Lege Artis Medicinae

[Pantaleon the doctor, patron saint of doctors]


JUNE 30, 1992

Lege Artis Medicinae - 1992;2(06)

[The spread of the cult of Pantaleon in the world; Traditions in Hungary; Places bearing the name of Pantaleon; The monastery of Saint Pantaleon; Memories of Pentele]



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Lege Artis Medicinae

[Immunological aspects of granuloma formation]

DANKÓ Katalin, SZEGEDI Gyula

[The process of inflammation can be classified as acute, subacute and chronic, as well as the special category of granulomatous inflammation. Classification of granulomatous inflammation based on morphologic criteria. These are epitheloid, histiocytic, foreign-body, necrobiotic and mixed inflammatory granuloma. The current knowledge suggests the following sequences for the mechanisms of granuloma formation in sarcoidosis (Fig 2): 1. T-cells are locally activated and proliferating 2. These activated T-cells release lymphokines that recruit and activate monocytes/macrophages 3. These activated monocytes/macrophages may differentiate into granuloma cells such as epithelioids cells and multinucleated giant cells and release pro-inflammatory profibrotic mediators that modulate the granulomatous and fibrotic process. It is hoped that further studies in sarcoidosis will help not only in clarifying the pathogenic mechanisms leading to granuloma formation, but also in eventually revealing the etiology of sarcoidosis. ]

Lege Artis Medicinae

[Transvaginal ultrasound examination of embryo development in early pregnancy (sono-embryology) II. central nervous system]

CSABAY László, SZABÓ István, NÉMET János, PAPP Zoltán

[In the second part of their paper, the authors look over the most important phases of the development of the central nervous system during the first trimester of pregnancy - especially considering the stages, which can be differentiated with a high resolution transvaginal transducer. The closed neural tube is developing at days 40 to 44 by the closure of the posterior neuropore, however at this time no brain structures can be detected by ultrasound. During the 7th week the three primary brain vesicles (prosencephalon, metencepha lon, myelencephalon) can be identified – a single ventricle can be seen by ultrasound. During the 8th week the secondary brain vesicles (telencephalon, diencephalon, mesencephalon, metencephalon, myelencephalon) can be separated. During the 9th week the lateral ventricles are filled out by the choroid plexus, which are retracted to the occipital horn by the 13th week. The appearance of the brain structures also takes place according to an accurate „calendar". The structures recognized by ultrasound can be compared to those of the central nervous system known from embryology. The problem of the primary prevention of the cerebrospinal malformations, which are among the most frequent congenital disorders, is not yet solved; therefore the early prenatal diagnosis of the structural anomalies has great importance. ]

Lege Artis Medicinae

[Laparoscopic varicocelectomy]

HOLMAN Endre, TÓTH Csaba, PÁSZTOR Imre, FICSÓR Ervin, PAPP Ferenc

[ With the spreading use of the laparoscope in the urological surgery laparoscopic varicocelectomy may become an alternative treatment of varicocele. The method can be advantageous mainly for patients with bilateral cases compared to the open operation. The authors report on two cases that have been the first urological laparoscopic operations in Hungary.]

Lege Artis Medicinae

[Vascular surgical aspects of small bowel ischaemia]

DÓBI István

[A brief account is given of acute and chronic diseases underlying the disorders of blood supply to the small bowel. In cases of acute disorders, considering the diagnostic difficulties involved, the author stresses the importance of commencing of a vasodilatator treatment immediately after the tentative diagnosis has been reached based on the first suspicious symptomes, and also requiring angiography to render the accurate diagnosis. This is the only possibility to increase (without irreversible tissue damages) the number of successful early vascular reconstructions which are the prerequisites to reducing in lethality. Finally, based on his own extensive experimental work, the author proposes to make allowances for the augmented local postischaemic vasoconstrictor trends of vascular reactivity in the complex therapeutic regimen of these diseases. ]

Lege Artis Medicinae

[Cardiovascular effects of sleep-related breathing disorders, a review]

VÁRDI Visy Katalin

[The acute and chronic cardiovascular effects of sleep related breathing disorders are summarized in this review. Obstructive sleep apnoea syndrome is characterized by recurrent upper airway collapse during inspiration. The resulting asphyxia causes hypoxia and arousal. The vigorous inspiratory efforts produce falls in blood pressure coinciding with each effort (pulsus paradoxus). A rise in blood pressure is seen concurrently with each termination of apnoea and arousal. Bradycardia induced by hypoxia in each obstructive period and increased frequency at time of arousals could lead to arrhythmias. This may result in a high prevalence of hypertension, acute myocardial infarction and arrhythmias in sufferers of obstructive sleep apnoea syndrome have. ]

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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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How to manage MuSK antibody-positive myasthenic crisis during pregnancy?


Myasthenia gravis (MG) is an autoimmune disease that is characterised by the formation of antibodies against acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. The course of the disease cannot be predicted during pregnancy. A subtype of MG with positive muscle-specific receptor tyrosine kinase (anti-MuSK) antibodies exhibits more localised clinical characteristics and a poor response to treatment compared with the disease subtype that involves positivity for acetylcholine receptor antibodies. Myasthenic crisis is more frequently observed in anti-MuSK-positive myasthenia patients. Anti-MuSK-positive myasthenic crisis management is very difficult and a risky situation during pregnancy. The reported case was 30 years old, female, 9 weeks pregnant and musk antibody positive. She stopped her treatment without asking her doctor because she was planning pregnancy in the 6-month period before her hospitalization. She was intubated for a long time in the intensive care unit due to myasthenic crisis and was very resistant to treatment. During this period, her pregnancy was terminated due to fetal anomaly. Plasmapheresis, IVIg and immunosuppressive treatments were applied. Our patient was discharged after a period of about 10 weeks. We share our treatment management.

