Hypertension and nephrology

[“Protecting our Vessels”. Continuing the “ÉRV” Program in 2011]

KISS István, KOLOSSVÁRY Endre, JÁRAI Zoltán, LUDÁNYI Andrea, FARKAS Katalin

APRIL 20, 2011

Hypertension and nephrology - 2011;15(02)

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Hypertension and nephrology

[Change in the approach of the treatment of hypertension in Hungary. Five years results of the „Live below 140/90!” Program]

KISS István, PÁL László, SCHANBERG Zsolt, BARNA István, ALFÖLDI Sándor, FARSANG Csaba, CHÁTEL de Rudolf, KÉKES Ede

[One of the potentials of the effective fight against endemic diseases is their exposition and the recognition of their dangers and risk factors. The other possibility is to increase the professional knowledge of the medical and healthcare employees along with the patients’ co-operation. For the prevention of complications and the adequate treatment of hypertension an extensive compliance program, called „Live below 140/90!” was initiated by the Hungarian Society of Hypertension in 2005. The mission was to give knowledge to the non-professional public about the symptoms of the disease and how to get information about it while helping patients’ relatives. The first message was the “Hit the target blood pressure value!”. With careful planning, treatment and taking of medicines the next phase could begin. The ratio of the patients who reached the target blood pressure increased by 5% during the two years of the Program between 2005 and 2007 therefore the message changed to “Hold the blood pressure there!”. The next step in the Program was to prevent the forming of complications and to treat the co-morbidities effectively among patients with pre-diabetes or diabetes and hypertension in 2008. The slogan was “Prevent the complications!”. As part of the Program we organized a roadshow named the “Day of caring!” and we announced the “Conscious Care” substudy focused on the public summoning about the stroke which is the most dangerous complication of hypertension. The year of 2011 is an absolutely new beginning in the communication of the Program since we started to use some very modern tools of the 21st century including YouTube, Facebook and others for the better education of the people. Based on the results of the initial Program we got to know the risks, co-morbidities, complications and the characteristics of the Hungarian hypertensive patients. We have recognized that most of the patients belong to the high and very high risk hypertensive category. Also more than 30 percent of them have a pre-diabetes condition. We have found that increased caring helps to build up the patients’ co-operation which in return improves the decrease of their blood pressure significantly. The Program therefore continues in 2011! Our intention is to enlarge the Hungarian Hypertension Register database and to get to know more and more epidemiologic and therapeutic features of the hypertension disease.]

Hypertension and nephrology

[Perindopril plus Indapamid CombinAtion blood preSSure reductiOn study (PICASSO)]

[INTRODUCTION - International and Hungarian (JNC-7, ESH/ESC2007 és 2009, MHT 2009) Guidelines suggest a target blood pressure <140/90 mmHg for hypertensive patients, and <130/80 mmHg for those with high/very high cardiovascular risk (e.g. patients with diabetes mellitus, chronic renal disease). It was proved that for achieving the most efficient antihypertensive effect and reducing side effects, thd use of drug combinations is needed in most patients. In Hungary, ACE-inhibitor plus diuretic combination is one of the most frequently used one in Hungary. The vérnyomáscsökaim of the PICASSO study was to evaluate the efficacy and metabolic effects of the fixed combination of high-dose perindopril plus indapamide (Coverex-AS Komb Forte®) in clinical practice of hypertonologists, cardiologists and general practicioners. PATIENTS AND METHODS - Patients with uncontrolled, grade 1 or 2 primary hypertension, age, >18 years were involved in the open, 3-month, multicentre, prospective, observational, non-interventional clinical study if the treating physician indicated a combination treatment with higher dose antihypertensive drugs. Blood pressure (also with ABPM), heart rate, metabolic parameters (plasma lipids, blood sugar, Na, K, creatinine, uric acid, GGT) were measured by routine methods, medical history and quality of life parameters were registered on a validated questionnaire. Changes in the above parameters were also separately evaluated in patients with different risk factors or with concomitant diseases. RESULTS - Data of 9683 patients were evaluated (54% women, 46% men, average age 61.8 years). By the end of the therapy used in the study, blood pressure average decreased from 159/93 to 131/80, by ABPM from 145/83 to 126/74 mmHg (24hr averages, systolic/diastolic blood pressure, respectively), the heart rate from 79 to 73 beats/min (p<0,001). Target blood pressure was achieved in 75,4% of patients with no major concomitant disease, but only in 14% of those with a concomitant disease characterised by lower target blood pressure. The diurnal index by ABPM did not change substantially. Clinically significant decreases were found in the plasma levels of total cholesterol, LDL-cholesterol, triglycerides, fasting glucose and uric acid levels, but there were no major changes in serum levels of HDLcholesterol, Na, K, and GGT. Quality of life parameters significantly improved by the end of the study. CONCLUSIONS - Combinations of perindopril and indapamide can be successfully and safely used in everyday practice.]

Hypertension and nephrology

[Restless legs syndrome in patients with chronic kidney disease]

LINDNER Anett, FORNÁDI Katalin, MOLNÁR Miklós Zsolt

[The aging of the population, the high prevalence of chronic diseases and the consequent rapid increase of healthcare expenditures present a difficult challenge for the medical care system and for the society in the developed countries. Sleep disorders are increasingly recognized as very frequent chronic diseases with significant pathophysiological and psychosocial consequences. In the last 20 years an increasing number of studies reported high prevalence of sleep disorders, such as restless legs syndrome in patients with kidney disease. Chronic renal failure is the most common condition presenting with secondary restless legs syndrome. It is associated with insomnia, depressive symptoms and anxiety, impaired quality of life, as well as elevated cardiovascular risk. Compliance of the patients with restless legs syndrome is decreased, and it is more likely that they discontinue dialysis treatment. This may be related to higher mortality in kidney disease patients with restless legs syndrome.]

