain public trust, improve data reliability, and assure the validity of analytic inferences, there must be independent and transparent evaluation. A mature and evidence-based approach needs not merely data science, but must be guided by the broader concerns of applied health informatics.

ODM-204 a novel dual inhibitor of CYP17A1 and androgen receptor: Early results from phase I dose escalation in men with castration-resistant prostate cancer

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Background: Castration-resistant prostate cancer (CRPC) is characterized by high androgen receptor (AR) expression, various AR mutations and persistent activation of AR signaling axis by residual tissue androgens and other steroids. Inhibiting both the AR and androgen biosynthesis may be more effective than inhibiting either alone to treat CRPC. ODM-204 is a potent, orally administered investigational non-steroidal dual inhibitor of CYP17A1 and the AR that has shown activity in nonclinical tumor models. Methods: We report early data of the DUALIDES phase I dose escalation part (NCT02344017), in which patients with metastatic CRPC (mCRPC) were enrolled into ODM-204 dose levels of 50, 100, 200, 300, 500 mg twice daily. Data cut-off was Oct 14th2016. Results: In the trial 23 patients with progressive mCRPC received increasing doses of ODM-204. At baseline, the median age of patients was 70 yrs (57-84 yrs), and median PSA was 46.5 ng/mL (0.7-249.6 ng/mL). Median time on treatment was 11.6 weeks (0.3-60.4 wks). Nine (39%) patients continued treatment for more than 12 weeks, and 4 (17.4%) patients were still receiving treatment at the time of data cutoff. ODM-204 was generally well tolerated, and the most commonly reported adverse events (AEs) were fatigue (n = 6, 26%), nausea (n = 6, 26%), decreased appetite (n = 5, 22%,) diarrhea (n = 5, 22%), and vomiting (n = 5, 22%). Two patients discontinued treatment due to an AE. The AUCt and Cmax values of ODM-204 in plasma increased with dose up to 300 mg after a single dose. Steady state values on day 8 were unexpectedly decreased in most patients, especially at higher doses, contrary to what was observed in the nonclinical monkey studies. Further, decreased predose concentrations were observed on day 29. PSA decreases were seen in 7 (30%) patients, and the median decrease was 47% (2-99%). At 12 weeks, 3 (13%) patients had a PSA response ( ≥ 50% reduction from baseline). Conclusions: Although evidence of anticancer activity was provided with ODM-204 in mCRPC, decreasing steady state concentration was observed. Clinical trial information: NCT02344017.

Improving Evaluation to Address the Unintended Consequences of Health Information Technology:. a Position Paper from the Working Group on Technology Assessment & Quality Development

BACKGROUND AND OBJECTIVES

With growing use of IT by healthcare professionals and patients, the opportunity for any unintended effects of technology to disrupt care health processes and outcomes is intensified. The objectives of this position paper by the IMIA Working Group (WG) on Technology Assessment and Quality Development are to highlight how our ongoing initiatives to enhance evaluation are also addressing the unintended consequences of health IT.

METHODS

Review of WG initiatives Results: We argue that an evidence-based approach underpinned by rigorous evaluation is fundamental to the safe and effective use of IT, and for detecting and addressing its unintended consequences in a timely manner. We provide an overview of our ongoing initiatives to strengthen study design, execution and reporting by using evaluation frameworks and guidelines which can enable better characterization and monitoring of unintended consequences, including the Good Evaluation Practice Guideline in Health Informatics (GEP-HI) and the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI). Indicators to benchmark the adoption and impact of IT can similarly be used to monitor unintended effects on healthcare structures, processes and outcome. We have also developed EvalDB, a web-based database of evaluation studies to promulgate evidence about unintended effects and are developing the content for courses to improve training in health IT evaluation.

CONCLUSION

Evaluation is an essential ingredient for the effective use of IT to improve healthcare quality and patient safety. WG resources and skills development initiatives can facilitate a proactive and evidence-based approach to detecting and addressing the unintended effects of health IT.

Pharmacokinetics, activity, and safety of ODM-201 in chemotherapy-naïve patients with metastatic castration-resistant prostate cancer: An open-label phase I trial with long-term extension

