[Personalized medicine and healthcare: where are we now, where should we go?]

The authors of this manuscript are representatives of different subdisciplines of medicine, all of them are experienced researchers. As of their origin, they are practicing doctors from the primary care and from the clinical/hospital setting, diagnostics experts, researchers from healthcare management, health economics, representatives of patients' rights and patient organizations. They are all devoted to the implementation of personalized medicine and personalized healthcare in Hungary. The current manuscript - also meant to be a keynote message provoking further discussion in the medical community - is devoted to correcting for two false ideas. One is that personalized medicine is not yet ready for practical applications, it is merely a research area of futurologists. The other false idea is that only (or mainly) the lack of financial resources hinders the introduction of personalized healthcare in Hungary. Orv Hetil. 2023; 164(6): 202-209.

Intraarticular Injection of a Cross-Linked Sodium Hyaluronate Combined with Triamcinolone Hexacetonide (Cingal) to Provide Symptomatic Relief of Osteoarthritis of the Knee: A Randomized, Double-Blind, Placebo-Controlled Multicenter Clinical Trial

OBJECTIVE

To evaluate the efficacy and safety of an intraarticular injection of Cingal (Anika Therapeutics, Inc., Bedford, MA) compared with Monovisc (Anika Therapeutics, Inc., Bedford, MA) or saline for the treatment of knee osteoarthritis.

DESIGN

This multicenter, double-blind, saline-controlled clinical trial randomized subjects with knee osteoarthritis (Kellgren-Lawrence grades I-III) to a single injection of Cingal (4 mL, 88 mg hyaluronic acid [HA] plus 18 mg triamcinolone hexacetonide [TH]), Monovisc (4 mL, 88 mg HA), or saline (4 mL, 0.9%). The primary efficacy outcome was change in WOMAC (Western Ontario and McMaster Universities Arthritis Index) Pain Score through 12 weeks with Cingal versus saline. Secondary outcomes included Patient and Evaluator Global Assessments, OMERACT-OARSI Responder index, and WOMAC Total, Stiffness, and Physical Function scores through 26 weeks.

RESULTS

A total of 368 patients were treated (Cingal, n = 149; Monovisc, n = 150; saline, n = 69). Cingal improvement from baseline was significantly greater than saline through 12 weeks ( P = 0.0099) and 26 weeks ( P = 0.0072). WOMAC Pain was reduced by 70% at 12 weeks and by 72% at 26 weeks with Cingal. Significant improvements were found in most secondary endpoints for pain and function at most time points through 26 weeks. At 1 and 3 weeks, Cingal was significantly better than Monovisc for most endpoints; Cingal and Monovisc were similar from 6 weeks through 26 weeks. A low incidence of related adverse events was reported.

CONCLUSIONS

Cingal provides immediate and long-term relief of osteoarthritis-related pain, stiffness, and function, significant through 26 weeks compared to saline. Cingal had similar immediate advantages compared with HA alone, while showing benefit comparable to HA at 6 weeks and beyond.

Balneotherapy in elderly patients: effect on pain from degenerative knee and spine conditions and on quality of life

BACKGROUND

Balneotherapy is an established treatment modality for musculoskeletal disease, but few studies have examined the efficacy of spa therapy in elderly patients with degenerative spine and joint diseases.

OBJECTIVES

To assess the effects of balneotherapy on chronic musculoskeletal pain, functional capacity, and quality of life in elderly patients with osteoarthritis of the knee or with chronic low back pain.

METHODS

The 81 patients in the study group underwent a 1 day course of 30 minute daily baths in mineral water. Changes were evaluated in the following parameters: pain intensity, functional capacity, quality of life, use of non-steroidal anti-inflammatory or analgesic drugs, subjective disease severity perceived by the patients, investigator-rated disease severity, and severity of pain perceived by the patients. We analyzed the results of 76 subjects as 5 did not complete the study.

RESULTS

Compared to baseline, all monitored parameters were significantly improved by balneotherapy in both investigated groups. Moreover, the favorable effect was prolonged for 3 months after treatment.

