Lege Artis Medicinae

[Nasal Congestion as an Endemic]

NEMESI Zsuzsa

AUGUST 20, 2010

Lege Artis Medicinae - 2010;20(08)

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Lege Artis Medicinae

[The drug-treatment of atherosclerosis by statins]

KÉKES Ede

[The pathogenesis of atherosclerosis is a complex and complicated process. The rule of some factors (lipoproteindeposition, oxidative stress, lipid peroxidation, endothel dysfunction, etc) is well known, but others are not yet clarified. Conventional, metabolic and some special residual factors have also influenced for the starting process. One of them, the lipid profile is the most important. Statins are able to decrease the lipid levels - LDL cholesterol - significantly to the physiological level. These drugs are essential for the primer and secunder cardiovascular prevention moreover it is advisable to give in acute coronary syndrome as well. The most excellent statin is rosuvastatin, because of beneficial effect to decreasing LDL cholesterol level and cardiovascular events. Rosuvastatin is able to produce a regression of atherosclerotic process int he vessel walls. Presumably this effect can be explained by their pleiotrop property.]

Lege Artis Medicinae

[Tracking the Forgotten Profession]

NAGY Zsuzsanna

Lege Artis Medicinae

[Need-adjusted inequalities in the use of healthcare in Hungary]

VITRAI József, BAKACS Márta, KAPOSVÁRI Csilla, NÉMETH Renáta

[INTRODUCTION - The reduction of need-adjusted inequalities in the use of healthcare results in higher efficiency and fairer allocation of resources. PATIENTS AND METHODS - Data for all patients who received inpatient care (same-day or hospital treatment) in 2007 were used in the analysis. Beyond the diagnostic and diagnosisrelated group’s weight information and the number of inpatient days, the patients’ record contained data on age, sex, and postal code of residency. Besides personal data, socio-economic characteristics and general indicators of healthcare capacity have been included in the applied multilevel statistical analysis. Inequalities were estimated for all patients, and separately for those treated for malignant tumour, cardio-vascular diseases, or other diseases. RESULTS - Significant regional inequalities were observed in one-day care but an order of magnitude less in longer inpatient care. Comparing the two major diagnostic groups, the inequalities were greater among patients with cardiovascular diseases than for those with cancer. Only a small fraction of the observed inequalities was explained by the differences in the composition of population of small regions. The inequalities in the use of healthcare were largely explained by socio-economic characteristics of the regions. CONCLUSIONS - Need-adjusted inequalities in the use of healthcare supported the hypothesis that efficiency of the Hungarian healthcare system can be significantly improved by allocating the available resources according to the patients’ need.]

Lege Artis Medicinae

[Modern beta-blocker therapy from the cardiologist’s viewpoint]

ÉDES István

[Following the publication of some large, randomised trials (LIFE, ASCOT), the benefits of the use of beta-blockers in hypertension have been questioned. On the basis of these clinical trials it has been posited that beta-blockers administered for the treatment of hypertonia are less effecient for stroke prevention. It has been suggested that first-generation beta-blockers (atenolol) have adverse metabolic effects (insulin sensitivity, lipid parameteres), which might contribute to the differences observed in clinical outcomes. On the basis of a number of clinical trials and meta-analyses performed in recent years it is now evident that the most important goal is to reach target blood pressure levels, which is usually achieved by combination therapy. Choosing drugs on the basis of strict protocols is less important. In general, beta-blockers remain one of the most important drug class for the treatment of hypertension. The author reviews the pharmacology of the cardioselective, vasodilatory drug nebivolol in detail, as well as clinical trials on nebivolol. Nebivolol has a neutral (or rather beneficial) effect on metabolic parameters (lipid parameters, blood glucose level and insulin sensitivity) as well as on left ventricular function. If hypertension is associated with cardiovascular diseases (left ventricular dysfunction, ischaemic hears disease, atrial fibrillation), nebivolol offers an excellent therapeutic alternative due to its excellent tolerability and side effect profile.]

