Lege Artis Medicinae

[Renal care - possibilities of complex organ protection]

WAGNER Gyula, AMMA Zoltán, JUHÁSZ László, KULCSÁR Katalin

NOVEMBER 20, 2010

Lege Artis Medicinae - 2010;20(11)

[The authors analyse data of the last ten years of renal care. According to the principles of care they prefer to have contact at least once to all patients with an estimated clearance less than 60 ml/min, and on a regular basis to those with less than 30 ml/min. Their fundamental ambition is to develop the most favourable therapy for the patients together with general practitioners and with representatives of other specialities. The most important aim is to reduce cardio-renal morbidity and mortality. Early detection and effective treatment of target organ damage are the tools for this. It is clear from their previous work that it was not successful in the first period of care (2000-2005) especially in patients with diabetic nephropathy. Before the initiation of renal replacement therapy only half of the patients have been seen by a nephrologist. One-year-mortality after initiating dialysis was significant among patients who did not receive such care. Their medication was also not up-to-date. Through regular continuing medical education for general practitioners and in close collaboration with diabetologist colleagues the number of patients taken care of has doubled. Furthermore, the proportion of patients with hypertension or diabetes as an underlying disease among the patients receiving renal care increased to 68%. These findings may contribute to that their patients receive effective treatment taking the actual therapeutic recommendations into account. Hopefully it will be apparent in the hard end-points at the time of the analysis of the second period.]

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Lege Artis Medicinae

[Central nervous system hemorrhage in Wegener’s granulomatosis]

SZABOLCSI Orsolya, SZÁNTÓ Antónia, ZEHER Margit

[In our case a 41-year-old man with following symptoms: non-productive coughing, fever, difficulty in breathing and weight loss was examined in February 2007, and on the basis of chest X-ray, CT and bronchoscopy, the possibility of neoplasm or tuberculosis cropped up. After the applied therapy (steroid, antibiotics, tuberculostatic drugs) the symptoms became more severe, i.e. hematuria and epistaxis were manifested. A tissue biopsy was carried out during bronchoscopy and the histological examination revealed granulomatous reaction. Meanwhile, the presence of c-ANCA was proved, and Wegener’s granulomatosis (WG) was diagnosed. In March 2007, sudden somnolence and left side hemiplegia developed, and a large haemorrhage was recognised on CT scan in the right fronto-temporal region, with regard to the haemorrhage, the patient had to undergo a neurosurgical operation. We started to treat him in April 2007 by intravenous steroid and 600 mg of cyclophosphamide (Cyc), and he regained the ability to walk again. In October 2007, the Cyc treatment was terminated, and we administered a maintenance therapy with methotrexat. During the regular medical check-up, a chest X-ray indicated a second attack in March 2008, which was confirmed by the chest CT, the clinical symptoms, increased anti-PR3 levels and c-ANCA positivity as well. The flair of the disease was established. Consequently, in April 2008 we decided on plasmapheresis therapy synchronised with Cyc. After that, we started an azathioprine maintenance therapy and he got rid of all the activation symptoms. We can say that with the adequate therapy started in good time and with the regular medical check up of the patient a good result can be achieved. It is true even in the case of WG disease associated by severe complication, for example central nervous hemorrhage.]

Lege Artis Medicinae

[It is Hard to Scoop out the Sea with a Net]

FERENCZI Andrea

Lege Artis Medicinae

[Trends of mortality amenable to health care in Hungary and in the Central Region, 1996-2006]

