Lege Artis Medicinae

[OIRT General Assembly in Dobogókő]

MAY 29, 1991

Lege Artis Medicinae - 1991;1(09-10)

[Report on the 1991 General Assembly of the Oncology Interventional and Regional Tumour Therapy Section and the associated scientific conference .]

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Lege Artis Medicinae

[Intendation: the principle hypothesis for conductive education]

HÁRI Mária

[The Conductive Education System has got special attention in the recent decade as an alternative form of integrating disabled persons to society (normalization). The primary goals of the system are costruction of an active life pattern, improvement of the cognitive functions and fulfilment of requirements of a complex and unified programme. This process is special in the (re)habilitation of the motor disabled. Instead of the sensomotoric teaching of orthofunction, its cognitive approach serves the learning of intendation and makes possible the development of orthofunctional spontaneity. Between 1968–88. 9772, 0–14 year old disabled children were registered, and 71% of them admitted. 80% of the younger age group, and 60% of the elder succeeded in integration. In the first half of 1989 80% of 268 children suffering mainly from cerebral palsy were admitted. The special formation of the groups, preparing for work and life, planning of the special education and running the program need well trained conductor staff. ]

Lege Artis Medicinae

[Diagnosis and treatment of neck pain]

BÁLINT Géza, SZEBENYI Béla, BÁLINT Péter

[Neck pain is a frequent syndrome; numerous diseases may stand in its background from a transient myalgia to vertebral malignoma. Thus its diagnostics has a great importance in the everyday practice of the general practicioners. After a short summary of the anatomic features and aetiopathogenesis, the article analizes the anamnesis and physical examination as well as the elements of radiology and laboratory tests. The most important characteristic features of the cervical syndromes, according to leading symptoms are summarized. ]

Lege Artis Medicinae

[Clinical aspects of congenital thrombophilia]

DOMJÁN Gyula, PÁL András, PETŐ Iván, SAS Géza

[In the recent decades the name ,,thrombophilia" has been accepted to denote the congenital, mostly inherited susceptibility to thromboses. The increased coagulability (hypercoagulation) is supposed to be the main cause of the evolution of congenital thrombophilia. Antithrombin III has an outstanding importance to neutralize the active factors developing in the course of the coagulative process, and heparin-cofactor 11 has become known recently. Protein C and protein S are also important regulators. The increased coagulability can be caused by congenital disturbances of the formation of fibrinogen and plasminogen and also by the decreased activity of the fibrinolytic system. Recently, we recognised several cases, where the cause of thrombophilia was simultaneous absence of two inhibitors of coagulation. We attach importance to those cases as well when the inherited defect of one inhibitor and a congenital metabolic disturbance occure together. The diagnosis of congenital thrombophilia needs a long series of laboratory tests. In the course of the treatment results can be expected from thrombolysis, probably from vascular surgical interventions and – in non recent cases – from anticoagulation. The substitution treatment is getting more important in these inhibitor deficiencies.]

Lege Artis Medicinae

[Predictive value of allergic rhinitis for bronchial asthma in childhood]

BITTERA István, GYURKOVITS Kálmán

[Asthmatic manifestations can be expected in 20 to 30% of children with allergic rhinitis. Risk factors were searched to predict later bronchial asthma in time. In a prospective study family history, clinical symptoms and laboratory signs, bronchial hyperreactivity (to histamine and to adenosine) and the lymphocyte beta-adrenergic receptor affinity and number were investigated. 31 of 40 patients responded with bronchoconstriction to histamin and 20 to adenosine. In 16 patients both provocation tests were positive. There was no significant difference in lymphocyte beta-adrenergic receptors between the patient group and the controls. It is suggested that children with allergic rhinitis who show bronchial hyperreactivity and a decreased number or affinity of lymphocyte beta-adrenergic receptors are more at risk to asthmatic manifestations. The risk is higher as the number of receptors decreases with age. The prognostic value of the above mentioned methods will be demonstrated by a subsequent retrospective study.]

Lege Artis Medicinae

[A consultation program for planning insulin therapy]

DEUTSCH Tibor, WÁGNER János, TAMÁS Gyula

[This paper describes a decision support system aimed to assist the day-to-day management of insulin treated diabetic patients based on blood glucose measurements. The therapeutic advices are generated by a multistep procedure involving qualitative reasoning to determine the direction of adjustments and numerical simulation of insulin effect on glycaemia to quantify the extent of control actions to achieve glucose control corresponding to the pre selected targets. The qualitative reasoning module uses meal time oriented glucose balances and distances from the glucose target values to guide the search for appropriate control actions. The simulation module contains a physiologically based glucose-insulin model which generates a 24 hour prediction of the patient's blood glucose profile based on these adjustments which allows the doctor to select the optimal control action from alternatives. The results of a preliminary study to compare the advices given by the system to that of an independent diabetologist are also presented for 11 patients.]

