Lege Artis Medicinae

[Changes to Gastroenterology Specialist Training Following Hungary’s Accession to the European Union]

LONOVICS János

NOVEMBER 30, 2004

Lege Artis Medicinae - 2005;15(01 klsz)

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Lege Artis Medicinae

[PHARMACEUTICAL PREVENTION OF THE UPPER GASTROINTESTINAL SIDE-EFFECTS OF NSAID THERAPY]

HERSZÉNYI László, TULASSAY Zsolt

[Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain and inflammation in patients with rheumatoid arthritis and osteoarthritis. However, they are also associated with a significant risk of gastrointestinal events with clinical and economic consequences. It is mandatory to rationalise the use of different NSAID treatment strategies in patients with varying degrees of gastrointestinal and cardiovascular risk. In patients for those aged <65 years with no previous gastrointestinal event and not concurrently on aspirin (low risk patients), the use of an NSAID should be considered as appropriate. For patients with a previous gastrointestinal event (high risk patients) or who concurrently received aspirin, an NSAID alone should be rated as inappropriate and either a coxib or selective cyclooxygenase-2 inhibitor, or an NSAID + proton pump inhibitor combination is considered as appropriate. Finally, for patients aged >65 years with a previous gastrointestinal event and on aspirin (patients with very high risk) a coxib in conjunction with a proton pump inhibitor is considered to be the best therapeutic strategy.]

Lege Artis Medicinae

[NOVEL ASPECTS OF COX-2 SELECTIVE NON-STEROIDAL ANTI-INFLAMMATORY DRUG THERAPY]

MŰZES Györgyi

[The cyclooxygenase (COX) metabolic pathway and prostaglandin production appear to play a causal role in the promotion and progression of human cancers. Recently COX-2 has received a great deal of interest since it is frequently overexpressed in a wide spectrum of cancers and precancerous lesions. Furthermore, elevated production of prostanoids (particularly PGE2) via COX-2 is associated with several pro-carcinogenic effects including increased proliferation, apoptosis resistance, tumor neoangiogenesis and invasiveness, host immunosuppression, and altered xenobiotic metabolism. Inhibitors of COX-1 and COX-2 (aspirin and most other nonsteroidal anti-inflammatory drugs) and of COX-2 alone (e.g. coxibs) have shown cancer preventive efficacy in epidemiological studies, experimental studies and in human clinical trials. Due to their improved side effect profile, COX-2 selective inhibitors appear to hold substantial promise for long-term administration in the setting of cancer prevention. Emerging data suggest that these agents may have potential in cancer treatment as well. In addition recent results indicate that COX-2 enzyme is also overexpressed in inflammatory processes of the central nervous system, e.g. in Alzheimer’s disease, so its suppression could offer a possible new therapeutic strategy even in the prevention and treatment of Alzheimer’s disease.]

Lege Artis Medicinae

[FROM ASPIRIN TO COXIBS - JANUS-FACE OF THE NONSTEROIDAL ANTI-INFLAMMATORY THERAPY]

NEMESÁNSZKY Elemér

[Since the introduction of aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) proved to be the most commonly used drugs in the world. One of the major factors limiting their use is gastrointestinal toxicity. It has long been recognised that NSAID use is associated with serious, sometimes life-threatening adverse effects, like gastrointestinal ulcers, bleeding and perforation. Recent studies have indicated that the combination of NSAID and aspirin significantly increases the risk of complications. Aspirin is like a two-edged sword, balancing cardiovascular prevention with the risk of gastrointestinal side effects. Past history of ulcer carries the highest individual risk and other contributing factors include age, concurrent anticoagulation, cortocisteroid therapy, as well as high-dose or multipleforms of NSAID use. The mechanism of action of NSAID is to inhibit prostaglandin production through cyclooxygenase (COX). The inhibition of COX-2 isoenzyme reduces inflammatory-mediated prostaglandins, while the inhibition of COX-1 reduces the level of prostaglandins needed for normal protecting mechanism of the gastric mucosa. Non-selective NSAID has impact on both COX-enzymes, while selective COX-2-inhibitors (such as coxibs) exert their effects without affecting mucosal defence significantly. It is important to note that the risk of complications can not be reduced to zero by any therapeutic approach. The most appropriate treatment modality is to administer PPI co-therapy for the sake of gastro-protection, especially in high-risk cases. Histamine-2-receptor antagonists are not effective in reducing ulcer and complication in that particular group of patients. It has turned out that the inhibition of the synthesis of COX-2 by rofecoxib increases the risk of developing thromboembolic events and myocardial infaction. This has led to the withdrawal of Vioxx from the market on 30. 09. 2004. Studies conducted in recents years shed new light on numerous beneficial effects of NSAID other than alleviate pain, cure inflammatory processes and diminish higher temperature. The incidence of colon polyps and adenomas as well as cancers is reduced among people who are on maintanance NSAID therapy. The process of stone formation in the biliary tract is also reduced in patients who are on NSAID treatment. Development of Alzheimer's disease seems to be hindered, however, this finding can not yet be considered as evidence based.]

