Lege Artis Medicinae

[Friedrich Schiller – a Physician or a Poet Prince?]

BECHER Péter, PATAI Árpád, MÁJER Katalin

AUGUST 20, 2010

Lege Artis Medicinae - 2010;20(08)

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Lege Artis Medicinae

[Variations to the Kreutzer Sonata – Leo Tolstoy Passed Away 100 Years Ago]

KISS László

Lege Artis Medicinae

[A chance to concretize the teratogenic risk: healthy babies born to mother with isotretinoin treatment during pregnancy]

TIMMERMANN Gábor, KONDÉR Béla, GIDAI János, CZEIZEL Endre

[The teratogenic risk means the probability of the occurrence of congenital abnormalities in fetuses after the exposure of teratogenic agents, mainly drugs during pregnancy. The recent highresolution ultrasound scanning may help us to concretize this teratogenic risk. The Genetic, Teratogenic and Family Planning Counseling Clinic of the authors in Budapest were visited by 10,557 couples or client between 1998 and 2007. Ten pregnant women visited this Clinic due to the isotretinoin (Roaccutan) treatment during pregnancy during the 10 years study period. At present Roaccutan is the most teratogenic drug among the medicinal products in Hungary because its teratogenic risk is 25% for a characteristic pattern of congenital abnormality syndrome including a/microtia, ventriculomegaly and contruncal cardiovascular malformation. These fetal defects are detectable by the high-resolution ultrasound scanning between 18th and 20th gestational week of pregnant women. Thus this examination was recommended for the 10 pregnant women with unintended use of isotretinoin (Roaccutan ) in early pregnancy. Six pregnant women followed our advice and the repeated ultrasound scanning was not able to detect the above-mentioned characteristic defects and all the 6 newborns were healthy after birth. In conclusion the recent highresolution ultrasound examination provides a chance for the diagnosis of certain fetal defect between 18th and 20th gestational week of pregnant women. The Hungarian law allows these pregnant women to decide the termination of pregnancy until 20th (24th) gestational week after the diagnosis of severe fetal defects. However, this approach can protect the life of the major part of fetuses in pregnant women at high risk.]

Lege Artis Medicinae

[Shall we save?]

KIS János Tibor

Lege Artis Medicinae

[Tiotropium as a first maintenance drug in COPD: secondary analysis of the UPLIFT trial]

BALIKÓ Zoltán

Lege Artis Medicinae

[On the safety of angiotensin-receptor blockers - A new attack on this drug class]

FARSANG Csaba

[Up until now, angiotensin-receptor blockers have been considered to be the safest cardio-, cerebro-, reno- and vasculoprotective drugs. In a previous metaanalysis, ARBs were accused of increasing the risk of myocardial infarction, but a number of metaanalyses and randomised, controlled trials have disproved this hypothesis. In a recent metaanalysis, ARBs were associated with an increased risk of tumours. The author reviews this issue, discusses the flaws of the above metaanalysis and, on the basis of the most up-to-date data in the literature, expert opinions and official statements (FDA, EMA), concludes that members of this drug class should continue to be used according to their approved indications, which is supported by their cardio-, reno-, cerebro- and vasculoprotective effects demonstrated in a number of appropriate, large-scale clinical studies.]

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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.

Clinical Neuroscience

[Advanced Parkinson’s disease characteristics in clinical practice: Results from the OBSERVE-PD study and sub-analysis of the Hungarian data]

TAKÁTS Annamária, ASCHERMANN Zsuzsanna, VÉCSEI László, KLIVÉNYI Péter, DÉZSI Lívia, ZÁDORI Dénes, VALIKOVICS Attila, VARANNAI Lajos, ONUK Koray, KINCZEL Beatrix, KOVÁCS Norbert

