Lege Artis Medicinae

[Ethical Issues in Psychotherapy – Part II ]

KOVÁCS József

JUNE 15, 2012

Lege Artis Medicinae - 2012;22(05)

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Lege Artis Medicinae

[Asserting basis-bolus principle by analogue insulin preparations in pre-pubertal child with diabetes]

BLATNICZKY László

[INTRODUCTION - The choice of insulin combination therapy in children with type 1 diabetes mellitus is determined basically by the diet as well as the age of the patient. However, life rhythms of individual children are widely different. As a consequence, insulin therapy must be tailored to individual needs, by chosing the optimal one from the available insulin products with different efficacy curves. The aim is, of course, to maintain near-normoglycaemia for years or decades. CASE STUDY - The author presents the case of a 10-year-old girl with diabetes for 4 years, whose insulin treatment has involved a number of combinations. Good metabolic balance could be obtained by premixed insulin preparations for more than two years. However, subsequent intensive treatment with human insulins had poor results. This was primarily due to the fact that the child had a rather hectic daily schedule and eating habits, although she ate - appropriately for her age - six meals per day. After changing the ratios of the meals while maintaining her six-mealsper- day regime, an analogue glargine/glulisine combination therapy was induced, with a significant increase in the basal/ bolus ratio. This treatment was successful: HbA1c level got to the target range, without changes - theoretically caused by the rapid analogue - in hypo- and hyperglycaemic periods before and after small meals, respectively. CONCLUSION - During the time of remission, treatment with premixed human insulin can maintain good metabolic balance even for years, while saving (at least) two pricks per day. Insulin treatment intensified by analogue insulins (glulisine/glargine) may be attempted in prepubertal children needing six meals a day, provided their lifestyle raises problems. Glargine, given in an increased ratio, can compensate the hyperglycaemic effect of minimised small meals.]

Lege Artis Medicinae

[Prevention and treatment of hepatic encephalopathy]

HUNYADY Béla

[As acute or chronic liver diseases progress, liver failure and related hepatic encephalopathy may develop. The latter occurs in more than 70% of patients with hepatic cirrhosis. Because of declining cognitive functions, sleep disturbances, memory problems and impaired motion coordination, this condition can - even in mild form - limit the patient's self-sufficiency and activity and can lead to a decreased quality of life and ability to work. Its most advanced stage, hepatic coma is one of the leading causes of liver-related mortality. These conditions generate a substantial healthcare costs. Treatment of hepatic encephalopathy involves dietary restrictions, prevention and treatment of precipitating factors, inhibition of the production and absorption of toxic substances (especially ammonia) and restoration of the amino acid balance. In addition to the traditionally used treatment with disaccharids (lactulose, lactitol), evidence has been accumulating regarding the efficacy and safety of a nonabsorbable antibiotic compound, rifaximin, which targets enteral pathogen bacteria, both in treatment and in prevention of hepatic encephalopathy. Artificial liver support therapies have been also introduced in Hungary. This review summarises the experience regarding treatment of hepatic encephalography for physicians involved in the management of patients with hepatic diseases.]

Lege Artis Medicinae

[Comparison of antihypertensive combinations in the managing of patients with hypertension]

RIGÓ Erzsébet

Lege Artis Medicinae

[Dangers and Opportunities of Psychedelics – Part III ]

SZUMMER Csaba

Lege Artis Medicinae

[Quo vadis? Whose life is it anyway? EBM based health politics and health based politics]

KAPÓCS Gábor

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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.

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

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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.

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[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. ]

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[THORACIC MENINGOCELE]

FEKETE Tamás Fülöp, VERES Róbert, NYÁRY István

[Herniation of the meninges through a defect of the spinal canal is a spinal meningocele, and is usually located dorsally in the lumbosacral region. Meningoceles are usually part of a complex developmental disorder, or of a systemic disease, or it can be iatrogenic, as well. We report a very rare case of a true anterior thoracic meningocele.]