Clinical Neuroscience

[Initial clinical experience with radio-frequency assisted percutaneous vertebral augmentation in the treatment of vertebral compression fractures]

MAROSFŐI Miklós, KULCSÁR Zsolt, BERENTEI Zsolt, GUBUCZ István, SZIKORA István

JULY 20, 2011

Clinical Neuroscience - 2011;64(07-08)

[Purpose - Percutaenous Vertebroplasty (PVP) is effective in alleviating pain and facilitating early mobilization following vertebral compression fractures. The relatively high risk of extravertebral leakage due to uncontrolled delivery of low viscosity bone cement is an inherent limitation of the technique. The aim of this research is to investigate the ability of controlled cement delivery in decreasing the rate of such complications by applying radiofrequency heating to regulate cement viscosity. Method and material - Thirty two vetebrae were treated in 28 patients as part of an Ethics Committee approved multicenter clinical trial using RadioFreqency assisted Percutaenous Vertebral Augmentation (RF-PVA) technique. This technique is injecting low viscosity polymethylmethacrylate (PMMA) bone cement using a pressure controlled hydraulic pump and applying radiofrequency heating to increase cement viscosity prior to entering the vertebral body. All patients were screened for any cement leakage by X-ray and CT scan. The intensity of pain was recorded on a Visual Analog Scale (VAS) and the level of physical activiy on the Oswestry Disability Index (ODI) prior to, one day, one month and three months following procedure. Results - All procedures were technically successful. There were no clinical complication, intraspinal or intraforaminal cement leakage. In nine cases (29%) a small amount of PMMA entered the intervertebral space through the broken end plate. Intensity of pain by VAS was reduced from a mean of 7.0 to 2.5 and physical inactivity dropped on the ODI from 52% to 23% three months following treatment. Conclusion - In this small series controlled cement injection using RF-PVA was capable of preventing clinically hazardous extravertebral cement leakage while achieving outcomes similar to that of conventional vertebroplasty.]

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Clinical Neuroscience

[Recent changes in the paradigm of limbic encephalitis]

ILLÉS Zsolt

[In the recent years, novel antibodies associated with limbic encephalitis have been described, which target such extracellular receptors or proteins that have been already indicated in the pathogenesis of hereditary or degenerative diseases. In a number of cases, where pathogenic role of antibodies generated against the voltage-gated potassium channel (VGKC) had been presumed, antibodies against a trans-synaptic scaffolding protein, LGI1 were indicated. Antibody response against NMDA-receptors has been suggested as a major cause of limbic encephalitis especially in young females, resulting in a typical clinical syndrome sometimes triggered by an ovarian teratoma. Antibodies against other receptors essential in synaptic transmission and plasticity (AMPA and GABAB receptors) have been also indicated, partially elicited by paraneoplastic processes. Such antibodies against surface proteins result in severe but potentially treatable diseases due to reversible internalization of the antigens crosslinked by the bivalent antibodies. In contrast, the rare classical onconeural antibodies reacting with intracellular targets (anti-Hu, anti-Ta/Ma2, anti- CV2/CRMP5) may elicit additional symptoms beside limbic encephalitis and the prognosis of such syndromes is poor.]

Clinical Neuroscience

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RAJNA Péter, TAJTI János

Clinical Neuroscience

[Modeling of human movements, neuroprostheses]

LACZKÓ József

[Modeling of human movements became very important as modern methods in informatics and engeniering are available to discern human movement characteristics that were hidden before. The construction of models of neural control and mechanical execution of human movements helps the diagnosis of movement disorders and predicts the outcome of clinical intervention and medical rehabilitation. Here I present methods for recording kinematic and muscle activity patterns. Measurements can be compared with predicted movement patterns based on mathematical models. There are an infinity of different muscle activity patterns or joint rotation patterns to perform a given motor task. I present the main approaches that are used to find such solutions from the infinity of choices that might be employed by the central nervous system. I present a practical application of movement modeling: In rehabilitation of spinal cord injured patients we develop and apply artificially controlled neuroprostheses to generate active cycling lower limb movements in the patients of the National Institute for Medical Rehabilitation.]

