Lege Artis Medicinae

[Non-alcoholic fatty liver disease]

BAFFY György1

FEBRUARY 24, 2022

Lege Artis Medicinae - 2022;32(01-02)

DOI: https://doi.org/10.33616/lam.32.003

Journal Article

[Non-alcoholic fatty liver disease is estimated to affect 25% of the global population. It is often joining other metabolic disorders and features a heterogeneous natural history. Significant liver injury is unlikely to develop from steatosis, while a third of steatohepatitis cases will progress into cirrhosis and as a severe complication may lead to primary liver cancer. The probability of these severe outcome increases with the degree of liver fibrosis and with the prevalent type 2 diabetes and two or more metabolic risk factors. Regardless of its stage, non-alcoholic fatty liver disease is in­creasing the susceptibility for cardiovascular diseases, diabetes and all malignancies, and as a result is shortening the life expectancy. However, general awareness of the disease among healthcare professionals and their patients remains limited. Lack of approved medications for the disorder is likely a major contributor to this discrepancy. Since the disease primarily stems from sustained caloric excess, lifestyle modification including Mediterranean type diet, avoidance of alcohol consumption, and regular physical activity are the mainstay of management. Better education campaigns may improve patient compliance and enhance the recognition and acceptance of this condition within primary care, in parallel with the introduction of two-step fibrosis screening to achieve more efficient identification and management of the high-risk patients. ]


  1. LeSection of Gastroenterology, VA Boston Healthcare System, 150 S Huntington Avenue, Room A6-46, Boston, MA 12130, USA.



Further articles in this publication

Lege Artis Medicinae

[Main features of cardiovascular rehabilitation in post-acute Covid-19]


[The COVID-19 pandemic caused by SARS-CoV-2 is a significant challenge worldwide. Cornerstones of in-patient management of this pandemic which harms predominantly the respiratory system are the acute and intensive care. However, the rehabilitation plays a key role in improving the functional status and quality of life of survivors and reducing the impact of complications. As estimated, 40-50% of discharged patients require some form of medical support and 4-5% of them require inpatient rehabilitation. In addition to the respiratory system involvement, cardiovascular effects caused by COVID-19 (heart failure and myocarditis, acute coronary syndrome, arrhythmia, venous thromboembolism) are part of the ongoing systemic inflammatory processes and may affect 7-28% of hospitalized patients and lead to long-term deterioration in quality of life and loss of work capacity. Based on available scientific databases, expert consensus and the recommendations of European professional societies, this summary presents the recommended method, conditions and intensity of post-Covid cardiac rehabilitation including physical training exercises. The summary concerns also the recommended conditions for re­turn to work and sporting activities. Struc­tured exercise training is a very important and low-risk component of cardiac rehabilitation, reducing cardiovascular complications, thromboembolic complications, sys­temic inflammation and mortality, improving functional recovery and endothelial function. The planning of physical training should be preceded by a complex assessment of patients. Assessments of risk, capacity and function are needed to select the intensity, frequency and mode of indivi­dualized training. This should be combined with appropriate secondary preventive medication, monitoring, diet therapy and psychotherapy in accordance with respected principle of gradual progression. Finally, the consensus recommendations suggest that home-based and tele-rehabilitation should play a prominent role, considering the epidemiological and capacity constraints that also affect rehabilitation. ]

Lege Artis Medicinae

[Cardiovascular prevention 2021 – Guidelines of European Society of Cardiology 2021. Prevention at the population level And Disease specific cardiovascular prevention]


[In our four-part publication we review the current state of cardiovascular prevention based on the European Society of Car­dio­logy Guidelines 2021. In part 1 we reviewed the risk factors, risk assessment, age-specificities, the influencing factors, including diabetes mellitus and chronic kidney disease. In part 2 we concerned comorbidities affecting the cardiovascular risk. In part 3 we reviewed the personalised cardiovascular prevention and the management of specific risk factors, including optimisation of life style factors, management of lipid levels and high blood pressure and anti­thrombotic therapy. This part 4, we review the community level preventive measures (physical activity, diet, smoking habits and alcohol consumption) and the importance of governmental and non-governmental interventions. We provide a brief summary about the principles of cardiovascular prevention in individuals with coronary artery disaese, heart failure, cerebrovascular dis­eases, lower extremity artery disaese, chronic kidney disease, atrial fibrillation, and in multimorbid patients.]

Lege Artis Medicinae

[Options for assessing the quality of postoperative pain relief: unidimensional scales]

