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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Lege Artis Medicinae

[Relationship Networks]

BUDA Béla

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

SZUMMER Csaba

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[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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[Risk of nonsteroidal antiinflammatory drugs. Focus on aceclofenac]

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[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.]

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. ]

Clinical Neuroscience

The etiology and age-related properties of patients with delirium in coronary intensive care unit and its effects on inhospital and follow up prognosis

ALTAY Servet, GÜRDOGAN Muhammet, KAYA Caglar, KARDAS Fatih, ZEYBEY Utku, CAKIR Burcu, EBIK Mustafa, DEMIR Melik

Delirium is a syndrome frequently encountered in intensive care and associated with a poor prognosis. Intensive care delirium is mostly based on general and palliative intensive care data in the literature. In this study, we aimed to investigate the incidence of delirium in coronary intensive care unit (CICU), related factors, its relationship with inhospital and follow up prognosis, incidence of age-related delirium and its effect on outcomes. This study was conducted with patients hospitalized in CICU of a tertiary university hospital between 01 August 2017 and 01 August 2018. Files of all patients were examined in details, and demographic, clinic and laboratory parameters were recorded. Patients confirmed with psychiatry consultation were included in the groups of patients who developed delirium. Patients were divided into groups with and without delirium developed, and baseline features, inhospital and follow up prognoses were investigated. In addition, patients were divided into four groups as <65 years old, 65-75 yo, 75-84 yo and> 85 yo, and the incidence of delirium, related factors and prognoses were compared among these groups. A total of 1108 patients (mean age: 64.4 ± 13.9 years; 66% men) who were followed in the intensive care unit with variable indications were included in the study. Of all patients 11.1% developed delirium in the CICU. Patients who developed delirium were older, comorbidities were more frequent, and these patients showed increased inflammation findings, and significant increase in inhospital mortality compared to those who did not develop delirium (p<0.05). At median 9-month follow up period, rehospitalization, reinfarction, cognitive dysfunction, initiation of psychiatric therapy and mortality were significantly higher in the delirium group (p<0.05). When patients who developed delirium were divided into four groups by age and analyzed, incidence of delirium and mortality rate in delirium group were significantly increased by age (p<0.05). Development of delirium in coronary intensive care unit is associated with increased inhospital and follow up morbidity and mortality. Delirium is more commonly seen in geriatric patients and those with comorbidity, and is associated with a poorer prognosis. High-risk patients should be more carefully monitored for the risk of delirium.

Clinical Neuroscience

A rare entity of acquired idiopathic generalised anhidrosis which has been successfully treated with pulse steroid therapy: Does the histopathology predict the treatment response?

ÖKTEM Özdemir Ece, ÇANKAYA Şeyda, UYKUR Burak Abdullah, ERDEN Simsek Nazan, YULUG Burak

Acquired idiopathic generalised anhidrosis is an uncommon sweating disorder characterized by loss of sweating in the absence of any neurologic, metabolic or sweat gland abnormalities. Although some possible immunological and structural mechanisms have been proposed for this rare entity, the definitive pathophysiology is still un­clear. Despite some successfully treated cases with systemic corticosteroid application, the dose and route of steroid application are controversial. Here, we present a 41-year-old man with lack of genera­lised sweating who has been successfully treated with high dose pulse intravenous prednisolone. We have discussed his clinical and histopathological findings as well as the treatment options in view of the current literature.

Clinical Neuroscience

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery

ONDER Burcu, KELES Yavuz Betul

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.