Lege Artis Medicinae

[Axel Munthe – “…who found the way to every soul”]

FALVAY Dóra

FEBRUARY 24, 2022

Lege Artis Medicinae - 2022;32(01-02)

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Lege Artis Medicinae

[Non-alcoholic fatty liver disease]

BAFFY György

[Non-alcoholic fatty liver disease is estimated to affect 25% of the global population. It is often joining other metabolic disorders and features a heterogeneous natural history. Significant liver injury is unlikely to develop from steatosis, while a third of steatohepatitis cases will progress into cirrhosis and as a severe complication may lead to primary liver cancer. The probability of these severe outcome increases with the degree of liver fibrosis and with the prevalent type 2 diabetes and two or more metabolic risk factors. Regardless of its stage, non-alcoholic fatty liver disease is in­creasing the susceptibility for cardiovascular diseases, diabetes and all malignancies, and as a result is shortening the life expectancy. However, general awareness of the disease among healthcare professionals and their patients remains limited. Lack of approved medications for the disorder is likely a major contributor to this discrepancy. Since the disease primarily stems from sustained caloric excess, lifestyle modification including Mediterranean type diet, avoidance of alcohol consumption, and regular physical activity are the mainstay of management. Better education campaigns may improve patient compliance and enhance the recognition and acceptance of this condition within primary care, in parallel with the introduction of two-step fibrosis screening to achieve more efficient identification and management of the high-risk patients. ]

Lege Artis Medicinae

[Main features of cardiovascular rehabilitation in post-acute Covid-19]

JENEI Zoltán, HORVÁTH Judit

[The COVID-19 pandemic caused by SARS-CoV-2 is a significant challenge worldwide. Cornerstones of in-patient management of this pandemic which harms predominantly the respiratory system are the acute and intensive care. However, the rehabilitation plays a key role in improving the functional status and quality of life of survivors and reducing the impact of complications. As estimated, 40-50% of discharged patients require some form of medical support and 4-5% of them require inpatient rehabilitation. In addition to the respiratory system involvement, cardiovascular effects caused by COVID-19 (heart failure and myocarditis, acute coronary syndrome, arrhythmia, venous thromboembolism) are part of the ongoing systemic inflammatory processes and may affect 7-28% of hospitalized patients and lead to long-term deterioration in quality of life and loss of work capacity. Based on available scientific databases, expert consensus and the recommendations of European professional societies, this summary presents the recommended method, conditions and intensity of post-Covid cardiac rehabilitation including physical training exercises. The summary concerns also the recommended conditions for re­turn to work and sporting activities. Struc­tured exercise training is a very important and low-risk component of cardiac rehabilitation, reducing cardiovascular complications, thromboembolic complications, sys­temic inflammation and mortality, improving functional recovery and endothelial function. The planning of physical training should be preceded by a complex assessment of patients. Assessments of risk, capacity and function are needed to select the intensity, frequency and mode of indivi­dualized training. This should be combined with appropriate secondary preventive medication, monitoring, diet therapy and psychotherapy in accordance with respected principle of gradual progression. Finally, the consensus recommendations suggest that home-based and tele-rehabilitation should play a prominent role, considering the epidemiological and capacity constraints that also affect rehabilitation. ]

Lege Artis Medicinae

[Cardiovascular prevention 2021 – Guidelines of European Society of Cardiology 2021. Prevention at the population level And Disease specific cardiovascular prevention]

VÁLYI Péter, KÉKES Ede

[In our four-part publication we review the current state of cardiovascular prevention based on the European Society of Car­dio­logy Guidelines 2021. In part 1 we reviewed the risk factors, risk assessment, age-specificities, the influencing factors, including diabetes mellitus and chronic kidney disease. In part 2 we concerned comorbidities affecting the cardiovascular risk. In part 3 we reviewed the personalised cardiovascular prevention and the management of specific risk factors, including optimisation of life style factors, management of lipid levels and high blood pressure and anti­thrombotic therapy. This part 4, we review the community level preventive measures (physical activity, diet, smoking habits and alcohol consumption) and the importance of governmental and non-governmental interventions. We provide a brief summary about the principles of cardiovascular prevention in individuals with coronary artery disaese, heart failure, cerebrovascular dis­eases, lower extremity artery disaese, chronic kidney disease, atrial fibrillation, and in multimorbid patients.]