[The majority of patients with advanced Parkinson’s disease are treated at specialized movement disorder centers. Currently, there is no clear consensus on how to define the stages of Parkinson’s disease; the proportion of Parkinson’s patients with advanced Parkinson’s disease, the referral process, and the clinical features used to characterize advanced Parkinson’s disease are not well delineated. The primary objective of this observational study was to evaluate the proportion of Parkinson’s patients identified as advanced patients according to physician’s judgment in all participating movement disorder centers across the study. Here we evaluate the Hungarian subset of the participating patients. The study was conducted in a cross-sectional, non-interventional, multi-country, multi-center format in 18 countries. Data were collected during a single patient visit. Current Parkinson’s disease status was assessed with Unified Parkinson’s Disease Rating Scale (UPDRS) parts II, III, IV, and V (modified Hoehn and Yahr staging). Non-motor symptoms were assessed using the PD Non-motor Symptoms Scale (NMSS); quality of life was assessed with the PD 8-item Quality-of-Life Questionnaire (PDQ-8). Parkinson’s disease was classified as advanced versus non-advanced based on physician assessment and on questions developed by the Delphi method. Overall, 2627 patients with Parkinson’s disease from 126 sites were documented. In Hungary, 100 patients with Parkinson’s disease were documented in four movement disorder centers, and, according to the physician assessment, 50% of these patients had advanced Parkinson’s disease. Their mean scores showed significantly higher impairment in those with, versus without advanced Parkinson’s disease: UPDRS II (14.1 vs. 9.2), UPDRS IV Q32 (1.1 vs. 0.0) and Q39 (1.1 vs. 0.5), UPDRS V (2.8 vs. 2.0) and PDQ-8 (29.1 vs. 18.9). Physicians in Hungarian movement disorder centers assessed that half of the Parkinson’s patients had advanced disease, with worse motor and non-motor symptom severity and worse QoL than those without advanced Parkinson’s disease. Despite being classified as eligible for invasive/device-aided treatment, that treatment had not been initiated in 25% of these patients.]

Lege Artis Medicinae

[The Private Physician and State Advisor of Tzar Alexander I János Orlay, a Polymath Physician ]

MOLNÁR László

Lege Artis Medicinae

[Committed physicians, emotional resonance for a better physician-patient relationship]

LAZÁNYI Kornélia, SZLUHA Kornélia

[With the advent of holistic medicine in the second half of the 20th century, the range of behavioural patterns that are expected from healthcare workers has also changed. Nowadays, numerous references in literature put emphasis on the potential positive impact of personal interactions between physician and patient on the healing process and overall well-being of patients. However, it does not come naturally to all workers with caring professions to seek personal interactions with their patients or display appropriate emotions. Some will have to make deliberate efforts, perform emotional labour, to achieve that goal. A healthcare worker’s commitment to healing and caring may make it easier for him/her to perform emotional labour. Emotional labour and commitment of 84 healthcare workers involved in oncology, and organizational factors with impact thereupon, were studied to explore the potential relationship between commitment and emotional labour. PANAS-X questionnaires were used to quantify emotional labour, while commitment and influencing factors were surveyed by means of explicative questions. Our findings confirmed a correlation between commitment and genuine acting as corroborated by literaure data. It was demonstrated that committed healthcare workers’ spontaneous emotions were more in compliance with what their patients expected them to display, and even their behavioural patterns were more in tune with the patients’ expectations. Confirmation as an organizational factor and colleague/ patient attitudes were found to have the strongest impact on commitment. It is essential that selection criteria for healthcare workers include examination for an altruistic caring attitude. Even more importantly, operators and managers of healthcare institutes should make efforts to create a good working environment and offer regular confirmative feedbacks for improved commitment by their employees.]

Hypertension and nephrology

[Patient-practitioner cooperation - medication adherence and persistence in the CONADPER-HU study]

SZEGEDI János, KÉKES Ede, KISS István

[Hypertension is a common popular disease, it basically determines the health status, morbidity, cardiovascular mortality, rehabilitation and quality of life of the population. Prevention, early detection, effective treatment of the disease, quality of care is an important part of the people’s health program. The success of the therapy, the attainment and long-term maintenance of the target blood pressure - in addition to many other factors - is determined by drug adherence and persistence, one of the crucial elements of which is the optimal cooperation of the physician and patient. The poor persistence causes most of the therapeutic failures. The main objective of the CONADPER-HU study was to optimize practitionerpatient cooperation (increased control, information delivery, home blood pressure measurement, telemedicinal equipements and software use), thus increasing the proportion of patients with target blood pressure and reducing the number of resistant hypertensive patients. The study proved that the complex care system is effective and has a positive impact on persistence. It has also been clarified that the first three months will decide on further sustained therapeutic success.]