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RÓZSA Csilla

[Family planning is an exceptionally important question in multiple sclerosis, as women of childbearing age are the ones most often affected. Although it is proven that pregnancy does not worsen the long-term prognosis of relapsing-remitting multiple sclerosis, many patients are still doubtful about having children. This question is further complicated by the fact that patients – and often even doctors – are not sufficiently informed about how the ever-increasing number of available disease-modifying treatments affect pregnancies. Breastfeeding is an even less clear topic. Patients usually look to their neurologists first for answers concerning these matters. It falls to the neurologist to rationally evaluate the risks and benefits of contraception, pregnancy, assisted reproduction, childbirth, breastfeeding and disease modifying treatments, to inform patients about these, and then together come to a decision about the best possible therapeutic approach, taking the patients’ individual family plans into consideration. Here we present a review of relevant literature adhering to international guidelines on the topics of conception, pregnancy and breastfeeding, with a special focus on the applicability of approved disease modifying treatments during pregnancy and breastfeeding. The goal of this article is to provide clinicians involved in the care of MS patients with up-to-date information that they can utilize in their day-to-day clinical practice. ]

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[Can we influence the negative drug attitude? Interpretation of the rejection of COVID-19 vaccine in the light of results of a pilot study ]

POGÁNY László , HORVÁTH A. András, LAZÁRY Judit

[Vaccination refusal is a serious obstacle to minimizing the spread of COVID-19. Nevertheless, the rejection of vaccine can be considered the result of a negative attitude towards medical treatment, and according to our previously published data, it can be influenced by the underlying affective state. Increased incidence of affective disorders and anxiety could be observed globally during the pandemic, which may have a significant impact on vaccination acceptance. The aim of our pilot study was to determine the association between clinical improvement of affective and neurocognitive symptoms and change of drug attitude and health control beliefs in a sample of psychiatric patients. A data set of 85 patients with psychiatric disorder has been analysed with the use of Patient’s Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) with 5 subscales (Negative Aspect of Medication – NA; Positive Aspect of Medication – PA; Doctor health locus of control- Doctor HLOC; Internal HLOC; Psychological Reactance – PR); Hospital Anxiety Depression Scale (HADS-Anx; HADS-Dep) and neurocognitive tests, such as the Stroop test and the Trail Making Tests. All the tests were performed before and after a 14 days treatment. Paired t-tests and generalized linear models were performed to assess the associations between the variables. The baseline scores of NA and HADS-Anx correlated significantly (p=0.001) and after two weeks of treatment NA decreased (p=0.001), while Doctor HLOC and Internal HLOC increased (p=0.001 and p=0.006). The patients performance of the neurocognitive tests improved (all p<0.05). The reduction of HADS-Anx (p=0.002) and HADS-Dep (p=0.006) scores showed significant associations with the decrease of NA. Increase of the PA score was associated with reduction of HADS-Dep (p=0.028). Improvement of neurocognitive functions had no effect on PHBQPT scores. Important conclusions can be drawn regarding the rejection of the COVID-19 vaccine based on the associations found between the intensity of affective and anxiety symptoms and the attitude towards treatment. Our findings suggest that affective symptoms have a negative influence on the attitude towards treatment and that the improvement of these symptoms can facilitate the acceptance of the therapy, regardless of diagnosis. The modest effect of the improvement of neurocognitive functioning on the attitude towards drugs and the significant role of affective-emotional factors suggest that the accep­tance of vaccination probably cannot be facilitated solely with the aid of educational programs. Considering the increasing incidence of affective disorders during the COVID-19 pandemic, the screening of affective and anxiety symptoms and treatment of these disorders could be an important step towards the acceptance of the vaccine. Although psychiatry is not considered as a frontline care unit of the COVID cases, more attention is needed to pay on the availability of mental health services because refuse of vaccine can develop due to affective disorders too.]

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[Investigating cognitive impairment in communities of practice – lessons learned]

VAJER Péter, JANCSÓ Zoltán, CSENTERI Orsolya, SZÔLLÔSI Gergô József, ANDRÉKA Péter

[In the “Three Generations for Health” programme, general practitioners were responsible for screening for dementia in their practices using mini-COG and Mini Mental State Examination. The aim was to present the screening results of those included, their assessment by the doctor and the further fate of the patients. After mini-COG test, MMSE test was performed in case of suspected dementia. The examiner categorized the result as abnormal or no abnormal, recorded the referral, and recorded the data in an online interface. Our study is a cross-sectional study; the evolution and distribution of the parameters described in the objectives are described with raw case numbers and proportions. Patients aged 55 years and over were recruited consecutively. Only those cases (29 730) where mini-COG and MMSE test results were available, their assessment by the physician, and referral data to specialist care were analyzed. The Mini-COG test revealed that 64% of the subjects were suspected of cognitive decline. Misclassification occurred in 13 015 cases, with 21% of the Mini-Cog test scores matching cognitive decline and 21% of lesions considered abnormal by GPs. The MMSE test raised the suspicion of dementia in 34% of the sample (10 174 people), with 4 262 (42%) of the participating GPs considering the result abnormal. 11% (2095 people) of people with abnormal Mini-Cog test scores and 17% (1709 people) of people with suspected dementia based on MMSE test scores were referred to specialist care. Our study assessed the practice of detecting cognitive decline in primary health care. The tools adopted for screening for dementia were used by practices, but the assessment of results and referral of suspected cases of dementia to specialist care were below the expected level. There is a need to improve primary care providers’ knowledge of dementia detection and treatment and to strengthen links with specialist care.]