Lege Artis Medicinae

[Options for assessing the quality of postoperative pain relief: unidimensional scales]

LOVASI Orsolya, LÁM Judit, LÉBER Andrea, GAÁL Péter

[The measurement of the quality of postoperative pain relief receives increasing attention in clinical practice since the not properly treated pain has several negative consequences for both the patients and the health care providers. An important component of the evaluation of the quality of care is the measurement of patient outcomes, which needs regular pain assessments and reliable pain assessment tools. The main goal of our paper is to review the literature on scales and pain assessment tools for postoperative pain assessment, the systematic literature search of which was performed by the PICO (population, intervention, control, and outcomes) technique. We found 396 accessible and evaluable articles in total, and out of them we summarized the results of the most important 31 in English and 3 in Hungarian. Organisations in the field of pain relief recommend the regular assessment of postoperative pain by unidimensional and multidimensional scales. Among unidimen­sional scales, we compared the Numerical Rating Scale (NRS), the Visual Analogue Scale (VAS) and the Verbal Descriptor Scale (VDS) with one another by discussing their advantages and limitations in measuring the intensity of postoperative pain. Al­though in clinical practice NRS is the most widely used one, VAS is more sensitive in the detection of changes and the best for statistical analysis. The advantage of VDS is that no significant differences can be detected in the interpretation of its results. At the same time, the application of VAS is the most difficult and the least preferred by patients and not always applicable immediately after the operation. The VDS is the least sensitive measurement tool, whose results are influenced by differences of the patients’ verbal interpretation, thus it is not applicable among patients with a weak vocabulary. In general, the main advantage of unidimensional scales is that they are fast and easy to use, but they measure only one dimension of pain, namely its intensity, and the association between the in­tensity ratings, the patients' subjective ex­perience of pain and its observable consequences are not unequivocal in certain cases. Consequently, when the circumstances permit, the use of multidimensional measurement tools should be considered.]

Lege Artis Medicinae

[Paradigm shift in the treatment of osteoarthrosis and the importance of prevention today]

DÖMSE Eszter

[Osteoarthrosis is a major burden on our society, both in terms of health affairs and health economy. The increasing strain on joints by competitive sports and the grow­ing prevalence of sedentary lifestyle are coupled main factors behind the increas­ing occurence of osteoarthritis in younger generations. Its pathomechanism is re­cently recognised to be a combination of inflammatory and degenerative processes. Concerning the serious and even quality of life worsening outcomes and its growing and spreading prevalence, the role of prevention has become crucial. This study reviews the preventive options, emphasiz­ing the importance of recreational sport and physical activities, while presenting also the new generation of chondroprotective agents. ]

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Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Clinical Neuroscience

[The Comprehensive Aphasia Test in Hungarian]

ZAKARIÁS Lilla, RÓZSA Sándor, LUKÁCS Ágnes

[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. ]

Lege Artis Medicinae

[History of vaccine production in Hungary ]

ÓCSAI Lajos

[This study presents the complete history of the Hungarian vaccine production, partly in association with the process of fighting vaccine-preventable infectious diseases, and underlines the fact that every government actively contributed to the age-adjusted mandatory vaccination schedule of the past 140 years. It demonstrates the various achievements from the smallpox lymph production through the launch of diphtheria serum production at Phylaxia and the establishment of the National Public Health Institute (OKI) with its vaccine production and the later institutional transformation of OKI into Humán as economic corporation to its closure. Among all OKI’s vaccine production activities, this study focuses on the production of influenza vaccines, due to its international importance in the 1960s and 1970s. The vaccine production against diphtheria tetanus and pertussis stands out from Humán’s activities, and the tetanus component of this vaccine is still used in the products of a multinational vaccine manufacturer. ]

Lege Artis Medicinae

[The Great Acceleration]

BRYS Zoltán