Lege Artis Medicinae

[Making way for pseudoscience?]

HARASZTI László

OCTOBER 27, 1993

Lege Artis Medicinae - 1993;3(10)

[In June 1993, the Royal British Medical Association decided that the subjects of paramedical medicine (naturopathy) would no longer be treated with disparaging disapproval, but would be taught in medical schools. This decision came as a surprise to most doctors, although chiropractic (osteopathy), herbal therapy (herbal medicine) and acupuncture have held their position in medicine for quite some time. ]

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Lege Artis Medicinae

[The surgical treatment of shoulder instability]

BÁLVÁNYOSSY Péter

[The author briefly reviews the static and dynamic stabilizing system and the biomechanics of the shoulder and describes his principles and techniques of the surgical treatment of instability. A modified Bankart procedure is used for recurrent anterior dislocation. Bone blocks are implanted in cases of locked posterior dislocation. Different forms of cranial instability are described as well as partial and total superior glenoidal lesions. The author discusses surgical procedures used in the treatment of these instabilities. Cranial instability leads to impingement syndrome, which results in rotator cuff lesions. These lesions increase instability and the increased impingement leads to further rotator cuff damage. This vicious cycle can be interrupted by surgical intervention.]

Lege Artis Medicinae

[Clinical application of specific antibodies in immunotherapy of transplantation]

PETRÁNYI Győző, PÁLÓCZI Katalin

[In organ and tissue transplantation practice as well as in the therapy of autoimmune, haematological, immunological and oncological diseases, the possibility for applying immunotherapy is occuring more frequently. The paper deals with all those reagents which are primarily of polyclonal or monoclonal immunglobuline origin and play a significant role in the various cell-bound immune reactions on the surface of lymphocytes. In addition to the anti-lymphocyte or/rather anti-thymocyte globuline as well as the Orthoclone (anti-CD3 monoclonal antibody) reagents well known in clinical practice, it also refers to other lymphocyte surface anti-marker monoclonal anti-bodies (anti CD4, -CD8; anti TCR, anti-LFA reagents) under clinical trial. The article reviews the possible uses of the group of immunotherapeutical reagents in the clinical practice of Kidney and bone marrow transplantation. The pharmacological mechanism, side effects, and prospects for a wider use of these reagents in the future are discussed.]

Lege Artis Medicinae

[The origin of serum catalase in healthy subjects and in some diseases]

GÓTH László

[The activity of serum catalase is highly increased in acute pancreatitis, hemolytic disorders and in some liver diseases, but there is no data on its tissue origin. The serum catalase activity was determined by a spectrophotometric assay in healthy subjects (n = 4275) as well as in increased erythropoesis (n = 424), in hemolytic diseases (hemolytic anemia = 12, megaloblastic anemia = 28, Zieve syndrome = 8, hemorrhage = 38), in acute pancreatitis, (n = 111), in liver diseases (fatty liver = 21, alcoholic hepatitis = 42, acute yellow atrophy = 18, toxic hepatitis = 15), and in liver congestion due to cardiac circulatory failure (n = 28). These diseases yielded increased serum catalase activity. This enzyme has no tissue specific isoenzymes, therefore mathematical and statistical approaches were used. The correlation between serum hemoglobin and serum catalase was analysed. The catalase release was estimated from the time activity curves of serum catalase and compared to its tissue equivalent. In healthy subjects about 60 percent of serum catalase derived from the erythrocytes and the rest from other tissues. During enhanced erythropoesis and in hemolytic diseases, similarly to hemoglobin, its source was the erythrocyte pool. In acute pancreatitis also the erythrocytes might be responsible for the increased serum catalase level. in some liver diseases as well as in liver congestion due to cardiac circulatory failure the increase of serum catalase derived from the liver cells. The diagnostic analysis of serum catalase requires the consideration of its increase as well as its origin. ]

Lege Artis Medicinae

[Prenatal follow up of a complex cardiac malformation complicated with complete AV block]

SZABÓ István, CSABAY László, NÉMET János, HAJDÚ Júlia, PAPP Zoltán

[In a congenital disorder of heart development where the complex cardiac malformation is pared with complete atrioventricular block heart rate is stabile between 50–60 beats/min. Transfer of atrial impulses through the AV node is fully blocked and the slow rhythmic heart beat is maintained by a ventricular pacemaker. In a case of such a complete cardiac malformation recognized in week 32 of gestation and the AV block complication caused stabile 57–58 beat/min bradycardia. 2-di mensional, pulsed and color Doppler ultrasonography was used to identify the disorder and to follow up the intrauterine condition of the fetus. Cardiotocography (CTG) could not generate appreciable results at such a low heart rate. During observation no centralization of fetal circulation causing intrauterine hypoxia was recorded. Updated knowledge on the pathogenesis and obs tetrical management of the fetal third degree AV block is also presented. In this case ultrasonography allowed clear-cut identification of the disorder and also ensured correct evaluation of the intrauterine status of the fetus when other diagnostic methods for evaluation were not applicable. ]

Lege Artis Medicinae

[Eurpean Concerted Action on Thrombosis and Disabilities Angioma Pectoris Study]

MATOS Lajos

[Patients with more than 50% stenosis in one or more coronary arteries had significantly higher fibrinogen levels (p<0.0001). Reduced fibrinolytic activity was also observed in patients with coronary artery stenosis, mainly due to higher levels of plasminogen activator inhibitor-1 (PAI). Decreased fibrinolytic activity was strongly associated with diabetes, elevated triglyceride levels, smoking and impaired left ventricular systolic pump function. Cholesterol levels correlated mainly with protein C and plasminogen levels.]