230

Background: The open phase I trial, ARAFOR, with long-term extension evaluated pharmacokinetics (PK), antitumor activity and safety of ODM-201 in chemotherapy-naïve patients with progressive mCRPC. Methods: PK phase: Patients received one 600 mg dose of ODM-201 capsules (6 x 100 mg) in fed state and one dose of either tablet formulation (TabA or TabB, 2 x 300 mg) in fed and fasted state in random order. Extension: Patients received ODM-201 600 mg (capsule) twice daily until disease progression/ intolerable adverse event (AE). A data cut-off date Apr 4, 2014 was used for analyses. Results: 30 patients were enrolled in PK and treated in the extension phase. Baseline characteristics: median age 68 yrs, ECOG score 0 in 67%, and ECOG 1 in 33% patients, median PSA 18.2 ng/mL. Median time from PC diagnosis to start of ODM-201 treatment was 39 months. Median time on ODM-201 treatment was 9.5 months (trial is on-going). ODM-201 plasma concentration–time curves were similar for the capsule, TabA, and TabB at fed state. Median tmax at fed state was longer than in fasted state (5–6 h vs. 4 h). Absorption was slower and plasma exposure about 2-fold greater at fed state compared to fasted state (AUCt, AUC¥ and Cmax values). All 30 patients completed the first 12 weeks of the extension phase. Prostate-specific antigen (PSA) responses (≥50% reduction from baseline) were seen in 25 (83%) patients (PSA reductions ≥90% in 9 [30%] patients). At 12 weeks, RECIST responses in soft tissue were noted in 6 patients (29%) and stable disease in 13 (62%) patients, 3 (11%) had improvement in skeletal metastases and 18 (67%) stabilised bone disease. 21 (70%) reported at least 1 AE, and treatment-related AEs occurred in 6 (20%) patients. No treatment-related AEs of grade 2 or higher were reported. Conclusions: Tablet and capsule formulations showed comparable single-dose pharmacokinetics. Dose level of 600 mg twice daily (capsule) showed significant antitumor activity and had a favourable safety profile. Updated results from the extension phase will be presented. A phase 3 ARAMIS trial at a dose of 600 mg twice daily in men with non-metastatic CRPC is currently ongoing. Clinical trial information: NTC01784757.

A study of two ODM-201 formulations with a safety and tolerability extension phase in patients with metastatic chemotherapy-naive castration-resistant prostate cancer (CRPC)

115^

Background: This open phase I trial assessed the bioavailability, and the effect of food on the bioavailability of ODM-201 600mg tablets compared to a 600mg capsule formulation. Efficacy, safety, and tolerability of ODM-201 were studied in the extension period. Methods: The study had two parts: a pharmacokinetic (PK), and a safety and tolerability part. Dosing was 600mg bid with or without food. In the PK part, three single doses of ODM-201 were given over 3 weeks. In the extension part patients could continue treatment until disease progression or until an intolerable adverse event or condition that prevented further dosing of ODM-201. Results: Thirty men with metastatic chemotherapy-naïve castration-resistant prostate cancer (CRPC) were enrolled, the median age was 68. The median prostate-specific antigen (PSA) was 18.2 ng/mL and testosterone 23.1 ng/dL at baseline. Food interaction was observed when ODM-201 formulations were administered after a high fat content breakfast compared to administration at fast. AUC and Cmaxvalues were about 50% lower after fast. Twenty nine patients have completed the 4-week visit. The PSA response rate (50% or more PSA decline) was 86%, with a median PSA decrease of -66% (-96, 5) at week 4 (N=18/21). Most commonly reported adverse events so far are fatigue, abdominal pain, diarrhea, hematuria, and nausea. Conclusions: ODM-201 600mg bid as tablets has comparable PK to capsules used in the phase II ARADES trial. It is well tolerated and has good PSA response in chemotherapy-naïve patients with CRPC . Clinical trial information: NCT01784757.

STARE-HI - Statement on Reporting of Evaluation Studies in Health Informatics: explanation and elaboration

BACKGROUND

Improving the quality of reporting of evaluation studies in health informatics is an important requirement towards the vision of evidence-based health informatics. The STARE-HI - Statement on Reporting of Evaluation Studies in health informatics, published in 2009, provides guidelines on the elements to be contained in an evaluation study report.

OBJECTIVES

To elaborate on and provide a rationale for the principles of STARE-HI and to guide authors and readers of evaluation studies in health informatics by providing explanatory examples of reporting.

METHODS

A group of methodologists, researchers and editors prepared the present elaboration of the STARE-HI statement and selected examples from the literature.

RESULTS

The 35 STARE-HI items to be addressed in evaluation papers describing health informatics interventions are discussed one by one and each is extended with examples and elaborations.

CONCLUSION

The STARE-HI statement and this elaboration document should be helpful resources to improve reporting of both quantitative and qualitative evaluation studies. Evaluation manuscripts adhering to the principles will enable readers of such papers to better place the studies in a proper context and judge their validity and generalizability, and thus in turn optimize the exploitation of the evidence contained therein.

LIMITATIONS

This paper is based on experiences of a group of editors, reviewers, authors of systematic reviews and readers of the scientific literature. The applicability of the details of these principles has to evolve as a function of their use in practice.

Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle. Joint Contribution of IMIA WG EVAL and EFMI WG EVAL

OBJECTIVES

To present the importance of Evidence-based Health Informatics (EBHI) and the ethical imperative of this approach; to highlight the work of the IMIA Working Group on Technology Assessment and Quality Improvement and the EFMI Working Group on Assessment of Health Information Systems; and to introduce the further important evaluation and evidence aspects being addressed.

METHODS

Reviews of IMIA, EFMA and other initiatives, together with literature reviews on evaluation methods and on published systematic reviews.

RESULTS

Presentation of the rationale for the health informatics domain to adopt a scientific approach by assessing impact, avoiding harm, and empirically demonstrating benefit and best use; reporting of the origins and rationale of the IMIA- and EQUATOR-endorsed Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) and of the IMIA WG's Guideline for Good Evaluation Practice in Health Informatics (GEP-HI); presentation of other initiatives for objective evaluation; and outlining of further work in hand on usability and indicators; together with the case for development of relevant evaluation methods in newer applications such as telemedicine. The focus is on scientific evaluation as a reliable source of evidence, and on structured presentation of results to enable easy retrieval of evidence.