CONCLUSIONS

This study showed that balneotherapy is an effective treatment modality in elderly patients with osteoarthritis of the knee or with chronic low back pain, and its benefits last for at least 3 months after treatment.

[Assessment of cerebrovascular reactivity using the breath-holding test in hypertensive and normotensive adolescents--preliminary results]

AIM

Authors report on preliminary results of cerebral vasoreactivity-tests performed in frame of the Debrecen Hypertension Study among hypertensive and healthy adolescents.

METHODS

Investigators measured blood flow velocities before and after 30 seconds of breath holding using transcranial Doppler sonography.

RESULTS

Blood flow velocities at rest were significantly higher in the hypertensive that in the healthy adolescent group. Breath holding induced less intensive cerebral vasoreactivity response in the hypertensive than in the normotensive group.

CONCLUSION

It is concluded that altered arteriolar function of the cerebral arterioles can be detected already in this early stage of hypertension.

Comparison of different methods evaluating the functional and structural abnormalities in hypertension

Functional and morphological abnormalities due to hypertension could be detected in neurologically symptom-free patients by CT, MRI, transcranial Doppler ultrasound, PET and SPECT. Neuropsychological tests also provide useful information. Single or combined application of these techniques reveals different aspects of parenchymal or vascular impairment in hypertension. The advantages and disadvantages of the different imaging techniques are reviewed and compared. The relatively simple, non-invasive transcranial Doppler (alone or combined with neuropsychological observations) could be recommended for screening and follow-up of hypertensive patients and seems to be a promising ancillary tool for evaluation of efficacy of antihypertensive therapy, but cannot replace the prospective controlled trials with hard endpoints.

Quantitative assessment of blood flow reserve using 99mTc-HMPAO in carotid stenosis

Dynamic imaging of the inflow of technetium-99m hexamethylpropylene amine oxime (HMPAO) to the brain has been proved to allow estimation of the hemispherical cerebral blood flow (CBF) using the Patlak plot. In this study, we compared the hemispherical CBF (in ml/min/100 g) of different patient groups. A total of 25 patients (comprising 13 with migraine and 12 scheduled for endarterectomy owing to angiographically confirmed severe stenosis of the internal carotid artery on at least one side) underwent baseline and acetazolamide 99mTc-HMPAO brain perfusion studies. In addition, acetazolamide 99mTc-HMPAO studies were performed in 12 healthy subjects (no baseline study was performed for ethical reasons.) Dynamic studies were acquired by means of a dual-detector gamma camera with a large field of view (HELIX, Elscint). Special difference images were created to make definition of the aortic arch and hemispherical brain regions easier and more reproducible. A semi-automatic method was developed to determine the transit time from the aorta to the brain, making the generation of the Patlak plot even more robust. The baseline CBF values did not significantly depend on the disease (P>0.1), whereas the CBF values obtained after acetazolamide provocation did do so (ANOVA, P<0.001). Patients suffering from migraine showed a significant increase in global CBF values after acetazolamide provocation (paired t test, P<0.05), but we could not find any effect of the provocation in patients awaiting carotid endarterectomy, indicating a lack of cerebrovascular reserve capacity. Comparison of the results of the acetazolamide study in patients and the control group revealed the CBF values to be significantly lower in patients with carotid stenosis (two-sample t-test, P<0.001), but not in those with migraine (P>0.1). In summary, using quantitative analysis of 99mTc-HMPAO brain studies we could objectively compare the CBF of patients suffering from different diseases. Especially the CBF values obtained after acetazolamide provocation permitted effective differentiation of disease states. The quantitative results may be of assistance in therapy planning, e.g. in selection of the correct operative technique.

[Treatment of migraine in patients with hypertension and ischemic heart disease]

Migraine is a common disorder with a prevalence of 9-10% in Hungary. Migraine can be accompanied by hypertension and/or ischemic heart disease sometimes in younger patients, but more frequently in the elderly, which is important for therapeutical considerations. The article reviews the literature with special focus on hypertension and coronary heart disease. In the second part, the authors summarize their experiences on headache patients.

