IN 2019, ST. CATHERINE HOSPITAL PLAYED A CRUCIAL ROLE IN THE IMPLEMENTATION OF PERSONALIZED MEDICINE IN CLINICAL PRACTICE
During 2019, physicians from St. Catherine Hospital published ten scientific articles in journals indexed in Science Citation Index and Current Contents, two scientific articles published in journals indexed in other indexing services, a book chapter published by Springer, and 11 scientific abstracts, all from the field of personalized medicine. At the same time, in 2019, physicians from St. Catherine hospital gave 40 invited lectures in different areas of personalized medicine.
Selected publications in 2019:
Borić I, Hudetz D, Rod E, Jeleč Ž, Vrdoljak T, Skelin A, Polašek O, Plečko M, Trbojević-Akmačić, Lauc G, Primorac D. “A 24-Month Follow-Up Study of the Effect of Intra-Articular Injection of Autologous Microfragmented Fat Tissue on Proteoglycan Synthesis in Patients with Knee Osteoarthritis”. Genes (Basel). 2019;10(12):1051-60.; https://doi.org/10.3390/genes10121051
The purpose of this study was to evaluate the effect of micro-fragmented fat tissue intra-articular injection 24 months after application in two ways: Indirectly using functional magnetic resonance imaging (MRI) assessment analyzing the glycosaminoglycans (GAG) content in cartilage by means of delayed gadolinium (Gd)-enhanced magnetic resonance imaging of cartilage (dGEMRIC), as well as clinical outcome on observed level of GAG using standard orthopedic physical examination including VAS assessment. 10 patients (18 knees) were included in a 24-month follow-up. Surgical intervention (lipoaspiration), followed by tissue processing and intra-articular injection of the final microfragmented adipose tissue product into the affected knee(s), was performed in all patients. Patients were assessed for a visual analog scale (VAS), dGEMRIC at the baseline, three, six, 12 and 24 months after the treatment. A magnetic resonance sequence in dGEMRIC due to infiltration of the anionic, negatively-charged contrast gadopentetate dimeglumine (Gd-DTPA2) into the cartilage indicated that the contents of cartilage glycosaminoglycans significantly increased in specific areas of the treated knee joint. Our results suggest that this method of single intra-articular injection of autologous microfragmented adipose tissue improves GAG content on a significant scale, with over half of the measurements suggesting relevant improvement 24 months after intra-articular injection opposed to the expected GAG decrease over the natural course of the disease
Polančec D, Zenić L, Hudetz D, Borić I, Jeleč Z, Rod E, Vrdoljak T, Skelin A, Plečko M, Turkalj M, Nogalo B, Primorac D. Immunophenotyping of a Stromal Vascular Fraction from Microfragmented Lipoaspirate Used in Osteoarthritis Cartilage Treatment and Its Lipoaspirate Counterpart. Genes (Basel). 2019;10(6):474-85. doi: 10.3390/genes10060474.
The aim of the study was to characterize a stromal vascular fraction from microfragmented lipoaspirate (SVF-MLA) applied for cartilage treatment in OA and compare it to that of autologous lipoaspirate (SVF-LA). In SVF-LA and SVF-MLA samples, the following population phenotypes were identified within the CD45− fraction: endothelial progenitors (EP), mature endothelial cells, pericytes, transitional pericytes, and supra-adventitial-adipose stromal cells (SA-ASC). The immunophenotyping profile of SVF-MLA was dominated by a reduction of leukocytes and SA-ASC, and an increase in EP, evidencing a marked enrichment of this cell population in the course of adipose tissue microfragmentation. The role of EP in pericyte-primed MSC-mediated tissue healing, as well as the observed hormonal implication, is yet to be investigated
Hudetz D, Borić I, Rod E, Jeleč E, Kunovac B, Polašek O, Vrdoljak T, Plečko M, Skelin A, Polančec D, Zenić L, Primorac D. Early results of intra-articular micro-fragmented lipoaspirate treatment in patients with late stages knee osteoarthritis: a prospective study. CMJ. 2019;60(3):227-36.