CONCLUSIONS

EBHI is feasible, necessary for efficiency and safety, and ethically essential. Given the significant impact of health informatics on health systems, care delivery and personal health, it is vital that cultures change to insist on evidence-based policies and investment, and that emergent global moves for this are supported.

eHealth in Europe - Status and Challenges

OBJECTIVES

To present European reflections on the concept of eHealth and emerging challenges related to further development of eHealth in Europe.

METHODS

A survey with 10 questions was distributed to representatives of the national member associations of the European Federation of Medical Informatics (EFMI).

RESULTS

The results document a shift from a constricting ICT-orientation to development of the entire health system where eHealth strategies, organizational change, and appropriate technological infrastructure are singled out as important aspects.

CONCLUSION

There are urgent needs to ensure that eHealth strategies and policies for further design and deployment of eHealth applications support sociable services and innovations in health care.

Health Informatics 3.0 and other increasingly dispersed technologies require even greater trust: promoting safe evidence-based health informatics. Contribution of the IMIA Working Group on Technology Assessment & Quality Development in Health Informatics

BACKGROUND

Health informatics is generally less committed to a scientific evidence-based approach than any other area of health science, which is an unsound position. Introducing the new Web 3.0 paradigms into health IT applications can unleash a further great potential, able to integrate and distribute data from multiple sources. The counter side is that it makes the user and the patient evermore dependent on the 'black box' of the system, and the re-use of the data remote from the author and initial context. Thus anticipatory consideration of uses, and proactive analysis of evidence of effects, are imperative, as only when a clinical technology can be proven to be trustworthy and safe should it be implemented widely - as is the case with other health technologies.

OBJECTIVES

To argue for promoting evidence-based health informatics as systems become more powerful and pro-active yet more dispersed and remote; and evaluation as the means of generating the necessary scientific evidence base. To present ongoing IMIA and EFMI initiatives in this field.

METHODS

Critical overview of recent developments in health informatics evaluation, alongside the precedents of other health technologies, summarising current initiatives and the new challenges presented by Health Informatics 3.0.

RESULTS

Web 3.0 should be taken as an opportunity to move health informatics from being largely unaccountable to one of being an ethical and responsible science-based domain. Recent and planned activities of the EFMI and IMIA working groups have significantly progressed key initiatives.

CONCLUSIONS

Concurrent with the emergence of Web 3.0 as a means of new-generation diffuse health information systems comes an increasing need for an evidence-based culture in health informatics.

Use of Headings and Classifications by Physicians in Medical Narratives of EHRs: An evaluation study in a Finnish hospital

OBJECTIVE

The purpose of this study was to describe and evaluate patient care documentation by hospital physicians in EHRs and especially the use of national headings and classifications in these documentations.

MATERIAL AND METHODS

The initial material consisted of a random sample of 3,481 medical narratives documented in EHRs during the period 2004-2005 in one department of a Finnish central hospital. The final material comprised a subset of 1,974 medical records with a focus on consultation requests and consultation responses by two specialist groups from 871 patients. This electronic documentation was analyzed using deductive content analyses and descriptive statistics.

RESULTS

The physicians documented patient care in EHRs principally as narrative text. The medical narratives recorded by specialists were structured with headings in less than half of the patient cases. Consultation responses in general were more often structured with headings than consultation requests. The use of classifications was otherwise insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation responses by both medical specialties.

CONCLUSION

There is an obvious need to improve the structuring of narrative text with national headings and classifications. According to the findings of this study, reason for care, patient history, health status, follow-up care plan and diagnosis are meaningful headings in physicians' documentation. The existing list of headings needs to be analyzed within a consistent unified terminology system as a basis for further development. Adhering to headings and classifications in EHR documentation enables patient data to be shared and aggregated. The secondary use of data is expected to improve care management and quality of care.

STARE-HI -Statement on Reporting of Evaluation Studies in Health Informatics

Objective Development of guidelines for publication of evaluation studies of Health Informatics applications.

Methods An initial list of issues to be addressed in reports on evaluation studies was drafted based on experiencesas editorsand reviewers and as authors of systematic reviews , taking into account guidelines for reporting of medical research. This list has been discussed in several rounds by an increasing number of experts in Health Informatics evaluation during conferences and by using e-mail.

ResultsA set of STARE-HI principles to be addressed in papers describing evaluations of Health Informatics interventions is presented. These principles include formulation of title and abstract, of introduction (e.g. scientific background, study objectives), study context (e.g. organizational setting, system details), methods (e.g. study design, outcome measures), results (e.g. study findings, unexpected observations)and discussion and conclusion.

Conclusion Acomprehensivelistofprinciplesrelevantforproperlydescribing Health Informatics evaluations has been developed. When manuscripts submitted to Health Informatics journals and general medical journals adhere to these aspects, readers will be better positioned to place the studies in a proper context and judge their validity and generalisability. STARE-HI may also be used for study planning and hence positively influence the quality of evaluation studies in Health Informatics. We believe that better publication of (both quantitative and qualitative) evaluation studies is an important step toward the vision of evidence-based Health Informatics.