Transcranial Doppler monitoring in hypertensive patients during physical exercise

PURPOSE

To evaluate the diagnostic value of a combined method, i.e. ergometer cycling with continuous bilateral transcranial Doppler monitoring (TCD) to detect cerebral hemodynamic abnormalities in recently diagnosed hypertensive patients.

METHODS

30 neurologically symptom-free, nontreated patients with essential hypertension and 30 age- and sex-matched controls were studied. Carotid ultrasound, resting ECG and blood parameters were investigated. Cycling ergometry was performed according to the WHO protocol. Blood pressure, heart rate, end-tidal CO2 (etCO2) and bilateral middle cerebral artery (MCA) blood flow velocity (MV) were monitored.

RESULTS

At rest, MV in the MCA did not differ significantly between controls and hypertensive subjects. MV continuously increased in controls until the end of loading whereas a plateau was reached at 4 min in hypertensive subjects. During 6 min of cycling, the time course of absolute values of MV in the MCA and that of the changes in the ratio of mean velocity/end-tidal CO2 (DeltaMV/DeltaetCO2) differed significantly between hypertensive subjects and controls (p = 0.03 and p = 0.02, respectively).

CONCLUSION

Ergometer cycling combined with TCD revealed altered vasoreactivity, therefore this may be a sensitive method for the detection of early hemodynamic impairment in nontreated hypertensive subjects.

[Review of the various methods investigating the CNS-complications of hypertension]

To summarise the structural and functional changes of the brain, caused by chronic hypertension and overview the studies performed on hypertensive patients by computer tomography, magnetic resonance imaging, transcranial Doppler ultrasound, positron emission tomography and single photon emission tomography. The definitive lesions--global or local atrophy, lacunar infarcts--can be sensitively detected by different morphological methods, whereas the hemodynamical alterations can be observed by the functional techniques. Mild cognitive deficits could be diagnosed in the early stage of the disease with different neuropsychological testing. Positron emission tomographic and single photon emission tomographic investigations could not be used routinously on hypertensive patients. The authors--based on own experiences--suggest the combined use of transcranial Doppler and neuropsychological testing, because these techniques are sensitive enough to detect early, subclinical abnormalities.

Cerebrovascular reserve capacity in patients with hyperlipidemia

PURPOSE

Because recent data are conflicting, it is not certain whether hyperlipidemia is an independent risk factor for cerebrovascular diseases. Decreased cerebrovascular reserve capacity refers to the decreased ability of the cerebral arterioles to adapt in critical conditions and probably predicts a higher risk of stroke. The aim of this study was to compare cerebrovascular reserve capacity in hyperlipidemic patients and healthy controls using transcranial Doppler sonography.

METHODS

Thirty-four hyperlipidemic patients and 21 healthy controls were examined. With transcranial Doppler sonography, the mean blood flow velocity in the middle cerebral artery was registered at rest and at 5, 10, 15, and 20 minutes after intravenous administration of 1,000 mg acetazolamide. Cerebrovascular reactivity and reserve capacity were calculated from mean blood flow velocities. Various laboratory measurements were also made and assessed for correlation with resting cerebral blood flow velocity and cerebrovascular reserve capacity.

RESULTS

No significant differences could be observed between controls and hyperlipidemic patients in cerebrovascular reactivity or cerebrovascular reserve capacity. No correlation was found between various laboratory measurements and resting cerebral blood flow velocity or cerebrovascular reserve capacity.

CONCLUSIONS

We could not demonstrate any differences in cerebrovascular reserve capacity between hyperlipidemic patients and healthy controls. Thus, the vasodilatory ability of the cerebral arterioles seems to remain unchanged in this patient group and is not correlated with the severity of hyperlipidemia.

Cerebrovascular reserve capacity many years after vasospasm due to aneurysmal subarachnoid hemorrhage. A transcranial Doppler study with acetazolamide test

BACKGROUND AND PURPOSE

Vasospasm in aneurysmal subarachnoid hemorrhage results in proliferative vasculopathy. Systemic hypertension also causes vascular hypertrophy. Both of these histological changes can lead to rigidity of the cerebrovascular system, reducing its autoregulatory capacity.