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Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

ÜNSAL Ünlü Ülkün, ŞENTÜRK Salim

Microdiscectomy (MD) is a stan­dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in­terlaminar lumbar discectomy (PELD) is another surgical op­tion that has become popular owing to reports of shorter hos­pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist’s costs), hospital stay, anesthetic drugs and materials, laboratory wor­kup, nur­sing care, and postoperative me­dication diffe­red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.

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. ]

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[The importance of patient reported outcome measures in Pompe disease]

MOLNÁR Mária Judit, MOLNÁR Viktor, LÁSZLÓ Izabella, SZEGEDI Márta, VÁRHEGYI Vera, GROSZ Zoltán

[In recent decades it has become increasingly important to involve patients in their diagnostic and treatment process to improve treatment outcomes and optimize compliance. By their involvement, patients can become active participants in therapeutic developments and their observations can be utilized in determining the unmet needs and priorities in clinical research. This is especially true in rare diseases such as Pompe disease. Pompe disease is a genetically determined lysosomal storage disease featuring severe limb-girdle and axial muscle weakness accompanied with respiratory insufficiency, in which enzyme replacement therapy (ERT) now has been available for 15 years. In our present study, patient reported outcome measures (PROMs) for individuals affected with Pompe disease were developed which included questionnaires assessing general quality of life (EuroQoL, EQ-5D, SF36), daily activities and motor performance (Fatigue Severity Score, R-PAct-Scale, Rotterdam and Bartel disability scale). Data were collected for three subsequent years. The PROM questionnaires were a good complement to the physician-recorded condition assessment, and on certain aspects only PROMs provided information (e.g. fatigue in excess of patients’ objective muscle weakness; deteriorating social activities despite stagnant physical abilities; significant individual differences in certain domains). The psychological effects of disease burden were also reflected in PROMs. In addition to medical examination and certain endpoints monitored by physicians, patient perspectives need to be taken into account when assessing the effectiveness of new, innovative treatments. With involvement of patients, information can be obtained that might remain uncovered during regular medical visits, although it is essential in determining the directions and priorities of clinical research. For all orphan medicines we emphasize to include patients in a compulsory manner to obtain general and disease-specific multidimensional outcome measures and use them as a quality indicator to monitor treatment effectiveness.]

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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

Validation of the Hungarian PHQ-15. A latent variable approach

STAUDER Adrienne, WITTHÖFT Michael, KÖTELES Ferenc

Somatic symptoms without a clear-cut organic or biomedical background, also called “medically unexplained” or “somatoform” symptoms, are frequent in primary and secondary health care. They are often accompanied by depression and/or anxiety, and cause functional impairment. The Patient Health Question­naire Somatic Symptom Scale (PHQ-15) was developed to measure somatic symptom distress based on the frequency and bothersomeness of non-specific somatic symptoms. The study aimed to (1) evaluate the Hungarian version of the PHQ-15 from a psychometric point of view; (2) replicate the bifactor structure and associations with negative affect described in the literature; and (3) provide the Hungarian clinical and scientific community with reference (normal) values split by sex and age groups. PHQ-15, depression (BDI-R), and subjective well-being (WHO-5) scores obtained from a large (n = 5020) and close to representative community sample (Hun­garostudy 2006) were subjected to correlation analysis and linear structural equation modeling. The PHQ-15 showed good internal consistency (Cronbach’s α = 0.810; McDonald’s ω = 0.819) and moderate to strong correlation with the BDI-R (rs = .49, p < 0.001) and WHO-5 (rs = -.48, p < 0.001). Fit of the bifactor structure was excellent; in independent analyses, the general factor was strongly associated with depression (β = 0.656±0.017, p < 0.001) and well-being (β = -0.575±0.015, p < 0.001), whereas the symptom specific factors were only weakly or not related to these constructs. The PHQ-15 score was higher in females and showed a weak positive association with age. The Hungarian PHQ-15 is a psychometrically sound scale which is positively associated with depression and ne­gatively related to subjective well-being. The bifactor structure indicates the existence and meaningfulness of a gene­ral factor representing the affective-motivational component of somatic symptom distress. The Hungarian version of the PHQ-15 is a brief and usable tool for the pre-screening of somatization disorder (DSM-IV) or somatic symptom disorder (DSM-5). The reported reference values can be used in the future for both clinical and research purposes.