Lege Artis Medicinae

[Network analysis in medicine]

BRYS Zoltán, BUDA Béla, PLUHÁR András

JULY 20, 2012

Lege Artis Medicinae - 2012;22(06-07)

[Network analysis is an increasingly used research method in medicine. Network analysis is a research and interpretation model at the same time. Our article outlines the various applications of network research in medicine and at its interdisciplinary boundaries. ]

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[Six-to-eight years after the diagnosis of type 2 diabetes the majority of patients require insulin treatment. Premixed insulin therapy provides an insulin profile that is closer to the physiological profile than that achieved by basal insulin supplementation and, in some cases, may serve as an alternative treatment in patients for whom intensified insulin therapy is unsuitable. However, if premixed human insulins are used, nocturnal hypoglycaemia occurs relatively frequently. Furthermore, patients must keep a lag-time of 30-45 minutes between the injection of insulin and eating. In contrast, if premixed insulin analogues are used, there is no need for such lag-time and both nocturnal and severe hypoglycaemia are less frequent than with human premixed therapy. The superiority of premixed insulin analogues compared with premixed human insulin therapy has been confirmed by a number of prospective, randomised controlled trials and retrospective analyses. The author summarises the results of these studies, emphasising the beneficial effects of premixed insulin analogues in the therapy of type 2 diabetes.]

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[Idiopathic retroperitoneal fibrosis (Morbus Ormond) associated with severe cardiomyopathy in a young man: a case report]

KOVÁCS Erzsébet, ZEHER Margit, SZÁNTÓ János, PÁSZTOR Éva, TÓTH László, PFLIEGLER György

[INTRODUCTION - The cause of idiopathic retroperitoneal fibrosis is unknown, but probably involves a chronic, nonspecific, autoimmune inflammation. This rare disease mostly affects middle-aged or elderly people, it hardly ever occurs in young people. It causes obstruction of the urinary tract, postrenal insufficiency as well as functional disorder of vital organs in the retroperitoneum and its surrounding area. The diagnosis is based on diagnostic imaging and histological examinations. Surgical treatment of the urinary obstruction is only efficient in the long-term if combined with immunomodulatory treatment. CASE REPORT - A young, 34-year-old man who presented with oedema in his legs was diagnosed with retroperitoneal fibrosis. Autoimmune serology was negative. He needed temporary nephrostomy on the right side. Treatment with steroid and colchicine was initially successful. His severe cardiomyopathy improved gradually. No regression occurred with tamoxifen, so we started to administer azathioprine with methylprednisolone. The control abdominal CT showed stagnation of the process. CONCLUSIONS - Because of the rarity of this disease, no randomised controlled trials are available regarding its treatment. The aim of treatment is to eradicate the symptoms, solve the urinary obstruction, maintain renal function and prevent progression of the disease. Improvement may be achieved by corticosteroids, cyclophosphamide, azathioprine, leflunomide, mycophenolate mofetil and tamoxifen. To our knowledge, this case is unique as no similar case with severe cardiomyopathy and idiopathic retroperitoneal fibrosis has been reported in the literature previously.]

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[NEPHROPATHY CAUSED BY PHYTOTHERAPY - LESSONS LEARNED]

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[Modern medical science, the ‘officially’ recognised medicine, relies on evidence based medicine, in contrast to the ancient, empirical practice that is gradually gaining ground in the population. This is now referred to as complementary alternative medicine. Alternative medicine has been present throughout the whole history of medicine and gaining popularity these days. Complementary medicine with its various branches and methodology, however, remains controversial - even in some aspects hazardous - due to the lack of scientifically valid evidence. The article deals in detail with the severe side effects of phytotherapy, with an illustration of the so-called ‘chinese herb nephropathy’, an ailment that afflicted more than 100 women on diet in Belgium. For two consecutive years these women took plant extracts labelled Stephania tetranda and Magnolia officinalis plus fenfluramin, diaethylpropion, cascara powder, acetazolamide, extracts of belladonna and meprobamate. The results: chronic renal failure, precancerous urinary tract conditions and aortic valve damage. Detailed analysis suspects the toxic substance of aristolochic acid found in one of the herbs to be the likely cause for the organ and tissue damage. These cases illustrate the need for the cautious approach towards phytotherapy and suggest that in the case of complementary medicine therapy one can not ignore the results of evidence based medicine. In this article, we critically analyse the state of modern and alternative medicine and emphasize that two separate types of medicine does not exist - only one, that has to integrate the methods of complementary medicine that are acceptable, and at the same time charlatan practice must not prevail.]

