Lege Artis Medicinae



NOVEMBER 30, 1994

Lege Artis Medicinae - 1994;4(01 KLSZ)

[This LAM supplement was prompted by a very topical issue. Antithrombotic therapy has come to the forefront of the treatment of cardiovascular patients. Prolonged anticoagulant therapy involves mainly the use of coumarin derivatives, and platelet aggregation inhibition involves the extensive use of acetylsalicylic acid. The topicality of this issue can be approached from two angles. First, the incidence of ischaemic heart disease and cerebrovascular disease in the developed world is alarmingly high.]



Further articles in this publication

Lege Artis Medicinae

[Antithrombotic therapy in cardiogenic thromboembolism]


[All 3 methods of antithrombotic therapy have a role in the primary and secondary prevention of cardiogenic thromboembolism. The most important modality is anticoagulant treatment which is indicated now in the majority of cases of nonvalvular atrial fibrillation. An tiplatelet therapy is of limited value in cardiogenic thromboembolism. The expanded clinical use of both kinds of treatment depends on increased safety and unchanged efficacy which can be achieved by reduced dosage and the combination of the two therapeutic methods. Thrombolytic therapy, until recently, has been limited to the thromboembolic diseases of the right heart. Presently, thrombolysis is being more and more often used in the lifesaving treatment of left sided prosthetic valve thrombosis. ]

Lege Artis Medicinae

[The role of echocardiography in anticoagulant treatment]


[Echocardiography is the method of choice to detect the cardiac source of embolism. Trans thoracic echocardiography is preferred for the diagnosis of left ventricular thrombus. Trans esophageal echocardiography is more sensitive than transthoracic echocardiography in the detection of possible sources of systemic emboli (41-65% versus 14–37%). Left atrial and appendage thrombus, spontaneous echocontrast, patent foramen ovale, atrial septum aneurysm, left atrial myxoma and prosthetic valve thrombus are more frequently demonstrated by transeso phageal echocardiography. Right atilai and ventricular thrombus, embolus in the pulmonary artery, patent foramen ovale and pulmonary hypertension should be examined in pulmonary embolism. ]

Lege Artis Medicinae

[Anticoagulant treatment in cerebrovascular diseases]

NAGY Zoltán

[The practice and indication of anticoagulation in the care of cerebrovascular patients is still controversial. It is hoped that improved diagnostic facilities, the extensive use of imaging techniques, more accurate assessment and monitoring of haemostasis, and the increasing number of multicentre studies will help us to better define the conditions for treatment. The use of anticoagulant therapy may be justified in stroke prevention, mainly to prevent cardioembolisation in cases where the probability of stroke is higher than 5%, and in cerebral venous thrombosis and deep vein thrombosis. The use of anticoagulation in the treatment of progressive ischaemic stroke is still controversial. The experience with heparin (coumarins, warfarin) has been well established, whereas there is currently a lack of data and extensive clinical trials on the use of low molecular weight heparins, heparinoids. ]

Lege Artis Medicinae

[Coumarin therapy]


[Coumarin oral anticoagulants are highly effective antithrombotic agents with relatively low risks of serious bleeding. Clinical uses and applications have evolved over the years. Recent changes include a, lower doses are used to treat most patients with thromboses, b, laboratory monitoring has been standardised thus intensities of anticoagulation are equivalent around the world, C, new indications for treatment have emerged from prospoective controlled clinical trials, for example profilaxis of embolic stroke in patients with chronic nonrheumatic atrial fibrillation. Coumarins inhibit the factors II, VII, IX, X and protein C and S. Traditionally the prothrombin time has been used to monitor the antithrombotic effects of the coumarins. The test is performed by the addition of a thromboplastin to recalcified plasma. The sensitivity of the thromboplastin to coumarin induced reduction in clotting factor activity is variable in the assay. Some thromboplastins are very sensitive, others are insensitive. Consequently, patients can receive different doses of coumarin depending on the thromboplastin used. To address this important clinical problem, the prothrombin time ratio is now modified by a factor (ISI) that reflects the „sensitivity" of the thromboplastin used and the result is termed International Normalised Ratio (INR). The main coumarin adverse effects (hae morrhage, teratogenicity and coumarin skin necroses and some special problems of coumarin therapy (diet, coumarin resistance, drug-drug interactions, the problem of over lapping heparin and coumarin, the problem of interval surgery) are also discussed.]