Clinical Neuroscience

[Extension of polynomial analysis of interstitial I-125 brachytherapy for 48 months]

KOLUMBÁN Zsuzsa, MAJOR Tibor, JULOW Jenő

[Objective - Previously we described from 20 patients’ data with our new “polynomial prediction approach” the volumetrical changes following gliomas I-125 brachytherapy. The aim of this study is to extend the polynomials for 48 months, and to carry out multivarial analysis of several different aspects. Methods - 20 inoperable low-grade gliomas were followed for a 48-month period after I-125 interstitial irradiation. The delivered dose on the tumor surface was 50-60 Gy. Dose planning and image fusion were done with the BrainLab Target 1.19 software, mathematical and statistical computations were carried out with the Matlab numeric computation and visualization software. Volumes of tumor necrosis, reactive zone and edema referred to as “triple ring” were measured on image fused control MRI and planning CT images. The measured volumes were normalized with respect to the reference volumes. Mean values of volumes were determined, then polynomials were fitted to the mean using the polynomial curve fitting method. The accuracy of our results was verified by correlating the predicted data with the measured ones. Results - We have found that the edema reaches its maximum two times after irradiation during the 48 months follow up period. We have shown that small tumors react more rapidly and creating greater volumes of the “triple ring” than bigger ones. Conclusions - The polynomial prediction approach proposed here reveals the dynamics of triple ring for 48 months. The derived polynomials and the multivarial analysis carried out afterwords help to (i) design the best treatment, (ii) follow up the patient's condition and (iii) plan reirradiation if necessary.]

Clinical Neuroscience

[Phylo- and ontogenetic aspects of erect posture and walking in developmental neurology]

BERÉNYI Marianne, KATONA Ferenc, CARMEN Sanchez, MANDUJANO Mario

[The group or profile of elementary neuromotor patterns is different from the primitive reflex group which is now called the “primitive reflex profile.” All these elementary neuromotor patterns are characterized by a high degree of organization, persistence, and stereotypy. In many regards, these patterns are predecessors or precursors of from them the specific human motor patterns which appear spontaneously later as crawling, creeping, sitting, and walking with erect posture. On the basis of our experiences it can be stated that the elementary neuromotor patterns can be activated in all neonates and young infants as congenital motor functions. With regards to their main properties and functional forms, the normal patterns can be divided into two main groups: (1) One group is characterized by lifting of the head and complex chains of movements which are directed to the verticalization of the body; (2) The other group is characterized by complex movements directed to locomotion and change of body position. The neuromotor patterns can be activated by placing the human infant in specific body positions that trigger the vestibulospinal and the reticulospinal systems, the archicerebellum and the basal gangliae. Most of these systems display early myelinisation and are functioning very soon. Many of the elementary neuromotor patterns reflect the most important - spontaneously developing - forms of human movements such as sitting upright in space and head elevation crawling and walking. The majority of the human neuromotor patterns are human specific. When the infant is put in an activating position, crawling, sitting up, and walking begin and last as long as the activating position is maintained. Each elementary neuromotor pattern is a repeated, continuous train of complex movements in response to a special activating position. The brainstem is not sufficient to organize these complex movements, the integrity of the basal ganglia is also necessary. Elementary sensorimotor patterns during human ontogenesis reflect phylogenetic develpoment of species specific human functions. During ontogenesis spontaneous motor development gradually arises from these early specific sensorimotor predecessors.. The regular use of the elementary neuromotor patterns for diagnostic puposes has several distinct advantages. The neuromotor patterns have a natural stereotypy in normal infants and, therefore, deflections from this regular pattern may be detected easily, thus, the activation of the elementary neuromotor pattern is a more suitable method for identifying defects in the motor activity of the neonate or young infant than the assessment of the primitive reflexes. The “stiumulus positions,” which activate specific movements according to how the human neonate or young infant is positioned, do not activate such motor patterns in neonate or young primates including apes. The characteristic locomotor pattern in these adult primates, including the apes, is swinging and involves brachiation with an extreme prehensility. This species specific motor activity is reflected in the orangutan and gibbon neonates by an early extensive grasp. However, according to our investigations, no crawling, creeping, elementary walk, or sitting up can be activated in them. Neonates grasp the hair of the mother, a vital function for the survival of the young. In contemporary nonhuman primates including apes, the neonate brain is more mature. Thus, pronounced differences can be observed between early motor ontogenesis in the human and all other primates. The earliest human movements are complex performances rather than simple reflexes. The distinction between primitive reflexes and elementary neuromotor patterns is essential. Primitive reflexes are controlled by the brainstem. All can be activated in primates. These reflexes have short durations and contrary to elementary sensorimotor patterns occur only once in response to one stimulus, e.g., one head drop elicits one abduction-adduction of the upper extremities correlated to adduction and flexion of the lower extremities to a lesser degree with the Moro reflex. Elementary neuromotor patterns are much more complex and most of them including elementary walk may be elicited as early as the 19th-20th gestational week, though less perfectly than later.]

