Lege Artis Medicinae

[Bacterial contamination and irritable bowel syndrome]

NOVÁK János

MARCH 22, 2012

Lege Artis Medicinae - 2012;22(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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[Epidemiological surveillance systems used by international organisations in military crisis management operations]

KOPCSÓ István, KISS Antal Zsolt

[Facing new challenges and growing requirements, the renewal and adjustment of doctrines, methods and technology is an indispensable progressive need for modern militaries. In order to achieve the maximal protection of troops and conservation of fighting strength, innovation is continuous and has greatly accelerated in the whole spectrum of Force Health Protection. Owing to the development of technology, portable capabilities that had been available only in the hinterland have become available in the military medical support area. Utilising mobile information technology solutions, the continuous, real-time information flow between the tactical level medical units and the higher level medical analysts and decision makers has become technically feasible, which results in a significant widening of epidemiological surveillance capabilities as well. We discuss the current challenges of expeditionary- type military operations and their general epidemiological aspects and the morbidity reporting and monitoring systems used in international military missions. Furthermore, we overview the milestones of the development of the NATO near-real-time epidemiological surveillance system, the NATO Deployment Health Surveillance Capability, which functions as a branch of the Budapestbased multinational NATO Centre of Excellence for Military Medicine.]

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[Clinical aspects of ischaemic bowel disease]

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[Decreased blood flow through the intestines leads to mesenteric ischaemia, which is characterised by cellular damage due to the lack of oxygen and nutrients. Extensive collateralisation between splanchnic vessels serves as a protective mechanism against ischaemia. Intestinal ischaemia can be classified on the basis of its timing, location and the vessels involved. Acute mesenteric ischaemia can result from arterial embolisation, arterial or venous thrombosis, or vasoconstriction secondary to systemic circulation disorder associated with hypovolaemia. Chronic mesenteric ischaemia develops as a consequence of partial or complete occlusion of splanchnic vessels. Colonic ischaemia is mainly caused by a limited circulation disorder of the inferior mesenteric artery. Mortality rates for the various forms of acute mesenteric ischaemia are different. However, early diagnosis before bowel infarction might improve survival. This paper summarises the cilical aspects, diagnosis and therapeutic options of intestinal ischaemia.]

Lege Artis Medicinae

[The new British recommendations for the treatment of lower back pain on the basis of the new NICE guidelines - comparison with the Hungarian therapeutic practice]

VERECKEI Edit, PALKONYAI Éva, SIMONCSICS Eszter, APÁTHY Ágnes, TEMESVÁRI I. Péter

[The new NICE guidelines on lower back pain emphasise the importance of clinical assessment. Radiological imaging methods are used primarily to exclude severe diseases, such as tumour, infection, trauma or inflammation. It’s crucial to inform patients and encourage them to use self-management and stay active. Pain management is guided by the analgesic ladder. A complex physical and psychological treatment is used, which involves a structured exercise programme, manual therapy and acupuncture, taking into account the preferences of the patient. Depending on the aetiology, surgical intervention should be considered in therapy-resistant cases. Finally, the authors compare the above guidelines with the Hungarian practice in this field.]

Lege Artis Medicinae

[Possibilities of applying basis/bolus method in treatment of adolescent with type 1 diabetes mellitus]

BLATNICZKY László

[INTRODUCTION - Since the end of the pastcentury, the basis/bolus method has been adeterminate factor of adjusting insulin thera-py. Experiences with insulin pump treatmentprove that well-quantified and adequatelytimed basal insulin treatment can fully com-pensate for the diurnal glucose-producingactivities of the liver and the diurnal changesin the activity of insulin receptors. Suitablyselected basal insulin treatment can, there-fore, keep the changes in blood sugar levelthat are dependent of the diet’s carbohydratecontent well under control. CASE REPORT - By presenting the approxi-mately five-year treatment of an adolescentboy, the author presents the current options(and failures) of insulin therapy that might beused with more or less success. Each treat-ment approach had its place in the variousstages of the patient’s diabetes. Nevertheless,insulin pump therapy, admittedly the moststate-of-the-art method today was unsuccess-ful due to patient’s lack of compliance, thusthis treatment had to be stopped. Still, on thebasis of the experiences with insulin pumptherapy, the restored intensive-conservativetreatment was set up on glargine basalinsulin, defining doses of bolus in correlationwith 10 grams of carbohydrate, which madethe diet less strict. This approach resulted ina considerable improvement of the patient’smetabolic profile. CONCLUSION - The right choice of thedoses and efficacy curve of basal insulin isessential for achieving a good metabolic bal-ance during intensive-conservative therapy.In case of deteriorating metabolic balance,suspending the inefficient insulin pump ther-apy is justified and means no disadvantagefor the patient, as long as the subsequentadjustment is prudent. By defining doses of ashort-acting bolus insulin analogue in corre-lation with carbohydrate intake along withglargine therapy permits adaptation to themetabolism of patients with poor compli-ance and unsatisfactory lifestyle - in expec-tation of better results. ]

