Lege Artis Medicinae

[Doppler or dopler?]

GRÉTSY Zsombor

MARCH 01, 2000

Lege Artis Medicinae - 2000;10(03)

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Lege Artis Medicinae

[The role of coronary artery revascularization in the management of heart failure and systolic left ventricular disfunction]

LENGYEL Mária

[Ischemic heart disease accounts for about 70% of chronic systolic heart failure and severe systolic left ventricular dysfunction. Prognosis of ischemic heart failure is worse than that of non-ischemic heart failure and can only be moderately improved with optimal drug treatment. Further improvement may be expected from revascularization in the presence of reversible left ventricular dysfunction which is called myocardial viability. Viability associated with chronic left ventricular dysfunction is caused by hibernation. Low dose dobutamine stress echocardiography is the best imaging modality to predict the improvement of left ventricular function after revascularization. Myocardial contrast echocardiography can further improve the diagnostic value of dobutamine echocardiography. The disadvantage of nuclear imaging methods for the diagnosis of viability is their low specificity. Revascularization surgery improves left ventricular function and survival when the amount of viable myocardium is adequate. However, the non-revascularized viable myocardium is an unstable condition which can effect the prognosis adversely. Although there are no randomized studies, coronary bypass surgery is considered indicated for severe left ventricular dysfunction if the viability of the myocardium and the operability of the coronary arteries are estabilished, even in the absence of angina. To establish these criteria for revascularization imaging studies (preferably low dose dobu tamine stress echocardiography) and coronary angiography are required. ]

Lege Artis Medicinae

[Action on Secondary Prevention through Intervention to Reduce Events]

MATOS Lajos

Lege Artis Medicinae

[The microbiology pharmacokinetics and clinical use of carbapenems]

BÁN Éva, PRINZ Gyula

[ Imipenem and meropenem the two currently available carbapenems inhibit the synthesis of the cell wall similarly to other bactericidal B-lactam antimicrobials. These agents have excellent activity against the vast majority of aerobic and anaerobic Gram-positive and Gram-negative organisms. In addition to other B-lactam resistant microbes (e.g. Chlamydia, Mycoplasma) only Stenotrophomonas maltophilia and Enterococcus faecium bacteria are naturally resistant to carbapenems. Carbapenems are extremely stable compounds against nearly all types of B-lactamases: from the penicillinase of Staphylococcus to Class A and Class B types of B-lactamase enzymes of Gram-negative bacteria. Secondary resistance against carbapenems was described in case of the following bacteria: penicilline resistant S. pneumoniae, methicilline resistant Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacter cloaceae, less frequently Enterobacter aerogenes, Serratia mercescens, Klebsiella pneumoniae and Acinetobacter baumannii. The pharmacokinetic profile of imipenem and meropenem are very similar. Carbapenems are valuable as empirical monotherapy due to their broad spectrum of antimicrobial activity and ß lactamase stability in the treatment of severe nosocomial infections, lower respiratory tract or intraabdominal infections and febrile neutropenia. The use of imipenem in central nervous system infection is not approved due to the high incidence of seizures. ]

Lege Artis Medicinae

[Confined placental mosaicism and uniparental disomy]

BODA Anikó, PAPP Zoltán

[Chromosomal mosaicism is defined as the presence of two or more cell lines having different chromosomal complements in the same individual. In the conceptus the extent of the mosaicism depends on the timing of chromosomal mutation occurance, the cell lineage affected, and the viability of the mutation. The resultant mosaicism can be either generalized, confined placental or confined embryonic. The process of the loss or removal of one of the three chromosomes from the trisomic conception, at least from the cells that will form the proper fetus is known as trisomic zygote rescue. As the result of this phenomenon, the embryo/fetus becomes disomic, while the placental compartment remains trisomic or mosaic. After losing a chromosome, the remaining pair might originate from the same parent. The presence of two chromosomes from one parent in a disomic cell line is termed uniparental disomy. Uniparental disomy is one form of aberrant origin for disomic cells, and the term „pseudodisomy" is also used. Uniparental disomy can involve homozygosity for the chromosome, and the term ,,isodisomy" has been suggested for this phenomenon. If the homozigosity for the chromosome is not complete, the term „heterodisomy" is used. Depending on the pathologic chromosome, the clinical consequences of the confined placental mosaicism and uniparental disomy can be intrauterine and/or postnatal growth restriction, spontaneous abortion. Increased perinatal morbidity and mortality, minor congenital malformations can result from the phenomena. Confined placental mosaicism and uniparental disomy are well known in syndromatology too. The connections of mosaic trisomy 7 and Silver-Russell syndrome, mosaic trisomy 15 and Angelman syndrome, mosaic trisomy 15 and Prader-Villi syndrome are described. Due to the presence of aneuploid cells in the placenta, confined placental mosaicism may cause placental dysfunction, hydropic degeneration of the placenta or „unexplained" highly increased serum hCG level. ]

