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Lege Artis Medicinae - 1993;3(03)
Content
Lege Artis Medicinae
MARCH 31, 1993
[Epidemiology of breast cancer]
[In 1987 breast cancer occupied the 3rd place among female cancers in the world. In Hungary, 13.577 women died due to cancer in 1990, 15,4% from breast cancer. The author uses international, and Hungarian data (at the country and county level) and also the data from his own research results. Incidence of breast cancer has risen continuously and shows a wide range in different parts of the world from 14,1 %000/year to 121,2%8000/year. The 5 year crude survival rate is between 40–65% and is slowly improving. In addition to the well-known risk-factors, the author emphasizes the role of mastopathy because in his patient group of 843 cases 2,3%, but in the mastopathy group 4,1% developed cancer. Therefore, this alteration should be considered as a high risk factor. Among close female relatives of breast cancer patients breast and other cancer has occurred much more frequently, than in that of a control group. Prostate cancer occurs significantly more frequently among 1 st degree male relatives. Therefore it is necessary to study the risk factors with epidemiologic methods and to broaden screening, detection and therapy in order to reduce the incidence and mortality of breast cancer. ]
Lege Artis Medicinae
MARCH 31, 1993
[Brest cancer screening, early diagnosis]
[There is no data in the medical literature concerning the late results of breast physical exam by paramedical personnel as a screening test. In a population screening for breast cancer in Debrecen, nearly 70 thousand women were observed from 1981 to 1985 and 298 new breast cancer patients were detected. 198 patients were from the screened population and 100 patients from the non screened population. All of the breast cancer patients were followed up, and the analysis was completed on 31st December 1991 with the help of statistical methods. The author analysed the overall survival, cumulative death rate and relative risk of dying according to age group. The difference of overall survival was 29% for the screened group. This result is nearly the same as that produced by mammographic screening.]
Lege Artis Medicinae
MARCH 31, 1993
[Diagnostics of breast cancer]
[The author interpretes and evaluates the diagnostic methods of breast cancer. Detailed description is given on physical examination, mammography, ultrasound examination, cytology, histology and miscellaneous methods, expressing their advantages and drawbacks. On clinical experience nowadays the combinative application of these by the same expert seems to be the most effective method, possibly in large breast clinic centres.]
Lege Artis Medicinae
MARCH 31, 1993
[Breast cancer markers of prognostic significance]
[Prognosis prediction of breast cancers is difficult, particularly in early clinical stage (1) or in tumors with practically identical histological structure and degree of differentiation (invasive ductal NOS cancer) because node negative tumors of early developmental stage or with identical structure may demonstrate different clinical course. In such cases the steroid hormone receptor content, the prolife rating capacity of the tumor and the so called independent prognostic factors like the onco gene and supressor gene expression (c-myc, C-erbB–2, p53), the growth factor receptor content (EGFr) and the so called differentiation antigens accompanied by low metastatising capacity (MAM–6, nm23) may help the pathologist in diagnostics. Examinations of these markers are planned to be introduced in future diagnostics and contribute to the elaboration of effective treatment schedules.]
Lege Artis Medicinae
MARCH 31, 1993
[The surgery of breast cancer]
[The incidence of breast cancer in Hungary is gradually increasing, not only in the elderly due to the increasing average age, but in younger women as well. In the operative stadia (St I-II), the best results can be achieved by a radical surgical intervention and an adjuvant radio-chemo-hormone therapy. The formerly routine radical mastectomies are being replaced by breast conserving procedures which remove the tumour and sacrife only the most necessary surrounding tissues to achieve the best local tumour control. The fundamental basis for this procedure was established by the clinical trials of B. Fisher and U. Veronesi. The practical basis is the circumstance, that owing to better propaganda, more frequent breast self examinations, and better mammographic and cytological facilities, more breast cancer will be recognized in an earlier stage.]
Lege Artis Medicinae
MARCH 31, 1993
[Chemotherapy of breast cancer ]
[Breast cancer is a systemic disease. The majority of local interventions do not result in remission. Improved results can be expected only with a prolonged drug treatment (adjuvant chemo- or hormone therapy). There is clear evidence available that an adjuvant therapy applied to early breast cancer can significantly decrease the yearly recurrence and mortality rate while improving the five and, to a greater degree, the ten-year survival rate. Advanced breast cancer is an incurable disease. Since no definitive recovery may occur, the relief of symptoms and improvement of the quality of life are of great importance. In cases of hormone-dependent tumours, endocrine therapy may lead to remission, while for rapidly progressing, viscerally metastasizing processes chemotherapy may be successful. Chemotherapy has reached its limit of efficiency therefore new approaches are required to increase its effectiveness and reduce its side effects.]
