Lege Artis Medicinae

[Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): a prespecified subgroup analysis of a randomised controlled trial]

SOMFAY Attila

NOVEMBER 20, 2009

Lege Artis Medicinae - 2009;19(11)

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[Dependency, Self-Help, Recovery]

NAGY Zsolt

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[Treatment of severe infections: principles of therapy and problems of resistance]

LUDWIG Endre

[The basic principles of the treatment of severe infections have recently been delineated : after having samples for microbiological tests, empiric therapy based on local resistance patterns should be introduced immediately, possibly within 1 hour in severe sepsis or in septic shock, the empiric therapy should be simplified according to the results of microbiological tests and/or improvement of the condition of patient , the antibiotics should be applied according to their pharmacodynamic properties, the duration of therapy should be shortened to the minimum time, in case of well responding non-complicated infection to 5-7 days., The most frequent problem pathogens in Hungary are the MRSA and ESBL-producing Gram-negatives. In severe infections with MRSA bacteremia, the therapy sholud be based on the vancomycin MIC of the pathogen. If MIC is below 1,5 mg/l, vancomycin is probably effective with a serum minimum concentration of 15 mg/l, while in case of less sensitive pathogens the administration of an alternative agent, such as linezolid, tigecyclin or daptomycin should be considered. In severe infections due to ESBL-producing pathogens, the carbapenems are the firts line antibiotics, while tigecyclin seems to be a promising alternative agent. The treatment of severe infections requires thorough care of the patient and skillnes in antimicrobial therapy in the period of multiresistant pathogens]

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[Acute hepatitis syndrome]

SCHULLER János

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[From Botticelli to Tiziano – Italian Renaissance Masterworks in the Museum of Fine Arts]

NAGY Zsuzsa

Lege Artis Medicinae

[The role of double-balloon endoscopy in the diagnosis and treatment of small intestinal disease compared with capsule endoscopy]

LAKATOS Péter László, HORVÁTH Henrik Csaba, ZUBEK László, PÁK Gábor, NÉMETH Artúr, RÁCZ István, PÁK Péter, FUSZEK Péter, NAGYPÁL Anna, GEMELA Orsolya, PAPP János

[INTRODUCTION - Until recently, only the proximal small bowel was accessible for diagnostic or therapeutic endoscopy. A new method, doubleballoon enteroscopy (DBE), provides high-resolution imaging and enables both diagnostic and therapeutic interventions in all segments of the gastrointestinal tract. Our aim was to report our experiences with the Fujinon EN-450 T5 therapeutic double-balloon endoscope and compare our findings with the results of earlier capsule endoscopy where this was available. METHODS - Between August 2005 and July 2009, 150 DBE procedures were conducted in 139 consecutive patients (M/F: 67/72, age: 51.1±18.6 years) who presented at our tertiary referral hospital. The examination was performed via the oral route in 112 patients, via the anal route in 16 patients, and via both routes in 11 patients. DBE was indicated due to obscure gastrointestinal bleeding in most cases (83), due to diagnosis or complication of IBD in 29 cases and due to polyposis syndrome or suspected neoplasia in 25 patients. In one patient we performed endoscopic retrograde cholangiopancreatography (ERCP). All procedures were performed using i.v. anaesthesia at our outpatient clinic. After the procedure, the patients were monitored in a recovery room for at least four hours. The results of previous capsule endoscopy were available in 27 patients. RESULTS - Small-bowel abnormalities ? mostly angiodysplasias, minor erosions or ulcers ? were detected in 50 (60.2%) of the patients with obscure gastrointestinal bleeding. Malignancy was found in 7,2% (6/83) of the patients who were examined because of bleeding (three gastrointestinal stoma tumour, one non-Hodgkin lymphoma, one previously undetected melanoma metastasis and one pancreatic adenomacarcinoma that involved the duodenum) Intervention was performed in 24 patients. IBD was diagnosed in five (38.5%) of the 13 patients in whom the disease was suspected. In patients with known Crohn-disease, DBE was indicated on the basis of the extent, behaviour and activity of the disease. Polypectomy was performed in eight patients with Peutz-Jeghers syndrome or familial adenomatous polyposis syndrome, whereas small-bowel adenocarcinoma was diagnosed in four patients. The concordance between the findings of capsule endoscopy and DBE was 51.8% (14/27), and in one patient DBE revealed malignancy that has not been detected by endoscopy. The average insertion length during the procedure was approximately 213 cm (range 50-480 cm, SD 111). CONCLUSIONS - On the basis of our results, DBE is a safe and useful method for assessing and treating small bowel disease, even if capsule endoscopy is contraindicated due to suspected strictures.]

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Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Lege Artis Medicinae

[Comment to the article titled “Exploratory study of outcomes of blood sample mass examinations by rank correlations”]

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[The author’s response to the comment on “Exploratory study of outcomes of blood sample mass examinations by rank correlations”]

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.

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[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]