Lege Artis Medicinae

[Man is not Made for Defeat – Hemingway’s Pathography]

KISS László

MAY 20, 2011

Lege Artis Medicinae - 2011;21(05)

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Further articles in this publication

Lege Artis Medicinae

[Relationship Networks]

BUDA Béla

Lege Artis Medicinae

[Psychological Approaches to the Psychedelic Experience: James Maslow and Transpersonal Psychology Part I ]

SZUMMER Csaba

Lege Artis Medicinae

[To fight for our self-esteem as well]

PAPP Magor

Lege Artis Medicinae

[The modern disciplines of diagnosing and treating back pain]

BÁLINT Géza

[The author presents the recommendations of international guidelines in the modern diagnosis and treatment of low back pain. Regarding diagnosis, it is very important to differentiate between “specific” and “aspecific” or “nonspecific” low back pain. The term “specific low back pain” includes all diseases and pathologies with well-defined aetiology and pathological process, including bacterial spondylitis, rheumatic spondylarthropathies, primary or secondary tumours, malignancies, myelon- or cauda equine compression, paresis, metabolic base diseases, pathological or nonpathological fractures are suspected. The presence of so called “red flags” indicate“specific” low back pain. This type of low back pain requires quick and precise diagnosis and specific treatment. All other kinds of low back pain, even those with very painful radiculopathy, and without paresis, cauda- or myelon compression can be considered as aspecific, even if caused by a herniated disc, because there is no absolute indication of discectomy. In case of aspecific low back pain, there is no need of any diagnostic imaging methods, because they would not influence treatment. The main points of treatment are to keep the patient active, quick mobilisation with appropriate analgesia and antiinflammatory treatment following no more than 2-3 days of bed rest, and return to work as soon as possible, with easier work conditions if needed. The longer the patient is on sick leave, the higher the risk he or she will never return to work. If initial active treatment is not is effective enough, the patient's case should be reassessed in 3-6 weeks. If a herniated disc is suspected, the necessary imaging methods should be performed, and the patient should be operated if necessary. With this method, chronic, disabling low back pain can be avoided in many cases. The danger of developing chronic low back pain are indicated by the so called “yellow flags”: dissatisfaction with work, allowance claim, insufficient and even false ideas about the causes and consequences of low back pain, fear, anxiety, depression. These problems can be alleviated by the positive athmosphere of the workplace, appropriate patient education, activity, anxiolytic and antidepressant drugs, activity and regular exercise.]

Lege Artis Medicinae

[Development of anticoagulation in the past two decades]

SAS Géza

[In the past two decades we have witnessed a gradually increasing significance of both prophylactic and therapeutic anticoagulation. The importance of thromboprophylaxis has become widely accepted in the course of surgical interventions and in various other fields of medicine, too. The introduction of low molecular weight heparins was a milestone in this respect. The need for long-term anticoagulation has become a common problem. The various recent aspects and topics of anticoagulation have been described in the current Hungarian medical literature, therefore, I focus on two general problems of medicine of our days from the aspects of our subject. The evaluation of information on the new, direct-acting inhibitors (anti-IIa and anti- Xa),and their high price present great difficulies, especially in the case of long-term anticoagulation therapy. Clinical data and experiences have been collected from patients who are greatly different from the majority of patients in the real world. The lack of antidote may also be a serious problem in case of these new drugs, as urgent neutralization might be necessary, for example in case of serious bleeding, accidents etc. Today, cost-effectiveness of medical interventions and drugs has become a major aspect, therefore, the high price of new anticoagulants might prevent their use in the clinical practice. Despite the optimistic expectations regarding new anticoagulants, at present we have to strive to treat our patients with the currently available, effective but affordable drugs, widening and improving their use.]

