Lege Artis Medicinae

[Do we have the right to die?]


SEPTEMBER 29, 1993

Lege Artis Medicinae - 1993;3(09)

[We have historical evidence that in ancient times a distinction was made between curable and incurable patients. The doctor had to relieve pain, but preparing for a dignified death was no longer part of his job. Even in later centuries, accompanying and assisting the dying was not considered a medical activity, but with the advent of pain relief and the possibility of artificial life support, this activity, like so many others (such as childbirth), became medicalised. The fear of death was accompanied by a fear of artificially sustained life.]



Further articles in this publication

Lege Artis Medicinae

[Ceftazidime - over ten years in the clinical practice]

SZALKA András, PRINZ Gyula

[This review discusses the principal features of ceftazidime based on the ten years experience since the introduction of the drug in the clinical practice: its broad antibacterial spectrum including Pseudomonas aeruginosa, favourable pharmacokinetics, wide range of indications, excellent clinical efficacy using empiric treatment or elective therapy and safety profile. ]

Lege Artis Medicinae

[What to expect of PTCA today?]


[This article is a review of the changing indications for percutaneous coronary angioplasty during the last decade. The role of revascularisation and especially of PTCA in the treatment of coronary heart disease is explained. Coronarography is the most important morphol gic diagnostic tool for coronary artery disease. The importance of the topic of this article is enhanced by the position of Hungary at the top of morbidity and mortality statistics, and by the infrequency of revascularisation procedures, especially PTCA. PTCA proved to be a real alternative to a surgical procedure in about half of the patients indicated for revascularisation. PTCA is less invasive, requires less time for recovery and is less expensive compared to bypass surgery. This article should draw attention of the family practitioner to the importance of this method. ]

Lege Artis Medicinae

[Myocardial contrast echocardiography]


[Symptoms of ischemic heart disease will occur when myocardial perfusion diminishes below a critical level. Coronarography will disclose the anatomic stenoses, but there is no direct correlation between the grade of stenosis and the change of myocardial perfusion. Myocardial contrast echocardiography is a new technique to analyze the myocardial perfusion. The contrast agent contains micro bubbles which have nearly the same dimensions as red blood cells. The microbubbles increase the „whiteness" of the perfused myocardium during the echocardiographic examinations. The change in „whiteness" of the myocardium correlates with myocardial perfusion. Intracoronary injections delineate the perfusion area of the coronary artery, and Thus the coronary flow reserve and the collateral flow area can be measured. The cardioplegia fluid distribution and the graft perfusion area are examined intraoperatively. Bedside myocardial perfusion studies will be possible through the transpulmonary passage of intravenously injected contrast agents. Myocardial contrast echocardiography can be applied both in the diagnosis and treatment of ischemic heart disease.]

Lege Artis Medicinae

[Randomised assessment of (the effect of) digoxin on inhibition of the angiotensin-converting enzyme study]


[Circulatory failure worsened to the point of discontinuation in 23 patients in the diuretic + ACE inhibitor + placebo only group, compared to only four patients in the digoxin group (p<0.001). The relative odds of worsening circulatory failure with placebo compared with digoxin was 5.9. All measured parameters of functional capacity (maximal exercise capacity, submaximal exercise capacity, NYHA grade) worsened with digoxin withdrawal. Similarly, quality of life (p=0.04), ejection fraction (p=0.001), heart rate (p<0.001) and body weight (p<0.001) decreased with digoxin instead of placebo.]

Lege Artis Medicinae

[Investigation of uterine circulation by transvaginal color doppler in early pregnancy]

SZABÓ István, CSABAY László, NÉMET János, PAPP Zoltán

[The circulatory changes and the characteristics of blood flow in certain uterine vessels can be detected by transvaginal color Doppler in early pregnancy. The uterine circulation of 53 patients with normal intrauterine pregnancies at 4–14 weeks of gestation and 104 non pregnant patients were investigated. The main uterine artery, arcuated and spiral arteries were demonstrated by color Doppler in all patients in early pregnancy and characteristic flow velocity waveforms were obtained in 94% of the cases. The impedance to flow in the main uterine artery was significantly lower and the mean velocity was significantly higher in early pregnancy than in non pregnant patients. The indices of impedance to flow decreased with gestation in the uterine branches and there was a progressive fall in these indices from the uterine artery to the spiral arteries. Mean blood velocity in the uterine artery increased with gestation. The hemodynamical changes which are proportional to gestation age give an indirect evidence of the adequate maternal blood supply for the growing embryo.]

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Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Clinical Neuroscience

Electrophysiological investigation for autonomic dysfunction in patients with myasthenia gravis: A prospective study


Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission. Autonomic dysfunction is not a commonly known association with MG. We conducted this study to evaluate autonomic functions in MG & subgroups and to investigate the effects of acetylcholinesterase inhibitors. This study comprised 30 autoimmune MG patients and 30 healthy volunteers. Autonomic tests including sympathetic skin response (SSR) and R-R interval variation analysis (RRIV) was carried out. The tests were performed two times for patients who were under acetylcholinesterase inhibitors during the current assessment. The RRIV rise during hyperventilation was better (p=0.006) and Valsalva ratio (p=0.039) was lower in control group. The SSR amplitudes were lower thereafter drug intake (p=0.030). As much as time went by after drug administration prolonged SSR latencies were obtained (p=0.043).Valsalva ratio was lower in the AchR antibody negative group (p=0.033). The findings showed that both ocular/generalized MG patients have a subclinical parasympathetic abnormality prominent in the AchR antibody negative group and pyridostigmine has a peripheral sympathetic cholinergic noncumulative effect.

Clinical Neuroscience

Cholinesterase inhibitors and memantine for the treatment of Alzheimer and non-Alzheimer dementias


In aging societies, the morbidity and mortality of dementia is increasing at a significant rate, thereby imposing burden on healthcare, economy and the society as well. Patients’ and caregivers’ quality of life and life expectancy are greatly determined by the early diagnosis and the initiation of available symptomatic treatments. Cholinesterase inhibitors and memantine have been the cornerstones of Alzheimer’s therapy for approximately two decades and over the years, more and more experience has been gained on their use in non-Alzheimer’s dementias too. The aim of our work was to provide a comprehensive summary about the use of cholinesterase inhibitors and memantine for the treatment of Alzheimer’s and non-Alzheimers’s dementias.

Clinical Neuroscience

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


[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. ]