Limitations This study is based on experiences from editors, reviewers, authors of systemati c reviews and readers of the scientific literature. The applicability of the principles has not been evaluated in real practice. Only when authors start to use these principles for reporting, shortcomings in the principles will emerge.

STARE-HI -statement on reporting of evaluation studies in health informatics

OBJECTIVE

Development of guidelines for publication of evaluation studies of Health Informatics applications.

METHODS

An initial list of issues to be addressed in reports on evaluation studies was drafted based on experiences as editors and reviewers and as authors of systematic reviews , taking into account guidelines for reporting of medical research. This list has been discussed in several rounds by an increasing number of experts in Health Informatics evaluation during conferences and by using e-mail.

RESULTS

A set of STARE-HI principles to be addressed in papers describing evaluations of Health Informatics interventions is presented. These principles include formulation of title and abstract, of introduction (e.g. scientific background, study objectives), study context (e.g. organizational setting, system details), methods (e.g. study design, outcome measures), results (e.g. study findings, unexpected observations) and discussion and conclusion.

CONCLUSION

A comprehensive list of principles relevant for properly describing Health Informatics evaluations has been developed. When manuscripts submitted to Health Informatics journals and general medical journals adhere to these aspects, readers will be better positioned to place the studies in a proper context and judge their validity and generalisability. STARE-HI may also be used for study planning and hence positively influence the quality of evaluation studies in Health Informatics. We believe that better publication of (both quantitative and qualitative) evaluation studies is an important step toward the vision of evidence-based Health Informatics.

LIMITATIONS

This study is based on experiences from editors, reviewers, authors of systematic reviews and readers of the scientific literature. The applicability of the principles has not been evaluated in real practice. Only when authors start to use these principles for reporting, shortcomings in the principles will emerge.

Cost-effectiveness of infliximab in the treatment of rheumatoid arthritis in clinical practice

OBJECTIVE

We evaluated the cost-effectiveness of infliximab therapy in Finnish RA patients in a real-life clinical setting and identified factors influencing it, using the national register of biological treatment (ROB-FIN).

METHODS

A cost-utility analysis was performed, derived from EQ-5D, and related to HAQ score and disease activity using multiple regression. QALYs were calculated based on these utilities, using patient-level data up to the last control registered. Cost-effectiveness analyses included costs per ACR50 responder, and costs per low DAS28 score (<3.2) achieved, in combination with a clinically significant improvement (>1.2). The costs considered were direct medical costs of infliximab and cost of intravenous infusion. Patient-level costs were calculated based on dose and dosage frequency, and were related to the difference in QALYs resulting from infliximab therapy.

RESULTS

The 297 patients had been treated with infliximab for an average of 21 months. The HAQ score and patient's global assessment improved significantly on infliximab therapy. More than two-thirds of the patients achieved a clinically important improvement in HAQ. A QALY gain occurred in 76%. 35% of these had an incremental cost-effectiveness ratio of < or =40,000 Euro/QALY gained, the median cost being 51,884 Euro. The cost per QALY gained was significantly lower for patients achieving an ACR50 response at 3, 12 and 24 months.

CONCLUSION

Treatment with infliximab and aiming at ACR50 response appears cost-effective, remembering the restrictions of an observational study set up. Current Care guidelines, which require sufficient disease control when deciding on continuing biological therapy, get support from these findings.

Success and failure factors in the regional health information system design process--results from a constructive evaluation study

OBJECTIVES

To identify success and failure factors in the design process of a regional health information system.

METHODS

A constructive evaluation study including interviews, observations, usability study and document analysis.

RESULTS

Modelling was found to be a key element for the successful implementation of a health information system. The developed service chain model helped to define use cases and to implement seamless service chains. User participation in the design process was a success factor resulting in good user acceptance and signs of positive impacts on work practices. Evaluation study also helped system developers to guide the system's further development. An important failure factor identified was the lack of semantic interoperability of the system components.

CONCLUSIONS

The results emphasize the socio-technical nature of health information systems. The starting point for development should be thorough insight into the health care work practices where the information systems are to be used. Successful system design should start from modelling of work processes, data and information flows and definition of concepts and their relations. Health informatics as a scientific discipline provides theories and models for the design and development process.

Factors influencing success and failure of health informatics systems--a pilot Delphi study

OBJECTIVES

The aim is to gain information on factors influencing success and failure for Health Informatics applications from a group of medical informaticians.

METHODS

Based on the presentations at a special topic conference on success and failure in Health ICT and analysis of the proceedings, we conducted a Delphi study on success and failure aspects.

RESULTS

A total of 110 success factors and 27 failure criteria were identified, distributed on categories like functional, organizational, behavioral, technical, managerial, political, cultural, legal, strategy, economy, education and user acceptance. These factors and criteria were rated for six different system types. Unanimously it was agreed that "collaboration and co-operation" and "setting goals and courses" are "essential for the success" of clinical systems, and "user acceptance" for educational systems. Similarly, the score "essential in order to avoid a failure" were given unanimously on clinical systems for "response rate and other performance measures" and on administrative systems for "not understanding the organizational context" with "not understanding or foreseeing the extent to which the new IT-system affects the organization, its structure and/or work procedures" as the highest scoring sub-item.

