LAM Extra for General Practicioners

[BACTERIAL CONTAMINATION AND IRRITABLE BOWEL SYNDROME]

NOVÁK János

JUNE 20, 2012

LAM Extra for General Practicioners - 2012;4(03)

[Irritable bowel syndrome (IBS) is one of the most common gastrointestinal condition, which affects 10-15% of adults in developed countries. Recent observations have raised the possibility that disturbances in the gut microbiota and/or the accompanying low-grade inflammatory state might contribute to the etiology and symptomatology of irritable bowel syndrome. Some studies indicate that small intestinal bacterial overgrowth (SIBO), as confirmed by hydrogen breath tests (HBT), is more prevalent in patients with irritable bowel syndrome than in matched controls without IBS. Although the data are conflicting, this observation has led to the hypothesis that bacterial contamination was the primary cause of IBS. As a consequence of this hypothesis, a lot of therapeutic options have found their way into the armamentarium of those who treat patients with IBS. These agents include probiotics, prebiotics, antibiotics and anti-inflammatory agents. This paper describes the various mechanisms by which changes in the gut flora might contribute to IBS and also discusses the efficacy and safety of antibiotic therapies, especially rifaximin, for treating IBS/SIBO symptoms.]

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LAM Extra for General Practicioners

[INSULIN SELF-TITRATION IN TYPE 2 DIABETES MELLITUS: BURDEN OR SOLUTION?]

TAKÁCS Róbert

[INTRODUCTION - Observational studies have verified that even in routine diabetes care, up to 1.3% reduction in HbA1c can be achieved with the initiation of a long-acting basal insulin analogue. We can get the same results in our patients using an insulin titration algorithm and close diabetological control. CASE REPORT - Metformin therapy of a 68-year old, moderately obese woman with type 2 diabetes was complemented by a long-acting basal insulin analogue (insulin glargine). Before initiation of insulin therapy, the patient received thorough dietetic and diabetic education by a qualified dietician and a diabetes nurse. The starting dose of insulin was 10 U, and then the patient was asked to increase the dose by 2 U every 3rd day depending on the mean of self-monitored fasting plasma glucose values in the previous 2 days. With the aid of a titration algorithm, optimal carbohydrate metabolism has been verified by laboratory parameters assessed 3 months later. CONCLUSION - Insulin self-titration based on appropriate patient education and close professional control makes a relatively simple therapeutic system the optimal decision in terms of a rapid and chronic normalisation of glucose control in a large patient group.]

LAM Extra for General Practicioners

[THE DIABETIC FOOT SYNDROME: PATHOMECHANISM, CLINICAL PICTURE, CURRENT TREATMENT AND PREVENTION]

JERMENDY György

[Diabetic foot syndrome is a characteristic late complication of diabetes mellitus. It can develop in patients with type 1 as well as type 2 diabetes mellitus, especially in case of a long duration of diabetes and sustained poor metabolic state. Diabetic neuropathy plays a pivotal role in the pathomechanism, but vascular symptoms might also contribute to the complex clinical picture. For making the diagnosis, evaluation of complaints, performing physical examination and using simple tests for identifying both distal, somatosensory neuropathy and potential angiopathy are of great importance. Therapeutic approaches aim to achieve proper glycaemic control, as well as to ameliorate symptoms of neuropathy, improve peripheral blood supply by medicines, angioplasty or intervention radiological methods, fight against infections and off-load the foot. Surgical intervention might also be necessary, and in severe cases, amputation might be needed. The diabetic foot syndrome increases mortality risk in patients with diabetes. Complaints related to diabetic foot syndrome are often resistant to treatment and tend to recur. Thus, prevention with long-term, good metabolic control and protection of the foot are of particular importance.]

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[DIURETICS IN CARDIOLOGY: PRESCRIBE OR USE?]

NAGY Viktor

[Diuretics are essential therapeutic tools. They effectively reduce blood pressure and have been shown in numerous hypertension clinical trials to reduce both cardiovascular and cerebrovascular morbidity and mortality. In addition, they are important components of the treatment of heart failure with apparent signs of congestion. While thiazides are recommended in mild forms, loop diuretics are used in the severe stages of congestive heart failure. Loop diuretics and thiazides often induce hypokalaemia, which has been demonstrated to be not as benign as thought before. Diuretic-induced hypokalaemia seems to be aldosterone dependent. Aldosterone levels increase during diuretic therapy. Aldosterone antagonists are unique among diuretics in that they improve survival of patients with heart failure independent of their effect on sodium metabolism. Because of this, diuretic treatment lives its renaissance in cardiology.]

