Lege Artis Medicinae

[Insulin pump therapy in type 1 diabetes in the light of efficacy, safety, and quality of life]

HIDVÉGI Tibor, SZEPESI Gábor, LUKÁCS Andrea, BARKAI László

NOVEMBER 03, 2015

Lege Artis Medicinae - 2015;25(10)

[The level of glycaemic control necessary to achieve optimal outcomes in subjects with type 1 diabetes mellitus typically requires intensified insulin therapy using multiple daily injections or continuous subcutaneous insulin infusion (CSII). For CSII, the insulins of choice are the rapid-acting insulin analogues: insulin aspart, insulin lispro and insulin glulisine. The advantages of CSII over multiple daily injections in adult and paediatric populations with type 1 diabetes include superior glycaemic control, lower insulin requirements and better health-related quality of life/patient satisfaction. An association between CSII and reduced hypoglycaemic risk is more consistent in children/adolescents than in adults. The use of CSII is widely recommended in both adult and pediatric type 1 diabetes mellitus populations, but is limited in pregnant patients. The review also discusses the result of the “A non-interventional trial to observe the effect of the use of Accu Chek Combo device on quality of life and metabolic control“(COM-1101-HU 1.3).]

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[Current questions on Pneumococcus infections: cardiovascular complications, cardiotoxicity and new opportunities for prevention among elderly people]

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[The respiratory tract infections, first of all severe pneumonia are associated with severe cardiovascular adverse events the significance of which that had not been recognised so far. Among the adverse events, the development of acute coronaria syndromes, heart failure, arrhythimias are the most important ones leading to significatly higher mortality even after several years. In the development of acute coronaria syndrome , the proinflammatory activites play the cenral role leading to the instability of coronaria plaques and plaque rupture associated with formation of platelet thrombi. The constriction of coronariae, peripherial vasodilatation and hypoxia also contribute to the deleterius complications. The role of pneumococci in this process seems to be especially significant since this pathogen exhibit a unique direct cardiotoxic effect, namely directly invades the myocardium and produce cardiotoxic substances. As a consequence, impairement of cardiomyocite function and contractility and formation of microscopic lesions in which later collagen deposition and long-term cardiac scarring can be detected. These pathological processes are developed despite of antibiotic treatment, consequently, vaccination against pneumococcal infection seems to be the only method for efficacious prevention of the myocardium damage and cardiovascular adverse events. According to the results of the CAPITA study, the conjugate polisaccharide vaccine decrease the number of pneumococcal pneumonia and invasive pneumococcal infections by 45 and 75% resp. in the elderly population. The recognition of the direct and indirect role of pneumococci in the development of early and late cardiovascluar adverse events gives a new aspect of the beneficial effect of efficacious vaccination.]

Lege Artis Medicinae

[The evaluation of statin adherence in patients from the village of Méhkerék]

HANYECZ Vince, DANI Győző, MÁRK László

[INTRODUCTION - One of the basic elements of cardiovascular prevention is lipid lowering therapy, the quality of which is indicated by the increasing rate of lipid target values achieved during recent years. Further improvement is needed and for this the enhancement of patient adherence to statin treatment is a possible way. PATIENTS AND METHODS - The prescription habits in 81 patients taking statins (41 atorvastatin and 40 rosuvastatin) from 392 randomly selected ones for another study were analysed from the database of general practitioner in the village called Méhkerék in Békés County, Hungary. RESULTS - The statin adherence of the patients was evaluated in two different ways: the estimation by the general practitioner and the determination of prescribed drug boxes during one year. There was no significant difference between the two methods. Similarly, no significant difference was found between the atorvastatin or rosuvastatin adherence. The reduction of total cholesterol was significantly greater in patients taking rosuvastatin (p=0.03). A significant correlation was found between the prescribed box numbers and the decrease of LDL- and total cholesterol. CONCLUSIONS - The patients’ adherence seems to be independent from the type of statin. For the evaluation of patient adherence the GP's simple estimation and determination of prescribed drug boxes during one year are equally appropriate. This suggests, that the GP would be able to select those patients whose education needs longer time. ]

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[Successfully applied fulvestrant treatment at patient with breast cancer]

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[Sudden death of a patient with purpura - post mortem recognized eosinophilic granulomatosis with polyangiitis]

DOBREAN Noémi, HAJNAL-PAPP Rozália, TUSA Magdolna, OROJÁN Iván, CSERNI Gábor

[INTRODUCTION - Systemic diseases may sometimes be challenging because physicians do not think about synthesizing the parts to a single entity. CASE REPORT - A 49-year-old asthmatic female was admitted to hospital for the investigation of her cutaneous symptoms suggestive of vasculitis associated with diffuse joint complaints. The chest X-ray raised the possibility of pneumonia or neoplastic disease. Following an episode of chest pain relieved by a non-steroidal anti-inflammatory drug, she suddenly died. Her previous history included restrictive cardiomyopathy, insufficiency of both atrioventricular valves and long dating eosinophilia. Autopsy revealed a partly granulomatous eosinophilic inflammatory process in several organs, including the heart, the lungs, the kidneys, the colon and the pituitary gland. Retrospective collection of unknown anamnestic features and symptoms made possible to unify the pieces of information and symptoms to a single entity, the Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis, EGPA). CONCLUSIONS - Bronchial asthma seldom leads to death. It can rarely be part of the Churg-Strauss syndrome, of which the manifestation may be related to the administration of leukotriene antagonists also used in the presented case. These drugs may allow the withdrawal of systemic steroid therapy which is beneficial not only in the treatment of asthma but also of the syndrome. Lowering the dose of steroids may promote the development of the full blown pattern of the latter.]