CONCLUSIONS

All success factors and failure criteria were considered relevant by the Delphi expert panel. There is no small set of relevant factors or indicators, but success or failure of a Health ICT depends on a large set of issues. Further, clinical systems and decision support systems depend on more factors than other systems.

Citric acid as a pH-regulating additive in granules and the tablet matrix in enteric-coated formulations for colon-specific drug delivery

Colon-specific drug-delivery systems have been extensively investigated over the last decade. The aim of the study reported here was to investigate whether times of commencement of drug liberation and absorption could be controlled by varying the amount of citric acid in granule cores or in the tablet matrix in enteric-coated multiple-unit tablets. One of the most important aims was to determine the optimal amounts and locations of citric acid in formulations intended as drugs targeted at the colon. Ibuprofen was used as the model drug. Drug release rates were studied in phosphate buffer at pH 6.8 and 7.4. A gradient dissolution study at pH 1.2, 6.8 and 7.4 was undertaken with two formulations. Drug absorption was studied by means of bioavailability tests. We concluded that the drug release rate could be controlled in vitro by changing the amount of citric acid in granule cores or the tablet matrix. In vivo tests confirmed that between 10 and 15% citric acid in the tablet matrix delayed the commencement of drug absorption most. This kind of formulations could be suitable for preparation of colon-specific dosage forms. It is probably unnecessary to include citric acid in granule cores. No logical correlation between in vitro and in vivo results was obtained.

Citric acid as excipient in multiple-unit enteric-coated tablets for targeting drugs on the colon

Delivery of drugs to the large bowel has been extensively investigated during the last decade. The aim of this study was to investigate whether enteric-coated tablets could be made from enteric-coated matrix granules and drug release targeted to the colon. Whether in vitro drug release rate and in vivo absorption could be delayed by adding citric acid to the granules and/or to the tablet matrix was also studied. Ibuprofen was used as model drug because it is absorbed throughout the gastrointestinal tract. Eudragit S and Aqoat AS-HF were used as enteric polymers. Drug release rates were studied at different pH levels and drug absorption was studied in bioavailability tests. The conclusion was that citric acid retarded in vitro drug release when used in multiple-unit tablets. In vivo absorption of ibuprofen was markedly delayed when citric acid was included in both granules and tablet matrix. Further studies are needed to determine the optimal amount of citric acid in formulations.

Genomic organization and promoter analysis of the human heat shock factor 2 gene

Heat shock factor 2 (HSF2) is a member of the heat shock transcription factor family, which appears to be activated during differentiation and development rather than on cellular stress. Here we report the isolation and characterization of the human hsf2 gene and its 5'-flanking region. The transcription unit of the human hsf2 gene consists of 13 exons dispersed over 33 kbp of genomic DNA on chromosome 6. The hsf2 mRNA is transcribed from multiple start sites, and initiation from the major site results in a transcript of 2.45 kb. A functional promoter, as determined by the ability to direct expression of a transiently transfected luciferase reporter gene, resides in a 950-bp upstream region of the human hsf2 gene. Examination of the core promoter sequence revealed a high GC content and lack of a canonical TATA box. This feature seems to be common among various species, as comparison of the hsf2 proximal promoter sequences from human, mouse, and rat showed distinct conserved regions. Moreover, the overall architecture of the human hsf2 gene is similar to its mouse counterpart. A comparison between human hsf2 gene and other hsf genes showed striking similarities in exon size. However, the exons are assembled in an hsf-specific manner.

Roles of the heat shock transcription factors in regulation of the heat shock response and beyond

The heat shock response, characterized by increased expression of heat shock proteins (Hsps) is induced by exposure of cells and tissues to extreme conditions that cause acute or chronic stress. Hsps function as molecular chaperones in regulating cellular homeostasis and promoting survival. If the stress is too severe, a signal that leads to programmed cell death, apoptosis, is activated, thereby providing a finely tuned balance between survival and death. In addition to extracellular stimuli, several nonstressful conditions induce Hsps during normal cellular growth and development. The enhanced heat shock gene expression in response to various stimuli is regulated by heat shock transcription factors (HSFs). After the discovery of the family of HSFs (i.e., murine and human HSF1, 2, and 4 and a unique avian HSF3), the functional relevance of distinct HSFs is now emerging. HSF1, an HSF prototype, and HSF3 are responsible for heat-induced Hsp expression, whereas HSF2 is refractory to classical stressors. HSF4 is expressed in a tissue-specific manner; similar to HSF1 and HSF2, alternatively spliced isoforms add further complexity to its regulation. Recently developed powerful genetic models have provided evidence for both cooperative and specific functions of HSFs that expand beyond the heat shock response. Certain specialized functions of HSFs may even include regulation of novel target genes in response to distinct stimuli.