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We aimed to investigate the association between fluoxetine use and the survival of hospitalised coronavirus disease (COVID-19) pneumonia patients. This retrospective case-control study used data extracted from the medical records of adult patients hospitalised with moderate or severe COVID-19 pneumonia at the Uzsoki Teaching Hospital of the Semmelweis University in Budapest, Hungary between 17 March and 22 April 2021. As a part of standard medical treatment, patients received anti-COVID-19 therapies as favipiravir, remdesivir, baricitinib or a combination of these drugs; and 110 of them received 20 mg fluoxetine capsules once daily as an adjuvant medication. Multivariable logistic regression was used to evaluate the association between fluoxetine use and mortality. For excluding a fluoxetine-selection bias potentially influencing our results, we compared baseline prognostic markers in the two groups treated versus not treated with fluoxetine. Out of the 269 participants, 205 (76.2%) survived and 64 (23.8%) died between days 2 and 28 after hospitalisation. Greater age (OR [95% CI] 1.08 [1.05–1.11], p<0.001), radiographic severity based on chest X-ray (OR [95% CI] 2.03 [1.27–3.25], p=0.003) and higher score of shortened National Early Warning Score (sNEWS) (OR [95% CI] 1.20 [1.01-1.43], p=0.04) were associated with higher mortality. Fluoxetine use was associated with an important (70%) decrease of mortality (OR [95% CI] 0.33 [0.16–0.68], p=0.002) compared to the non-fluoxetine group. Age, gender, LDH, CRP, and D-dimer levels, sNEWS, Chest X-ray score did not show statistical difference between the fluoxetine and non-fluoxetine groups supporting the reliability of our finding. Provisional to confirmation in randomised controlled studies, fluoxetine may be a potent treatment increasing the survival for COVID-19 pneumonia.

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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.

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Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

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Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

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NALBANTOGLU Mecbure, AKALIN Ali Mehmet, GUNDUZ Aysegul, KIZILTAN Meral

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission. Autonomic dysfunction is not a commonly known association with MG. We conducted this study to evaluate autonomic functions in MG & subgroups and to investigate the effects of acetylcholinesterase inhibitors. This study comprised 30 autoimmune MG patients and 30 healthy volunteers. Autonomic tests including sympathetic skin response (SSR) and R-R interval variation analysis (RRIV) was carried out. The tests were performed two times for patients who were under acetylcholinesterase inhibitors during the current assessment. The RRIV rise during hyperventilation was better (p=0.006) and Valsalva ratio (p=0.039) was lower in control group. The SSR amplitudes were lower thereafter drug intake (p=0.030). As much as time went by after drug administration prolonged SSR latencies were obtained (p=0.043).Valsalva ratio was lower in the AchR antibody negative group (p=0.033). The findings showed that both ocular/generalized MG patients have a subclinical parasympathetic abnormality prominent in the AchR antibody negative group and pyridostigmine has a peripheral sympathetic cholinergic noncumulative effect.

Lege Artis Medicinae

[Risk of nonsteroidal antiinflammatory drugs. Focus on aceclofenac]

FARSANG Csaba

[Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most frequently used pharmaceuticals. Nevertheless, a number of studies emphasized that NSAIDs were damaging not only the gastrointestinal (GI), but also the cardiovascular (CV) system, could increase the blood pressure, the frequency of coronary events (angina, myocardial infarction) and stroke incidence, as well as they might deterio­rate renal functions. The National Institute for Health and Care Excellence (NICE) did not find evidence that administering NSAIDs could increase the risk of developing COVID-19 or worsened the condition of COVID-19 patients. However, unwanted effects of specific drugs differ substantially in their occurrence and seriousness as well. It seemed to be for a long time that the NSAIDs provoked higher GI-risk was closely related to the COX1/COX2 selectivity, like the cardiovascular (CV) risk to the COX2/COX1 selectivity, however, the recent data did not prove it clearly. Based on the available literature while pondering the gastrointestinal and cardiovascular adverse events, among all NSAIDs the aceclofenac profile seemed to be the most favourable.]