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Cases of inborn errors of metabolism diagnosed in children with autism

CAKAR Emel Nafiye, YILMAZBAS Pınar

Autism spectrum disorder is a neurodevelopmental disorder with a heterogeneous presentation, the etiology of which is not clearly elucidated. In recent years, comorbidity has become more evident with the increase in the frequency of autism and diagnostic possibilities of inborn errors of metabolism. One hundred and seventy-nine patients with diagnosis of autism spectrum disorder who presented to the Pediatric Metabolism outpatient clinic between 01/September/2018-29/February/2020 constituted the study population. The personal information, routine and specific metabolic tests of the patients were analyzed retrospectively. Out of the 3261 patients who presented to our outpatient clinic, 179 (5.48%) were diagnosed with autism spectrum disorder and were included in the study. As a result of specific metabolic examinations performed, 6 (3.3%) patients were diagnosed with inborn errors of metabolism. Two of our patients were diagnosed with classical phenylketonuria, two with classical homocystinuria, one with mucopolysaccharidosis type 3D (Sanfilippo syndrome) and one with 3-methylchrotonyl Co-A carboxylase deficiency. Inborn errors of metabolism may rarely present with autism spectrum disorder symptoms. Careful evaluation of the history, physical examination and additional findings in patients diagnosed with autism spectrum disorder will guide the clinician in the decision-making process and chose the appropriate specific metabolic investigation. An underlying inborn errors of metabolism may be a treatable cause of autism.

Lege Artis Medicinae

[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

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[Health status and costs of ambulatory patients with multiple sclerosis in Hungary]

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[Background and purpose - Data on disease burden of multiple sclerosis from Eastern-Central Europe are very limited. Our aim was to explore the quality of life, resource utilisation and costs of ambulating patients with multiple sclerosis in Hungary. Methods - Cross-sectional questionnaire survey was performed in two outpatient neurology centres in 2009. Clinical history, health care utilisation in the past 12 months were surveyed, the Expanded Disability Status Scale and the EQ-5D questionnaires were applied. Cost calculation was conducted from the societal perspective. Results - Sixty-eight patients (female 70.6%) aged 38.0 (SD 9.1) with disease duration of 7.8 (SD 6.7) years were involved. Fifty-five (80.9%) had relapsing-remitting form and 52 (76.5%) were taking immunomodulatory drug. The average scores were: Expanded Disability Status Scale 1.9 (SD 1.7), EQ-5D 0.67 (SD 0.28). Mean total cost amounted to 10 902 Euros/patient/year (direct medical 67%, direct nonmedical 13%, indirect costs 20%). Drugs, disability pension and informal care were the highest cost items. Costs of mild (Expanded Disability Status Scale 0-3.5) and moderate (Expanded Disability Status Scale 4.0-6.5) disease were 9 218 and 17 634 Euros/patient/year respectively (p<0.01), that is lower than results from Western European countries. Conclusion - Our study provides current inputs for policy making and contributes to understanding variation of costof- illness of multiple sclerosis in Europe.]

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[The complex intensive care and rehabilitation of a quadriplegic patient using a diaphragm pacemaker]

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[A 21 year female polytraumatized patient was admitted to our unit after a serious motorbike accident. We carried out CT imaging, which confirmed the fracture of the C-II vertebra and compression of spinal cord. Futhermore, the diagnostic investigations detected the compound and comminuted fracture of the left humerus and femur; the sacrum and the pubic bones were broken as well. After the stabilization of the cervical vertebra, a tracheotomy and the fixation of her limbs were performed. She spent 1.5 years in our unit. Meanwhile we tried to fix all the medical problems related to tetraplegia and respiratory insufficiency. As part of this process she underwent an electrophysiological examination in Uppsala (Sweden) and a diaphragm pacemaker was implanted. Our main goal was to reach the fully available quality of life. It is worth making this case familiar in a wider range of public as it could be an excellent example for the close collaboration of medical and non-medical fields.]

Clinical Neuroscience

A case with reversible neurotoxicity induced by metronidazole

EREN Fulya, ALDAN Ali Mehmet, DOGAN Burcu Vasfiye, GUL Gunay, SELCUK Hatem Hakan, SOYSAL Aysun

Background - Metronidazole is a synthetic antibiotic, which has been commonly used for protozoal and anaerobic infections. It rarely causes dose - and duration - unrelated reversible neurotoxicity. It can induce hyperintense T2/FLAIR MRI lesions in several areas of the brain. Although the clinical status is catastrophic, it is completely reversible after discontinuation of the medicine. Case report - 36-year-old female patient who had recent brain abscess history was under treatment of metronidazole for 40 days. She admitted to Emergency Department with newly onset myalgia, nausea, vomiting, blurred vision and cerebellar signs. She had nystagmus in all directions of gaze, ataxia and incompetence in tandem walk. Bilateral hyperintense lesions in splenium of corpus callosum, mesencephalon and dentate nuclei were detected in T2/FLAIR MRI. Although lumbar puncture analysis was normal, her lesions were thought to be related to activation of the brain abscess and metronidazole was started to be given by intravenous way instead of oral. As lesions got bigger and clinical status got worse, metronidazole was stopped. After discontinuation of metronidazole, we detected a dramatic improvement in patient’s clinical status and MRI lesions reduced. Conclusion - Although metronidazole induced neurotoxicity is a very rare complication of the treatment, clinicians should be aware of this entity because its adverse effects are completely reversible after discontinuation of the treatment.