Comparison between low- and standard-dose ACTH tests in premature infants at risk for chronic lung disease

In order to find a sensitive method to evaluate adrenocortical function in premature infants, we compared low- (0.5 microg/1.73 m(2)) and standard-dose (250 microg/1.73 m(2)) adrenocorticotropin tests (LD- and SD-ACTH) in 12 very-low-birth-weight infants before and 2 days after the end of dexamethasone therapy (duration 9-14 days) for chronic lung disease. Basal serum cortisol levels were inappropriately low in several infants already before dexamethasone therapy (median 190, range 60-357 nmol/l). The 95% confidence intervals of mean serum cortisol levels at 20 min were equal in LD- and SD-ACTH, while at 60 min, the low-dose gave a clearly lower response than the standard-dose test. The LD-ACTH can be used in premature infants as in older children and adults, but the criteria for adrenocortical insufficiency need to be defined.

On conceptualization of a decision support system in health informatics

A decision support system can be approached from two major disciplinary perspectives, those of information systems science (IS) and artificial intelligence (AI). We present in this study an extended ontology for a decision support system in health informatics, which is founded on experience from related research fields as well as being informed by our case studies. The ontology emphasises the need to cover environmental and contextual variables as an integral part of a decision support systems development methodology. With the addition of these variables, the focus in decision support systems development shifts from a task ontology towards a domain ontology. The results of this study help the system developers to take the system's context into account through the set of defined variables that are linked to the application domain. These variables explicate relevant constructs and present a vocabulary for a decision support system. However, applying the ontology requires a more thorough analysis of the domain and therefore more qualified resources for systems development. This indicates the need to focus more on education and training in health informatics.

The VATAM guidelines

Evaluation and assessment of the impact of information and communication technology in medicine is gaining interest. Unfortunately, till now there were no agreed upon approaches. The objective of the VATAM project is to develop guidelines that will assist assessors to set-up and execute studies. This paper describes the background of the VATAM project and provides an account of the current state of the guidelines. It concludes with an indication of the developments that will take place in the short term to further elaborate the guidelines and some considerations for consolidation of VATAM's results.

Inventory of validation approaches in selected health telematics projects

This paper presents the results from an inventory of validation approaches and methodologies which have been used in selected health telematics projects. The inventory was performed in the VATAM Validation of Telematic Applications in Medicine project, HC1115HC. The purpose of the inventory was to analyse the methodologies and their application assumptions in order to identify possibilities for harmonization and consolidation. The inventory was performed using five validation dimensions: IT-development; quality; user; technology assessment and marketing. The inventory results show that possibilities exist to synthesise methodologies and to provide practical guidance and support for projects that are developing health telematics applications. All stakeholders in health telematics projects, i.e. users, health care decision-makers, developers, suppliers and IT-industries, can benefit from practical validation guidelines and support for validation when guidelines are represented in a usable, easy to access and informative way.

Organic acids as excipients in matrix granules for colon-specific drug delivery

Interest exists in developing site-specific systems for release of a drug in the lower part of the small intestine or in the colon. The aim of this study was to investigate whether drug release rates from enteric matrix granules could be influenced by using organic acids as excipients. Ibuprofen was used as a model drug and Eudragit S and Aqoat AS-HF as enteric polymers. The dissolution rates of the drug were investigated at different levels of pH (5.8, 6.8 and 7. 4). Drug absorption was studied in bioavailability tests in healthy volunteers. In vitro/in vivo correlation was also investigated. It was concluded that although inclusion of an organic acid in a formulation retarded in vitro release of the model drug, no corresponding effect was evident in in vivo studies. Bioavailability tests are therefore important early on during development of new dosage forms or formulations. Although no correlation between in vitro and in vivo results was generally evident correlation could be demonstrated for individual formulations following mathematical transformation of data.

Enteric polymers as binders and coating materials in multiple-unit site-specific drug delivery systems

The aim of this study was to develop a multiple-unit, site-specific drug formulation allowing targeting of drug release in the colon. Initially, characteristics of matrix pellets containing various enteric polymers as binders were tested. An enteric coating was then added to the formulations. Ibuprofen and furosemide were used as model drugs. The former is absorbed throughout the gastrointestinal tract, the latter only from upper parts. Methacrylate copolymers, hydroxypropyl methylcellulose acetate succinates and cellulose acetate phthalate were used as enteric polymers. The properties of the products were initially tested via dissolution studies at different pHs, then via bioavailability studies in healthy volunteers. The main conclusion was that drug release can be targeted on the distal part of the small intestine and the colon by preparing film-coated matrix pellets in which enteric polymers dissolving at pH approximately 7 have been used both as binders in the pellets and as coating material. This conclusion is based on the finding that absorption of ibuprofen from the formulations developed was adequate, with a lag-time of about 2 h and tmax values at 4-5 h, where as absorption of furosemide from the analogous products was negligible. It was also found that uncoated pellets as such could represent a slow-release formulation for furosemide, a problem drug as far as modified-release products are concerned.

VATAM: developing consensus in validation of health telematics applications

VATAM (Validation of Telematics Applications in Medicine) is an EU supported project in the Health care sector of the Telematics Application Programme. Its objective is to assist other health telematics projects by providing a platform for discussion on validation, eventually resulting in 'guidelines for validation of telematics applications in medicine'. The VATAM work can be subdivided into three phases: the inventory phase (1996) in which information is collected on validation approaches in the Telematics Application Programme, previous efforts and expertise. The dissemination phase (1997) will be used to extend and adapt the framework developed in the inventory phase, through cooperation with other projects The experiences phase (1998) in which the projects are actually applying validation, will be used by VATAM to validate the VATAM methodology. VATAM has finished the inventory phase successfully and is now working on the dissemination phase by--among others--establishing contacts with other projects, and providing information on the inventory through the World Wide Web (URL: http:(/)/www-vatam.unimaas.nl). This paper discusses the approach adopted and the proposed VATAM framework to structure the large variety of validation approaches.

