Lege Artis Medicinae

[Breakthrough in restoring vision]

KATONA Ferenc

NOVEMBER 30, 2021

Lege Artis Medicinae - 2021;31(11)

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Lege Artis Medicinae

[Relationship of adolescents’ eating behavior and motivations with self-control and risk perception]

SZABÓ Katalin, PIKÓ Bettina

[Obesity and related diseases caused by unhealthy eating form a serious public health problem already in youth. In terms of prevention, it is essential to explore adolescents’ eating behaviors and factors influencing their diet. Our study aimed to explore adolescents’ eating behaviors, its motivations and their relation to self-control and risk perception related to eating behavior. Participants were 374 high school students (48% males; mean age: 16 years, S.D.=1.5) from Szeged and Bu­da­pest. Self-administered questionnaire was used for data collection which assessed socio-demographics, eating behaviors, mo­ti­vation, eating behavior related risk perception and self-control. Using factor analysis, we categorized eating behaviors (“junk food/drink consumption”; “health-oriented nutrition”; and “snacking and habit-oriented nutrition”), and eating motivations (“social, emotional and external motives”; “traditions and internal motives”; and “health motives”). According to correlation analysis, self-control was positively related to health-oriented nutrition and health motives and negatively to junk food/drink consumption and social, emotional and external motives. These two latter factors were associated with an increased risk perception as well. Our results draw the attention to strengthen self-control and explore the role of risk perception and eating motivations in school health education programs. ]

Lege Artis Medicinae

[Cardiovascular prevention 2021 – Guidelines of European Society of Cardiology 2021. Special considerations]

VÁLYI Péter, KÉKES Ede

[On 31 August 2021, the European Society of Cardiology published its guideline “Prevention of cardiovascular disease in clinical practice”. This guideline provides a comprehensive review about risk factors of atherosclerotic cardiovascular disease, their assessment, potential modifiers, treatment and prevention of the cardiovascular dis­ease itself at societal and individual levels respectively. The previous guideline issued 2016, had to be updated due to the recent significant advances in risk prediction of cardiovascular disease on atherosclerotic background and due to the beneficial effects of treatment, emerging new drugs and therapeutic targets. The risk assessment system has undergone a major overhaul and now predicts the risk of fatal and non-fatal cardiovascular events together over a 10-year horizon and over a lifetime. In the new guideline, age plays a more important role in risk classification than before. The risk assessment and staged management of apparently healthy people or patients with established atherosclerotic cardiovascular disease, diabetes mellitus and other specific diseases or conditions are detailed. The positive impact of influencing risk factors, the years of life gained can recently be presented in a lifetime perspective, which will help to make an individually tailored decision on the extent of interventions, while taking into account also the patient’s preferences.]

Lege Artis Medicinae

[The history of acute stroke care in Hungary ]

BERECZKI Dániel

[Stroke is one of the most frequent causes of death and the most important cause of permanent disability worldwide and also in Hungary. The Hungarian medical literature has mentioned this disease and has been giving recommendations for its treatment since 1690. Initially folk medicines, herbal preparations and phlebotomy were used as standard therapy. Later, cooling the head joined these methods. Pharmacy preparations emerged at the middle of the 19th century. From the middle of the 20th century, products of the pharmaceutical industry like blood flow enhancers and neuroprotective drugs were in the frontline of the acute care. Anti­hy­per­ten­sive, antithrombotic and lipid-lowering medications became part of stro­ke prevention. Imaging techniques – mainly computer tomography of the brain and ultrasound examination of the cervical large arteries – have radically changed the diagnostics of cerebrovascular diseases from the middle of the 1980s. Since the 1990s, diagnostic and therapeutic decisions are based on reliable evidence from good quality clinical trials. Since the beginning of the 21st century, reperfusion treatments (intravenous thrombolysis and mechanical thrombectomy) re­present the most effective emergency care. The current direction is the extension of the therapeutic time-window of reperfusion treatments based on sophisticated neruoimaging. This review provides a brief summary of the development of stroke care in the last three and a half centuries as reflected in the Hungarian medical literature. ]

Lege Artis Medicinae

[New approach in the treatment of elevated lipoprotein(a)]