Lege Artis Medicinae

[GASTROINTESTINAL COMPLICATIONS OF LOW-DOSE ASPIRIN TREATMENT]

RÁCZ István

[Since its synthesis more than 100 years ago aspirin has become one of the most successful drug. Low-dose, long-term aspirin therapy reduces the risk of myocardial infarction, the frequency of cerebral stroke and also reduces the mortality of peripheral arterial diseases and systemic embolisms. With aspirin therapy becoming more and more widespread current knowledge is also getting more concerned about the gastrointestinal risks and beneficial effects. Aspirin therapy causes gastrointestinal damages by the inhibition of endogenous prostaglandin synthesis. The ion trapping effect and the injury of mucosal barrier as well as the inhibition of platelet aggregation are also responsible for gastrointestinal damages. According to epidemiological studies lowdose aspirin treatment increases the risk of acute upper gastrointestinal bleeding by 1.5-2.0 fold. However, endoscopic studies indicate that gastroduodenal ulcers may develop even in 10 percent of cases on long term aspirin treatment, most frequently in a symptom-free form. Older age as well as Helicobacter pylori infection increase the risk of aspirin induced ulcers. Beside Helicobacter pylori eradication therapy, preventive proton-pump-inhibitor treatment and the widespread of new non-toxic aspirin derivates may decrease the risk of gastrointestinal complications. Capsule endoscopy also seems to be a promising diagnostic tool for detecting aspirin induced small bowel erosions and ulcers. Long-term aspirin treatment increases the risk of acute bleeding from large bowel diverticulas especially with non-steroidal anti-inflammatory drug co-therapy present. Long-term, low-dose aspirin treatment is a promising method for the chemoprevention of colorectal cancers.]

Lege Artis Medicinae

[Gastrointestinal Protective Efficacy of Esomeprazole Comparative Studies in the International Literature]

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[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

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[The connection between the socioeconomic status and stroke in Budapest]

VASTAGH Ildikó, SZŐCS Ildikó, OBERFRANK Ferenc, AJTAY András, BERECZKI Dániel

[The well-known gap bet­ween stroke mortality of Eastern and Western Euro­pean countries may reflect the effect of socioeconomic diffe­rences. Such a gap may be present between neighborhoods of different wealth within one city. We set forth to compare age distribution, incidence, case fatality, mortality, and risk factor profile of stroke patients of the poorest (District 8) and wealthiest (District 12) districts of Budapest. We synthesize the results of our former comparative epidemiological investigations focusing on the association of socioeconomic background and features of stroke in two districts of the capital city of Hungary. The “Budapest District 8–12 project” pointed out the younger age of stroke patients of the poorer district, and established that the prevalence of smoking, alcohol-consumption, and untreated hypertension is also higher in District 8. The “Six Years in Two Districts” project involving 4779 patients with a 10-year follow-up revealed higher incidence, case fatality and mortality of stroke in the less wealthy district. The younger patients of the poorer region show higher risk-factor prevalence, die younger and their fatality grows faster during long-term follow-up. The higher prevalence of risk factors and the higher fatality of the younger age groups in the socioeconomically deprived district reflect the higher vulnerability of the population in District 8. The missing link between poverty and stroke outcome seems to be lifestyle risk-factors and lack of adherence to primary preventive efforts. Public health campaigns on stroke prevention should focus on the young generation of socioeconomi­cally deprived neighborhoods. ]

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[The Comprehensive Aphasia Test in Hungarian]

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[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. ]

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[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

Lege Artis Medicinae

[Thiazide- or thiazide-like diuretics should be used in the treatment of patients with hypertension? Particularities of the situation in Hungary]

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[Diuretics have remained the cornerstone of the antihypertensive treatment since their widespreading in the 1960s. According to the 2018 ESC/ESH Guidelines for the management of arterial hypertension, in the absence of evidence from direct comparator trials and recognizing that many of the approved single-pill combinations are based on hydrochlorothiazide, this drug and thiazide-like indapamide can be considered suitable antihypertensive agents. In the 2018 Hungarian guidelines indapamide is named as the most efficacious diuretic in the treatment of patients with hypertension. The aim of the publication is redefining thiazide- and thiazide-like diuretic use in the treatment of hypertensive patients, with particular attention to presently available hydrochlorothia­zide and indapamide, and their combination drugs in Hungary.]