Lege Artis Medicinae

[Ethical Issues in Psychotherapy – Part I]

KOVÁCS József

APRIL 20, 2012

Lege Artis Medicinae - 2012;22(04)

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Lege Artis Medicinae

[Treatment of hepatocellular carcinoma by liver transplantation: results in Hungary]

GÖRÖG Dénes, VÉGSŐ Gyula, DOROS Attila, GERLEI Zsuzsa, FEHÉRVÁRI Imre, NEMES Balázs, KÓBORI László

[INTRODUCTION - Hepatocellular carcinoma is an internationally accepted indication for liver transplantation in selected cases. The aim of this study was to present treatment results of patients diagnosed with hepatocellular carcinoma and put on the waiting list between 1995 and 2010. PATIENTS AND METHODS - Sixty patients were put on the waiting list, 23 of who died or became unfit for operation while waiting for transplantation. Liver transplantation was performed in 37 patients. Pathological examination revealed no tumour in 3 of the explanted livers, whereas incidentalomas were detected in 4 livers that were explanted because of cirrhosis. Thus, in total 38 patients were examined. RESULTS - Four patients died within 3 months of surgery because of arterial circulatory problems or graft dysfunction and 14 patients died thereafter, including seven whose tumour recurred. There was no recurrence of tumours in the early state among the 25 patients meeting the Milan criteria, and the overall 1-, 3-, and 5-year survival rates with an average follow-up period of 39 months were similar to those after transplantation because of viral cirrhosis: 72%, 72% and 67% vs. 78%, 71% and 67%, respectively. Survival rates after tumours beyond the Milan criteria were significantly lower (69%, 38%, 23%). CONCLUSION - Early-state (T1,T2) hepatocellular carcinoma that has developed following cirrhosis and is unsuitable for resection can be efficiently treated with liver transplantation, but our results do not support the use of transplantation for the treatment of tumours that do not fit the Milan criteria.]

Lege Artis Medicinae

[Were the Middle Ages an Age of Darkness? ]

GAÁL Csaba

Lege Artis Medicinae

[Insulin self-titration in type 2 diabetes mellitus: burden or solution?]

TAKÁCS Róbert

[INTRODUCTION - Observational studies have verified that even in routine diabetes care, up to 1.3% reduction in HbA1c can be achieved with the initiation of a long-acting basal insulin analogue. We can get the same results in our patients using an insulin titration algorithm and close diabetological control. CASE REPORT - Metformin therapy of a 68-year old, moderately obese woman with type 2 diabetes was complemented by a long-acting basal insulin analogue (insulin glargine). Before initiation of insulin therapy, the patient received thorough dietetic and diabetic education by a qualified dietician and a diabetes nurse. The starting dose of insulin was 10 U, and then the patient was asked to increase the dose by 2 U every 3rd day depending on the mean of self-monitored fasting plasma glucose values in the previous 2 days. With the aid of a titration algorithm, optimal carbohydrate metabolism has been verified by laboratory parameters assessed 3 months later. CONCLUSION - Insulin self-titration based on appropriate patient education and close professional control makes a relatively simple therapeutic system the optimal decision in terms of a rapid and chronic normalisation of glucose control in a large patient group.]

Lege Artis Medicinae

[The Illness of Franz Kafka and his Perception of the World ]

GERLINGER Lilla

Lege Artis Medicinae

[Roma cancer patients’ illness cognition and their attitudes toward medical treatment]

