Lege Artis Medicinae



OCTOBER 20, 2003

Lege Artis Medicinae - 2003;13(07)

[Without treatment, infective endocarditis (IE) is a fatal disease and in spite of contemporary diagnostic and therapeutic tools its prognosis is still poor. The most important first step is the early rise of clinical suspicion which should be confirmed by the new clinical criteria. Echocardiography is a major criterium: transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) both in the diagnosis and in the detection of complications of infective endocarditis. Complications can be valvular (embolism, valvular dysfunction) or perivalvular (abscess, pseudoaneurysm formation) with hemodynamic consequences. TEE is recommended as the first line diagnostic technique (mostly in prosthetic valve infective endocarditis) or as a second study following negative TTE or positive TTE with high clinical risk factors or to define embolic risk. In addition to classical surgical indications, early ”preventive” indications are emphasized which can decrease the still high operative mortality. Improvement of outcome in infective endocarditis can only be expected with agressive management meaning early suspicion, early TEE and early operation.]



Further articles in this publication

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[The 18th International Conference on Allergy and Clinical Immunology 7-12 September 2003, Vancouver]


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[Scientific Browsing]

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[Interferon-α proved to be the most effective therapy of chronic hepatitis C. Its combination with ribavirin enhances the antiviral activity and this modality has become the therapeutic standard recommended worldwide during the past few years. Metaanalysis of the international studies revealed that only 12-19% of the patients became virus-free following a 48-week long course of α interferon monotherapy. The combination treatment with ribavirin for 48 weeks increased the proportion of sustained responders to 35-45%. The introduction of pegylated interferons resulted in significantly higher response rates. The new therapeutic possibilities are due to the modified pharmacokinetic characteristics of the drug by changing the size and the structure of the molecules. Multicentre studies investigating the clinical effectiveness of the 40 kD sized pegylated interferon α-2a as well as the 12 kD sized pegylated interferon α-2b in combination with ribavirin reported 56% and 54% response rate, respectively. However, there is significant heterogeneity in the results according to the type of drug administered and to the genotype of the hepatitis C virus, as well as in the basal viral level and the stage of hepatic fibrosis, respectively. The message and the conclusion of the viral kinetic studies are worth remembering: if the result of the HCV nucleic acid test is still positive at week 12 or 24, therapy should be ceased due to the patient non-responder status. Since pegylated interferons are also available in Hungary the authors felt useful to give an overview of the current knowledge, summarizing the results of the relevant studies and provide a suggested state-of-the-art therapeutic protocol based on international consensus.]

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[Going further on the footprints of the past]


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All articles in the issue

Related contents

Clinical Neuroscience

Association of anterior thoracic meningocele and azygos lobe of the lung

DENIZ Ersay Fatih, SENAYLI Atilla, BICAKCI Ünal

Here we report an anterior thoracic meningocele case. Twoyears- old female patient was presented with kyphosis. Azygos lobe of the lung was also demonstrated during radiological studies. Posterolateral thoracotomy incision and extralpeural approach was performed for excision of the anterior meningocele to untether the cord. Although both anomalies are related to faulty embryogenesis and it is well known that faulty embryogenesis may also reveal coexisting abnormalities, we could not speculate a common mechanism for anterior thoracic meningocele and azygos lobe of the lung association.

Clinical Neuroscience

Attitude of spine surgeons towards the application of 3D technologies - a survey of AOSpine members

ÉLTES Endre Péter, KISS László, BARTOS Márton, EÖSZE Zsolt, SZÖVÉRFI Zsolt, VARGA Pál Péter, LAZÁRI Áron

Background - 3D technologies (3D virtual and physical model, 3D printing, computer aided engineering, finite element analysis based simulations) play an important role in personalized spine surgery. Objective - In collaboration with AOSpine a global, online survey-based study was performed in order to determine the acceptance rate and the factors which stand against the wider spread of 3D technologies. Methods - A survey containing 21 questions was developed and divided into five pages, every page corresponding to one chapter. Our analysis is based on the responses of 282 spine surgeons from 57 countries. To interpret our results in a global context, we used the Human Development Index of the respondent's countries in comparisons. Results - Significant difference between the AOSpine regions (p ≤ 0.05) was found, with the highest acceptance in Asia-Pacific region. There was no significant difference in acceptance score according to the field of spine surgery, or the surgical experience in years (p=0.77, and p=0.19). In the case of public practice, we found significantly higher acceptance compared to private and mixed (public and private) surgical practice (p ≤ 0.05). The acceptance of the technology varied based on the respondent’s resident country’s Human Development Index and was significantly different between „Medium” vs “Very high” (p = 0.0005) and „High” vs „Very high” (p=0.019) category. Significant positive correlation was found between the acceptance score and the HDI score (Spearman test, ρ = 0.37, p = 0.007). The main limitation factor was identified as the lack of information. Conclusion - There is high interest among spine surgeons towards the incorporation of 3D technologies into the clinical practice. Education, the healthcare system, and the economic environment plays a major role in acceptance. Our results provide the basis of a strategy to promote the application of 3D technologies.

Clinical Oncology

[Surgical view on the perioperative oncological treatment of liver metastases originated from colorectal cancer]


[Recent development of surgery resulted in fundamental changes in assessment of resectability of liver tumors. Surgical interventions became more radical and more effective. Colorectal liver metastasis (CLM) represents the most frequent hepatic tumor, where therapeutic options require close collaboration between surgeons and oncologists, and up-to-date approach from both. As the fact is, that CLM is a metastasis of a primary colorectal carcinoma, it seems to be obvious to apply perioperative chemotherapy. Results justify serious precaution. Neoadjuvant chemotherapy did not improve overall survival. Several data testify, that even perioperative chemotherapy is not indicated in these cases. Adjuvant chemotherapy can be applied after extended liver resections and two stages hepatectomies. About 20% of patients with initially inoperable CLM may be rendered resecable after systemic chemotherapy. Prognosis of synchron CLM is bad, 5 year survival is less than 20%. Disappearing CLM needs special respect, high level of perfection in liver surgery is essential. After chemotherapy postoperative morbidity is rising, technical diffi culties may occur. Further studies are required to examine possible effect of new targeted molecular therapy-based regimens on resectability. Individualized multidisciplinary treatment planning is mandatory.]

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[The multidisciplinary pathological examination of colorectal carcinomas - From the biopsy sample to the K-RAS mutation analysis]


[BACKGROUND - The role of pathologist in the reporting of colorectal carcinomas (CRC) has dramatically changed in the past 20 years. This change has been generated by the enormous progress in the surgical, radiological, oncological and pathological techniques and their interactions. AIM - To interpret the role of pathologist in the colorectal multidisciplinary team. METHODS - The most important histopathological prognostic and predictive factors, the surgical planes, the involvement of circumferencial margin, the regression grade after neoadjuvant chemoradiotherapy were assessed in 964 patients treated with operable colorectal cancer during 2001-2007 in the County Hospital of Baranya and the four nearby city hospitals. RESULTS - Most of our patients (>75%) were treated with advanced stage tumors. The lymph nodes were harvested through careful slicing, visual inspection and palpation - accordingly the average lymph node count increased from 7.45 to 19.0. After using elastic fibre stain we detected twice as much vascular invasion then before. The results of the surgical quality after TME and APER were somewhat dissapointing. Although the ratio of the specimens resected in the mesoretal fascial plane was comparable to the international results (39.8%), the ratio of resections in the muscularis propria plane was unacceptably high (47.8%) and it was more pronounced (50-100%) between the low volume surgeons of the small city hospitals. The involvement of the circumferencial resection margin was affected by the advanced pT and pN stage, the vascular invasion, the surgical plane, the type and number of resection performed by the surgeons, the regression grade after preoperative chemoradiotherapy and the gender. CONCLUSIONS - In addition to the traditional histopathological features the pathologist has to investigate the quality features of the preopreative assessment, the surgical planes of excision and the grade of regression after neoadjuvant chemoradiation and feed back these results to the members of the CRC multidisciplinary team. The optimal treatment of the CRC can be achived only in this setting.]

Hungarian Immunology

[Clinical and immunoserological characteristics of mixed connective tissue disease (MCTD) associated with pulmonary arterial hypertension (PAH)]

VÉGH Judit, CSÍPŐ István, UDVARDY Miklós, KAPPELMAYER János, LAKOS Gabriella, ALEKSZA Magdolna, ZEHER Margit, SZEGEDI Gyula, BODOLAY Edit

[INTRODUCTION - The authors investigated the clinical characteristics, survival, accumulated damage index and immunoserological abnormalities in patients with mixed connective tissue disease (MCTD) associated with pulmonary arterial hypertension (PAH). PATIENTS AND METHODS - Anti-U1RNP autoantibodies, anti-endothelial cell antibodies, anti-cardiolipin antibodies and serum trombomodulin as well as von Willebrand factor antigen concentrations were measured in 25 patients with MCTD associated with PAH (11 right heart catheterization and 14 Doppler echocardiography) and in 154 MCTD patients without PAH. Changes in arterial pulmonary pressure were followed up by echocardiography. RESULTS - In the 25 patients PAH followed MCTD diagnosis in the average 11.6±4.5 years of the diseases. The probability of survival was lower in MCTD patients with PAH than in the 154 non-PAH MCTD patients (five years survival rate in MCTD with PAH: 73.39%, vs. 96.43% in non PAH MCTD; p<0.01; 10 years survival rate 86.74% vs. 93.25%; p<0.01). Anti-endothelial cell antibodies were more frequently present in MCTD patients sera with PAH than in non PAH MCTD (p<0.001). Serum trombomodulin and vWFAg levels were higher in MCTDPAH patients than in non PAH MCTD patients (trombomodulin:34.2±15.3 ng/ml vs. 11.8±6.5 ng/ml; p<0.001; vWFAg: 311.1±147% vs. 172.5± 141%. Significant correlations were noticed between the quantity of anti-endothelial cell antibodies and serum trombomodulin level (r=0.466) as well as the quantity of anti-endothelial cell antibodies and vWFAg serum level (r=0.550). CONCLUSION - Survival probability was worse for MCTD patients with PAH than for non PAH MCTD patients. Our results suggest that in MCTD the presence of anti-endothelial cell antibodies and endothelial cell activation may play a role in the development of pulmonary arterial hypertension and in the maintenance of obliterative vascular processes.]