KARÁDI István

[Lipoprotein(a) is a genetic trait, resembling the structure of low density lipoprotein (LDL). Due to its high atherogenicity it is an independent risk factor for atherosclerotic vascular diseases. External impacts (as dietary and lifestyle measurements) do not decrease its plasma level thus the primary and secondary cardiovascular prevention prefers primarily the drug therapy. How­ever, widely used lipid lowering agents do not have any impact on its plasma level. Recently, the PCSK9 inhibitor monoclonal antibodies (evolocumab and alirocumab), the small interfering mRNA inclisiran, and particularly the antisense oligonucleotide targeting the LPA mRNS, further the clinical use of pelacarsen produced significant lipoprotein(a) lowering effect. Beyond the atherosclerotic vascular diseases, lipoprotein(a) plays an important role in the pathogenesis of the calcific aortic valvular stenosis, as well. The usage of the above-men­tioned biological therapies in this condition is also promising. ]

Lege Artis Medicinae

[A practical demonstration of critically assessing health economic analyses]

MERÉSZ Gergô, DÓCZY Veronika, HÖLGYESI Áron, NÉMETH Gergely

[During the critical assessment of health economic analyses, it is useful to present their uncertainties within a standardized framework. The aim of this research is to demonstrate how to use the procedural framework to identify, quantify and interpret such uncertainties through the examples of cell and gene therapies. Based on the review of methodological documents used by the Di­vi­sion of Health Technology Assessment at the National Institute of Pharmacy and Nutrition of Hungary (NIPN), and formalizing the current practice in its own framework, first we identify the uncertainty factors of the analysis and then examine their quantification in the submitted health economic model. Subsequently, we interpret their impact on the cost-effectiveness conclusion and determine the significance of all uncertainty factors. By applying the framework on the cost-effectiveness analysis of tisagenlecleucel as our example, we identified the following uncertainty factors. Although it is challenging to quantify, there is significant uncertainty related to the effectiveness of comparator procedure, which is due to single-arm clinical trials and the use of secondary data sources. The discount rate had a quantifiable and significant impact on both health gains and costs. Methods used to estimate relative effectiveness are also quantifiable but have less of an impact on the conclusions. The presented framework proved to be appropriate, with some li­mitations to document and arranging uncertainties of health economic analyses. It is advised to use this framework for reimbursement decisions for public financing. A possible subject of methodological development is the further formalization of identifying factors of uncertainty.]

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Lege Artis Medicinae

[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

Clinical Neuroscience

[Experience with natalizumab-treatment at Semmelweis University]

GOMBOS Barbara, ILJICSOV Anna, BARSI Péter, HEGEDÛS Katalin, SIMÓ Magdolna

[Multiple sclerosis is an autoimmune demyelinating disorder of the central nervous system. During the last two decades, numerous disease modifying drugs have been introduced for the treatment of the relapsing-remitting form of the disease. Since 2010, natalizumab (NTZ) treatment has been used as a second-line therapy for patients with breakthrough disease. In comparison to conventional immunomodulant drugs, NTZ has a more specific effect in that it prevents the entry of immune cells into the central nervous system without interfering with systemic immune response. The efficacy and the safety of NTZ have been confirmed by several studies. The most severe side-effect of NTZ is progressive multifocal leukoencephalopathy, which has been associated with an increased incidence in patients with anti-JCV antibody positivity, and in those who have been undergoing NTZ treatment for over two years and who have received prior immunosuppressive therapy. In the present study, our experience with natalizumab treatment of 37 patients at the Department of Neurology of Semmelweis University during the last 6 years is presented. We have observed a significant decrease of disease activity in our patients; in many cases the disease has become inactive both clinically (36/37) and radiologically (34/37). The patients’ quality of life has improved significantly during the treatment. In accordance with the literature, we confirm that NTZ is a highly effective treatment in a carefully selected patient group, and can be administered without significant inconvenience to the patient. ]

Clinical Neuroscience

Posterior reversible encephalopathy syndrome as an initial manifestation of systemic lupus erythematosus

