Lege Artis Medicinae

[ Intracoronary stents]

MANISH M. Gandhi1, KEITH D. Dawkins2

APRIL 01, 2000

Lege Artis Medicinae - 2000;10(04)

[Over the past five years, there has been a significant increase in the use of intracoronary stents, which are used during percutaneous transluminal angioplasty (PTCA) as an adjunct to revascularization of angina patients. In 1996, 25,000 PTCA interventions were performed in the UK, using stents in half of the patients (mean 46%, standard deviation 15-99%), a fivefold increase over the 1994 data (based on a personal report by HH. Gray).]


  1. Levelező Szerző
  2. Wessex Cardiothoracic Center, Southampton University Hospital, Southampton



Further articles in this publication

Lege Artis Medicinae


VÁLYI-NAGY István, PETŐ Mónika, CSÁSZÁR Albert, VIRÓK Dezső, BURIÁN Katalin, HELTAI Krisztina, GÖNCZÖL Éva

[The well-known risk factors of atherosclerosis (high level of serum cholesterol, high blood pressure, diabetes, smoking) can only be re cognized in about half of the patients. Athero sclerosis begins in childhood. In vivo and in vitro data suggest that certain pathogens, like the intracellular bacterium Chlamydia pneu moniae (member of the Chlamydia genus) and cytomegalovirus (member of the herpesvirus family) may play a role in the development of atherosclerosis. Both pathogens infect the pop- ulation in childhood. Infected patients are often symptom-free, sometimes Chlamydia pneumoniae may cause respiratory disease. Both Chlamydia pneumoniae and cytomega- lovirus can be detected in atherosclerotic plaques and patients with atherosclerosis carry pathogen-specific antibodies more frequently and in higher titers. Aortic lesions similar to human atherosclerotic plaques can be indu ced by infection with Chlamydia pneumoniae or cytomegalovirus in experimental animals. Antichlamydial treatment results in the regres sion of these lesions in the infected animals. In vitro infection of tissue culture cells of human arterial origin with Chlamydia pneumoniae or cytomegalovirus results in the induction of cel- lular changes characteristic to atherosclerosis. Strategies to prevent or treat atherosclerosis might be complemented by antimicrobial treatment if the infectious origin of the disease is further confirmed. ]

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[Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography]


Lege Artis Medicinae

[Disparity in the perception of the disease in asthmatics and their pulmonologists plus resource in Hungary (HUNAIR study)]


[INTRODUCTION - Bronchial asthma is a chro­nic disease having an increasing prevalence in childhood and adulthood, affecting about 3-5% of the population in the developed countries. The AIR study in the United Kingdom compared the perception of the disease in asthmatic patients' to the view of their physicians (pulmonologists). Based on the results of AIR Study the Hungarian Board of Pulmonologists conducted a partially different survey in Hungary (H UNAIR Study). The fundamental objective of the HUNAIR Study was to address the following questions: 1. The persisting symptoms and limitations in daily activity of treated pediatric and adult asth­matic patients. 2. Comparison of the GINA classification of asthmatic patients (based on self-assessed symptom severity) and their pulmonologists. 3. Determination of the total asthma-related drug costs in different severity categories. 4. Determination of the total asthma-related cost for the society and its components (total drug costs, cost of lost workdays, cost of emergency visits, cost of specialist visits, cost of GP visits, cost of hospitalisation) in the different severity categories. 5. Potential differences in total cost between adult and pediatric asthmatic patients. PATIENTS AND METHODS - Data collection based on questionnaires was carried out from October 1998 to May 1999 and was directed by the Board of Pulmonologist. 699 adults and 375 children participated in the survey. The study was conducted in 19 adult and 8 pediatric cent­res in Hungary with the participation of 103 pulmonologists. RESULTS - Significant difference was found in the severity classification (based on GINA ) done by the physicians or the patients themselves. Substantial proportion of patients complained of more symptoms and limitations considering their own condition more severe than indicated by their physicians. Minor difference was found in the use of inhaled steroids among patients with mild, moderate and severe persistent asth­ma. An approximate "one-third " rule could be set up by the health economic evaluation: about 1/3 of the total cost was made up by lost work­ days, 1/3 by drug costs and 1/ 3 by other costs. One-third of the total drug cost was made up by controller and reliever antiasthmatics , 1/3 by emergency medicines and 1/3 by other medi­cines. Cost distribution of controller and reliever medicines: in case of adult patients 1/3 of the costs was constituted by controller medication and 2/3 (73%) by reliever medicines. That ratio was reversed in children: about 2/3 (73%) of the costs was spent on controller and '1 3 on reliever medicines. Further findings: 1. The increased health care resource utilisation correlated with the physician's perception more than the patient's self-assessment; 2. the resource utilisa­tion was twice as high in asthmatic children as in adults ; 3. the resource utilisati on was not affected by the usage of inhaled steroids during the 14 days of the study. CONCLUSIONS - lt can be concluded that in real life situations the current medical treatment of asthmatic patients is unsatisfactory (vs. in clinical trials). The cost-effectiveness of any medication can only be studied in a complex way, considering all the costs incurred in real life situations. New end-points are needed to assess the condition of asthmatics, which con­sider the limitations of patients in their daily routine activities and are not based exclusively on lung function tests.]