LOVASI Orsolya, LÁM Judit, LÉBER Andrea, GAÁL Péter

[The measurement of the quality of postoperative pain relief receives increasing attention in clinical practice since the not properly treated pain has several negative consequences for both the patients and the health care providers. An important component of the evaluation of the quality of care is the measurement of patient outcomes, which needs regular pain assessments and reliable pain assessment tools. The main goal of our paper is to review the literature on scales and pain assessment tools for postoperative pain assessment, the systematic literature search of which was performed by the PICO (population, intervention, control, and outcomes) technique. We found 396 accessible and evaluable articles in total, and out of them we summarized the results of the most important 31 in English and 3 in Hungarian. Organisations in the field of pain relief recommend the regular assessment of postoperative pain by unidimensional and multidimensional scales. Among unidimen­sional scales, we compared the Numerical Rating Scale (NRS), the Visual Analogue Scale (VAS) and the Verbal Descriptor Scale (VDS) with one another by discussing their advantages and limitations in measuring the intensity of postoperative pain. Al­though in clinical practice NRS is the most widely used one, VAS is more sensitive in the detection of changes and the best for statistical analysis. The advantage of VDS is that no significant differences can be detected in the interpretation of its results. At the same time, the application of VAS is the most difficult and the least preferred by patients and not always applicable immediately after the operation. The VDS is the least sensitive measurement tool, whose results are influenced by differences of the patients’ verbal interpretation, thus it is not applicable among patients with a weak vocabulary. In general, the main advantage of unidimensional scales is that they are fast and easy to use, but they measure only one dimension of pain, namely its intensity, and the association between the in­tensity ratings, the patients' subjective ex­perience of pain and its observable consequences are not unequivocal in certain cases. Consequently, when the circumstances permit, the use of multidimensional measurement tools should be considered.]

Lege Artis Medicinae

[Paradigm shift in the treatment of osteoarthrosis and the importance of prevention today]

DÖMSE Eszter

[Osteoarthrosis is a major burden on our society, both in terms of health affairs and health economy. The increasing strain on joints by competitive sports and the grow­ing prevalence of sedentary lifestyle are coupled main factors behind the increas­ing occurence of osteoarthritis in younger generations. Its pathomechanism is re­cently recognised to be a combination of inflammatory and degenerative processes. Concerning the serious and even quality of life worsening outcomes and its growing and spreading prevalence, the role of prevention has become crucial. This study reviews the preventive options, emphasiz­ing the importance of recreational sport and physical activities, while presenting also the new generation of chondroprotective agents. ]

Lege Artis Medicinae

[Telephone based supporting program to quit tobacco smoking in Hungary]

TÓTH Erzsébet, CSELKÓ Zsuzsa, DARWISH Diána, PATAKI Erika, BARTA Veronika , CSÁNYI Péter, BOGOS Krisztina

[The National Korányi Institute of Pulmonology, Methodology Centre for Tobacco Smoking Cessation Support has been operating a free quitline since 2013. The aim of the program is to provide professional advice on how to quit smoking, to spread information about supporting services and to refer interested smokers to specialized health care providers. Proactive calls following a specific protocol are available once a week for a six week period. This study presents the activities of our service in the last six years. Data of our retrospective longitudinal study were analysed by descrip­tive statistical methods. Between 2015 and 2020, there were received 24 286 messages received on the answering machine of the quit-line service. We were able to initiate conversation with approximately 55% of the interested callers. The free of charge quit-line is used predominantly by lower educated and indigent people. Program participants had a serious nicotine addiction. The program is particularly useful for smokers who are otherwise less likely to receive expert support. Between 2015 and 2020, the average abstinence rate of program participants was 16% after their proactive calls. The initial abstinence rate was 19% in 2015, which dropped to 6% in 2020. In this period the average quit rate was 13% at the six-month and 9% at the one-year follow-up. One possible reason for the low cessation rate is that the telephone counselling program can focus only on changing the patients’ behaviour without the in-person help of pharmacological support. Thus healthcare workers play a key role in encouraging of quit smoking and managing the nicotine withdrawal.]

All articles in the issue

Related contents

Clinical Neuroscience

Fluoxetine use is associated with improved survival of patients with COVID-19 pneumonia: A retrospective case-control study

NÉMETH Klára Zsófia, SZÛCS Anna , VITRAI József , JUHÁSZ Dóra , NÉMETH Pál János , HOLLÓ András

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.

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

Cholinesterase inhibitors and memantine for the treatment of Alzheimer and non-Alzheimer dementias


In aging societies, the morbidity and mortality of dementia is increasing at a significant rate, thereby imposing burden on healthcare, economy and the society as well. Patients’ and caregivers’ quality of life and life expectancy are greatly determined by the early diagnosis and the initiation of available symptomatic treatments. Cholinesterase inhibitors and memantine have been the cornerstones of Alzheimer’s therapy for approximately two decades and over the years, more and more experience has been gained on their use in non-Alzheimer’s dementias too. The aim of our work was to provide a comprehensive summary about the use of cholinesterase inhibitors and memantine for the treatment of Alzheimer’s and non-Alzheimers’s dementias.

Lege Artis Medicinae

[Diagnosis and treatment of microvascular coronary heart disease. Specialities of conditions in Hungary]


[Invasive investigations show that in two-thirds of patients the myocardial ischaemia persists without obstructive coronary disease and any other heart conditions (INOCA). The underlying cause may be microvascular dysfunction (CMD) with consecutive microvascular coronary disease (MVD) and microvascular or epicardial vasospastic angina (MVA). The modern practice of clinical cardiology while using the developed non-invasive cardiac imaging permits exact measuring of the coronary flow with its characteristic indices. All of these improve the diagnosing of CMD-induced myocardial ischemia and provide opportunity to determine primary MVD cases. Since the recognition and treatment of MVD is significantly underrep­resented in the Hungarian medical care, the primary stable microvascular angina (MVA) is described in detail below with its modern invasive and non-invasive differential diagnosis and treatment, concerning especially its frequency provoked by high blood pressure and female coronary heart diseases. There are highlighted all recommended diagnostic procedures available under domestic conditions.]