AYAS Özözen Zeynep, ÖCAL Öncel Ruhsen, GÜNDOGDU Aksoy Asli

Posterior reversible encephalopathy syndrome (PRES) is a disorder which is diagnosed with its characteristic clinical and radiological findings, typically resolves with treatment. The prevalence of PRES in systemic lupus erythematosus (SLE) patients is not exactly known. A systemic disorder frequently appears as a presenting symptom in SLE. However, in rare cases, the disease starts with a neurological manifestation. Here we report a 35-year-old woman presenting with a headache and blurred vision. She had neurologic symptoms and cerebral lesions on magnetic resonance imaging (MRI) suggesting PRES. The patient was diagnosed with SLE during the etiological investigation of PRES. In this article, we aimed to emphasize that PRES as an initial presentation of SLE.

Clinical Neuroscience

A case with reversible neurotoxicity induced by metronidazole

EREN Fulya, ALDAN Ali Mehmet, DOGAN Burcu Vasfiye, GUL Gunay, SELCUK Hatem Hakan, SOYSAL Aysun

Background - Metronidazole is a synthetic antibiotic, which has been commonly used for protozoal and anaerobic infections. It rarely causes dose - and duration - unrelated reversible neurotoxicity. It can induce hyperintense T2/FLAIR MRI lesions in several areas of the brain. Although the clinical status is catastrophic, it is completely reversible after discontinuation of the medicine. Case report - 36-year-old female patient who had recent brain abscess history was under treatment of metronidazole for 40 days. She admitted to Emergency Department with newly onset myalgia, nausea, vomiting, blurred vision and cerebellar signs. She had nystagmus in all directions of gaze, ataxia and incompetence in tandem walk. Bilateral hyperintense lesions in splenium of corpus callosum, mesencephalon and dentate nuclei were detected in T2/FLAIR MRI. Although lumbar puncture analysis was normal, her lesions were thought to be related to activation of the brain abscess and metronidazole was started to be given by intravenous way instead of oral. As lesions got bigger and clinical status got worse, metronidazole was stopped. After discontinuation of metronidazole, we detected a dramatic improvement in patient’s clinical status and MRI lesions reduced. Conclusion - Although metronidazole induced neurotoxicity is a very rare complication of the treatment, clinicians should be aware of this entity because its adverse effects are completely reversible after discontinuation of the treatment.

Clinical Neuroscience

[BRAIN LATERALIZATION AND SEIZURE SEMIOLOGY: ICTAL CLINICAL LATERALIZING SIGNS]

HORVÁTH A. Réka, KALMÁR Zsuzsanna, FEHÉR Nóra, FOGARASI András, GYIMESI Csilla, JANSZKY József

[Clinical lateralizing signs are the phenomena which can unequivocally refer to the hemispheric onset of epileptic seizures. They can improve the localization of epileptogenic zone during presurgical evaluation, moreover, their presence can predict a success of surgical treatment. Primary sensory phenomena such as visual aura in one half of the field of vision or unilateral ictal somatosensory sensation always appear on the contralateral to the focus. Periictal unilateral headache, although it is an infrequent symptom, is usually an ipsilateral sign. Primary motor phenomena like epileptic clonic, tonic movements, the version of head ubiquitously appear contralateral to the epileptogenic zone. Very useful lateralization sign is the ictal hand-dystonia which lateralizes to the contralateral hemisphere in nearly 100%. The last clonus of the secondarily generalized tonic-clonic seizure lateralizes to the ipsilateral hemisphere in 85%. The fast component of ictal nystagmus appears in nearly 100% on the contralateral side of the epileptic focus. Vegetative symptoms during seizures arising from temporal lobe such as spitting, nausea, vomiting, urinary urge are typical for seizures originating from non-dominant (right) hemisphere. Ictal pallor and cold shivers are dominant hemispheric lateralization signs. Postictal unilateral nose wiping refers to the ipsilateral hemispheric focus compared to the wiping hand. Ictal or postictal aphasia refers to seizure arising from dominant hemisphere. Intelligable speech during complex partial seizures appears in non-dominant seizures. Automatism with preserved consciousness refers to the seizures of non-dominant temporal lobe.]