ROHÁNSZKY Magda, NÓTÁR Ilona, SZABÓNÉ Kármán Judit, KONKOLY THEGE Barna

[INTRODUCTION - In this qualitative pilot study, our goal was to investigate the illness representation of gipsy cancer patients and to examine their attitudes toward medical treatment. SAMPLE AND METHODS - Deep interviews were made with 20 persons (60% female; Mage=39.2±15.1 years). The included participants approximately represented the group composition of the Hungarian Roma population. RESULTS - For most of our respondents, cancer is a frightening disease meaning some kind of punishment and the end of life. The potential causes of the disease usually remain completely incomprehensible. The participants proved to be very under-informed in relation to their treatment - even when compared to the low level of information among Hungarian cancer patients in general. In the face of the supporting presence of family members, our respondents often stated that there was nobody to share their deeper emotional problems with. About half of the patients reported on impolite and inefficient treatment attributed to prejudice against their Gipsy identity. However, deeper analyses revealed, that in most of these cases, mistreatment was a consequence of the general shortcomings of the health care system (e.g. lack of time) - being labelled as discrimination by our respondents. Almost every participant sees his/her only role in recovery merely in the participation in medical treatment - not attributing enough significance to life style changes and even less to alternative / complementary medicine. CONCLUSION - Special training to improve communication skills with gipsy patients is needed - especially for general practitioners. We also suggest preparing handouts to Roma cancer patients that provide easy-to-understand information on the medical treatments and health behaviours that serve the coping with cancer and their prevention.]

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Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

Clinical Neuroscience

[Interdisciplinary approach of vestibular system impairment]

PONGRÁCZ Endre

[In the first part of this review the definition of vertigo/dizziness was discussed. The major difference between the two signs is the exsistence of the direction, which is specific for vertigo. Dizziness is a frequent complaint in the clinical practice. Its frequency is increasing with advance of age, to intimate the play of declining cognitive process in the pathogenesis of its. The popular health significance of vertigo is in the rowing number of the patients. The onset of the most cases with acute vertigo appears between secundums and minutes so the patients will be provided in circumstances of emergency department. First of all three form schould be take into account: neuronitis vestibularis, benign paroxysmal positional vertigo and Meniere syndrome. Without tipical periferal signs of vertigo, central cause should be searched, principally stroke (lysis possibility). The differential diagnose of the different dizzeness/vertigo forms according to the elapsed time of the onset or congenital and acquired nystagmus was created in tables. The recommendations of the therapy of acute and chronic dizziness/ vertigo syndroms are, lack of results of evidence based trials doubtful. The more often used drugs based on clinical trials are discussed as vinpocetine, betahistine and piracetam. The in vitro and in vivo data suggest that the last molecule is eligible to use both in periferal and central type of vertigo syndroms.]

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[Clinical neurophysiological methods in diagnosis and treatment of cerebrovascular diseases]

NAGY Ildikó, FABÓ Dániel

[Neurophysiological methods are gaining ground in the diagnosis and therapy of cerebrovascular disease. While the role of the EEG (electroencephalography) in the diagnosis of post-stroke epilepsy is constant, quantitative EEG para-meters, as new indicators of early efficiency after thrombolysis or in prognosis of patient’s condition have proved their effectiveness in several clinical studies. In intensive care units, continuous EEG monitoring of critically ill patients became part of neurointenzive care protocols. SSEP (somatosesnsory evoked potencial) and EEG performed during carotid endarterectomy, are early indicative intraoperativ neuromonitoring methods of poor outcome. Neurorehabilitation is a newly discovered area of neurophysiology. Clinical studies have demonstrated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the rehabilitation of stroke patients. Brain computer interface mark the onset of modern rehabi-litation, where the function deficit is replaced by robotic tehnology. ]

Clinical Neuroscience

[Earlier and more efficiently: the role of deep brain stimulation for parkinson’s disease preserving the working capabilities]

DELI Gabriella, BALÁS István, KOMOLY Sámuel, DÓCZI Tamás, JANSZKY József, ASCHERMANN Zsuzsanna, NAGY Ferenc, BOSNYÁK Edit, KOVÁCS Norbert

[Background – The recently published “EarlyStim” study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson’s disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. Methods – We reviewed the data of 39 young (<60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job (“Job+” group, n=15) and retired patients (without active job, “Job-” group, n=24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. Results – As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p<0.01, McNemar test). Conclusion – Although our retrospective study has several limitations, our results fit well with the conclusions of “EarlyStim” study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.]