The aim of this study was to analyze clinical and functional effects of intra-articular injection of autologous micro-fragmented lipoaspirate (MLA) in patients with late stage knee osteoarthritis (KOA). Secondary aims included classifying cell types con- tributing to the treatment effect, performing detailed MRI- based classification of KOA, and elucidating the predictors for functional outcomes. Seventeen patients (85%) showed a substantial pattern of KOOS and WOMAC improvement, significant in all accounts. KOOS score improved from 46 to 176% when compared with baseline, WOMAC decreased from 40 to 45%, while VAS rating decreased from 54% to 82% (all P values were <0.001). Three patients (15%) received a total knee replace- ment and were not followed up completely.
Hudetz D, Jeleč Ž, Rod E, Borić I, Plečko M, Primorac D. The Future of Cartilage Repair. In: Personalized Medicine in Healthcare Systems: legal, Medical and Economic Implications. (Editors: Nada Bodiroga-Vukobrat, Daniel Rukavina, Krešimir Pavelić, Gerald G. Sander). Cham: Springer Nature Switzerland, Switzerland; 2019. p.375-411.
Articular cartilage is a hyaline cartilage 2-4 mm thick. It is composed of a 95% of dense extracellular matrix (ECM) and 5% of highly specialized cells called chondrocytes. Due to its avascular, aneural and alymphatic state, it has a limited repair potential. Articular cartilages’ main function is to provide smooth, lubricated surface for low friction articulation and at the same time articular cartilage minimizes the stress and strains on the matrix. Articular cartilage could be damaged by normal wear and tear or injury and it can cause severe pain, inflammation and some degree of disability. Its management consist of pharmacological (acetaminophen, NSAID, salicylate, selective COX-2 inhibitors or opioids) and non-pharmacological therapies. Non-pharmacological treatment includes physical therapy and decreasing the load in the joint by modifying patient’s habits. A new class of agents (symptomatic or disease modifying osteoarthritic drugs (S/DMOADs) including glucosamine and chondroitin sulfate is receiving wide publicity. At the same time, numerous published reports advising the use of hyaluronic acid injections: viscosupplementation in patients with symptomatic osteoarthritis. Operative treatment includes different surgical debridement and microfracture techniques, osteochondral autograft transfers, osteochondral allograft transplantation, etc. New techniques and concepts are being developed not only to treat damaged or diseased joint cartilage but also to find ways of achieving regeneration to normal cartilage that will give long-lasting improvements and allow patients to return to a fully active lifestyle. Nevertheless, as two stage procedures involving cell culture are expensive and cumbersome, there is an increasing push towards a single stage stem cell treatment. Currently, there are a number of new methods with cartilage repair aim, including autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), intra-articular administration of autologous microfragmented fat tissue with Ad-MSCs, etc. In this chapter, we will discuss some current treatments and the emerging strategies/techniques employed by researchers and physicians thriving to repair articular cartilage through biological means.
Mandac Rogulj I, Matišić V, Arsov B, Boban L, Juginović A, Molnar V, Primorac D. Dasatinib-induced nephrotic syndrome: a case of phenoconversion. CMJ. 2019;60(3):250-54.
