1
|
Jacobs LM, Helder LS, Albers KI, Kranendonk J, Keijzer C, Joosten LA, Strobbe LJ, Warlé MC. The role of surgical tissue injury and intraoperative sympathetic activation in postoperative immunosuppression after breast-conserving surgery versus mastectomy: a prospective observational study. Breast Cancer Res 2024; 26:42. [PMID: 38468349 PMCID: PMC10926636 DOI: 10.1186/s13058-024-01801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Breast cancer is the second most common cause of death from cancer in women worldwide. Counterintuitively, large population-based retrospective trials report better survival after breast-conserving surgery (BCS) compared to mastectomy, corrected for tumour- and patient variables. More extensive surgical tissue injury and activation of the sympathetic nervous system by nociceptive stimuli are associated with immune suppression. We hypothesized that mastectomy causes a higher expression of plasma damage associated molecular patterns (DAMPs) and more intraoperative sympathetic activation which induce postoperative immune dysregulation. Immune suppression can lead to postoperative complications and affect tumour-free survival. METHODS In this prospective observational study, plasma DAMPs (HMGB1, HSP70, S100A8/A9 and S100A12), intraoperative sympathetic activation (Nociception Level (NOL) index from 0 to 100), and postoperative immune function (plasma cytokine concentrations and ex vivo cytokine production capacity) were compared in patients undergoing elective BCS (n = 20) versus mastectomy (n = 20). RESULTS Ex vivo cytokine production capacity of TNF, IL-6 and IL-1β was nearly absent in both groups one hour after surgery. Levels appeared recovered on postoperative day 3 (POD3), with significantly higher ex vivo production capacity of IL-1β after BCS (p = .041) compared to mastectomy. Plasma concentration of IL-6 was higher one hour after mastectomy (p = .045). Concentrations of plasma alarmins S100A8/A9 and S100A12 were significantly higher on POD3 after mastectomy (p = .003 and p = .041, respectively). Regression analysis showed a significantly lower percentage of NOL measurements ≤ 8 (absence of nociception) during mastectomy when corrected for norepinephrine equivalents (36% versus 45% respectively, p = .038). Percentage of NOL measurements ≤ 8 of all patients correlated with ex vivo cytokine production capacity of IL-1β and TNF on POD3 (r = .408; p = .011 and r = .500; p = .001, respectively). CONCLUSIONS This pilot study revealed substantial early postoperative immune suppression after BCS and mastectomy that appears to recover in the following days. Differences between BCS and mastectomy in release of DAMPs and intraoperative sympathetic activation could affect postoperative immune homeostasis and thereby contribute to the better survival reported after BCS in previous large population-based retrospective trials. These results endorse further exploration of (1) S100 alarmins as potential therapeutic targets in breast cancer surgery and (2) suppression of intraoperative sympathetic activation to substantiate the observed association with postoperative immune dysregulation.
Collapse
Affiliation(s)
- Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Leonie S Helder
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Kim I Albers
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Josephine Kranendonk
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | | | - Leo Ab Joosten
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
- Department of Medical Genetics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj- Napoca, Romania
| | - Luc Ja Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands.
| |
Collapse
|
2
|
Daniels AM, Kranendonk J, Wyers CE, Janzing HMJ, Sassen S, van Rietbergen B, Geusens PPMM, Kaarsemaker S, Hannemann PFW, Poeze M, van den Bergh JP. What Is the Diagnostic Performance of Conventional Radiographs and Clinical Reassessment Compared With HR-pQCT Scaphoid Fracture Diagnosis? Clin Orthop Relat Res 2023; 481:97-104. [PMID: 35833810 PMCID: PMC9750568 DOI: 10.1097/corr.0000000000002310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 10/29/2020] [Accepted: 06/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Conventional radiographs and clinical reassessment are considered guides in managing clinically suspected scaphoid fractures. This is a unique study as it assessed the value of conventional radiographs and clinical reassessment in a cohort of patients, all of whom underwent additional imaging, regardless of the outcome of conventional radiographs and clinical reassessment. QUESTIONS/PURPOSES (1) What is the diagnostic performance of conventional radiographs in patients with a clinically suspected scaphoid fracture compared with high-resolution peripheral quantitative CT (HR-pQCT)? (2) What is the diagnostic performance of clinical reassessment in patients with a clinically suspected scaphoid fracture compared with HR-pQCT? (3) What is the diagnostic performance of conventional radiographs and clinical reassessment combined compared with HR-pQCT? METHODS Between December 2017 and October 2018, 162 patients with a clinically suspected scaphoid fracture presented to the emergency department (ED). Forty-six patients were excluded and another 25 were not willing or able to participate, which resulted in 91 included patients. All patients underwent conventional radiography in the ED and clinical reassessment 7 to 14 days later, together with CT and HR-pQCT. The diagnostic performance