Lege Artis Medicinae

[Ethical dilemmas]

KOVÁCS József

SEPTEMBER 19, 2007

Lege Artis Medicinae - 2007;17(08-09)

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Lege Artis Medicinae

[ANTIHYPERTENSIVE THERAPY IN VIEW OF RECENT CLINICAL STUDIES]

ALFÖLDI Sándor

[Different antihypertensive agents, while having the same blood pressure lowering effect, will have significantly and clinically important different impact on the serum levels of glucose, lipids, insulin, potassium, creatinine, as well as on albumin excretion, heart rate, body weight, central pressure, various hypertensive target organ damages, and, in particular, 24-hour blood pressure dinamics. There is agreement in that the main benefits of first-line antihypertensive agents are related to the lowering of blood pressure itself. Some other drugs, however, have shown preventive and protective cardiovascular properties in certain patient groups, independent of their blood pressure lowering effect as measured traditionally.]

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[Differences in the Prolonged Use of Drugs for Chronic Obstructive Pulmonary Disease]

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[BENEFICIAL EFFECT OF INSULIN DETEMIR ON THE BODY WEIGHT OF DIABETICS]

BECHER Péter

[Detemir is the newest base insulin analogue. In phase III trials and the PREDICTIVE study, the use of insulin detemir in various treatment regimens (basal-bolus or in combination with an oral antidiabetic) did not lead to weight gain in either types of diabetes, in contrast to what is usually observed with insulin therapy. Similar results were obtained when neutral protamine Hagedorn insulin or glargine were replaced by detemir, or insulin-naive patients received detemir as a new therapeutic regime. The mechanism of the beneficial effect on body weight is not clear yet. It may be related to the reduction in the number of hypoglycaemic episodes. It may also be associated with a stronger action of detemir on hepatocytes compared to peripheral tissues due to its acylation, which results in an effective suppression of hepatic glucose output without promoting lipogenesis in the adipocytes. Detemir reaches the insulin receptors of the hypothalamus faster than regular insulin, therefore, satiety develops in a shorter time. These hypotheses still require further studies.]

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[INFLAMMATORY BOWEL DISEASE IN CHILDREN]

BODÁNSZKY Hedvig, VERES Gábor

[The term inflammatory bowel disease includes two similar, but distinct intestinal diseases so far of unknown ethiology - ulcerative colitis and Crohn’s disease. They used to be considered diseases of young adults, but in recent decades they have become more common among children, with characteristics different from those in adults. In the past they were considered severe, incurable diseases, but today, owing to modern nutrition, medical and surgical treatment, both diseases have became well manageable, even though complete recovery can not yet be expected.]

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[Authorization and Marketing of Medicines in the European Union Member States]

BORVENDÉG János

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[Decisional collisions between evidence and experience based medicine in care of people with epilepsy]

RAJNA Péter

[Background – Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose – To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods – Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results – There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology – including genetic background –, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion – Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions. ]

Clinical Neuroscience

Novel structured MRI reporting system in neonatal hypoxic-ischemic encephalopathy - issues of development and first use experiences

LAKATOS Andrea, KOLOSSVÁRY Márton, SZABÓ Miklós, JERMENDY Ágnes, BAGYURA Zsolt, BARSI Péter, RUDAS Gábor, KOZÁK R. Lajos

Purpose - To develop an evidence-based, standardized structured reporting (SR) method for brain MRI examinations in neonatal hypoxic-ischemic encephalopathy (HIE) suitable both for clinical and research use. Materials and methods - SR template development was based on comprehensive review of the pertinent literature with the basic sections and subdivisions of the template defined according to MRI sequences (both conventional and diffusion-weighted, MR-spectroscopy (MRS), and T2*-weighted imaging), and the items targeted on age-related imaging patterns of HIE. In order to evaluate the usability of the proposed SR template we compared data obtained from the brain MR image analysis of 87 term and 19 preterm neonates with the literature. The enrolled 106 infants were born between 2013 and 2015, went through therapeutic hypothermia according to the TOBY criteria due to moderate to severe asphyxia and had at least one brain MRI examination within the first two weeks of life. Ethical approval was obtained for this retrospective study. Descriptive statistical analysis was also performed on data exported from the structured reporting system as feasibility test. Results - The mean gestational age of the study population was 38.3±2.2 weeks; brain MRI was performed on 5.8±2.9 day of life, hence in 78% of our patients after the conclusion of therapeutic hypothermia. Our main imaging findings were concordant to the pertinent literature. Moreover, we identified a characteristic temporal evolution of diffusion changes. Interestingly 18% (n=19/106) of the clinically asphyxiated infants had isolated axial-extraaxial haemorrhage without any imaging sign of HIE. Conclusion - In this article our approach of reporting HIE cases with our novel SR template is described. The SR template was found suitable for reporting HIE cases, moreover it uncovered time and location dependent evolution of diffusion abnormalities (and pseudonormalization, as well), suggesting its usefulness in clinical research applications. The high number of isolated intracranial haemorrhages, and the changing diffusion pattern emphasizes the importance of early imaging in HIE.

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