We present the case of a 33-year-old chronic myeloid leu-kemia (CML) female patient, in whom the occurrence of nephrotic syndrome, during the treatment with tyrosine kinase activity inhibitors (TKIs), was potentially influenced by transient phenoconversion. Seven years after the CML diagnosis in 2004 and complete response, the patient experienced pain in the mandible and extremities. After this, imatinib was replaced by nilotinib, but generalized maculopapular rash was presented and successfully treated with antihistamines. The therapy was then discontinued due to planned pregnancy, and the patient experienced a relapse of CML with BCR-ABL/ABL1 transcripts of 18.9%. Dasatinib was introduced, and CML was in remission. Two years later, urine protein levels (6.19 g/L) and erythrocyte sedimentation rate were elevated (ESR = 90 mm/3.6 ks). The patient was diagnosed with nephrotic syndrome. With dasatinib dose reduction, urine protein level returned to the reference range. In order to determine the best genotype-guided therapy, the patient underwent pharmacogenomic testing, showing a homozygous CYP3A4 genotype *1/*1, associated with extensive metabolizer (EM) enzyme phe- notype, typical for normal rates of drug metabolism for TKIs. However, this was inconsistent with nephrotic syndrome occurrence. A possible explanation would be CYP3A4 EM genotype coding a poor metabolizer enzyme phenotype, leading to the drug accumulation in the patient’s blood. This transient phenoconversion can be explained by inflammation with elevated ESR during nephrotic syndrome. This case shows that a broader approach that recognizes genetic, clinical, and epigenomic factors is required for a quality decision on the personalized therapy regimen.
Turkalj M, Matišić V, Šimić A, Juginović A, Erceg D, Tješić Drinković D, Höppner W, Primorac D. Cystic fibrosis presentation in del. F508 and p. Tyr109Glyfs compound heterozygote CFTR state: a case report. CMJ. 2019;60(3):246-9.
We report a case of cystic fibrosis (CF) in a 15-year-old female patient who is a compound heterozygote for CFTR gene, with delta F508 and Tyr109Glyfs mutations detected. This is the first detailed description of such a case in the medical literature. The primary CF presentation occurred at the age of 9 in the form of gastrointestinal symptoms including greasy, bulky, and foul-smelling stool. The patient exhibited delayed growth, with her height and weight being below the 5th centile for age according to the World Health Organization growth curves. Pancreatic enzyme supplement treatment was started immediately, alongside high-fat and high-calorie diet, resulting in patient’s recovery and development. DNA analysis of CFTR gene demonstrated the presence of del. F508 mutation and a rare combining deletion and insertion mutation p. Tyr109Glyfs. The combination of the two mutations is very rare in CF patients and is therefore valuable to document this case in order to provide information on disease progression, therapy options, and outcomes. With standard treatment and early diagnosis, the patient is currently doing well and is not restricted by the disease in her daily and sports activities.
Jeleč Ž, Primorac D, Antičević D. Personalized surgery approach in severe form of osteogenesis imperfecta type III: point of view. J Pediatr Orthop B. 2019;28(5):505-8.
Osteogenesis imperfecta (OI) is a genetic disorder characterized by fragile bones. It is our aim to illustrate variability in clinical presentation of severe form of OI. As an example of personalized surgery approach we present an 11-year-old girl with OI type III. Prior to referral to our hospital, she was treated with 18 cycles of bisphosphonates as well as with several different surgical procedures. Due to no improvement in her mobility status she underwent two additional surgeries at our hospital with a 5-month interval between them. Prior to the surgery, molecular genetic analysis was performed and the clinical diagnosis of OI was confirmed. Using the Fassier-Duval intramedullary telescoping nail, we performed correction osteotomies of both femurs and lower legs in two separate settings, with a very good final result. According to our experience, the Fassier-Duval nailing system is good option, but one should pay attention to many details while performing surgery. Thus, making treatment of OI patients very personalized. In this paper we present a unique personalized approach in OI: firstly, diagnosing COL1A1 gene mutations and secondly, performing a complex two-part surgery.
Pavlović T, Štefančić K, Rožanković M, Boban L, Borić I, Molnar V, Zekan P, Primorac D. Radiol Case Rep. 2019;15(2):136-40. doi: 10.1016/j.radcr.2019.10.031.
We report a case of a 39-year old male patient who presented to us with several months of lower back pain. Following clinical assessment, the patient underwent a magnetic resonance imaging exam, which after using advanced imaging protocols showed a ventrolateral disc hernation toward the psoas muscle. Based upon the findings in the magnetic resonance and the electromyoneurographic examination, the decision was made to treat the patient conservatively. Coronal planes are useful for discerning changes of various origins not usually seen on the sagital and axial planes. If needed, additional advanced protocol is available for increased specificity and diagnostic accuracy.