KAVAS-2: Knowledge Acquisition, Visualization and Assessment System

The objective of KAVAS-2 is the development of a tool, named KAVIAR, with which domain experts can make their knowledge explicit. It contains components for (computer assisted) knowledge elicitation and for machine learning. A key issue in KAVAS is the assessment of the quality of the classification and domain models built. Various quality measures are available and implemented in KAVIAR to assess the quality of models, specifically those developed from data bases by machine learning techniques.

OpenLabs: the application of advanced informatics and telematics for optimization of clinical laboratory services

OpenLabs has four major objectives: to improve the efficiency and effectiveness of clinical laboratory services by the integration of Knowledge Based Systems (KBSs) with Laboratory Information Systems (LISs) and equipment; to provide and implement standard solutions for Electronic Data Interchange (EDI) between laboratories and other medical systems; to specify a fully Open architecture for an integrated Clinical LIS and demonstrate the integration of various KBS modules on the open architecture platform; and to demonstrate the integration of OpenLabs modules with existing LISs.

Interpretative reporting and alarming based on laboratory data

The utilisation of laboratory services for patient diagnosis and management involves many steps with both clinical and laboratory components. The clinical components include the decision to order a test, interpretation of the test results and actions taken on the basis of the results. The laboratory components on the other hand include receipt of the request, specimen collection, preparation and analysis, result entry, test result validation and verification and reporting of the results. In this paper, which is part of the OpenLabs project, we concentrate on the post-analytical applications which include interpretation and reporting of the laboratory results to the users in primary care and in high dependency care units. The final objective of the work described is to develop generic modules which can be integrated both with an Open laboratory information system architecture and existing laboratory information processing environment.

DNA synthesis in prolyl 4-hydroxylase positive fibroblasts in situ in synovial tissue. An autoradiography-immunoperoxidase double labeling study

DNA synthesis in prolyl 4-hydroxylase (PH; EC 1.14.11.2) positive fibroblasts in situ in synovial tissue was studied using an autoradiography-avidin-biotin-peroxidase complex (ABC) double labeling. Fibroblasts in monolayer culture and in situ in synovial tissue were PH positive, whereas freshly isolated peripheral blood lymphocytes, monocytes, dendritic cells and granulocytes were PH negative. In rheumatoid arthritis (RA) 37 +/- 3 (22-56)% of all DNA synthesizing cells in situ were PH containing fibroblasts, whereas all DNA synthesizing cells in patients with meniscus lesion were PH positive. In both conditions, more than half of the self-replicating fibroblasts were located in the lining cell layer. This is probably not an artifact caused by insufficient penetration of 3H-thymidine because most of the DNA synthesizing lymphocytes were deep down in the synovial stroma. In RA 51 +/- 8 (17-88) PH positive fibroblasts in the S phase of the cell cycle were observed/3 mm2 synovial tissue, whereas the corresponding figure in meniscus patients was only 1 +/- 1 (0-5) (p less than 0.01). This suggests that the local fibroblasts in RA are activated, probably as a result of various fibroblast growth factors produced locally as a result of the inflammatory synovitis. In RA however, less than 1% of all local fibroblasts were self-replicating in situ, whereas labeling indices over 5% were not uncommon in RA synovial fibroblast cultures. This finding suggests that uncontrolled fibroblast proliferation is regulated in vivo by negative feedback mechanisms.

Synovial fibroblasts

Chronic synovitis refers to fibrin deposits on the surface of proliferating superficial synovial lining cells leading to villous hyperthrophy, and associated with foci of cell necrosis and infiltration of chronic inflammatory cells. The superficial synovial lining cells include fibroblast-like type B cells and macrophage-like type A cells. Fibroblast- and macrophage-like cells in the early or leading edge of pannus may represent an extension of these cells, which themselves may be nothing else than stromal fibroblasts and macrophages adapted to the particular micro-milieu prevailing at the interface of hyaluronate (HA) containing synovial fluid and richly vascularized loose connective tissue in the sublining stroma. In all three locations fibroblasts are exposed to various humoral substances, extracellular matrix (ECM) and cell-cell contacts, which may modify their phenotype and function. Therefore, one would expect differences in the fibroblasts in inflammatory and non-inflammatory synovial tissue. These changes can be best understood by considering some of the basic fibroblast properties, namely migration, substrate adherence, proliferation and synthesis and degradation of ECM.