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MANHALTER Nóra, PALÁSTI Ágnes, BOZSIK György, ÁFRA Judit, ERTSEY Csaba

[Background - The deleterious effect of primary headaches on the sufferers’ quality of life (QOL) has been abundantly documented using both generic and headache-specific instruments. The currently used questionnaires focus on a limited number of factors and therefore may not be sensitive enough to detect the effect of headache type and headache characteristics on QOL, despite the obvious clinical differences. We have devised a comprehensive questionnaire that may be more sensitive to the burden of headache. Objective - To assess the psychometric properties of the new questionnaire on a group of migraineurs. Patients and method - We studied 117 migraineurs who completed the validated Hungarian version of the SF-36 generic QOL measure and our new, 25-item questionnaire. Reliability was assessed by internal consistency, measured by Cronbach’s a of all items. Content validity was exam- ined by calculating the correlation of the items with subscales of the SF-36 measure. The correlation of the patients’ migraine characteristics with the questionnaire’s items was used to assess criterion validity. Results - The questionnaire was quick and easy to administer. The questionnaire demonstrated good reliability, with Cronbach’s alpha being 0.893. Content validity was adequate; most “physical” items of the new questionnaire showed significant correlations with the bodily pain and role physical SF-36 subscales and most “psychical” and “social” items were correlated with mental health and social functioning SF-36 subscales. Criterion validity was adequate, with headache severity being correlated with most of the items. Discussion - In this study the new headache-specific quality of life instrument showed adequate psychometric properties.]

Clinical Neuroscience

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[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.]

Lege Artis Medicinae

[End of the line? Addenda to the health and social care career of psychiatric patients living in Hungary’s asylums]

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[Introduction - Cluster headache (CH), which affects 0.1% of the population, is one of the most painful human conditions: despite adequate treatment, the frequent and severe headaches cause a significant burden to the patients. According to a small number of previous studies, CH has a serious negative effect on the sufferers’ quality of life (QOL). In the current study, we set out to examine the quality of life of the CH patients attending our outpatient service between 2013 and 2016, using generic and headache-specific QOL instruments. Methods - A total of 42 CH patients (16 females and 26 males; mean age: 39.1±13.5 years) completed the SF-36 generic QOL questionnaire and the headache- specific CHQQ questionnaire (Comprehensive Headache- related Quality of life Questionnaire), during the active phase of their headache. Their data were compared to those of patients suffering from chronic tension type headache (CTH) and to data obtained from controls not suffering from significant forms of headache, using Kruskal-Wallis tests. Results - During the active phase of the CH, the patients’ generic QOL was significantly worse than that of normal controls in four of the 8 domains of the SF-36 instrument. Apart from a significantly worse result in the ‘Bodily pain’ SF-36 domain, there were no significant differences between the CH patients’ and the CTH patients’ results. All the dimensions and the total score of the headache-specific CHQQ instrument showed significantly worse QOL in the CH group than in the CTH group or in the control group. Conclusion - Cluster headache has a significant negative effect on the quality of life. The decrease of QOL experienced by the patients was better reflected by the headache-specific CHQQ instrument than by the generic SF-36 instrument. ]

Clinical Neuroscience

[Treatment of dystonia by deep brain stimulation: a summary of 40 cases]

DELI Gabriella, BALÁS István, KOMOLY Sámuel, DÓCZI Tamás, JANSZKY József, ILLÉS Zsolt, ASCHERMANN Zsuzsanna, TASNÁDI Emese, NAGY Ferenc, PFUND Zoltán, BÓNÉ Beáta, BOSNYÁK Edit, KULIFFAY Zsolt, SZIJJÁRTÓ Gábo

[Background - Bilateral pallidal deep brain stimulation (DBS) is an established treatment option for primary generalized and segmental dystonia. In the present study we evaluated the results of our dystonia patients treated by DBS. Methods - The surgical results of forty consecutive dystonia patients underwent DBS implantation were analyzed (age: 43.7±17.7 years; sex: 22 men; etiology: 24 primary and 16 secondary dystonia; topography: 24 generalized, 12 segmental and four hemidystonia; disease duration: 16.1±9.3 years). Severity of dystonia measured by Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and health-related quality of life measured by EQ-5D scale were obtained preoperatively and compared to the scores obtained at postoperative six months and subsequent yearly follow-ups. The average follow-up lasted 2.5 years (median, 0.5-8 years). In all cases the BFMDRS scores were re-evaluated by a rater blinded to the treatment. Treatment responsiveness was defined as an at least 25% improvement on the BFMDRS scores. Non-parametric Mann-Whitney, McNemar and Kruskal-Wallis tests were applied to test statistical significance. Results - Severity of dystonia improved from 31 to 10 points (median, 68% improvement, p<0.01) in the primary dystonia group, whereas in secondary dystonia these changes were statistically insignificant (improvement from 40 to 31.5 points, 21.2%, p>0.05). However, the health-related quality of life significantly improved in both groups (primary dystonia: 0.378 vs. 0.788 and secondary dystonia: 0.110 vs. 0.388, p<0.01). Significantly more patients in the primary dystonia group responded to DBS treatment than those in the secondary dystonia group (83.3% vs. 37.5%, p<0.01). Conclusion - Our results are in accordance with previously published international findings demonstrating that DBS is a highly effective and long-lasting treatment option for primary dystonia. DBS is considerably less efficient in secondary dystonia; however, it still has a high impact on the quality of life presumably due to its pain-relieving effect.]