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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.]

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LAM Extra for General Practicioners

[VITAMIN D TREATMENT: HORMONE THERAPY FOR PATIENTS WHO NEED IT OR SIMPLY A SUPPLEMENTATION FOR EVERYONE?]

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[Various medical associations issue different recommendations for the prevention and treatment of vitamin D deficiency. These significant differences are partly explained by the different definition of normal vitamin D level and the use of completely different mathematical models to predict the increase in vitamin D level as a response to therapy. According to the Institute of Medicine (IOM), the target vitamin D level is 20 ng/ml, whereas the Endocrine Society (ES) recommends 30 ng/m as the miminum target value. According to the ES, a 1 ng/ml increase of vitamin D level can be reached by a daily intake of 100 NE, while the IOM recommends 3.6 ng/ml. Moreover, the IOM states that the effect of therapy on serum level is nonlinear. These differences show that the ES and IOM have different views on the risk of adverse effects. The IOM recommends 400 IU vitamin D daily for children younger than 1 year, 800 IU for those above 70 years and 600 IU/per day for everyone else. The ES recommend 400-1000 IU daily for all infants and 1500- 2000 IU for adults. Screening, however, is not recommended by either society. To decrease uncertainty concerning the side effects of higher-dose vitamin D treatment, it is important to understand, use and support the function of the pharmacovigilance system of the pharmaceutical industry that manufactures and markets various (prescription, over-the-counter) preparations. This is what the author aims to highlight in the second part of this article. Using this system, both the doctor and the patient can help support and accept the justification of higher-dose vitamin D therapy.]

Lege Artis Medicinae

[Treatment of clubfoot with the Ponseti method]

KISS Sándor, TEREBESSY Tamás, HORVÁTH Nikoletta, DOMOS Gyula, GRESITS Orsolya, SZŐKE György

[INTRODUCTION - Congenital clubfoot is a severe developmental disorder. Without treatment, only the lateral border of the foot can be loaded and the sole faces the contralateral side. Good results can usually be achieved with early redression by serial casting (generally from the first week after birth) followed by extensive surgery at age six months (Achilles tendon lengthening, capsulotomy of the talo-crural and subtalar joints). The above procedure has been revolutionised by the method described by Ignacio Ponseti based on his own experiences, which has modified the casting technique and has also radically changed the surgical intervention. In this paper we report our experiences with Ponseti’s method and draw attention to this less invasive procedure. PATIENTS AND METHODS -The essence of Ponseti’s techniqe is reposition of the talonavicular joint, for which the foot is corrected in a different way compared with previous practice. Following redression for 8-10 weeks, percutaneous complete Achilles tenotomy is performed and the foot is fixed for further three weeks. A special orthesis is worn in the following 6 months for 24 hours a day and the same ortézis is suggested for overnights afterwards. In our institution, 171 clubfeet (45 unilateral, 126 bilateral; 84 right, 87 left; 25 girls, 83 boys) were treated between 2007 and 2012. Our results were evaluated with the help of the Pirani score, which is a widely used method for assessment of clubfoot treatment. RESULTS - Results were evaluated at the beginning of the treatment, at the end of redression and after percutaneous Achilles tenotomy. Pirani scores were 4.54±1.30; 1.48±1.02 and 0.59±0.45 respectively. The average dorsal flexion of the ankle joints was 23±12 degrees. CONCLUSION - Our own observations support the good results published in the literature, therefore the less invasive Ponseti method is suggested for the primary treatment of congenital clubfoot.]