Bach-Rojecky L, Vađunec D, Lozić M, Žunić K, Špoljar GG, Čutura T, Erceg D, Primorac D. Challenges in anesthesia personalization: resolving the pharmacogenomic puzzle. Per Med. 2019;16(6):511-25. doi: 10.2217/pme-2019-0056.
Clinicians are witnessing differences in the doses required for induction and maintenance of anesthesia, as well as prolonged recovery in some patients. Predictable factors like patient characteristics, factors related to the procedure, pharmacological characteristics of anesthetics and adjunctive drugs, might explain some of the observed differences. However, the role of various polymorphisms of genes encoding for drugs' molecular targets, transporters and metabolic enzymes can have a significant impact on anesthesia outcome, too. In the present paper, we critically discuss pharmacological characteristics of the most common drugs used in anesthesia, with a focus on the possible genetic background of unpredictable diversities in anesthesia outcomes.
Rod E, Matić I, Antunović M, Vetma V, Pavičić I, Hudetz D, Marijanović I, Primorac D, Ivković A. Optimization of an ex vivo gene transfer to the hamstrings tendons muscle remnants: potential for genetic enhancement of bone healing. Croat Med J. 2019;60(3):201-11.
Aim of this study was to assess whether an adenoviral vector carrying the bone morphogenetic protein genes (Ad.BMP-2) can transduce human muscle tissue and direct it toward osteogenic differentiation within one hour. This in vitro study, performed at the Department of Molecular Biology, Faculty of Science, Zagreb from 2012 to 2017, used human muscle tissue samples collected during anterior cruciate ligament reconstructions performed in St Catherine Hospital, Zabok. Samples from 28 patients were transduced with adenoviral vector carrying firefly luciferase cDNA (Ad.luc) by using different doses and times of transduction, and with addition of positive ions for transduction enhancement. The optimized protocol was further tested on muscle samples from three new patients, which were transduced with Ad.BMP-2. Released bone morphogenetic protein 2 (BMP-2) levels in osteogenic medium were measured every three days during a period of 21 days. Expression of osteogenic markers was measured at day 14 and 21. After 21 days of cultivation, muscle tissue was immunohistochemically stained for collagen type I detection (COL-I). The new transduction protocol was established using 108 plaque-forming units (P<0.001) as an optimal dose of adenoviral vector and 30 minutes (P<0.001) as an optimal contact time. Positive ions did not enhance transduction. Samples transduced with Ad.BMP-2 according to the optimized protocol showed enhanced expression of osteogenic markers (P<0.050), BMP-2 (P<0.001), and COL I. This study confirms that Ad.BMP-2 can transduce human muscle tissue and direct it toward osteogenic differentiation within 30 minutes.
Bach-Rojecky L, Vađunec D, Žunić K, Kurija J, Šipicki S, Gregg R, Mikula I, Primorac D. Continuing war on pain: a personalized approach to the therapy with nonsteroidal anti-inflammatory drugs and opioids. Per Med. 2019;16(2):171-84.
Successful pain management requires the delivery of analgesia with minimal risk of adverse drug reactions. Nonsteroidal anti-inflammatory drugs and opioids remain the mainstay of treatment for the majority of patients. Unfortunately, almost 50% of all patients experience inadequate pain relief and serious side effects. Allelic variants in genes coding for target proteins, transporters and enzymes, which govern analgesic drugs action and their fate in the organism, might explain inter-individual variability in pain severity and in drug-induced pain relief and toxicities. Additionally, it seems that epigenetic changes contribute to the highly variable response to pain treatment. Therefore, pharmacogenomic testing might be a valuable tool for personalization of pain treatment, with a multidisciplinary team approach involved.
Primorac D and Bach-Rojecky L. Could a Personalized Approach to Therapy End the war on Pain?