All articles in the issue

Related contents

Clinical Neuroscience

A variant of Guillain-Barre syndrome after SARS-CoV-2 vaccination: AMSAN

TUTAR Kaya Nurhan, EYIGÜRBÜZ Tuğba, YILDIRIM Zerrin, KALE Nilufer

Introduction - Coronavirus disease 2019 (COVID-19) is a respiratory infection that has rapidly become a global pandemic and vaccines against SARS-CoV-2 have been developed with great success. In this article, we would like to present a patient who developed Guillain-Barré syndrome (GBS), which is a serious complication after receiving the inactive SARS-CoV-2 vaccine (CoronaVac). Case report – A 76-year-old male patient presented to the emergency department with nine days of progressive limb weakness. Two weeks prior to admission, he received the second dose of CoronaVac vaccine. Motor examination revealed decreased extremity strength with 3/5 in the lower extremities versus 4/5 in the upper extremities. Deep tendon reflexes were absent in all four extremities. Nerve conduction studies showed predominantly reduced amplitude in both motor and sensory nerves, consistent with AMSAN (acute motor and sensory axonal neuropathy). Conclusion - Clinicians should be aware of the neuro­logical complications or other side effects associated with COVID-19 vaccination so that early treatment can be an option.

Clinical Neuroscience

[Diagnosis of multiple sclerosis: A review of the 2017 revisions of the McDonald criteria]


[The revolutionary progress of research in neuroimmu­nology has led to the introduction of disease modifying therapies in multiple sclerosis at the end of the last century. The International Panel on Diagnosis of Multiple Sclerosis originally proposed the 2001 McDonald criteria to facilitate the diagnosis of MS in patients with the first objective neurological symptom(s) suggesting demyelinating event, when magnetic resonance imaging is integrated with clinical and other paraclinical diagnostic methods. New terms have been introduced to substitute clinical information by MRI: dissemination in space - indicating a multifocal central demyelinating process and dissemination in time - indicating the development of new CNS lesions over time. The criteria for diagnosis of Multiple Sclerosis have continuously evolved, they were modified in 2005 and 2010 allowing for an earlier and more accurate diagnosis of MS over time, and they provided the most up-to-date guidance for clinicians and researchers. The last recommended revisions relied entirely on available evidence, and not on expert opinion thereby reducing the risk of the misdiagnosis. The 2017 McDonald criteria continue to apply primarily to patients experiencing a typical, clinically isolated syndrome. In this review, we provide an overview of the recent 2017 revisions to the criteria of dissemination in space and time with the importance of the presence of CSF-specific oligoclonal bands; keeping fully in mind that there is no better explanation for symptoms than diagnosis of MS. In the future, validation of the 2017 McDonald criteria will be needed in diverse populations. Further investigations are required on the value of new MRI approaches, on optic nerve involvement, on evoked potential and optical coherence tomography, in order to assess their possible contribution to diagnostic criteria.]

Clinical Neuroscience

Long-term follow-up results of concomitant chemoradiotherapy followed by adjuvant temozolomide therapy for glioblastoma multiforme patients. The importance of MRI information in survival: Single-center experience

LUKÁCS Gábor, TÓTH Zoltán, SIPOS Dávid, CSIMA Melinda, HADJIEV Janaki, BAJZIK Gábor, CSELIK Zsolt, SEMJÉN Dávid, REPA Imre, KOVÁCS Árpád