characteristics and accuracy of conventional radiographs and clinical reassessment were compared with those of HR-pQCT for the diagnosis of fractures since this was proven to be superior to CT scaphoid fracture detection. The cohort included 45 men and 46 women with a median (IQR) age of 52 years (29 to 67). Twenty-four patients with a median age of 44 years (35 to 65) were diagnosed with a scaphoid fracture on HR-pQCT. RESULTS When compared with HR-pQCT, conventional radiographs alone had a sensitivity of 67% (95% CI 45% to 84%), specificity of 85% (95% CI 74% to 93%), positive predictive value (PPV) of 62% (95% CI 46% to 75%), negative predictive value (NPV) of 88% (95% CI 80% to 93%), and a positive and negative likelihood ratio (LR) of 4.5 (95% CI 2.4 to 8.5) and 0.4 (95% CI 0.2 to 0.7), respectively. Compared with HR-pQCT, clinical reassessment alone resulted in a sensitivity of 58% (95% CI 37% to 78%), specificity of 42% (95% CI 30% to 54%), PPV of 26% (95% CI 19% to 35%), NPV of 74% (95% CI 62% to 83%), as well as a positive and negative LR of 1.0 (95% CI 0.7 to 1.5) and 1.0 (95% CI 0.6 to 1.7), respectively. Combining clinical examination with conventional radiography produced a sensitivity of 50% (95% CI 29% to 71%), specificity of 91% (95% CI 82% to 97%), PPV of 67% (95% CI 46% to 83%), NPV of 84% (95% CI 77% to 88%), as well as a positive and negative LR of 5.6 (95% CI 2.4 to 13.2) and 0.6 (95% CI 0.4 to 0.8), respectively. CONCLUSION The accuracy of conventional radiographs (80% compared with HR-pQCT) and clinical reassessment (46% compared with HR-pQCT) indicate that the value of clinical reassessment is limited in diagnosing scaphoid fractures and cannot be considered directive in managing scaphoid fractures. The combination of conventional radiographs and clinical reassessment does not increase the accuracy of these diagnostic tests compared with the accuracy of conventional radiographs alone and is therefore also limited in diagnosing scaphoid fractures. LEVEL OF EVIDENCE Level II, diagnostic study.
Collapse
Affiliation(s)
- Anne M. Daniels
- Department of Surgery, VieCuri Medical Centre, Venlo, the Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | | | - Caroline E. Wyers
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Sander Sassen
- Department of Radiology, VieCuri Medical Centre, Venlo, the Netherlands
| | - Bert van Rietbergen
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Piet P. M. M. Geusens
- Department of Orthopaedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands
- Faculty of Medicine, Hasselt University, Belgium
| | - Sjoerd Kaarsemaker
- Department of Orthopaedic Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Pascal F. W. Hannemann
- Department of Surgery, Subdivision of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martijn Poeze
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Subdivision of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Joop P. van den Bergh
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| |
Collapse
|
3
|
Kranendonk J, Willems LH, Vijver-Coppen RVD, Coenen M, Adang E, Donders R, Zeebregts CJ, Deneer V, Reijnen M, Kramers C, Warlé MC. CYP2C19 genotype-guided antithrombotic treatment versus conventional clopidogrel therapy in peripheral arterial disease: study design of a randomized controlled trial (GENPAD). Am Heart J 2022; 254:141-148. [PMID: 35988587 DOI: 10.1016/j.ahj.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 03/08/2022] [Revised: 07/04/2022] [Accepted: 08/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clopidogrel is recommended in international guidelines to prevent arterial thrombotic events in patients with peripheral arterial disease (PAD). Clopidogrel itself is inactive and metabolism is dependent on the CYP2C19 enzyme. About 30% of Caucasian PAD patients receiving clopidogrel carry 1 or 2 CYP2C19 loss-of-function allele(s) and do not or to a limited extent convert the prodrug into its active metabolite. As a result, platelet inhibition may be inadequate which could lead to an increased risk of adverse clinical events related to arterial thrombosis. A CYP2C19 genotype-guided antithrombotic treatment might be beneficial for PAD patients. METHODS GENPAD is a multicenter randomized controlled trial involving 2,276 PAD patients with an indication for clopidogrel monotherapy. Patients with a separate indication for dual antiplatelet therapy or stronger antithrombotic therapy are not eligible for study participation. Patients randomized to the control group will receive clopidogrel 75 mg once daily without pharmacogenetic guidance. Patients randomized to the intervention group will be tested for carriage of CYP2C19 *2 and *3 loss-of-function alleles, followed by a genotype-guided antithrombotic treatment with either clopidogrel 75 mg once daily for normal metabolizers, clopidogrel 150 mg once daily for intermediate metabolizers, or acetylsalicylic acid 80 mg once daily plus rivaroxaban 2.5 mg twice daily for poor metabolizers. The primary outcome is a composite of myocardial infarction, ischemic stroke, cardiovascular death, acute or chronic limb ischemia, peripheral vascular interventions, or death. The secondary outcomes are the individual elements of the primary composite outcome and clinically relevant bleeding complications. CONCLUSION The aim of the GENPAD study is to evaluate the efficacy, safety, and cost-effectiveness of a genotype-guided antithrombotic treatment strategy compared to conventional clopidogrel treatment in PAD patients.