Hypertension and nephrology

[Voiding sonocystography with ultrasound contrast material for the diagnosis of vesicoureteral reflux]

KIS Éva

[Voiding sonocystography with intravesical administration of ultrasound contrast agent is a sensitive method to detect vesicoureteral reflux without irradiation. Depicting microbubbles in the ureters and collecting system is feasible even with very small amounts of a second-generation ultrasound contrast agent, Sonovue. The reflux is graded (I-V) in a similar manner to the system used in voiding cystourethrography. In this article a detailed description is presented.]

Hypertension and nephrology

[Water intoxication caused by diuretics]

RADÓ János, KOVÁCS Andrea

[Water metabolism in the organism is regulated very exactly under normal circumstances. Sometimes, however, when the level of the antidiuretic hormone is inappropriately high and fluid consuming is not limited, water intoxication can develop. This is especially paradoxical during treatment with diuretics. Authors observed in a cachectic, potassium wasting, 87-year-old female patient, hyponatremia associated with clinical water intoxication developing in a hot period of summer, during long-term thiazide diuretic (chlorthalidone) treatment administered because of high blood pressure. Diagnosis was based besides the clinical picture on the severe hyponatremia and was supported by the relatively high urine osmolality in the presence of a very low plasma osmolality. Despite treatment of hyponatremia in accordance to the recommandations “overcorrection” occurred and turned into fatal hypernatremia. In the period of low plasma osmolality the patient was treated with intravenous infusions containing isotonic saline supplemented with potassium. When hypertonicity developed hypotonic intravenous infusions were given. Authors discuss the literature of hyponatremia with special reference to the dilemmas of therapy such as “slow” versus “rapid” correction as well as procedures to be done in case of “overcorrection”.]

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Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

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CSÁBI Eszter, ZÁMBÓ Ágnes, PROKECZ Lídia

[A growing body of evidence suggests that sleep plays an essential role in the consolidation of different memory systems, but less is known about the beneficial effect of sleep on relational memory processes and the recognition of emotional facial expressions, however, it is a fundamental cognitive skill in human everyday life. Thus, the study aims to investigate the effect of timing of learning and the role of sleep in relational memory processes. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. Our results suggest that the timing of learning and sleep plays an important role in the stabilizing process of memory representation to resist against forgetting.]

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[The connection between the socioeconomic status and stroke in Budapest]

VASTAGH Ildikó, SZŐCS Ildikó, OBERFRANK Ferenc, AJTAY András, BERECZKI Dániel

[The well-known gap bet­ween stroke mortality of Eastern and Western Euro­pean countries may reflect the effect of socioeconomic diffe­rences. Such a gap may be present between neighborhoods of different wealth within one city. We set forth to compare age distribution, incidence, case fatality, mortality, and risk factor profile of stroke patients of the poorest (District 8) and wealthiest (District 12) districts of Budapest. We synthesize the results of our former comparative epidemiological investigations focusing on the association of socioeconomic background and features of stroke in two districts of the capital city of Hungary. The “Budapest District 8–12 project” pointed out the younger age of stroke patients of the poorer district, and established that the prevalence of smoking, alcohol-consumption, and untreated hypertension is also higher in District 8. The “Six Years in Two Districts” project involving 4779 patients with a 10-year follow-up revealed higher incidence, case fatality and mortality of stroke in the less wealthy district. The younger patients of the poorer region show higher risk-factor prevalence, die younger and their fatality grows faster during long-term follow-up. The higher prevalence of risk factors and the higher fatality of the younger age groups in the socioeconomically deprived district reflect the higher vulnerability of the population in District 8. The missing link between poverty and stroke outcome seems to be lifestyle risk-factors and lack of adherence to primary preventive efforts. Public health campaigns on stroke prevention should focus on the young generation of socioeconomi­cally deprived neighborhoods. ]

Clinical Neuroscience

[The Comprehensive Aphasia Test in Hungarian]

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[In this paper we present the Comprehensive Aphasia Test-Hungarian (CAT-H; Zakariás and Lukács, in preparation), an assessment tool newly adapted to Hungarian, currently under standardisation. The test is suitable for the assessment of an acquired language disorder, post-stroke aphasia. The aims of this paper are to present 1) the main characteristics of the test, its areas of application, and the process of the Hungarian adaptation and standardisation, 2) the first results from a sample of Hungarian people with aphasia and healthy controls. Ninety-nine people with aphasia, mostly with unilateral, left hemisphere stroke, and 19 neurologically intact control participants were administered the CAT-H. In addition, we developed a questionnaire assessing demographic and clinical information. The CAT-H consists of two parts, a Cognitive Screening Test and a Language Test. People with aphasia performed significantly worse than the control group in all language and almost all cognitive subtests of the CAT-H. Consistent with our expectations, the control group performed close to ceiling in all subtests, whereas people with aphasia exhibited great individual variability both in the language and the cognitive subtests. In addition, we found that age, time post-onset, and type of stroke were associated with cognitive and linguistic abilities measured by the CAT-H. Our results and our experiences clearly show that the CAT-H provides a comprehensive profile of a person’s impaired and intact language abilities and can be used to monitor language recovery as well as to screen for basic cognitive deficits in aphasia. We hope that the CAT-H will be a unique resource for rehabilitation professionals and aphasia researchers in aphasia assessment and diagnostics in Hungary. ]