Lege Artis Medicinae

[Home management of chronic obstructive pulmonary disease]

MÜHLBACHER Szilvia, VADÁSZ Imre

[Cessation of smoking is the primary condition for the successful management of COPD. The aim of pharmacotherapy is to diminish symptoms (dyspnoe, cough and expectoration) to increase cardiorespiratory performance and to improve the quality of life. Pharmacotherapy is based upon administration of bronchodilators (anticholinergic and beta-agonist preparations as well as theo phyllin). In the case of acute exacerbation anti- biotic treatment is indicated. Effectiveness of inhalative corticosteroids is not established well yet, whereas the oral and parenteral administration of corticosteroids is limited by severe side effects. In the advanced stage of disease long term oxygen therapy can increase survival and improve the quality of life. Respiratory rehabilitation is an essential component in the management, it facilitates expectoration and corrects respiratory technique, increases muscular force and performance, improves quality of life. Active cooperation of patients is necessary for the successful management of the desease; the patient should be informed on the particulars of the disease and on the required contribution.]

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Clinical Neuroscience

The applications of transcranial Doppler in ischemic stroke

FINNSDÓTTIR Herdis, SZEGEDI István, OLÁH László, CSIBA László

Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the in­crea­sed intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Micro­em­boli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast en­chan­ced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt.

Clinical Neuroscience

Evaluation of ischemic stroke patients with systemic cancer

UFUK Emre, TASKIN Gunes, IREM Pinar, FURUZAN Kokturk, ESENGUL Liman, ORHAN Yağiz

Purpose - In cancer patients, an ischemic stroke can be seen as both a direct effect of cancer and a complication of treatment. This condition can negatively affect the follow-up and treatment of these patients. For this research, we aimed to evaluate the clinical features, stroke types and etiological features of ischemic stroke patients with histories of cancer or found to have cancer during the aetiological investigation. Materials and methods - We retrospectively evaluated 100 patients (57 males, 43 females) who were hospitalized with acute stroke and determined to have the presence of cancer or a cancer history during the aetiological investigation between 2011 and 2016. All the demographic features, stroke types and localizations, National Institutes of Health Stroke Scale (NIHSS) scores, Rankin Scale scores, durations of cancer and cancer treatments were recorded. Results - The mean age of the patients was 67.07 ± 10.9 years old, the median NIHSS score was 5, and the median Rankin Scale score was 4. While 79% of patients had ischemic stroke risk factors, 21% did not. Atherosclerotic stroke was the most common stroke type (49%, n=49) and cryptogenic strokes were detected in 21% (n=21). In addition, 63% of the patients had chronic cancer (later than 6 months), 31% of the patients had recent cancer histories (less than 6 months), and 29% of the patients had metastases. Among all the malignancies, lung cancer (n=23), gastrointestinal cancer (n=20) and gynaecological-breast cancer (n=16) were the three most common. Moreover, 37% of the patients underwent chemotherapy, 29% underwent radiotherapy, and 88% of the patients had Carotid/Vertebral Doppler USG abnormalities. Conclusion - Similar to what is stated in the literature, an atherosclerotic stroke was the most common type of stroke in the cancer patients. Stroke risk factors were not detected in 21% of the patients, and in the majority of the patients, atherosclerotic changes in the carotid artery were observed in the Doppler examinations. In the aetiology and prognosis of ischemic stroke, it is important to keep in mind the existence of cancer in addition to the classical stroke risk factors.

Lege Artis Medicinae

[Summary data of Hungary's comprehensive health screening program (MAESZ) 2010-2019]

BARNA István, KÉKES Ede, HALMY Eszter, BALOGH Zoltán, KUBÁNYI Jolán, SZŐTS Gábor, NÉMETH János, PÉCSVÁRADY Zsolt, MAJOROS Attila, DAIKI Tenno, ERDEI Ottilia, DANKOVICS Gergely