Collapse
Affiliation(s)
- J Kranendonk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L H Willems
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - M Coenen
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E Adang
- Department of Epidemiology and Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University Of Groningen, Groningen, The Netherlands
| | - Vhm Deneer
- Department of Clinical Pharmacy, Division of Laboratories, Pharmacy and Biomedical Genetics University Medical Center Utrecht, Utrecht, The Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht university, Utrecht, The Netherlands
| | - Mmpj Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands; Multimodality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - C Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
4
|
Willems LH, Nagy M, Ten Cate H, Spronk HMH, Jacobs LMC, Kranendonk J, van Leeuwen M, Meijer D, Middeldorp S, Groh LA, Warlé MC. ChAdOx1 vaccination, blood coagulation, and inflammation: No effect on coagulation but increased interleukin-6. Res Pract Thromb Haemost 2021; 5:e12630. [PMID: 34934894 PMCID: PMC8652129 DOI: 10.1002/rth2.12630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Vaccination is the leading approach in combatting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. ChAdOx1 nCoV-19 vaccination (ChAdOx1) has been linked to a higher frequency of rare thrombosis and thromboembolism. This study aimed to explore markers related to the blood coagulation system activation and inflammation, before and after ChAdOx1 vaccination. PATIENTS AND METHODS An observational cohort study including 40 health care workers. Whole blood samples were collected before, and either 1 or 2 days after vaccination. Activated coagulation factors in complex with their natural inhibitors were determined by custom ELISAs, including thrombin:antithrombin (T:AT), kallikrein:C1-esterase-inhibitor (PKa:C1Inh), factor(F)IXa:AT, FXa:AT, FXIaAT, FXIa:alpha-1-antitrypsin (α1AT), FXIa:C1inh, and FVIIa:AT. Plasma concentrations of interleukin (IL)-6 and IL-18 were quantified via ELISA. Analyses were performed using Wilcoxon signed-rank test. RESULTS Levels of FVIIa:AT decreased with a median (IQR) of 707 (549-1028) pg/ml versus 598 (471-996) pg/ml, p = 0.01; and levels of IL-6 increased, 4.0 (1.9-6.8) pg/ml versus 6.9 (3.6-12.2) pg/ml, p = 0.02, after vaccination. No changes were observed in T:AT, PKa:C1Inh, FIXa:AT, FXa:AT, FXIaAT, FXIa:α1AT, FXIa:C1inh, and IL-18. CONCLUSION ChAdOx1 leads to an inflammatory response with increased levels of IL-6. We did not observe activation of the blood coagulation system 1-2 days following vaccination.
Collapse
Affiliation(s)
- Loes H. Willems
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Magdolna Nagy
- Departments of Internal Medicine and BiochemistryMUMC and CARIM School for Cardiovascular DiseasesMaastrichtThe Netherlands
| | - Hugo Ten Cate
- Departments of Internal Medicine and BiochemistryMUMC and CARIM School for Cardiovascular DiseasesMaastrichtThe Netherlands
- Center for Thrombosis and HaemostasisGutenberg University Medical CenterMainzGermany
| | - Henri M. H. Spronk
- Departments of Internal Medicine and BiochemistryMUMC and CARIM School for Cardiovascular DiseasesMaastrichtThe Netherlands
| | - Lotte M. C. Jacobs
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Josephine Kranendonk
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Maaike van Leeuwen
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Danielle Meijer
- Department of Laboratory MedicineLaboratory of HematologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Saskia Middeldorp
- Department of Internal MedicineRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Laszlo A. Groh
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Michiel C. Warlé
- Department of SurgeryRadboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| |
Collapse
|
5
|
Mars M, Kranendonk J, van de Wiel A, Feskens E, Geelen A. Fast eaters have higher BMI, waist circumference and body fat: validation and results of questioning eating rate in an observational study. Appetite 2014. [DOI: 10.1016/j.appet.2014.06.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|