Lege Artis Medicinae

[An Endless Story?]

BÁNFALVI Attila

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Hungarian Radiology

[Balloon dilatation and metallic stent placement in inferior vena cava stenosis complicating liver transplantation]

DOROS Attila és munkatársai

[INTRODUCTION - The only successful therapy for end stage liver cirrhosis is liver transplantation. The anastomotic stenosis of the inferior vena cava is rare but serious complication. In these cases surgery is a high risk procedure; therefore interventional radiological methods are recommended. PATIENTS AND METHODS - Eleven patients developed 12 caval stenosis from 365 liver transplant recipients in Budapest. One of the patients had caval stenosis again after retransplantation. Dilatation was performed with 10- 25 mm large balloon catheters in 6 cases and 6 metallic stents (12-24 mm in diameter) were implanted. All the procedures were performed via the common femoral vein. RESULTS - The success of the intervention was measured by the morphological results, clinical signs and by the changes of superior-inferior vena cava pressure gradients. Before the intervention 14 Hgmm mean pressure gradient was measured, which decreased to 8 Hgmm post intervention. Eleven patients developed renal insufficiency before treatment; this was reversible in 6 cases. One patient had impaired renal function before treatment, and later on again, after retransplantation. Three of 4 patients with renal insufficiency died in the post operative period. One stent migration was noticed prompting surgical fixation of the stent. CONCLUSION - Inferior vena cava stenosis represents a serious complication after liver transplantation, causing ascites, hydrothorax and venous congestion in the kidneys and the liver. In the critical post operative period surgery is not recommended, risking the viability of the liver and the life of the patient. Interventional radiology with balloon dilatation and stent implantation is the method of choice in these cases, primary stenting with large self expanding metallic stents is necessary in elastic stenosis caused by torsion of the anastomosis.]

Clinical Neuroscience

[Symptomatic trigeminal autonomic cephalalgia without headache]

RÓZSA Anikó, KOVÁCS Krisztina, GUBA Katalin, GÁCS Gyula

[We report the case of a 60-year-old man who exhibited trigeminal autonomic symptoms on his right side (numbness of the face, reddening of the eye, nasal congestion) occurring several times a day, for a maximum of 60 se­conds, without any pain. The complaints were similar to trigeminal autonomic cephalalgia, just without any headache. Our 60-year-old male patient underwent a craniocervical MRI as part of his neurological workup, which revealed lesions indicative of demyelination. Further testing was guided (ophthalmological examination, VEP, CSF test) by the presumptive diagnosis of multiple sclerosis. It is likely that in his case the cause of these trigeminal and autonomic paroxysms is MS. Here we present an overview of the few cases we found in the literature, although we did not find any similar case reports. Perhaps the most interesting among these is one in which the author describes a family: a 54-year-old female exhibiting the autonomic characteristics of an episodic cluster headache, only without actual headache, her son, who had typical episodic cluster headaches with autonomic symptoms, and the woman’s father, whose short-term periorbital headaches were present without autonomic symptoms. We had not previously encountered a case of trigeminal autonomic cephalalgia without headache in our practice, nor have we had an MS patient exhibiting similar neurologic symptoms. The significance of our case lies in its uniqueness. ]

Lege Artis Medicinae

[Does venous congestion decrease renal function - fiction or real?]

KOPITKÓ Csaba, MEDVE László, GONDOS Tibor

[Venous congestion can result in dysfunction of several organs. Although experimental data on renal dysfunction caused by venous congestion were already published about 90 years ago, those were difficult to extrapolate to humans, due to significant interracial differences. Acute pre-renal, or volume-sensitive kidney injury might respond to volume replacement; however, overt fluid resuscitation with or without right ventricular dysfunction can result in elevated central venous pressure. The glomerular capillary blood pressure, i. e. net filtration pressure in a single glomerulus is about 10 mmHg. Kidney dysfunction can both increase intra-abdominal pressure or elevate central venous pressure with or without decreased mean arterial pressure, can lead to renal dysfunction. In studies among patients with heart failure, or after cardiac or abdominal surgery, the increase of central venous pressure or intra-abdominal pressure above 8 mmHg resulted in impaired kidney function. This review summarizes both pre-clinical and clinical data on the role of intra-abdominal hypertension and venous congestion in the development of acute kidney injury.]

