Lege Artis Medicinae

[Competency list of the general practice, 2005]

KRAMER Imre

SEPTEMBER 15, 2006

Lege Artis Medicinae - 2006;16(08-09)

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Lege Artis Medicinae

[A new simple tool for tonometric determination of the pCO2 in the gastrointestinal tract]

BODA Domokos, TÁLOSI Gyula, KASZAKI József

Lege Artis Medicinae

[STATE-OF-THE-ART DIAGNOSIS AND TREATMENT OF PITUITARY ADENOMAS SECRETING GROWTH HORMONE]

CZIRJÁK Sándor

[The history of the treatment of pituitary adenomas that cause acromegaly is as long as that of neurosurgery. While in the first half of the past century the aim of surgery was to save the patient's life, later the radical removal of the tumour was coupled with an effort to decrease complications, morbidity and mortality to the minimum. Today, beside all these, the complete sparing of the remaining hypophyseal substance and restoration of normal pituitary function are also important goals. The achievement of these goals is efficiently served by recent advances in microscopy, the minimally invasive methods of craniotomy, the availability of endoscopy in neurosurgery, three-dimensional computerguided neuronavigation, intraoperative colour Doppler sonography, as well as intraoperative real-time MRI. Recent developments in pharmacological research have created new promising conservative treatment modalities that supplement surgery, including somatostatin analogues and growth hormone receptor agonists. Also as supplementary treatment to surgery, occasionally replacing it, new radiosurgical methods, such as stereotaxic radiation, gamma knife, and heavy particle irradiation have gained grounds in neurosurgical practice.]

Lege Artis Medicinae

[BRONCHUS ASSOCIATED LYMPHOID TISSUE LYMPHOMA]

HERTEL Katalin, ZSIRAY Miklós, SOLTÉSZ Ibolya

[INTRODUCTION - Primary lymphomas rarely occur in the lung. CASE REPORT - The authors present the case of an asymptomatic 61-year-old man. The patient was identified on routine chest X-ray having a streak infiltrate in the upper lobe of the right lung, which did not respond to antibiotics. On histological examination of the bronchoscopic specimen BALT- (bronchus associated lymphoid tissue) lymphoma was presumed. Since staging showed the disease to be localized, lobectomy was performed. The patient is symptom-free 16 months after surgery and there is no relapse. CONCLUSION - Although BALT-lymphomas are of low-grade malignancy in most of the cases, relapses can develop in the original organ or in other extra-nodal locations years later and BALTlymphomas may also transform into large-cell lymphomas of more aggressive behaviour.]

Lege Artis Medicinae

[DIAGNOSIS, DIFFERENTIAL DIAGNOSIS AND TREATMENT OF HYPERPROLACTINAEMIA]

IVÁN Gabriella, GÓTH Miklós

[Hyperprolactinaemia is one of the most common endocrine diseases. Besides hypothyroidism- associated hyperprolactinaemia and that arising as a side effect of certain drugs, the most common cause of hyperprolactinaemia is a pituitary microadenoma (<10 mm in diameter) or macroadenoma (≥10 mm) that produces prolactin (prolactinoma). In addition, several physiological conditions can elevate (mostly temporarily) the serum prolactin level, therefore, setting up the precise diagnosis requires careful evaluation of the patient’s history and the laboratory, clinical, and imaging findings. Moreover, macroprolactinaemia, which is usually not a pituitary tumour-related disease, should also be ruled out. Prolactinomas represent the most common form of functioning pituitary adenomas, accounting for 30-40% of such tumours. The typical clinical symptoms of hyperprolactinaemia may be modulated by the mass effect of macroadenomas. In women the disease typically manifests as menstrual disturbance of various degree, including primary or secondary amenorrhoea, oligomenorrhoea, short luteal phase, infertility and galactorrhoea. In men reduced libido, impotence, infertility, gynaecomastia and, rarely, galactorrhoea are the typical symptoms. Dopamine agonist therapy is the first choice of treatment. Dopamine agonist therapy (bromocriptine and the recently developed quinagolide and cabergoline) successfully lowers the serum prolactine level in nearly 90% of cases, and, importantly, it also reduces the size of the tumour in the majority of cases. This explains why today surgery and radiotherapy are only used in rare special cases of prolactinoma.]

Lege Artis Medicinae

[BREAST CANCER CARE: FROM PREVENTION TO SURVEILLANCE]

KAHÁN Zsuzsanna

[Breast cancer is the most common malignancy in women in developed countries. The development of most breast cancers is related to various hormonal effects, while 10% is associated with inherited gene mutations. Most of the primary prevention methods aim at decreasing the effects of hormones, but education on proper lifestyle is also an important risk-lowering method. The primary treatment of early breast cancer is usually breast-conserving surgery, either with the targeted removal of regional lymph nodes (by sentinel lymph node labelling) or with axillary block-dissection. The aim of postoperative radiotherapy is the eradication of the tumour cells left behind. Beside the locoregional tumour control this also plays a role in the prevention of recurrence or a secondary systemic dissemination. Adjuvant systemic treatments are used for the eradication of disseminated microscopic tumour foci. The use of modern adjuvant treatments may reduce death from the disease by up to 50%. The risks of relapse or death may be estimated based on established prognostic factors. While in low-risk patients it is not worth starting medical treatment, especially in view of the side effects, while in other cases chemo- or hormonal therapy may save the patient's life. The choice of the medical treatment should also depend on the patient's general health, the concomittant diseases and her preferences. The collaboration of the various specialists involved in the care of breast cancer patients can best take place at specialised breast centres that are equipped with the necessary technical basis, knowledge and professional experience.]