Lege Artis Medicinae
MARCH 31, 1993
[Indications for radiotherapy after conservative surgery of early breast cancer]
[Breast saving surgery combined with radio therapy for early breast cancer results in a remission rate equal to that attained by radical surgery as confirmed by investigations abroad and in this country. The performance of combined therapy is recommended only in centers with adequate technical facilities for postoperative radiotherapy (Megavolt therapy, Boost therapy). We think that for pTapN. stage breast cancers conservative surgery in itself is satisfactory. For pT -pT2 and pN1a PN1bi stage cancers, however, postoperative radiotherapy is obligatory.]
Lege Artis Medicinae
MARCH 31, 1993
[Possibilities of breast reconstruction after mastectomy]
[Possibilities of breast reconstruction are described in this article. Respects affecting reconstruction-time are expounded. Three categories of breast forming operation methods are described as simple implantation, breast reconstruction with local flaps and breast forming with musculocutan flaps.]
Lege Artis Medicinae
MARCH 31, 1993
[Psychological rehabilitation of breast cancer patients]
[The prejudices and fears concerning the diagnosis of cancer is analysed. The author describes the psychological aspects of breast cancer: the anxieties aroused by mutilation, loss of female identity, fear of death and dying. The connection of coping mechanisms and the outcome of the illness is explained, and the experiences concerning psychosocial rehabilitation are presented. The author emphasises the importance of psychological support in respect of quality of life and the duration of the survival period. ]
Lege Artis Medicinae
MARCH 31, 1993
[Postoperative movement therapy of breast cancer patients]
[Movement therapy of patients operated for breast cancer is presented interpreting the model at the National Institute of Oncology. The conservative management of upper extremity lymphedema is detailed on the experiences of the treatment of 200 breast cancer patients by lymphdrainage. The importance of information on future behaviour for the patients is emphasized. ]
Lege Artis Medicinae
MARCH 31, 1993
[Postoperative care of breast cancer patients]
[The author reports on the aspects of postoperative care of breast cancer patients . He points out the difficulties and the crucial importance of the psychical leading. Premenopausal patients should be differentieted from post menopausal ones. Patients having got over a radical operation call for different strategy than those with reduced radical operation. The author points out that the whole body should always be examined. The proposed methods of examination and the time of necessary control examination are reported. The plastic surgery for breast reconstruction is proposed only after a 3 year symptom-free period. ]
Lege Artis Medicinae
MARCH 31, 1993
[When to stop a clinical trial of a medicine?]
[Most randomised clinical trials require periodic evaluation of the data collected. On the one hand, monitoring the data increases the effectiveness of the trial and, on the other hand, ethical considerations are based on the partial results, which may lead to the termination or modification of the trial. This article discusses the ethical question of when to stop a clinical trial of a drug, and presents the statistical rules for stopping trials related to these ethical decisions. Other topics include the question of the organisation of data assessment committees, premature publication and the problem of overestimation in discontinued trials. A number of examples on this topic help to ensure that the issues discussed can be applied in daily practice.]
Lege Artis Medicinae
MARCH 31, 1993
[Dissociation hypothesis of the disorders of eating behaviour]
[The two basic types of disordered eating behaviour are anorexia nervosa and bulimia nervosa. However, obesity can be inserted in the continuum between them, as well. Many ideas of the pathogenesis of these psychosomatic disorders have been suggested (biological models, relationship between eating disorders and the affective or obsessive compulsive spectrum, family dynamic, addictive and cognitive models). The authors – emphasizing the need for a multidimensional etiopathogenetic approach – discuss the data supporting a dissociation model of eating disorders. The dissociative disorder often develops after traumatic experiences (e. g. sexual abuse). This mechanism may be characteristic mainly of a subgroup of bulimic patients, but it sometimes seems to be valid in anorexia, obesity, or other types of eating disorders. The dissociation model is supported by the enhanced hypnotic susceptibility of bulimic patients, corroborated in several studies. On the basis of these data, for patients with eating disorders and suspected dissociative pathomechanism, hypnotherapy seems to be an advantageous therapeutic strategy.]
Lege Artis Medicinae
MARCH 31, 1993
[Social security and environmental protection]
[The work to modernise the domestic social security system has presented a wide range of questions and challenges for professionals. The decoupling of health care financing from public expenditure, the division of tasks and scope of care between the central fund and social insurance, and the development of the concept of health insurance and its practical methods, all of which have given rise to new tasks and activities.]
Lege Artis Medicinae
MARCH 31, 1993
[Is the consultation a prop or a shackle?]
[We are in the middle of a health reform process. Every day we are faced with the constraints of the new situation. There is a succession of briefings, open forums, written polemics. It does not require much imagination to imagine what our medical colleagues, gathered around a conference table and selected according to a given theme, might have to say in their debates. And the reform concept itself offers plenty to talk about: while in many areas it regulates the fine details, in others, on the contrary, it leaves plenty of scope for the free choice of those involved and the influence of local circumstances and bargaining positions.]