Clinical Neuroscience

Creutzfeldt-Jakob Disease: A single center experience and systemic analysis of cases in Turkey

USLU Ilgen Ferda, ELIF Gökçal, GÜRSOY Esra Azize, KOLUKISA Mehmet, YILDIZ Babacan Gulsen

We aimed to analyze the clinical, laboratory and neuroimaging findings in patients with sporadic Creutzfeldt-Jakob disease (CJD) in a single center as well as to review other published cases in Turkey. Between January 1st, 2014 and June 31st, 2017, all CJD cases were evaluated based on clinical findings, differential diagnosis, the previous misdiagnosis, electroencephalography (EEG), cerebrospinal fluid and cranial magnetic resonance imaging (MRI) findings in our center. All published cases in Turkey between 2005-2018 were also reviewed. In a total of 13 patients, progressive cognitive decline was the most common presenting symptom. Two patients had a diagnosis of Heidenhain variant, 1 patient had a diagnosis of Oppenheimer-Brownell variant. Seven patients (53.3%) had been misdiagnosed with depression, vascular dementia, normal pressure hydrocephalus or encephalitis. Eleven patients (87%) had typical MRI findings but only 5 of these were present at baseline. Asymmetrical high signal abnormalities on MRI were observed in 4 patients. Five patients (45.4%) had periodic spike wave complexes on EEG, all appeared during the follow-up. There were 74 published cases in Turkey bet­ween 2005 and 2018, with various clinical presentations. CJD has a variety of clinical features in our patient series as well as in cases reported in Turkey. Although progressive cognitive decline is the most common presenting symptom, unusual manifestations in early stages of the disease might cause misdiagnosis. Variant forms should be kept in mind in patients with isolated visual or cerebellar symptoms. MRI and EEG should be repeated during follow-up period if the clinical suspicion still exists.

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Cyanocobalamin and cholecalciferol synergistically improve functional and histopathological nerve healing in experimental rat model

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Introduction - Peripheral nerve injury (PNI) is a frequent problem among young adults. Hopefully, regeneration can occur in PNI unlike central nervous system. If nerve cut is complete, gold standard treatment is surgery, but incomplete cuts have been tried to be treated by medicines. The aim of the study was to evaluate and compare clinical and histopathological outcomes of independent treatment of each of Vitamin B12 (B12) and Vitamin D3 (D3) and their combination on sciatic nerve injury in an experimental rat model. Materials and methods - Experimental animal study was performed after the approval of BEH Ethics Committee No. 2015/10. 32 rats were grouped into four (n=8) according to treatment procedures, such as Group 1 (controls with no treatment), Group 2 (intraperitoneal 1 mg/kg/day B12), Group 3 (oral 3500 IU/kg/week D3), Group 4 (intraperitoneal 1 mg/kg/day B12+ oral 3500 IU/kg/week D3). Sciatic Functional Index (SFI) and histopathological analysis were performed. Results - SFIs of Group 2, 3, 4 were statistically significantly higher than controls. Group 2 and 3 were statistically not different, however Group 4 was statistically significantly higher than others according to SFI. Axonal degeneration (AD) in all treatment groups were statistically significantly lower than in Group 1. AD in Group 4 was significantly lower than in Group 2 and 3; there was no significant difference between Group 2 and 3. There was no significant difference between Group 1,2 and 3 in Axonolysis (A). But A of Group 4 was significantly very much lower than all others. Oedema- inflammation (OE-I) in all treatment groups were significantly lower than in Group 1; there was no significant difference between Group 2 and group 4. OE-I in Group 2 and 4 were significantly lower than in Group 3. There were no significant differences between Group 1, 2 and 3 in damage level scores; score of Group 4 was significantly lower than of Group 1. Conclusions - B12 and D3 were found effective with no statistically significant difference. But combined use of B12 and D3 improve nerve healing synergistically. We recommend combined use of B12 and D3 after PNI as soon as possible.

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[The majority of patients with advanced Parkinson’s disease are treated at specialized movement disorder centers. Currently, there is no clear consensus on how to define the stages of Parkinson’s disease; the proportion of Parkinson’s patients with advanced Parkinson’s disease, the referral process, and the clinical features used to characterize advanced Parkinson’s disease are not well delineated. The primary objective of this observational study was to evaluate the proportion of Parkinson’s patients identified as advanced patients according to physician’s judgment in all participating movement disorder centers across the study. Here we evaluate the Hungarian subset of the participating patients. The study was conducted in a cross-sectional, non-interventional, multi-country, multi-center format in 18 countries. Data were collected during a single patient visit. Current Parkinson’s disease status was assessed with Unified Parkinson’s Disease Rating Scale (UPDRS) parts II, III, IV, and V (modified Hoehn and Yahr staging). Non-motor symptoms were assessed using the PD Non-motor Symptoms Scale (NMSS); quality of life was assessed with the PD 8-item Quality-of-Life Questionnaire (PDQ-8). Parkinson’s disease was classified as advanced versus non-advanced based on physician assessment and on questions developed by the Delphi method. Overall, 2627 patients with Parkinson’s disease from 126 sites were documented. In Hungary, 100 patients with Parkinson’s disease were documented in four movement disorder centers, and, according to the physician assessment, 50% of these patients had advanced Parkinson’s disease. Their mean scores showed significantly higher impairment in those with, versus without advanced Parkinson’s disease: UPDRS II (14.1 vs. 9.2), UPDRS IV Q32 (1.1 vs. 0.0) and Q39 (1.1 vs. 0.5), UPDRS V (2.8 vs. 2.0) and PDQ-8 (29.1 vs. 18.9). Physicians in Hungarian movement disorder centers assessed that half of the Parkinson’s patients had advanced disease, with worse motor and non-motor symptom severity and worse QoL than those without advanced Parkinson’s disease. Despite being classified as eligible for invasive/device-aided treatment, that treatment had not been initiated in 25% of these patients.]