Clinical Neuroscience

Adult attachment and parental bonding in irritable bowel syndrome and in panic disorder - Implications for psychotherapy

PÉNZES István, CZEGLÉDI Edit, SZALAI Dömötör Tamás, CSALA Irén, TÚRY Ferenc

Background and purpose - Attachment theory provides an integrative perspective about the interplay between cognitive, affective, behavioral and interpersonal processes and is relevant for understanding irritable bowel syndrome (IBS) and panic disorder (PD). The aim of the present study was to examine the adult attachment style and parental bonding of IBS and PD patients. Methods - In a cross-sectional questionnaire-based study, 65 PD and 65 IBS patients with clinical diagnosis participated. Measures were Attachment Style Questionnaire, Experiences in Close Relationships Scale - Revised, and Parental Bonding Instrument. Results - The frequencies of insecure attachment (80.0% vs. 63.1%) and paternal neglect (35.4% vs. 16.9%) were higher in IBS than in PD (χ2 (1)=4.571, p=0.033, and χ2 (3)=7.831, p=0.050, respectively). The frequency of secure attachment was significantly higher for optimal paternal bonding than with suboptimal paternal bonding (75.0% vs. 21.9%, χ2 (1)=19.408, p<0.001). According to the results of multiple binary logistic analysis, optimal paternal bonding predicted secure attachment after adjusting for the background variables (OR=9.26, p=0.001). Conclusion - A high frequency of insecure attachment was present in both groups, especially in IBS. With regard to maternal bonding, IBS and PD groups showed similar patterns, while an apparent difference was observed for paternal bonding. These highlighted the developmental similarities of these two, symptomatically different disorders. While optimal maternal bonding did not predict adult attachment security, paternal bonding did thus replete with therapeutic implications. Attachment functions, like responsiveness, attunement and affection modulation were apparent in the psychotherapist-patient relationship as well.

Clinical Neuroscience

[Treatment of complex regional pain syndrome with amitriptyline]

KOMOLY Sámuel

[Introduction - Complex regional pain syndrome is a di­stressing neuropathic pain condition without known etiology and evidence based treatment. Case presentation - Here a posttraumatic severe case of complex regional pain syndrome is presented, successfully treated by amitriptyline monotherapy. Amitriptyline is one of the most effective evidence based treatments of peri­pheral diabetic neuropathic pain and other neuropathic pain syndromes. Discussion - Amitriptyline seems to be effective to decrease pain, autonomic and motor symptoms in chronic regional pain syndrome. Conclusion - Controlled trials may be warranted to test the effectiveness of amitriptyline in complex regional pain syndrome.]

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[Teriparatide has become one of the most important drug in the treatment of osteoporosis in Hungary. Although this is not a new drug, a number of questions arise regarding its use in everyday practice. When should we use it as first-line treatment? When should we change the used therapy to teriparatide? What kind of effect can we expect after the start of teriparatide therapy? What are the potential side effects? Financing rules limit, but do not fully control our therapeutic decisions, as these are mostly based on scientific data. In this review, we summarise new and older scientific data regarding teriparatide from practical aspects.]

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[Novelties in the management of Hodgkin lymphoma]

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[Hodgkin lymphoma is a lymphoproliferativ disease, it is about 12-18% of all lymphomas. It has typical morphologic, clinical and therapeutic features, which can distinguish from other lymphoma types. Due to risk- and PET/CT adapted treatment Hodgkin lymphoma is a curable lymphoma with an 80-90% long-term survival, however, refracter- and relapsed patients’ therapy is a great challange. Cure rate can increase due to the development of the diagnostic and treatment modalities, but the use of standard recommendation is necessary. The aim of this review is to show new WHO 2016 lymphoma classifi cation, role of the new diagnostic options, especially 18FDG-PET/CT, Lugano classifi cation and fi rst-line and salvage therapeutic possibilities and to introduce the immunotherapy, like brentuximab vedotin and PD1 inhibitors. Certain points of hemopoietic stem cell transplantation will be also covered.]