Lege Artis Medicinae

[Disorders of despair]

BÁNFALVI Attila

OCTOBER 20, 2010

Lege Artis Medicinae - 2010;20(10)

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Lege Artis Medicinae

[Successful localization of an insulinoma with angiography]

BAKÓ Barnabás, LÁZÁR István, TARKÓ Erzsébet, OROSZ Péter

Lege Artis Medicinae

[Why are the screening facilities in Hungary unexploited?]

DÖBRŐSSY Lajos, KOVÁCS Attila, DÖBRŐSSY Bence, BUDAI András, BONCZ Imre, MARGITAI Barnabás, KOÓS Tamás

[In Hungary, as a component of the National Public Health Programme, the “supply side” of the organised mass screening for early detection of some cancers has been established which would be capable of carrying out - in time periods set by the state-of-the-art - the regular screening of the population eligible by age. Unfortunately, the stated objectives of the programme have not fulfiled because the “demand side”, that is the compliance of the target population with the offered screening has remained far below the expectations. As a consequence, both the effectiveness and economic viability of the programme are damaged. The paper is to single out the possible causes: crudeness of concept of “organised screening”, the limited accessibility of sevices, anomalies of hralth care system, and, above all, some psychological side-effects of screening process.]

Lege Artis Medicinae

[A new DPP-IV inhibitor: saxagliptin]

KIS János Tibor, MÉSZÁROS Gabriella

[Saxagliptin is a selective, potent inhibitor of dipeptidyl peptidase-IV (DPP-IV). By inhibiting DPP-IV, saxagliptin reduces the degradation of endogenous incretin hormones, resulting in increased glucose-dependent insulin and decreased glucagon secretion from the pancreas islets. Clinical trials of saxagliptin as monotherapy and as combination therapy with other oral antidiabetic medications including metformin, glibenclamide, glipizide, pioglitazone and rosiglitazone have demonstrated clinical benefits in different glycaemic endpoints. Due to its glucose- dependent mechanism of action, saxagliptin as monotherapy or in combination with metformin results in a very low risk for hypoglycemia. It has also been shown to be generally well-tolerated, with not having any relevant effect on weight. The authors summarize the most important saxagliptin trials.]

Lege Artis Medicinae

[Beethoven’s Diseases]

KÖVES Péter

Lege Artis Medicinae

[Concomitant occurrence of multiple myeloma and diffuse large B-cell lymphoma]

RADVÁNYI Mónika, ILLÉS Árpád, MÉHES Gábor, KAJTÁR Béla, FAZAKAS Ferenc, GARAI Ildikó, GERGELY Lajos

[We report a case of a 50-year-old male patient, in whom the coexistence of multiple myeloma and diffuse large B cell lymphoma was confirmed. In December 2007, the patient was admitted to the department of internal medicine with fatigue resulting from mild anemia. A tumor of the left testis was discovered, and after semicastration diffuse large B cell lymphoma was diagnosed by histopathological analysis (clinical stage: II/EB). Examination of the bone marrow revealed a plasmocytic infiltrate of 60%, while 36.1 g/l IgG-kappa paraprotein was found in the peripheric blood, fulfilling the diagnostic criteria of multiple myeloma (Durie-Salmon stage: I). The patient received six cycles of rituximab- CHOP-21 chemotherapy for diffuse large B cell lymphoma. Following a transient improvement, the multiple myeloma showed progression, therefore we switched to VTD protocol (bortezomib, thalidomid, dexamethason). The patient underwent high dose chemotherapy and autologous hematopoietic stem cell transplantation. Both hematologic diseases showed complete remission. Both tumour samples were tested for immunoglobulin heavy-chain rearrangement by polymerase chain reaction and DNA sequence analysis, according to which the possibility for clonal relationship between multiple myeloma and diffuse large B cell lymphoma could not be confirmed.]