NAGY Csilla, JUHÁSZ Attila, PÁLDY Anna

[INTRODUCTION - Despite of the decreasing trend of amenable mortality it is a significant contributor to social and economic loss due to premature death. This paper assesses the trends of amenable mortality over time, its contribution to the years of potential life lost (YPLL), furthermore reveals the spatial inequalities of the amenable mortality in the central region in relation to socioeconomic status and number of the inhabitants of municipalities. METHODS - This study describes the trend of the years of potential life lost due to amenable mortality during the period 1996-2006 in Hungary, in Pest county and in Budapest. The spatial epidemiological analysis of the amenable mortality was carried out by using smoothed indirectly standardised mortality ratio calculated by full hierarchical Bayesian methods at municipality level. The association between the spatial distribution of amenable mortality and socio-economic status was assessed by using a “Deprivation Index” elaborated by the authors. RESULTS - The years of potential life lost of males were 7207 (per 100 000) and respectively for females these value was 3870 (per 100 000) in Hungary in 2006. The amenable mortality is a significant contributor to years of potential life lost despite its decreasing trend. The amenable mortality accounted for approximately one third of the males’ and the females’ years of potential life lost. The risk of amenable mortality is higher in the less populated areas and the less-favoured socioeconomic situation coexists with high mortality risk. CONCLUSION - Approximately in average 32 000 persons died due to amenable mortality per year during the investigation period in Hungary. The results of the study provide essential information to the local policy-makers, and managing health professionals. The results can be used principally to inform planning healthcare development programs.]

Lege Artis Medicinae

[Robert Schumann, the Romantic Composer ]

KÖVES Péter

Lege Artis Medicinae

[In vitro efficiency of doripenem, a new carbapenem against Gram-negative, aerob, problem bacteria - Prospective, multicentric, Hungarian study]

NAGY Erzsébet, SAQQA Muhammad, SZABÓ Judit, MESTYÁN Gyula, SZIKRA Lenke, KONKOLY THEGE Marianne

[INTRODUCTION - Doripenem is a new carbapenem derivative, it’s chemical structure is similar to that of meropenem (substitution of one sulfamoxil-aminomethyl chain for the dimethylcarboxy chain) and has one 1-beta-methyl chain which provides resistance to dyhidropeptidase-I enzyme produced by the human kidney. It has a broad-spectrum of activity against multiresistant Gram-negative bacilli such as ESBL-producing Enterobacteriaceae and non-fermentative Gramnegativ bacilli including some strains of Pseudomonas aeruginosa that are resistant to other carbapenems. In 2010 between February and June a multi-centre comparative study was carried out including 5 Hungarian laboratories to investigate the in vitro activity of doripenem. MATERIAL AND METHODS - 1000 fresh, clinically relevant isolates were included both ESBLproducing and non-producing Enterobacteriaceae strains and resistant and multi-resistant Pseudomonas aeruginosa and Acinetobacter strains. The activity of doripenem and the comparator antibiotics (other carbapenems) were tested by the disc diffusion method. In the case of intermediate resistant strains the MIC of doripenem was also determined by the E-test methodology. RESULTS - All but one isolate belonging to the Enterobacteriaceae (592 isolates) were fully susceptible to doripenem. The only Enterobacter strain which proved to be intermediately susceptible to doripenem by the disc diffusion method was also found to be susceptible showing an MIC of 0.125 μg/ml. In the case of the 163 Pseudomonas aeruginosa and the 121 Acinetobacter spp isolates doripenem was the most active carbapenem compared with imipenem and meropenem (78.6% and 50.5% for doripenem versus 67.5% and 42.0% for imipenem and 68.7% and 30.2% for meropenem, respectively). CONCLUSION - According to our multi-centre study doripenem was highly active against both the ESBL-producing and ESBL-non-producing Enterobacteriaceae strains and against a great part of the Pseudomonas and Acinetobacter isolates often involved in nosocomial infections.]

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[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

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[The role of LDL-cholesterol in cardiovascular risk has been established in a number of studies. According to current recommendations, therefore, the primary goal of lipidlowering therapy is reducing the level of LDL-cholesterol. Of lipid-lowering drugs, statins are the most efficient in reducing cardiovascular risk. According to large studies on statins, however, there is a significant residual risk even in patients receiving aggressive treatment. It is well known that many patients continue to have dyslipidaemia despite statin therapy, and not all patients with cardiovascular disease have elevated LDL-cholesterol levels. These observations indicate that lipids other than LDL-cholesterol also have a role in the development of atherosclerosis. A growing attention is paid to non-HDL-cholesterol as a cardiovascular risk factor. Calculating non-HDL-cholesterol target is easy: LDL-cholesterol measurement plus 0,8. Non-HDL-cholesterol incorporates a number of atherogenic lipoprotein particles [VLDL-cholesterol, IDL-cholesterol, LDL-cholesterol, and lipoprotein(a)]. As the atherogenic effect of apoB-containing lipoproteins (LDL, IDL-C és VLDL) is significant, they may be stronger predictors of coronary heart disease (CHD) risk than LDL-cholesterol is. Considering the strong correlation between apoB and non-HDLcholesterol and the limitations of apoB measurement (standardisation, cost), non- HDL-cholesterol is a more useful parameter and therapeutic target, especially if triglyceride levels are greater than 2.26 mmol/l.]