Lege Artis Medicinae

[Modern approach to functional gastrintestinal disorders]


[Functional gastrointestinal disorders defined as a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemichal abnormalities, are everpresent in the society and in physicians' offices. These conditions account for half of the referrals to gastroenterologists, at least in the ,,developed countries". The pathophysiological mechanisms involved in the pathogenesis of these disorders are complex. The symptoms are believed to be biologically multidetermined, abnormalities in motor activity, visceral sensation (hypersensitivity and hyperalgesia) and/or central perception are the best known pathogenetic factors. Cultural/familiar influence, psychosocial status, life stress and early life events may also play important role in the development or amplification of the symptoms. Since functional gastrointestinal disorders are interrelated in their pathophysiology and clinical expression, many patients will have overlapping clinical features. Predominant symptoms, however, may be used for classifying these disorders (functional dyspepsia, irritable bowel syndrome etc) and for the positive (symptom-based) diagnostic approach of the functional gastrointestinal disorders. A biopsychosocial model created to explain complex pathophysiology described above provides the rationale also for the use of a multidisciplinary approach in the therapy. ]

Lege Artis Medicinae

[Funcitonal Dyspepsia]


[Functional dyspepsia is defined as a group of different epigastric symptoms without definite morphological, biochemical or infectious origin, having overlapping clinical features. The pathogenesis of the syndrome is surely multi factorial, involving the alterations of visceral perception, as well. Gastric acid hypersecretion does not play an essential role in the development of symptoms, however its pharmacological inhibition may result in symptomatic improvement. Several clinical studies have proved recently that Helicobacter pylori infection has secondary importance in the clinical history of functional dyspepsia patients, nevertheless (in the ulcer-like functional dyspepsia subgroup) eradication therapy is generally accepted as a preventive tool. The dysmotility-type subgroup of the functional dyspepsia syndrome is caused primarily by a multifactorial mixture of gastrointestinal motility disorders and altered visceral perception. The need for positiv diagnosis is emphasized by the authors. The correct doctor-patient relationship plays the most important role in the management of functional dyspepsia patients, complete with a well proven series of acid-inhibitory, prokinetics and anti-anxiety drugs.]

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Clinical Neuroscience

[Application of minimally invasive instrumental spine surgery technique in lumbal diseases of degenerative or traumatic origin]

SCHWARCZ Attila, KASÓ Gábor, BÜKI András, DÓCZI Tamás

[Paradigm change has recently taken place in spine surgery with the application of minimally invasive techniques. Minimally invasive techniques have several advantages over the open traditional techniques: less blood loss, preservation of spine muscle integrity, shorter hospitalization, early mobilization, reduced pain levels, lower risk of infection. The presented cases cover following lumbar pathologies: segmental spinal instability, LV-SI grade II. spondylolisthesis, degenerative spondylolisthesis, spine trauma. Unilateral or bilateral mini-open technique was employed in the degenerative cases, depending on symptoms and signes. If unilateral symptoms - pathology was identified, screws and rod were implanted percutaneously on the side contralateral to the pathology. The segmental fusion between vertebral bodies was always assured by a cage and autologous bone. The presented trauma case involved combined AO type A2 and B fractures. The anterior column was strengthened with vertebral body stents filled with bone cement, the posterior column was fixed with a percutaneously implanted screw rod system. Insertion of stents in the collapsed vertebra significantly increased the vertebral body height and also improved the stability of the spine. Minimally invasive spine surgery techniques appear more advantageous over the traditional open spine surgery that necessitates for large midline approaches.]

Clinical Oncology

[Invasive endoscopy in oncology]


[Recent advances in interventional gastrointestinal endoscopy have led to a large variety of new diagnostic and minimally invasive endoscopic surgical procedures in oncological patients. Endoscopic ultrasound with the possibility of fi ne needle aspiration is currently one of the most accurate imaging technology for adequate staging of gastrointestinal cancers including oesophageal, gastric, rectal and pancreatic cancer. Endoscopic mucosal resection and endoscopic submucosal dissection offers a minimal invasive endoscopic treatment modality as an alternative for laparoscopic surgery for patients with early intramucosal neoplasias, fl at adenomas and laterally spreading tumors of the oesophagus, stomach, duodenum and colorectum. Self-expandable metal stents are now readily available for endoscopic palliation of different type of malignant gastrointestinal obstructions including oesophageal, duodenal, colonic and biliary stenosis. These recent developments of interventional gastrointestinal endoscopy lead to more precise and accurate tumor staging and more effective oncological therapy for patients with gastrointestinal cancers.]