METHODS

Blood flow velocity (BFV) in the middle cerebral artery at rest and cerebrovascular reserve capacity (CVRC) (percent rise in BFV after acetazolamide stimulation) measured by means of transcranial Doppler sonography were studied many years after aneurysmal subarachnoid hemorrhage in patients with proven cerebral vasospasm (mean BFV > 160 cm/s). The BFV under resting conditions and the CVRC values of the ipsilateral and the contralateral hemispheres were measured in 29 patients (mean age, 43 years; mean follow-up, 4.6 years) and compared with those of control subjects.

RESULTS

Persistent high BFV (> 120 cm/s) was found in three patients in the peripheral branch of the ipsilateral middle cerebral artery. In the main trunks of the arteries of the anterior circle of Willis, BFV was normal in all cases. CVRC was normal in all patients (ipsilateral, 52 +/- 21%; contralateral, 56 +/- 17%); values did not differ significantly from each other or from the control value (45 +/- 18%). The higher value of CVRC on the contralateral side was found to be statistically significant in selected groups (hypertensive patients and patients with residual infarct on late CT).

CONCLUSIONS

Proliferative vasculopathy developed at the time of vasospasm must have resolved and did not reduce late vasoreactivity. Comorbidity with hypertension also did not seem to influence the late vasoreactivity toward normalization.

Cerebrovascular reactivity in hypertensive patients: a transcranial Doppler study

PURPOSE

We studied the usefulness of transcranial Doppler sonography for assessing changes in vasoreactivity in patients with hypertension and the hemodynamic consequences of hypertension.

METHODS

The study group comprised 25 patients with chronic severe hypertension and 25 age- and sex-matched healthy subjects. Cerebrovascular reserve capacity was assessed by transcranial Doppler recording of the blood flow velocity in both middle cerebral arteries before and 5, 10, 15, and 20 minutes after intravenous injection of 1 g of acetazolamide (Diamox). Blood pressure, blood gases, and other blood parameters were also measured before and after acetazolamide injection. The sizes of the left atrium, left ventricle, and aortic root were measured by echocardiography and correlated with the vasoreactivity after acetazolamide injection.

RESULTS

After acetazolamide injection, no significant changes in blood pressure were observed in either group. The mean blood flow velocity in the middle cerebral arteries of hypertensive patients (60.8 +/- 2.6 cm/sec) was not significantly different from that of controls (58.8 +/- 1.9 cm/sec) before acetazolamide injection. Ten minutes after acetazolamide injection, the percentage change in blood flow velocity was significantly lower in the hypertensive group (36.2 +/- 4.5%) than in the controls (52.6 +/- 3.7%). A significant negative correlation (p < 0.05) between decreased vasoreactivity and increased size of the left atrium and aortic root was observed.

CONCLUSIONS

Vasoreactivity decreases in hypertensive patients without neurologic deficits or computed tomography abnormalities. Enlargement of the left atrium correlates well with the severity of the impairment in vasoreactivity. Transcranial Doppler sonography can be a sensitive tool in the investigation of vascular impairment caused by hypertension and in the follow-up of hypertensive patients.

Cerebrovascular reactivity measured by transcranial Doppler in migraine

Changes in the diameter of intracranial arteries might have a major role in the pathophysiology of migraine. Though several studies have found alterations in velocity of blood flow and in cerebral vasomotor reactivity of intracranial arteries in migraineurs in headache-free periods, as well as during migraine attacks, the results are inconclusive. To determine if intracranial hemodynamic characteristics of patients with migraine differ from those of controls, we measured baseline velocity of blood flow by transcranial Doppler in the middle cerebral arteries in headache-free periods in 51 migraine patients and in 101 age-matched controls. Cerebrovascular reactivity was measured after intravenous administration of acetazolamide in 12 migrainous patients and in 19 controls. Baseline mean velocity was significantly higher in the migraine group (70 versus 65 and 72 versus 65 cm/s with P = 0.02 and P = 0.0007 on the left and right sides, respectively). The difference stayed significant during acetazolamide stimulation, but the course of response did not differ between controls and migraineurs. Despite statistical significance, absolute differences were small. Therefore, middle cerebral artery velocity measurements and the acetazolamide test are not useful for the diagnosis of migraine in the interictal period.