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Clinical Neuroscience

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

ÜNSAL Ünlü Ülkün, ŞENTÜRK Salim

Microdiscectomy (MD) is a stan­dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in­terlaminar lumbar discectomy (PELD) is another surgical op­tion that has become popular owing to reports of shorter hos­pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist’s costs), hospital stay, anesthetic drugs and materials, laboratory wor­kup, nur­sing care, and postoperative me­dication diffe­red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.

Lege Artis Medicinae

[Diagnosis and treatment of microvascular coronary heart disease. Specialities of conditions in Hungary]

SZAUDER Ipoly

[Invasive investigations show that in two-thirds of patients the myocardial ischaemia persists without obstructive coronary disease and any other heart conditions (INOCA). The underlying cause may be microvascular dysfunction (CMD) with consecutive microvascular coronary disease (MVD) and microvascular or epicardial vasospastic angina (MVA). The modern practice of clinical cardiology while using the developed non-invasive cardiac imaging permits exact measuring of the coronary flow with its characteristic indices. All of these improve the diagnosing of CMD-induced myocardial ischemia and provide opportunity to determine primary MVD cases. Since the recognition and treatment of MVD is significantly underrep­resented in the Hungarian medical care, the primary stable microvascular angina (MVA) is described in detail below with its modern invasive and non-invasive differential diagnosis and treatment, concerning especially its frequency provoked by high blood pressure and female coronary heart diseases. There are highlighted all recommended diagnostic procedures available under domestic conditions.]

Lege Artis Medicinae

[Focus on Lege Artis Medicinae (LAM)]

VASAS Lívia, GEGES József

[Three decades ago, LAM was launched with the goal of providing scientific information about medicine and its frontiers. From the very beginning, LAM has also concerned a special subject area while connecting medicine with the world of art. In the palette of medical articles, it remained a special feature to this day. The analysis of the history of LAM to date was performed using internationally accepted publication guidelines and scientific databases as a pledge of objectivity. We examined the practice of LAM if it meets the main criteria, the professional expectations of our days, when publishing contents of the traditional printed edition and its electronic version. We explored the visibility of articles in the largest bibliographic and scientific metric databases, and reviewed the LAM's place among the Hun­ga­rian professional journals. Our results show that in recent years LAM has gained international reputation des­pite publishing in Hungarian spoken by a few people. This is due to articles with foreign co-authors as well as references to LAM in articles written exclusively by foreign researchers. The journal is of course full readable in the Hungarian bibliographic databases, and its popularity is among the leading ones. The great virtue of the journal is the wide spectrum of the authors' affiliation, with which they cover almost completely the Hungarian health care institutional sys­tem. The special feature of its columns is enhanced by the publication of writings on art, which may increase Hungarian and foreign interest like that of medical articles.]

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

[Consensus statement of the Hungarian Clinical Neurogenic Society about the therapy of adult SMA patients]

BOCZÁN Judit, KLIVÉNYI Péter, KÁLMÁN Bernadette, SZÉLL Márta, KARCAGI Veronika, ZÁDORI Dénes, MOLNÁR Mária Judit

[Background – Spinal muscular atrophy (SMA) is an autosomal recessive, progressive neuromuscular disorder resulting in a loss of lower motoneurons. Recently, new disease-modifying treatments (two drugs for splicing modification of SMN2 and one for SMN1 gene replacement) have become available. Purpose – The new drugs change the progression of SMA with neonatal and childhood onset. Increasing amount of data are available about the effects of these drugs in adult patients with SMA. In this article, we summarize the available data of new SMA therapies in adult patients. Methods – Members of the Executive Committee of the Hungarian Clinical Neurogenetic Society surveyed the literature for palliative treatments, randomized controlled trials, and retrospective and prospective studies using disease modifying therapies in adult patients with SMA. Patients – We evaluated the outcomes of studies focused on treatments of adult patients mainly with SMA II and III. In this paper, we present our consensus statement in nine points covering palliative care, technical, medical and safety considerations, patient selection, and long-term monitoring of adult patients with SMA. This consensus statement aims to support the most efficient management of adult patients with SMA, and provides information about treatment efficacy and safety to be considered during personalized therapy. It also highlights open questions needed to be answered in future. Using this recommendation in clinical practice can result in optimization of therapy.]