Lege Artis Medicinae

[The use of carvedilol following invasive interventions]


[The primary goals of the treatment of AMI are to rapidly open - either mechanically or by thrombolysis - the blocked blood vessel and to keep it open. Restarting of the blood flow in blocked vessels results in an increased load in volume, pressure and metabolism in the blood vessel's supply area, which triggers the activation of a pathophysiological cascade. Pathophysiological processes accompanying the opening of the blood vessel include activation of catecholamines, RAS and neutrophils and subsequent free radical production, and increases in the levels of proinflammatory citokines and intracellular CA levels, that is, the so called oxygen paradox. The above mentioned processes can be blocked by beta receptor blockers (BRB) as demonstrated by class I, type A evidence. A number of clinical studies have shown their clinical efficiency following PCI. The PAMI, StentPAMI, AirPAMI and CADILLAC studies have proved that BRBs decrease mortality and morbidity after the intervention. The third-generation BRB carvedilol, which acts as a beta and alpha blocker in patients with STEMI successfully treated with PCI, and is also a Ca-channel blocker and a free radical trap, is the firstchoice agent for both theoretical and clinical reasons. Animal studies have shown that carvedilol results in greater reductions in the levels of markers indicating postinfarction reperfusion and ventricular remodeling (MCP1, MMP2, TIMP2) compared with metoprolol. Animal studies have also showed that carvedilol is the most efficient BRB for preventing the damaging of gap junction structure in reperfusion, and for inhibiting the ventricular arrhythmias induced by reperfusion, through restoring connexin 43. The beneficial effect of this drug on the cardiovascular events and mortality following myocardial infarction have been demonstrated in a number of human studies with hard endpoints. The unique efficiency of carvedilol in vascular prevention following PCI has been demonstrated by the short-term and longterm efficiency of carvedilol-filled stents, compared with BMSE-filled stents. Information on the postintervention, long-term (3-year) efficiency of carvedilol in a large (N :7500) patient group is expected to be published in 2015 in the CAPITAL-RCT study coordinated by the University of Kyoto. In summary, the results of experimental and clinical studies on carvedilol have shown that within the BRB group, carvedilol is highly recommended for the prevention of oxygen paradox following successful PCI and preserving the myocardium.]

Hungarian Radiology

[Self-expanding metallic stents in intrahepatic biliary strictures after liver transplantation]

DOROS Attila, NÉMETH Andrea, HARTMANN Erika, DEÁK Pál Ákos, JUHAROSI Gyöngyi, LÉNÁRD Zsuzsa, KOZMA Veronika, GÖRÖG Dénes, GERLEI Zsuzsa, FEHÉRVÁRI Imre, NEMES Balázs, KÓBORI László

[INTRODUCTION - Bile duct complications remain a key problem of liver transplantation. Two main types are recognized: anastomotic and intrahepatic. In cases of anastomotic strictures good results can be achieved with surgery or minimally invasive therapy. Intrahepatic stenosis usually requires retransplantation. In this report the results of intrahepatic metallic stent placements are analyzed. PATIENTS AND METHODS - Since 1995, 20 patients with intrahepatic bile strictures were referred for percutaneous treatment. Of 34 percutaneous transhepatic cholangiography, 33 successful drainages were performed and 58 balloon dilatations were employed to overcome. In 13 patients, 20 metallic stents were implanted. One bleeding complication was successfully treated with selective embolization. RESULTS - The average follow up time was 35 months. 14 patients have no symptoms, 12 of them after metallic stent placements and 4 of them after retransplantation (2 patients had metallic stents at retransplantation). One patient has metallic stent and an external drain waiting for retransplantation. Three patients died after 7 retransplantations. Two patients died on the waiting list, one with and one without external drain. There were no deaths after successful metallic stent placement. CONCLUSION - After meticulous preparations metallic stent placement is safe and effective in intrahepatic biliary stenosis after liver transplantation. The patients can be stabilized till the retransplantation, or it can even be avoided.]

Hungarian Radiology

[Interventional radiology of multiple biliary stenoses]


[INTRODUCTION - In palliative treatment of malignant bile duct obstruction the endoscopic and the percutaneous methods are the possible options. In multiple lesions the percutaneous method must be preferable. Decrease of the bilirubin level to normal gives an opportunity for further treatment of the oncology patients. CASE REPORT - Authors report three patients’ case history, when following an unsuccessful endoscopic retrograde cholangiopancreatography, percutaneous cholangiography revealed multiple biliary stenoses. In all cases successful stent implantations were performed (three stents in one patient, two stents in two patients). The bilirubin levels decreased rapidly and the quality of life improved in all cases. Following the stent implantation selective cytostatic treatment (one patient) and systemic cytostatic treatment (one patient) were performed. The mean survival time was 300 days. CONCLUSION - In the case of multiple biliary stenoses the percutaneous stent implantation is an acceptable palliative method, which permit the possibilities of further interventional radiological or oncological treatments.]