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BORS Katalin, KÓSA József, BORBÉLY Judit, TABÁK Ádám, HORVÁTH CSABA

[INTRODUCTION - MERLIN (Management of Osteoporosis in Elderly with Calcitonin) is an open-label, multicenter, prospective, follow-up study conducted in Hungary, part of which is to assess the impact of treatment with Miacalcic, - an intranasal salmon calcitonin, on the quality of life (QoL) among patients with osteoporosis. In this paper we report the preliminary results of the MERLIN study. PATIENTS - The study initially involved 1949 senior patients (aged >65 years) to whom calcitonin was prescribed for osteoporosis according to the application instructions. Patients presented at outpatient clinics and consisted of two groups; they were either newly diagnosed or they had been receiving a therapy for osteoporosis other than calcitonin. METHODS - This latter group discontinued their previous treatment and all patients received 200 IU intranasal salmon calcitonin (SCT) once daily for three months. Patient and physician questionnaires were used to collect information on the patients' QoL (EQ-5D VAS) and their general well-being at baseline and at follow-up visits at week 4 and week 12. RESULTS - Calcitonin use was associated with improvements in all EQ-5D domains and component scores as well as in VAS. Patients with previously known osteoporosis who, switched to calcitonin therapy achieved better results (0,046 QALY), than the newly diagnosed patients (0,0405 QALY). CONCLUSIONS - We conclude that intranasal SCT 200 IU daily is safe and effective in improving QoL of both, male and female patients with low bone mineral density.The conclusions that can be drawn from this study are limited due to the lack of a control group and to the unblinded design. Further placebo-controlled studies are needed to confirm these results. Nevertheless, our study was the first in Hungary to evaluate the quality of life impact of an osteoporosis treatment, and hopefully it will be followed by more such studies directed to other osteoporosis treatments.]

Ca&Bone

[Bone metabolism and body mass index in postmenopausal women]

TÁRCZY Csaba, TOLDY Erzsébet, SZERB János, VARGA László

[INTRODUCTION - In addition to several other causes constitutional factors play an important role in the development of osteoporosis.Various aspects of bone metabolism were examined to explain the differences in bone density between women with low and high body mass index (BMI). PATIENTS AND METHOD - One hundred and ninetytwo postmenopausal women were included in the study. Bone density was measured by forearm densitometry.To assess bone formation, serum osteocalcin levels were measured, while the rate of bone absorption was estimated from C-terminal telopeptide levels of collagen type I measured in urine and blood. RESULTS - The prevalence of osteoporosis was higher in women with low BMI than in those with normal or higher BMI. Bone metabolism - both formation and absorption - was increased in both groups, however, in women with low BMI this increase was more pronounced and bone metabolism tended to be shifted to absorption compared to patients with normal or higher BMI. CONCLUSION - Postmenopausal lean women have accelerated bone metabolism compared to obese women. This fact and the shift to absorption may be the main reasons for the higher frequency of osteoporosis found by densitometry in women with low BMI than in those with higher BMI.]

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[Bone mineral density and diabetes mellitus - First results]

TÕKE Judit, TAMÁS GYULA, STELLA Péter, NAGY Erzsébet, NÁDASDI Ágnes, VARGA Piroska, KERÉNYI ZSUZSA

[INTRODUCTION - Data on bone mineral density (BMD) in diabetes mellitus are contradictory in the literature. Early studies described a decreased bone mineral density in type 1 diabetes mellitus (T1DM), but recent studies report no osteopenia in T1DM.The BMD may depend on the quality of treatment for diabetes mellitus and on the presence of chronic complications. In type 2 diabetes mellitus (T2DM) the BMD is not decreased, occasionally it can even be increased. PATIENTS AND METHODS - Bone mineral density was measured in 122 regularly controlled diabetic patients (T1DM: n=73, mean age: 43.6±11.1 years,T2DM: n=49, mean age: 61.8±9.8 years) by dual energy X-ray absorptiometry at the lumbar spine and at the femur. Results were compared to those of 40 metabolically healthy control persons with a mean age of 47.5±11.9 years.The patients’ carbohydrate metabolism was assessed by the average HbA1c level of the last three years.These values were 7.9±1.4 % in T1DM, and 7.5±1.7 % in T2DM. BMDs were classified based on the T-score and Z-score using the WHO criteria. RESULTS - There was no significant difference in T1DM or in T2DM compared to the reference group in the prevalence of either osteoporosis or of osteoporosis and osteopenia combined. CONCLUSION - BMD was not found to be decreased in patients with well-controlled metabolism compared to healthy controls.]

Clinical Oncology

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Hungarian Radiology

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