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[A new, effective tool in the treatment of hypertension in light of the available evidence]

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[Hypertension is important even in the group of common diseases. Cardiovascular mortality could be significantly reduced if high blood pressure could not only be treated, but controlled as well. The newly introduced fixed combination perindopril-amlodipin-indapamide medication could be a good tool for genereal practitioners, specialists in internal medicine and cardiologists. Combined treatment with the ACE inhibitor perindopril, the new vasorelaxant type diuretic indapamide and the third generation type Ca-chanel blocker amlodipin is effective in reducing blood pressure. Besides effectivity the organ protective pleiotrop qualities (cardioprotective, plakk stabilising, antiatherosclerotic, antithrombotic, stroke preventive, endothel dysfunction reducing, renal protetcion granting) provide a long lasting beneficial impact on life expectancy and a better quality of life to the patients. If we choose the right dosage, we could raise the compliance level of patients resulting in excellent degrees of compliance. In our article we wanted to draw attention to the major evidencies which are the best acknowledgements of this triple combination although we didn’t explore all avenues.]

Lege Artis Medicinae

[Treatment of hypercholesterolemia in the elderly]

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[The percentage of population aged ≥65 years is mounting worldwide, among them those over 75 years is also growing. Athe­ro­scle­rosis is one of the most important and common disorder in the elderly responsible primarily for premature death and cognitive declining and impaired quality of life. Adequate lipid lowering therapy can decrease the risk of cardiovascular events – the main cause behind mortality – can extend life expectancy and improve the quality of life of patients. Effect of dietary treatment on cardiovascular risk reduction is as beneficial as in the younger populations. Regular physical activity reduces the risk of cardiovascular and overall mortality by 26% in males and 20% in females aged ≥65 years. If the medical history is negative for vascu­lar disorders, statin administration as a primary prevention is indicated for patients 65>years. In the population aged 75≥years individual benefit/risk assessment is needed before statin administration. Larger risk reduction can be achieved between 65-75 years than in subjects over 75 years. Concerning secondary prevention, statin treatment is of pre-eminent significance, and its administration is evidence-based in the elderly. For achieving the lipid goals, combined therapy with statin and ezetimibe is recommended in the primary as well as secondary cardiovascular prevention. ]

Lege Artis Medicinae

[Pycnogenol in the clinical practice of French maritime pine bark extractum]

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[Polyphenols, which belong to the group of flavonoids, can be found in a number of plants, and are present in a high concentration in the French maritime pine bark. The authors summarise results of large-scale experimental and clinical studies on pycnogenol, the standardised extract of French maritime pine bark. Pycnogenol decreases production and effects of free radicals (antioxidant effect). It has antiinflammatory properties, and, by the stimulation of eNOSsynthesis, it increases the production of vasodilatory compounds (e.g. NO, prostacyclin) and decreases that of vascoconstrictor compounds (endothelin-1, thromboxane) materials. These changes lead to vasodilation, which results in increased tissue perfusion and decreased blood pressure. Pycnogenol also decreases platelet aggregation and LDL-cholesterol level and increases HDL-cholesterol level. Its antidiabetic effect has also been shown. Consequently, it may substantially decrease cardiovascular risk. In addition to these results, pycnogenol has been also found to have antibacterial and antiviral effects. It has been successfully used in children with attention deficit hyperactivity disorder, as well as in adults with dysmenorrhea, climacterial disturbances, glaucoma or asthma bronchiale.]