Clinical Neuroscience

[Closure of nasocranial fistulas with “bath-plug” technique and multilayer reconstruction]

PISKI Zalán, BÜKI András, NEPP Nelli, BURIÁN András, RÉVÉSZ Péter, GERLINGER Imre

[Background and purpose - In case of dehiscenses developing on the anterior scull base, complete closure resulting in the cessation of the communication between the nasal cavity and the intracranial space is mandatory as soon as possible, in order to prevent serious complications. With the development of the endoscopic techniques, the endonasal management for the reconstruction has become available in recent decades. Methods - We aim to present the reconstruction techniques applied in our department in the cases of two patients recently operated at our institute. The choice of methods primarily depends on the size and the localization of the defect. Dehiscenses under 5 mm of diameter can be closed with the so called “bath-plug” technique, while bigger defects, where the required closure of the plug is not possible, can be solved with multilayer reconstruction. We use autogenous fascia, fat and muco-periosteum in both cases. Results - Our patient, who underwent the aforementioned “bath-plug” procedure, could be discharged after a few days of uneventful postoperative period. During a tenmonth follow- up period new fistula formation was not observed. In the case of a patient who underwent multilayer reconstruction, meningitis occurred postoperatively, which was resolved after antibiotic therapy. During a 17- month follow- up period recurrent liquorrhoea did not occur. Conclusion - With suitable technical background and appropriate endoscopic skills the surgeries of the anterior skull base cerebrospinal fluid fistulas can be performed efficiently and with low complication rate. These are minimally invasive procedures accompanied by less surgical trauma, morbidity and shorter hospitalization, hence these techniques are considered to be cost-effective and well- tolerated for the patients.]

Hungarian Immunology

[Pseudolymphoma orbitae]

VÁNCSA Andrea, GERGELY Lajos, NEMES Zoltán, BÍRÓ Edit, ILLÉS Árpád, BAKÓ Gyula

[INTRODUCTION - Pseudolymphoma orbitae is a rare and difficult entity. The cooperation of the pathologist and clinician is needed to properly manage the patient. CASE REPORT - The authors report the case history of a 38 years old male patient. His disease started at the age of 30. He was previously treated with allergic rhinitis. No definitive diagnosis was made for eight years. Several surgical biopsies were made from nasal mucosa, but no specific histologyical diagnosis was applicable. At the age of 30 he developed an unilateral exophthalmus on the left side. Thyroid associated ophthalmopathy was ruled out several times with laboratory analysis. High dose methylprednisone therapy was repeatedly given with limited results. At the age of 34 orbital CT and MRI scan confirmed the pseudotumour orbitae already compressing the optical nerve. Laboratory analysis again ruled out thyroid associated ophthalmopathy. Churg-Strauss syndrome, Wegener’s granulomatosis or Sjögren’s syndrome could be ruled out. A bone marrow trephine biopsy excluded systemic hematological disease as well. A biopsy was performed from the retrobulbar mass again, which confirmed the lymphoid hyperplasia with B-cell dominance. High dose methylprednisone and local irradiation resulted only moderate decrease of the mass, so systemic chemotherapy was started using CVP (cyclophosphamide, vincristin, prednisone) then CHOP (CVP + anthrycycline) polychemotherapy for eight cycles and subcutaneous interferon-α for 20 months. CONCLUSIONS - This resulted a complete regression of the disease, and the patient is well for 48 months now.]