Duloxetine in OsteoArthritis (DOA) study: effects of duloxetine on pain and function in end-stage hip and knee OA - a pragmatic enriched randomized controlled trial.

BACKGROUND: Some osteoarthritis (OA) patients experience inadequate pain relief from analgesics like acetaminophen and nonsteroidal anti-inflammatory drugs. This could be the result of experienced non-nociceptive centralized pain. Placebo-controlled randomized trials (RCT) have proven the effectiveness of duloxetine for OA and several chronic pain conditions where central sensitization (CS) is one of the key underlying pain mechanisms. OBJECTIVES: Assess the efficacy of an 8-week duloxetine treatment compared to usual care in end-stage knee and hip OA patients with a level of centralized pain. DESIGN: Pragmatic, enriched, open-label RCT. METHODS: Patients were randomized to duloxetine or to care-as-usual. Primary outcome was pain in the index joint, measured with the pain domain of the Knee injury and Osteoarthritis Outcome Score (KOOS) or the Hip disability and Osteoarthritis Outcome Score (HOOS). The intention-to-treat principle was used, with mixed-model repeated measures to analyze the effect. RESULTS: One hundred eleven patients were randomized. Nearly 44% felt much to very much better after duloxetine usage compared to 0% in the care-as-usual group (p < 0.001). The duloxetine group scored 11.3 points (95%CI: 5.8, 16.8) better on the pain domain of the KOOS/HOOS (p < 0.001). Knee patients improved significantly more than hip patients (18.7 [95%CI: 11.3, 26.1] versus 6.0 [95%CI: - 2.6, 14.5] points better). CONCLUSIONS: Adding duloxetine treatment seems to be beneficial for end-stage knee OA patients with neuropathic-like symptoms (at risk of CS). End stage Hip OA patients seem to be nonresponsive to duloxetine. TRIAL REGISTRATION: Dutch Trial Registry with number NTR 4744 (15/08/2014) and in the EudraCT database with number 2013-004313-41 .

Duloxetine in OsteoArthritis (DOA) study: study protocol of a pragmatic open-label randomised controlled trial assessing the effect of preoperative pain treatment on postoperative outcome after total hip or knee arthroplasty.

INTRODUCTION: Residual pain is a major factor in patient dissatisfaction following total hip arthroplasty or total knee arthroplasty (THA/TKA). The proportion of patients with unfavourable long-term residual pain is high, ranging from 7% to 34%. There are studies indicating that a preoperative degree of central sensitisation (CS) is associated with poorer postoperative outcomes and residual pain. It is thus hypothesised that preoperative treatment of CS could enhance postoperative outcomes. Duloxetine has been shown to be effective for several chronic pain syndromes, including knee osteoarthritis (OA), in which CS is most likely one of the underlying pain mechanisms. This study aims to evaluate the postoperative effects of preoperative screening and targeted duloxetine treatment of CS on residual pain compared with care-as-usual. METHODS AND ANALYSIS: This multicentre, pragmatic, prospective, open-label, randomised controlled trial includes patients with idiopathic hip/knee OA who are on a waiting list for primary THA/TKA. Patients at risk for CS will be randomly allocated to the preoperative duloxetine treatment programme group or the care-as-usual control group. The primary end point is the degree of postoperative pain 6 months after THA/TKA. Secondary end points at multiple time points up to 12 months postoperatively are: pain, neuropathic pain-like symptoms, (pain) sensitisation, pain catastrophising, joint-associated problems, physical activity, health-related quality of life, depressive and anxiety symptoms, and perceived improvement. Data will be analysed on an intention-to-treat basis. ETHICS AND DISSEMINATION: The study is approved by the local Medical Ethics Committee (METc 2014/087) and will be conducted according to the principles of the Declaration of Helsinki (64th, 2013) and the Good Clinical Practice standard (GCP), and in compliance with the Medical Research Involving Human Subjects Act (WMO). TRIAL REGISTRATION NUMBER: 2013-004313-41; Pre-results.

Optimization of poly(ethylene glycol) precipitation of hepatitis A virus used to prepare VAQTA, a highly purified inactivated vaccine.

Poly(ethylene glycol) precipitation has been successfully used to concentrate and purify hepatitis A virus from crude lysate preparations for production of VAQTA, a highly purified, formalin-inactivated hepatitis A vaccine. Initial results showed that nucleic acids present in the starting material were problematic for the performance of the poly(ethylene glycol) precipitation step. Extensive experiments were carried out to identify processing conditions suitable for vaccine manufacture which would enhance product yield and improve purity. Results of these studies indicated that the earlier practice of concentrating crude virus-containing lysate using semipermeable membranes led to aggregation of high molecular weight nucleic acids. This aggregated material coprecipitated with the virus during the subsequent poly(ethylene glycol) precipitation step; variable amounts of nucleic acids led to inconsistent virus recovery and product purity. Nuclease treatment of the crude lysate preparations decreased the molecular size of the nucleic acids and significantly reduced their coprecipitation with the virus. Further experiments demonstrated that optimal placement of the nuclease treatment was at the lysate stage followed by a capture step using anion exchange chromatography. These steps combined with optimization of the virus concentration, ionic strength, and pH of the poly(ethylene glycol) precipitation led to effective and selective concentration of the virus which significantly enhanced process reproducibility and control.

[Pleural empyema in mechanically ventilated patients with pneumonia]. / Pleura-empyeem bij beademde patiënten met pneumonie.