Lege Artis Medicinae
MARCH 31, 1993
[Accepted and rejected]
[When a pious reader tries to understand a law by browsing through the Hungarian Gazette, he or she is interested to know what the future regulations will be. However, he very rarely finds out what has not been adopted. We can get an idea of this by looking at the amendments tabled by MEPs and listening to the debates in committee meetings. As we shall see, in many cases, especially from the opposition, the proposals are made in the spirit of a concept that is at odds with the government's, and in others they are made on the basis of professional considerations or individual ideas. ]
Lege Artis Medicinae
MARCH 31, 1993
[On amortisation - finally getting serious]
[For two years now, we have been hearing from doctors, investors, ministers, state secretaries, insurance experts and OTF officials who want to do business that "entrepreneurial health care" will remain an empty slogan as long as social security is not capable of sector-neutral financing, as long as it does not take amortization into account when setting prices, which do not even exist today (let alone interest on invested capital). Seeing that there is once again no attempt to solve the problem in the bill on the financial basis of social security and its 1993 budget, the Free Democrat MEP Csaba Fáklya has thrown a stone into the water.]
Lege Artis Medicinae
MARCH 31, 1993
[How and from what do we invest?]
[Gyula Kincses said that something should be done in the field of new investments in the first half of 1993, because what has happened in the last two years is not comforting. Deadlines had slipped, applications or their processing had been delayed, and the reception of new investments was rather disorganised. The rapporteur therefore suggested that, if an investment was to be financed by the budget, it would be a good idea to decide relatively soon whether it was to be financed by the social security system. "This is where the proposal obliges the E-fund. On the second, where it does not oblige, but merely authorises the E-fund manager to decide in what order of priority and in what amounts it can enter into contracts for new entries, because as long as there is no pure performance funding, these usually have an additional impact. Therefore, there are some that are demonstrably cost-saving and others that are clearly and demonstrably niche."]
Lege Artis Medicinae
MARCH 31, 1993
[What goes in your pocket?]
[One of the cornerstones of the health reform is whether the pay situation of the notoriously underpaid workers in the sector will finally be resolved. If you analyse pay in any area of the health sector, you will find that it is staggeringly low for what is otherwise a responsible job. Education does not seem to have much bearing on pay. The doctor is just as outrageously underpaid as the assistant who assists him or the 'support staff' who work in the background. We are fighting in words against parasolvency and gratuity, but we know that if they did not accept it, they would be living with their families at or below the minimum subsistence level. It seems that the reform of primary care has not yet brought about any radical change in wages, and the introduction of card money has not made workers any richer... Just as fundamental change without adequate development and investment is not to be expected in the wake of well-intentioned reform. ]
Lege Artis Medicinae
MARCH 31, 1993
[The Minister thanks]
[The rapporteur for the in-depth parliamentary debate was Gyula Fekete (MDF) from the Committee on Budget, Tax and Finance. He said that his committee had discussed the motions to amend the revenue and expenditure of the Budget and its balance with particular attention. ]
Lege Artis Medicinae
MARCH 31, 1993
Lege Artis Medicinae
MARCH 31, 1993
[The "Fornarina"]
[The Galleria Nazionale in Rome houses a portrait of a bare-breasted young woman. Tradition, confirmed by the signature on the bracelet (RAPHAEL VRBINAS), has for centuries identified the painting as the work of Raphael and the sitter as one of the "amorous nature" of the painter.]
Lege Artis Medicinae
MARCH 31, 1993
[Proposal for the establishment of an epilepsy institute - in 1802]
["epilepsy sufferers with spectacular symptoms have always been a focus of attention. Despite this, the social situation of people with epilepsy worldwide is generally unsettled. The perception of the disease is dominated by a generalised perception that (dis)judges all epileptics equally (1).]
Lege Artis Medicinae
MARCH 31, 1993
[Saint László, protector against the plague]
[The Hungarian cult of the plague, or in the vernacular the cult of the saints (Sebestyén, Rozália, Rókus) who protect against the black death, glandular death, and death by pestilence (1), has been most thoroughly described by Sándor Bálint. His research was continued by Zoltán Szilárdfy, who compiled an iconography of the anti-plague images of the Virgin Mary, embedded in a broad historical and ethnographic context (2).]
Lege Artis Medicinae
MARCH 31, 1993
[Suicide attempts by unemployed people in Budapest]
[Mass and open unemployment is a new phenomenon in Hungarian society. Statistical data on this phenomenon were last provided by the 1949 census before 1990. Since then the concept of unemployment has not appeared openly in Hungarian statistics, as the phenomenon itself was incompatible with the principle of full employment. This social fact, which did not officially exist, could only be deduced indirectly from other sources. In recent years, data on jobseekers in employment offices have provided evidence of the existence of the phenomenon, followed by measures prior to the introduction of the open unemployment benefit system (job placement allowance, loan for a new start) in 1987 and, finally, the registers of unemployment benefit recipients since 1989, which have been the legalisation of unemployment. This is also the reason for the increase in the number of unemployed (1, 2). ]
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