Lege Artis Medicinae

[Do you have to die here?]

VITRAI József, FÜZESI Zsuzsanna, KAPOSVÁRI Csilla, KAPÓCS Gábor, RÁCZ József, SINKÓ Eszter

SEPTEMBER 21, 2009

Lege Artis Medicinae - 2009;19(08-09)

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Lege Artis Medicinae

[The importance of vitamin D deficiency in practice]

TAKÁCS István

[The effects of vitamin D in bone health have been known since the 1920s. Recently, it has been proven that its role in the body is much more complex. Activated vitamin D is a steroid hormone that regulates transcription of more than 200 human genes through its receptor that is detectable in almost all types of cells. In contrast to the former conceptions, it can be activated not only in the kidneys; moreover, local 1-α-hydroxylation plays a greater role in its extraskeletal effects. Vitamin D deficiency, currently defined as serum levels of <30 ng/ml, is caused by the lack of ‘effective’ sunlight exposition. Thus, vitamin D deficiency is one of the most frequent deficiencies in the developed world that plays a role not only in the development of skeletal conditions but many other diseases, as well. A low vitamin D level causes a reduced calcium absorption, a higher bone remodelling rate and increased bone loss. It also reduces muscle strength and increases the risk of falling. Normal vitamin D status is required for the effectiveness of drugs for osteoporosis treatment; however vitamin D treatment in itself is not effective in osteoporosis. An increasing number of studies show the benefits of vitamin D supplementation and treatment in extraskeletal conditions. Vitamin D plays an important role in the prevention of several auto-immune diseases, infections, cardiovascular diseases, and cancers. Therefore, all UV-B radiation-deprived adults require an intake of vitamin D to maintain a level of >30 ng/ml. Vitamin D3 treatment is safe. The necessary dose can be reliably approximated by the calculation that an incremental consumption of 100 IU/day raises serum vitamin levels by 1,0 ng/ml. Clinical trials suggest that for the vast majority of individuals, a prolonged intake of 10,000 IU/day does not pose any risk.]

Lege Artis Medicinae

[Up-to-date management of systemic sclerosis]

SZŰCS Gabriella

[Systemic sclerosis is a chronic autoimmune disease characterized by three major features: widespread fibrosis in the skin and internal organs, a non-inflammatory small vessel obliterative vasculopathy and immunological activation with disease-specific autoantibodies. It is necessary to take a systematic approach to the diagnosis and evaluation of each case in order to provide appropriate treatment. Disease-modifying approaches can be classified according to the underlying pathogenic process. Thus vascular therapies include agents used for Raynaud’s phenomenon, critical digital ischaemia and organ-based vascular complications such as scleroderma renal crisis and pulmonary hypertension. Immunosuppressive drugs are used in lung involvement or rapid skin progression. The results of different anti-fibrotic therapies are controversial. Finally in managing organ-based manifestations and complications a multidisciplinary approach to the therapy is useful with patient education as an integral component of successful management.]

Lege Artis Medicinae

[The role of neurohormonal regulation in the development of insulin resistance in chronic stress]

MOLNÁR Ildikó

[The effects of the chronic stress could not be avoided recently. The pathognomic regulation of the neurohormonal events is responsible for the manifestation of diseases such as obesity, cardiovascular diseases, diabetes mellitus type 2, depression, tumors, inflammations, allergy. Two major regulatory systems are involved in the neuroendocrine alterations caused by stress: the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic nervous systems. The chronic activation of the adrenocortical system leads to insulin resistance and obesity associating with vascular, arteriosclerotic and inflammatory symptoms. The revealing of the pathognomic events on time and the enhanced physical activity may provide the effective prevention of these frequent diseases.]

Lege Artis Medicinae

[Side effects of long-term treatment with proton pump inhibitors]

PAP Ákos

Lege Artis Medicinae

[Carcinoid tumours - various manifestations and possibilities of treatment]

IGAZ Péter, RÁCZ Károly

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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

[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. ]

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.]

Lege Artis Medicinae

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

VÁLYI Péter

[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.]

Clinical Neuroscience

Acute effect of sphenopalatine ganglion block with lidocaine in a patient with SUNCT

KOCATÜRK Mehtap, KOCATÜRK Özcan

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNCT/SUNA) is a rare severe headache. At the time of an attack, it can hinder a patient from eating and requires acute intervention. The sphenopalatine ganglion is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. Sphenopalatine ganglion block has long been used in the treatment of headache, particularly when conventional methods have failed. Here, we present a patient who was resistant to intravenous lidocaine, but responded rapidly to sphenopalatine ganglion block during an acute episode of SUNCT/SUNA.