Introduction - Glioblastoma multiforme (GBM) is the most common malignant primary anomaly of central nervous system. The GBM infiltrates the nearly sturctures from the initial tumor and its metastatic attribution is well known. The aim of our single-centered retrospective study was to introduce the importance of postoperative medical imaging confirmation of total tumor resection for patient with GBM combined concomitant and adjuvant chemoradiotherapy on a 10 year long patient follow up. Methods - From January 2006 to April 2015 we registered 59 patients with newly diagnosed GBM at the University of Kaposvár Health Center Institute of Diagnostic Imaging and Radiation Oncology. The histological diagnosis was confirmed by a proficient neuropathologist (World Health Organisation WHO; grade IV astrocytoma). According to histological status if the ECOG performance status of patients allowed it the mutidisciplinary oncoteam recommended adjuvant chemoradiotherapy all features strictly by Stupp protocol. (60 Gy dose on the gross tumor volume and 2-3 cm margin for the clinical target volume with parallel 75 mg/m2 TMZ. Four weeks after monotherapial phase patients had to recieve 6 cycles of TMZ first cycle with 150 mg/m2 up to 200 mg/m2). The irradiation was carried out by a conformal three dimensional planning system. Results - 59 patients with the median age of 63 (range 17-84) year. Our sample counted 34 male patients and 25 woman patients. 14 patients underwent gross total tumor resection while, 39 patients underwent partial resection and the rest from our sample 6 patients passed through biopsy. Statistical analysis showed a lengthier survival among males than females, with a median survival of 13 months for males and females, the OS of 26.209 for males, meanwhile 15.625 for females. However, the difference is not considerable (log-rank p=0.203). Our study found that the estimated survival of patients at least 50 years old is significantly shorter at a median survival of 12 months (log rank p=0.027) than that of patients below 50 years of age at a median survival of 23 months. The longest estimated median survival was calculated with patients of ECOG '0' condition (16 months). However, no significant difference was found in the estimated survival of patients of different ECOG conditions (log-rank p=0.146). Based on the extent of surgery, complete resection resulted in the longest average survival of 36.4 months, followed by 21.5 months among patients with biopsy, and 15.8 months among patients with partial resection. Different surgical procedures, however, did not result in significant differences in survival (log-rank p=0.059). The overal survival of patients who had complete resection confirmed by MRI compared with the overal survival of patients with residual tumor confirmed by MRI as well we can estimate that there is significant difference between these two groups (p=0,004). Conclusion - Despite complex and intense treatment, recurrence is inevitable and causes relatively rapid death. In our analysis complete resection, as defined from the neurosurgeon’s report and postoperative MRI, resulted in an independently significant improvement in OS. Our results are the evidences that the treatment of patients with glioblastoma multiforme in Hungary is at least on the same level as any other developed European countries.

Lege Artis Medicinae

[Non-alcoholic fatty liver disease]

BAFFY György

[Non-alcoholic fatty liver disease is estimated to affect 25% of the global population. It is often joining other metabolic disorders and features a heterogeneous natural history. Significant liver injury is unlikely to develop from steatosis, while a third of steatohepatitis cases will progress into cirrhosis and as a severe complication may lead to primary liver cancer. The probability of these severe outcome increases with the degree of liver fibrosis and with the prevalent type 2 diabetes and two or more metabolic risk factors. Regardless of its stage, non-alcoholic fatty liver disease is in­creasing the susceptibility for cardiovascular diseases, diabetes and all malignancies, and as a result is shortening the life expectancy. However, general awareness of the disease among healthcare professionals and their patients remains limited. Lack of approved medications for the disorder is likely a major contributor to this discrepancy. Since the disease primarily stems from sustained caloric excess, lifestyle modification including Mediterranean type diet, avoidance of alcohol consumption, and regular physical activity are the mainstay of management. Better education campaigns may improve patient compliance and enhance the recognition and acceptance of this condition within primary care, in parallel with the introduction of two-step fibrosis screening to achieve more efficient identification and management of the high-risk patients. ]

Clinical Neuroscience

[Systemic thrombolysis and endovascular intervention in postpartum stroke]


[Introduction - There are no previously published cases about intravenously applied recombinant tissue plasminogen activator in acute ischemic stroke during puerperium. Case presentation - We report a 40-year-old woman with postpartum acute ischemic stroke caused by multiple cervical artery dissections treated by systemic thrombolysis and endovascular intervention. Discussion - There are only limited data regarding thrombolytic treatment in acute stroke during pregnancy and puerperium. Current acute stroke treatment guidelines - while considering pregnancy as a relative exclusion criterion - do not deal with the postpartum state. Conclusion - As the condition is rare, randomized controlled trials are not feasible, therefore further reports on similar cases could eventually help us suggest guidelines or at least propose recommendations for the acute thrombolytic treatment of strokes occurring in pregnancy and puerperium.]