Two males aged 41 and 32 years developed pneumonia which responded inadequately to antibiotic treatment and necessitated mechanical ventilation. It was only after surgical and digital opening, drainage of pus pockets and daily pleural lavage that the clinical picture improved. The microorganisms cultured from both patients included Streptococcus milleri, probably acquired by aspiration. Thoracic empyema as a complication of pneumonia is clinically recognised by lack of response to antimicrobial agents. For the diagnosis, ultrasonographic and CT imaging, followed by pleural puncture are used. Simple parapneumonic effusions are managed by drainage with or without rinsing with normal saline, while in advanced empyema, instillations with fibrinolytic agents have proved safe and effective. Sometimes, video-assisted thoracoscopic or conventional surgery is necessary to clear the pleural space, while in complicated cases, extensive surgical procedures are warranted.

Optimization and scale-up of solvent extraction in purification of hepatitis A virus (VAQTA).

Solvent extraction is a very powerful purification step in the preparation of VAQTA, a highly purified, inactivated hepatitis A vaccine. Extraction of an aqueous product-containing protein solution with chloroform through vigorous shaking causes irreversible denaturation of contaminant proteins at the interface. However, the hepatitis A virus (HAV) remains viable and soluble in the aqueous phase. Because three phases (air, aqueous, and organic) are involved, and the mixing is carried out in individual bottles, there is very little theory available to characterize this process, so it must be studied experimentally. This extraction step was characterized by following the removal of a specific impurity from the aqueous phase as a representative marker for the degree of protein precipitation. These experiments led to the identification and optimization of the important variables controlling the extraction step. They were found to be mixing time and size of vessel, with longer mixing times resulting in higher purity and larger bottle size leading to faster kinetics of impurity removal. These parameters are most likely related to solvent/aqueous interfacial area and the resulting shear due to shaking. We conclude that, to scale up this type of mixing, the kinetics of impurity removal need to be determined experimentally for the systems and equipment under consideration.

Protein refolding in reversed micelles.

A novel process has been developed which uses reversed micelles to isolate denatured protein molecules from each other and allows them to refold individually. These reversed micelles are aqueous phase droplets stabilized by the surfactant AOT and suspended in isooctane. By adjusting conditions such that only one protein molecule is present per reversed micelle, it was possible to achieve independent folding without encountering the problem of aggregation due to interactions with neighboring molecules. The feasibility of this process was demonstrated using bovine pancreatic ribonuclease A as a model system. It was shown that denatured and reduced ribonuclease can be transferred from a buffered solution containing guanidine hydrochloride into reversed micelles to a greater extent than native enzyme under the same conditions. The denaturant concentration can then be significantly reduced in the reversed micellar phase, while retaining most of the protein, by means of extractive contacting stages with a denaturant-free aqueous solution. Denatured and reduced ribonuclease will subsequently recover full activity inside reversed micelles within 24 h upon addition of a mixture of reduced and oxidized glutathione to reoxidize disulfide bonds. Extraction of this refolded enzyme from reversed micelles back into aqueous solution can be accomplished by contacting the reversed micelle phase with a high ionic strength (1.0M KCl) aqueous solution containing ethyl acetate.

Protein refolding in reversed micelles: Interactions of the protein with micelle components.

A novel process has been developed to improve the refolding yield of denatured proteins. It uses reversed micelles to isolate denatured protein molecules from each other and thus, upon refolding, reduces the intermolecular interactions which lead to aggregation. The feasibility of this process was first demonstrated with Ribonuclease A as a model protein. In the present work, we expanded the scope of this study to better understand both the general mechanisms of protein refolding in reversed micelles and the biotechnological applicability of the process. First, we investigated the interactions between the individual components of the reversed micellar system (the protein molecule, the denaturant guanidine hydrochloride (GuHCl), and the surfactant (AOT)) during the refolding process. We then extended our studies to a more hydrophobic protein, gamma-interferon, which aggregates upon refolding in aqueous solution. However, it was also found to aggregate in our reversed micelle process during the extraction step. Since gamma-interferon is a much more hydrophobic protein than RNase, we hypothesize that interactions between hydrophobic amino acids and the surfactant layer may interfere with refolding. This hypothesis was tested by studying the refolding of chemically modified RNase. The substitution of 55% of the surface lysine residues with hydrophobic caproyl groups caused a significant decrease in the refolding yield of RNase in the reversed micellar system without affecting aqueous solution renaturation. In addition, the extraction efficiency of the enzyme from reversed micelles back into aqueous solution was severely reduced and resulted in aggregation. These experiments indicate that unfolded hydrophobic Proteinsinteract with the Surfactant molecules, which limits their ability to refold in reversed micelles.

Use of nuclease enzyme in the purification of VAQTA, a hepatitis A vaccine.

The development of the purification process for VAQTA, which results in a highly purified inactivated hepatitis A vaccine, was driven by modifications in the cell-culture and harvest methods which permit hepatitis A virus propagation to support large-scale manufacture. The starting material for the purification was initially a concentrated cell pellet scraped from roller bottles. However, when the cell-culture method was scaled up to use high-surface-area Nunc cell factories or Costar cubes, the early steps in the process had to be modified to handle large volumes of dilute lysate. Membrane concentration was used at first, and a highly purified vaccine was prepared, but virus-poly(nucleic acid) complexes were formed, which reduced the yields in later processing steps. The introduction of a nuclease digestion immediately after harvest followed by capture chromatography on an anion-exchange column eliminated the formation of these complexes and resulted in more consistent performance and higher yields of downstream operations.