Practical Pain Management. 2019;19(3):50-3.
Chronic pain affects around 20% of the adult population worldwide and represents a huge burden for the affected individuals, with a significant negative impact on their quality of life, daily functioning, and work productivity. Consequently, the financial direct and indirect cost of chronic pain on an annual basis is enormous, ranging from $560 to 635 billion. Chronic pain denotes one of the greatest challenges in contemporary medicine, both from the aspect of basic researchers seeking an explanation of complex pain mechanisms, to clinicians trying to find an optimal therapeutic strategy for their patients. Although findings from laboratories often contribute to the clarification of complex pain pathophysiology and suggest novel molecular targets, pain treatment is still grounded on two classes of analgesic drugs: NSAIDs and opioids. Responses to these “pain killers” vary to a great degree (~40-fold), with nearly 50% of all patients experiencing inadequate pain relief as well as various disturbing or even unbearable side effects. Considering challenges in individual pain treatment, pharmacogenomic studies may clarify inter-individual differences in analgesic efficacy and tolerability. At St. Catherine’s Hospital, in Croatia, in collaboration with OneOme, co-founded by the Mayo Clinic, clinicians are routinely using PGx tests (Right-Med) “covering” CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, OPRM1, and COMT genes in order to design a successful pain management protocol. The risk of adverse drug reactions are minimized while patient outcomes are optimized. Due to multiple factors involved in this type of decision-making, which integrates not only knowledge of pharmacogenetics and epigenetics, but also of individual medication’s pharmacological characteristics and their interactions with other drugs and xenobiotics, a multidisciplinary team approach is necessary. This practice works to enable optimal, timely, evidence-based, and cost-effective pain management. Going forward, the authors strongly believe that to meet current challenges in individual pain treatment, clinicians should place crucial importance on additional pharmacogenomics to help clarify inter-individual differences in analgesic effect and tolerability of the drugs before engaging in a full treatment plan.
Ašić A, Salazar R, Storm N, Doğan S, Höppner W, Marjanović D, Primorac D. Population study of thrombophilic markers and pharmacogenetic markers of warfarin prevalence in Bosnia and Herzegovina. Croat Med J. 2019;60(3):212-20.
The aim of this study was to investigate the prevalence of common genetic variants that can serve as markers of thrombophilia and warfarin pharmacogenetics in Bosnia and Herzegovina. The study was performed between August and October 2017, on 130 healthy unrelated adult volunteers from Bosnian-Herzegovinian population sample. The prevalence of the following genetic variants was determined: F5 c.1601G>A (factor V Leiden), F2 c.*97G>A (factor II or prothrombin mutation), F13A1 (factor XIII) c.103G>T, MTHFR (methylenetetrahydrofolate reductase) c.665C>T and c.1286A>C, as well as PAI-1 (plasminogen activator inhibitor 1) c.-816A>G and c.-844G>A as markers of thrombophilia risk, and *2 and *3 alleles of CYP2C9 (cytochrome P450 2C9) and five variants of VKORC1 (vitamin K epoxide reductase complex subunit 1) as markers of warfarin pharmacogenetics. DNA was isolated from buccal swabs using salting out method, while genotyping was performed using matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry. Minor allele frequencies for two main thrombophilia risk factors, F5 c.1601G>A and F2 c.*97G>A were 0.023 and 0.008, respectively. Combined data for the markers of warfarin pharmacogenetics imply that 57.4% study participants can be expected to metabolize warfarin at an extensive, 40.3% at intermediate, and 2.3% at a poor rate. This study reports the first extensive population genetic data for thrombophilia and warfarin pharmacogenetic markers in Bosnia and Herzegovina. Allele frequencies of genetic variants are within the general average for European populations, and their presence implies the necessity of introduction of personalized medicine in warfarin-mediated antithrombotic therapy.
Articles published in journals listed in Science Citation Index and Current Contents.
Articles published in journals listed in other scientific indexes:
Books and Contributions to Books: