Lege Artis Medicinae

[Atypical forms of the gastroesophageal reflux disease]

KIS János Tibor, NEMESÁNSZKY Elemér

AUGUST 20, 2002

Lege Artis Medicinae - 2002;12(08)

[There is growing interest in the gastroenterology literature towards gastroesophageal reflux disease (GERD) these days. The prevalence of the disease is much higher than estimated earlier and it frequently appears in atypical forms. Literature data suggests that 30-40% of the individuals suffer from gastroesophageal reflux disease. A broad spectrum of presentation of gastroesophageal reflux disease exists, e.g. noncardiac chest-pain, ear-nose-throat symptoms, pulmonary symptoms, dental erosions, chronic cough and hiccups. Atypical forms often cause diagnostic and treatment difficulties. Authors analyze the frequency, morbidity and the pathomechanism of the extraesophageal manifestations, based on self-experience. The main goal of the review is to help to establish the diagnosis of GERD, to recognize its atypical signs and to outline the diagnostic steps to be taken. Most up-to-date treatment strategies are also presented. By the demonstration of interesting cases, authors emphasize the diagnostic importance of intragastric pH-monitoring.]

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Lege Artis Medicinae

[Changes in the hormonal therapy of breast cancer patients]

MOSKOVITS Katalin

[The hormonal therapy for breast cancer patients seems to be changing. At present the new, third generation aromatase inhibitors are the standard second line therapy for postmenopausal, receptor positive advanced breast cancer patients. Currently, tamoxifen (TAM) stands as the ”gold standard” first line therapy, with ist role changing, due to the aromatase inhibitors which seems to be more effective than TAM and have less side-effects. For these reasons, aromatase inhibitors may be useful in the adjuvant setting, but long-term side-effects are not yet known. In the next few years, sufficient experience will be gained with these drugs which might help us to change practice. Pure antioestrogens are also promising new drugs. Recently, the LHRH analogues were the preferred drug of choice in premenopausal women, in contrast to surgical or radiological ovarian ablation. All receptor positive breast cancer patients should receive hormonal therapy, regardless of age, menopausal status, node status, tumour size, but we should avoid hormonal therapy for the endocrine nonresponsive patients.]

Lege Artis Medicinae

[SCIENTIFIC DIGEST]

Lege Artis Medicinae

[Physicians’ attitudes and suppositions in 2001 in the Polyclinic of the Hospitaller Brothers in Budapest]

BALÁZS Péter

[INTRODUCTION - Following the total socioeconomic changes in Hungary in 1989, no scientific analysis has been made about physicians' religious attributes in the new circumstances. These attributes, after four decades of political anticlericalism may affect essentially the ideological and socio-economic patterns of medical professionalism. Hungary’s 2001 census favoured such an inquiry, since it went back to the traditional questions about religious affiliations. METHODS - The ”sensitive” questions ot the census were accepted without any obstacle in the whole population and backed up the present study together with the newly established religious atmosphere in the hospital of roman catholic Hospitaller Brothers of St. John of God, which was reopened on the 1st of July, 2000. The collection of data started in November 2000 ending in December 2001. All 98 full time employed physicians participated in the inquiry carried out by personal interviews guided by the same 51 questions. Following more than half a century span, the aim of the present study was to gain measurable information about the doctors’ unknown religious affiliation and its impact on clinical problems with ethical dimensions. RESULTS - All the doctors cooperated willingly in face-to-face interviews. There was a high proportion of religious affiliation (83 persons out of 98) without any sign of mysticism in the professional values. However, the pre-eminent role of psychological factors in the healing process was stressed, opposed to the simplified materialism of medicine. The same ideological pattern was represented while ranking other professions in the social hierarchy. No physicians experienced a conflict between their religious belief and professional activity in the dayto- day service. CONCLUSION - According to the extremely underpaid medical profession in Hungary, doctors of the new hospital do not believe that now they should tolerate their underpaid status as altruistic missionaries. However, they know exactly that balancing professionalism and business of medicine, is not a task for a single hospital but an urgent one of the whole society.]

Lege Artis Medicinae

[Quality assessment in the management of acute coronary syndromes]

ZÖLLEI Éva, PAPRIKA Dóra, VINCZE Dóra, KOVÁCS Katalin, RUDAS László

[INTRODUCTION AND METHODS - Quality monitoring activities are essential for improving the care of acute coronary patients. The aim of our study was to establish a registry and assess the adherence to widely used quality indicators. We investigated two groups of patients, those admitted to our Intensive Care Unit with the diagnosis of acute myocardial infarction (Group 1) and unstable angina (Group 2). RESULTS - Group 1. consisted of 173 patients, of whom 60% was eligible for thrombolysis. In 5 cases no acute reperfusion therapy was done. For reperfusion we used systemic thrombolysis in 74% and primary coronary angioplasty in 26%. The prehospital delay was 150 minutes, the ”door-to-needle” time and the ”door-toballoon” time were 30 minutes and 102 minutes, respectively. 95% of the patients received aspirin, 79% beta-blocker, 82% angiotensin converting enzyme inhibitor and 39% cholesterol lowering medications. Group 2. included 84 patients, most of them had high risk features according to the Braunwald classification and the American College of Cardiology, American Heart Association guideline. Coronary angiography was performed in 80 cases. Regarding revascularization, 43 patients underwent coronary bypass surgery, 30 percutan angioplasty with stent implantation in 18. In this group aspirin was given in 82, unfractionated heparin in 9, low molecular weight heparin in 49, glycoprotein IIb/IIIa inhibitor in 15 cases. 21 patients received intravenous nitroglycerin, 70 patients betablocker and 57 patients cholesterol lowering drugs. DISCUSSION - Quality management is extremely useful in assessing our practice, our shortcomings and developments.]

Lege Artis Medicinae

[Esomeprazole compared with lansoprazole in the treatment of erosive esophagitis]

NEMESÁNSZKY Elemér

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Lege Artis Medicinae

[MANAGEMENT OF GASTROINTESTINAL DISEASES DURING PREGNANCY]

NOVÁK János, TAKÁCS Tamás, ÚJSZÁSZY László, BENE László, OLÁH Attila, RÁCZ István

[Medical treatment of gastrointestinal diseases has developed dramatically in the past 10 years. However, management of gastrointestinal disorders in pregnancy is still a serious challenge and requires special expertise. This paper provides recommendations on the indications of gastrointestinal endoscopy and treatment options based on the best available evidence, primarily from large retrospective studies and case reports. Currently there are no generally applicable, widely accepted, evidence-based guidelines available on the treatment of pregnant women. The risks of the gastrointestinal disease versus those of the medications used to treat it should be considered with regard to the health of both the mother and the foetus in each individual case. The risks and benefits of treatment and the consequences of withholding treatment should be discussed with the patient, the obstetrician and any other clinicians involved, and should be carefully documented.]

Lege Artis Medicinae

[THE INFLUENCE OF GASTROESOPHAGEAL REFLUX DISEASE AND ITS TREATMENT ON ASTHMATIC COUGH]

BÖCSKEI Csaba, VICZIÁN Magdolna, BÖCSKEI Renáta, HORVÁTH Ildikó

[INTRODUCTION - Gastroesophageal reflux is known to cause chronic cough and it is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease in asthmatic patients with chronic cough, to analyse the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. PATIENTS AND METHODS - 126 asthmatic patients with chronic dry cough were studied. Diagnosis of gastroesophageal reflux disease was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring, while control group consisted of the patients without gastroesophageal reflux (negative pH results). The study group patients received the proton pump inhibitor esomeprazole (40 mg/day for three months) and standard treatment for asthma was continued. During the study pulmonary function tests (forced expiratory volume in one second and peak expiratory flow) were evaluated four times and the reflux symptom scores as well, using a questionnaire. RESULTS - The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for three months) not only diminished gastroesophageal reflux symptoms but also improved asthma outcome measures. Baseline pulmonary function values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another three months, the dose of inhaled steroids could be reduced with sustained therapy against gastroesophageal reflux. CONCLUSION - Our data shows that reflux events preceded coughing in most cases and that treatment of gastroesophageal reflux disease caused an improvement in different outcome measures of asthma suggest that gastroesophageal reflux disease worsens asthma and its treatment is of clinical importance in the effective management of these patients.]

Lege Artis Medicinae

[THE RELATIONSHIP BETWEEN GASTROESOPHAGEAL REFLUX DISEASE AND DAYTIME SLEEPINESS]

VÁRDI Visy Katalin, DEMETER Pál, CSABA Iván, GYULAI Nóra, SIKE Róbert, TÓTH G. Tamás, NOVÁK János, MAGYAR Pál

[INTRODUCTION - Recent studies have shown a potential relationship between gastroesophageal reflux disease and daytime sleepiness. The increased sleepiness is one of the symptoms due to decreased daytime performance caused by the breathing difficulties during sleep. The aim of this study was to analyse the potential relationship between gastroesophageal reflux disease (GERD) and daytime somnolence. PATIENTS AND METHODS - The Epworth Sleepiness Scale was used to assess daytime somnolence for 134 patients undergoing upper panendoscopy and it was correlated to the severity of the endoscopic findings, according to the Savary-Miller classification. Data was analysed witf multivariant linear and logistic regression analysis. RESULTS - A positive tendency was found between reflux disease and daytime somnolence along with the severity of GERD. In the case of the more severe type - Savary-Miller III - the increase of daytime somnolence was significantly higher (p<0,05), than in the case of nonerosive type wich represents the mildest degree of reflux disease. CONCLUSION - According to the results of the study the more severe forms of GERD can influence the effect on daytime somnolence.]

Lege Artis Medicinae

[TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE]

PAPP János

[In the acidic type of gastroesophageal reflux disease treatment is based on the use of proton pump inhibitors. Efficiency of the treatment is primarily assessed by the changes in symptoms. A long-term, continuous drug use is invariably necessary. In typical cases an increased dose or combination therapy is rarely required, however, in the presence of extraesophageal symptoms, the use of higher doses has been found to be beneficial. The minimum efficient drug amount is usually determined by gradually decreasing the dose. Surgery is mainly recommended for young patients, but it is indispensable in the management of complications or in volume reflux. Endoscopic antireflux therapy is still considered a clinical trial. Treatment of Barrett’s oesophagus by drugs or antireflux surgery does not decrease the incidence of Barrett’s cancer - the mostly recommended approach is endoscopic ablation.]

Lege Artis Medicinae

[The connection between gastroesophageal reflux disease and obstructive sleep apnoea]

DEMETER Pál, VÁRDI Visy Katalin

[Clinical knowledge on the gastroesophageal reflux disease has been increased with the subject of extragastrointestinal complications in the last decade. Because of cardiological, pulmonological, laryngeal and dental complications, an interdisciplinary approach is required. The non-cardiac chest pain, bronchial asthma, chronic bronchitis, chronic caugh, posterior laryngitis and acidic damage of dental enamel are the most important complications. Authors study a less common connection between the gastroesophageal reflux disease and obstructive sleep apnoea. Sleeping can be considered as a risk factor of the reflux event by itself, because of the decrease of primary peristalsis, producing of saliva, and acidic and volume clearance of oesophagus as well. During obstructive sleep apnoea negative intrathoracic pressure increases extremely, resulting in increased transdiaphragmatic gradient of pressure as well. In addition, the powerful movement of diaphragm twitches the lower oesophageal sphincter through the phrenoesophageal ligament. These two mechanism practically promotes the reflux event in patients with obstructive sleep apnea. The new challenge for the gastroenterologists is to further research this new connection, to play more active role in the complex therapy, and to have a new diagnostic approach of serious gastroesophageal reflux disease.]