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Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

Clinical Neuroscience

Delirium due to the use of topical cyclopentolate hydrochloride

MAHMUT Atum, ERKAN Çelik, GÜRSOY Alagöz

Introduction - Our aim is to present a rare case where a child had delirium manifestation after instillation of cyclopentolate. Case presentation - A 7-year old patient was seen in our outpatient clinic, and cyclopentolate was dropped three times at 10 minutes intervals in both eyes. The patient suddenly developed behavioral disorders along with gait disturbance, and complained of visual hallucinations 20-25 minutes after the last drop. The patient was transferred to intensive care unit and 0.02 mg/kg IV. physostigmine was administered. The patient improved after minutes of onset of physostigmine, and was discharged with total recovery after 30 minutes. Conclusion - Delirium is a rare systemic side effect of cyclopentolate. The specific antidote is physostigmine, which can be used in severely agitated patients who are not responding to other therapies.

Clinical Neuroscience

Valproic acid associated pleuropericardial effusion: case report

DEMIR Figen Ulku

Introduction - Valproic acid is an effective antiepileptic and mood stabilizer used in the treatment of many neurological and psychiatric disorders. Although there are frequently seen side effects, effusions between layers of pleural and pericardial membranes are rare to be seen. Case - Pleuropericardial effusion was detected in a 23 years old woman who was under valproic acid treatment because of epileptic seizure. After 1 year of valproic acid treatment, patient complained of dyspnea. As all the researches intended on etiology were usual, valproic acid has been thought to be responsible for the matter. Control examination after 1.5 months regarding the end of treatment revealed complete recovery of pleuropericardial effusion. Discussion - Pleural and pericardial effusions are rarely seen complications related to the use of valproic acid. It must also be kept in mind that valproic acid causes a potential for such side effects which can be blamed etiologically when the other possibilities for patients are excluded.

Hypertension and nephrology

[Association between cyclothymic affective temperament and hypertension]

NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[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.]

Clinical Neuroscience

Relationship between Status Epilepticus Severity Score and etiology in adult NCSE patients

GENC Fatma, ERDAL Abidin, AKCA Gizem, KARACAY Ertan, GÖKSU Özaydın Eylem, KUTLU Gülnihal, GÖMCELI Bicer Yasemin

Purpose - Nonconvulsive status epilepticus (NCSE) is a heterogeneous, severe neurological disorder of different etiologies. In this study, the outcomes of NCSE episodes was assessed in a large series of adult patients. Our objective was to evaluate relationship between Status Epilepticus Severity Score (STESS) and etiology and the role of etiological factors on predicting the outcomes. Method - In this retrospective study, the medical records of 95 patients over 18 years of age who were diagnosed with NCSE between June 2011 and December 2015 were reviewed. Their treatment and follow-up for NCSE was performed at the Epilepsy Unit in Department of Neurology, Antalya Research and Training Hospital. Etiological factors thought to be responsible for NCSE episodes as well as the prognostic data were retrieved. The etiological factors were classified into three groups as those with a known history of epilepsy (Group 1), primary neurological disorder (Group 2), or systemic/unknown etiology (Group 3). STESS was retrospectively applied to patients. Results - There were 95 participants, 59 of whom were female. Group 1, Group 2, and Group 3 consisted of 11 (7 female), 54 (33 female), and 30 (19 female) patients, respectively. Of the 18 total deaths, 12 occurred in Group 2, and 6 in Group 3. The negative predictive value for a STESS score of ≤ 2 was 93.88% (+LR 2.05 95% CI: 1.44-2.9 and -LR 0.3 95% CI 0.10-0.84 ) in the overall study group. While the corresponding values for Group 1 (patients with epilepsy), Group 2 (patients with primary neurological disorder), and group 3 (patients with systemic or unknown etiology) were 100%, 92.59% (+LR 2.06 95%CI: 1.32-3.21 and -LR 0.28 95% CI 0.08-1.02 ) 83.33% (+LR 1.14 95%CI: 0.59-2.9 and -LR 0.80 95% CI 0.23-2.73). Conclusions - This study included the one of the largest patients series ever reported in whom STESS, a clinical scoring system proposed for use in patients with status epilepticus, has been implemented. Although STESS appeared to be quite useful for predicting a favorable outcome in NCSE patients with epilepsy and primary neurological disorders, its predictive value in patients with systemic or unknown etiology was lower. Further prospective studies including larger NCSE samples are warranted.