A cytochemical study on the effects of energy deprivation on autophagocytosis in Ehrlich ascites tumor cells

The effect of energy deprivation on autophagocytosis in Ehrlich ascites tumor cells was studied using cytochemical techniques. Autophagocytosis was induced with vinblastine incubation (0.1 mM) and the cellular ATP-level was lowered with 2-deoxy-D-glucose (0.35 mM). Acid phosphatase was used as a marker for lysosomal enzymes and imidazole-buffered osmium tetroxide impregnation in order to study the effects of energy deprivation on the maturation of autophagic vacuole (AV) membranes. Control and vinblastine treated cells maintained their ATP-levels throughout the incubation period tested (120 min). 2-Deoxy-D-glucose alone and with vinblastine decreased the intracellular ATP-level significantly after only 3 min incubation. Most of the AV's in control and vinblastine treated cells contained degraded material and acid phosphatase activity. Their membranes were stained only slightly or not at all with imidazole-buffered osmium tetroxide. 2-Deoxy-D-glucose alone as well as with vinblastine induced in particular an accumulation of early stages of AV's. These vacuoles contained undegraded cytoplasmic material and no acid phosphatase activity and their membranes were stained usually partly with imidazole-buffered osmium tetroxide. The membranes of some early AV's resembled endoplasmic reticulum and still had attached ribosomes. It was concluded that the inhibition of cellular energy production used in the present study did not inhibit autophagic sequestration but retarded the maturation of AV membranes and impaired the functioning of lysosomal hydrolases.

Phenotypic characterization of 3H-thymidine incorporating cells in rheumatoid arthritis synovial membrane

Tritiated-thymidine incorporating cells in synovial tissue samples from ten patients with definite or classic rheumatoid arthritis (RA) were studied by combining two techniques. Tritiated-thymidine-labelled cells were seen in autoradiography and simultaneously the subtype of them was determined with immunoperoxidase staining using monoclonal antibodies. Tritiated-thymidine-labelled cells comprised 0.8 +/- 0.4% of all the inflammatory cells in RA synovial membrane. Of all 3H-thymidine-labelled cells 34 +/- 17% were positive for OKT8 and 19 +/- 8% for OKT4 monoclonal antibodies. OKM1-positive cells comprised 7 +/- 3% of all 3H-thymidine labelled cells, whereas only a few (3 +/- 4%) of them were positive for pan-B monoclonal antibody. This study emphasizes the importance of activated OKT8 lymphocytes in RA synovial membrane.

Lymphocyte activation in rheumatoid arthritis synovial fluid in vivo

Monoclonal antibodies were used in avidin-biotin-peroxidase complex staining for activation marker analysis of rheumatoid synovial fluid cells. Although Ia expression indicates T cell activation, cells displaying receptors for interleukin 2 (Tac)-and transferrin receptor (T9)- positive proliferating cells were relatively few. Similarly, activated terminal effector cells of suppressor/cytotoxic nature were scarce in rheumatoid synovial fluid, as suggested by a low expression of Tac and 4F2 markers. The in vivo situation in the rheumatoid arthritic (RA) joint does not seem to be due to the inability of synovial fluid lymphocytes to become activated, because mitogen stimulation in vitro, in spite of a low proliferative response, induced expression of all the activation markers studied. The relevance of the present observations to the down-regulation of the active, inflammatory-immune response in situ is speculative, but the data show that in spite of T-cell activation and Ia expression, activated terminal effector cells of suppressor/cytotoxic nature are few in the RA joint in vivo.

Proliferating cells in the synovial fluid in rheumatic disease. An analysis with autoradiography-immunoperoxidase double staining

The subtype of the proliferating cells in the synovial fluid of patients with rheumatoid arthritis (RA), ankylopoietic spondylarthrosis (SPA), and osteoarthritis (OA) was studied with autoradiography-immunoperoxidase double staining. Of all spontaneously proliferating synovial fluid cells in chronic arthritis, 59 +/- 4% displayed T8 differentiation marker, whereas T4 (21 +/- 4%) and B (2 +/- 1%) cells were few. Of all T4+ and all T8+ lymphocytes, 0.55 +/- 0.1% and 0.90 +/- 0.1%, respectively, incorporated [3H]thymidine. The [3H]thymidine labelling index for B cells was 0.30 +/- 0.1%. This was in contrast to OA, in which no proliferating lymphocytes were observed in the synovial fluid. Our findings suggest that the predominance of proliferating T8+ cells in the synovial fluid reflects an underlying chronic inflammation. Because RA and SPA synovium is a site of intense immunoglobulin production, our finding of the predominance of activated, proliferating T8+ cells may also reflect a dissociation between phenotype and function as a reason for the chronicity of the joint inflammation.

Characterization of the DNA-synthesizing cells in rheumatoid synovial tissue

DNA-synthesizing cells from the rheumatoid arthritis synovial tissue of 7 patients and from 5 patients with traumatic and degenerative joint lesions were studied by incubating fresh synovial tissue samples with tritiated thymidine. Labelled cells were identified using autoradiography. The tissue sections were stained with methyl green pyronine. It was found that 0.66% (range 0.38-1.4) of the cells were labelled with 3H-thymidine whereas in control materials the percentage was 0.17 (range 0-0.38). Approximately half of the labelled subsynovial cells in rheumatoid patients (range 37-67%) were small lymphocytes, according to morphological criteria. About one-tenth of the labelled cells (range 0-17%) looked like medium-sized lymphocytes, while the rest had the characteristics of fibroblasts or were unidentifiable.