[The comprehensive screening program of Hun­gary (MAESZ) 2010-2020-2030 is a unique initiative in Hungary and worldwide too. This largest humanitarian program provides by the latest technology free scree­ning tests for all residents in Hungary. The program developed by 76 pro­fessional organizations offers 38 scree­ning tests to every participants free of charge, in a special designed screening truck. Screening program performed by MAESZ includes cardiovascular, ophthalmologic, dermatologic, gynecologic, and neurologic investigations, lab tests, audiometry, blood pressure and arterial stiffness measurements, and venous Doppler ultrasound examinations. More­over, screening tests for lactose intolerance, colon malignancy, inflammatory bowel disease, reflux disease, urine incontinency, prostatic cancer and physical activity level were evaluated. Starting 2020, a dental screening station will be added to the mobile unit for early detection of oral cancers. Beyond screening tests, special attention is paid to assess health threatening risk factors, such as smoking, alcohol con­sumption, physical inactivity, un­healthy nutrition, and obesity. The program demonstrates the key elements of first aid from reanimation to bandage of burns in cooperation with professional and civil organisations. Furthermore, during the waiting time, participants get lifestyle recommendations and a health booklet with a bar code enabling the immediate computer analysis of test outcomes. Since the 2018/2019 school year the official prevention program for children entitled “Travel around the Empire of Health” was started. During its 10 years, the MAESZ performed 7 million free of charge screening tests on 1,886 scenes, enrolled 560,000 participants, invested 16,000 hours for prevention, handed out 1,200,000 health booklets and 391,000 prevention info packages to thousands of fami­lies. More than 20,000 health professionals (GPs, nurses, dietetics, health development agents, public health government officials, Accident Prevention Committee of National Police Headquarters, General Directorate of Social Affairs and Child Protection and non-governmental organizations) have been participated. The program designed to improve social health aims to help more and more Hun­garian citizens to be informed about their health status and to reminds them of the importance of prevention. ]

Clinical Neuroscience

Can high uric acid levels be an independent risk factor for acute ischemic stroke due to large-artery atherosclerosis?

ACAR Türkan, ARAS Guzey Yesim, GÜL Sinem Sidika, ACAR Atılgan Bilgehan

Introduction - Uric acid is a molecule that is known to act as a natural antioxidant in acute oxidative stress conditions such as acute ischemic stroke (AIS). Although there are several studies on the prognostic value of serum uric acid (UA) level, especially the AIS, its importance in ischemic stroke is still controversial. Our aim in this study is to investigate whether the serum UA level is an indicative biomarker in the large-artery atherosclerosis in the AIS etiology. Material and method - Of the patients admitted to Sakarya University Training and Research Hospital Depart-ment of Neurology between January 2017 and November 2017, 91 hospitalized patients, who had AIS diagnosis and had their uric acid levels measured, were analyzed retrospectively. Patients with diabetes mellitus (DM), hypertension (HT), smoking habit, obesity, gout, hyperlipidemia (HL) and renal failure were excluded from the study. Patients were classified as anterior system and posterior system infarct. Then, patients were divided into two groups, one with internal carotid artery (ICA) > 50% stenosis and the other with ICA < 50% stenosis according to carotid-vertebral artery doppler USG examination performed for etiology. Serum UA, total bilirubin, direct bilirubin and indirect bilirubin levels of both groups were statistically compared. Results - In the comparison of serum UA values of ICA>50% stenosis and ICA<50% stenosis group of AIS patients, a statistically significant difference was found between the UA levels (p<0.000), but there was no difference between total bilirubin, direct bilirubin and indirect bilirubin values (p>0.05). Conclusion - High uric acid levels can be considered an independent, indicative risk factor for large-artery disease in AIS.

Clinical Neuroscience

[Hemodynamic adaptation of fetal brain]

JAKOBOVITS Ákos, HENDRIK Jörn

[Doppler color ultrasonography of the middle cerebral and umbilical arteries was performed on 104 fetuses born at term. A total of 254 investigations were carried out. Of the 104 fetuses studied, 52 infants had birth weights appropriate for gestational age (mean 3409.2 g) and 52 infants were small for gestational age (mean 2272.1 g). Cerebral hemodynamic adaptation was observed in growth retarded fetuses due to placenta! insufficiency. ln these cases the elevated umbilical vascular resistance evidenced the placenta! insufficiency. At the same time the decrease of the cerebral vascular velocimetry indexes indicated the improving cerebral blood supply. Only the systolic/diastolic ratio was significantly reduced in growth retarded fetuses when compared with normal controls. ln the umbilical artery the pulsatility index and systolic/diastolic ratio were raised significantly in growth retarded fetuses. The ratio of the cerebral arterial to umbilical cord artery index values proved a better indicator of the difference between growth retarded and normal controls than the index of the cerebral or umbilical artery alone. The ratios of all three index values of the growth retarded fetuses were significantly smaller than those of the normal controls (pulsatility index 1.03 versus 1. 60, resistance index 0.84 versus 1.19 and systolic/diastolic ratio 1.01 versus 2.02). The ratios of the small for date fetuses due to other, nonplacental causes were simi­ lar to the normal controls. The blood circulation disorder evokes hemodynamic adaptation in the feta! brain. The intrauterine growth restriction is a consequence of this disturbed blood supply. The cerebral circulatory adaptation failed in the small for date fetuses non associated with decreased blood supply.]