Lege Artis Medicinae

[Report about experiences on professional competition of tender Innovative Techniques in Wound Management 2022]

HARSÁNYI László

JULY 18, 2022

Lege Artis Medicinae - 2022;32(06-07)

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Lege Artis Medicinae

[Attitudes towards end-of-life decisions among neonatology intensive care workers – Legal aspects behind decisions ]

FEITH Helga Judit, SALLAI Eszter Zsófia, SOÓSNÉ Kiss Zsuzsanna, GÉZSI András, GRADVOHL Edina, KOVÁCS Aranka, BERBIK István, SZABÓ Miklós

[Minors’ end-of-life dilemmas are among the most difficult decisions. Premature infants’ chance of survival has greatly improved thanks to the development of technology. Under-age children’s quality of life, as an aspect, does not appear in the effective Hungarian legislation. The aim of our study is to survey the change in NICU (neonatology intensive care unit) workers’ opinions/attitudes after a 20-year-period about restrictions in severely impaired new-borns’ intensive cares. Quantitative, complete sociological surveys in the Hungarian NICUs using self-administered, anonymous questionnaires (n = 728). Cross-Tabulation analysis and Pearson chi-squared test have been used for the data evaluation. In both studies, the majority of participants agreed that if the condition is fatal, it may be appropriate to limit the intensive care. Acceptance of treatment withdrawal has increased, but active euthanasia is still not accepted. Most healthcare workers are unsatisfied with the current legal order and there is a need for change, especially in cases of fatal and poor prognosis. Despite the fact that the effective Hungarian health care regulation does not allow withdrawal of treatment even in severe conditions, a significant number of those working at Hungarian NICUs would consider it as acceptable in some cases, moreover the share of acceptance has in­creased in the last two decades. Comparing the results with the current regulations, it can be suggested that it is necessary to increase the sensitivity of the legislators and to change the related legislation.]

Lege Artis Medicinae

[Herbs and natural substances used in Covid-19 caused by Wuhan and Delta variants of SARS-Cov-2 in the light of clinical trials]

CSUPOR Dezsô

[The use of medicinal plants in the preven­tion and treatment of Covid-19 started soon after the pandemic began. In some countries (e.g. China), the use of medicinal plants for this purpose was an officially declared goal. The plants used in therapy were selected on the basis of in silico studies, preclinical data or extrapolation of folk medicinal experience. In other parts of the world, the majority of medicinal plants are used by Covid patients outside of formal medicine, typically as food supplements. In this article, we review randomised controlled clinical trials of herbal preparations, indtoducing the potential place of herbal preparations in the therapy of Covid-19. A total of 17 trials were identified, most of which studied the effect on disease symptoms. Although most of the products tested were shown to be effective in at least one endpoint, the quality of the studies (mostly open-label, using non-standardised formulations) does not allow positive conclusions on efficacy. ]

Lege Artis Medicinae

[Dual incretin therapy – a novel approach in the antidiabetic therapy of type 2 diabetes ]

WINKLER Gábor, KIS János Tibor

[The introduction of incretin-based blood glucose lowering drugs, the dipeptidyl peptidase inhibitors, and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have opened up new perspectives in the antidiabetic treatment of type 2 diabetes. Beneficial properties of these drugs have directed the attention to study further enterohormones with potentially favourable effects on carbohydrate metabolism. Since the point of attack of these hormones is partly different partly identical, based on theoretical considerations, activating simultaneously their receptors in terms of glycemic control may result in synergistic and additive effects. This study reviews the concept of lowering the blood sugar level in type 2 diabetes based on multiagonistic receptor stimulation further the potential benefits of co-stimulating GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptors. It also briefly discusses the first data on tirzepatide as the first representative of dual receptor agonists accepted for clinical use by the FDA.]

Lege Artis Medicinae

[Modern approach and advanced treatment of obesity ]

SIMONYI Gábor, BEDROS J. Róbert, WITTMANN István

[Obesity is a recurrent, progressive chronic disease associated with body fat accumula­tion the body. Due to the nature of the dis­ease, its treatment and care is a life-long program. Elements of therapy: lifestyle modification (diet and exercise), psychological treatment, medication and if necessary, surgery. The Hungarian Society of Obesity and Exercise, recommends a low-carbohydrate and high-protein diet in the first half year of the weight loss program. During physical activity, dynamic, aerobic forms of movement (e.g. walking, jogging, swimming, cycling, etc.) are preferred. The options of drug treatment in Hungary are orlistat, naltrexone/bupropion fixed dose combination and liraglutide sc (3.0 mg) and bariatric surgery, which all can contribute successfully to the weight loss program.]

Lege Artis Medicinae

[Clinical protocol of the early childhood eating and sleep disorders outpatient clinic ]

SCHEURING Noémi, GULÁCSI Ágnes, ÁGOSTON Olga, SIBA Mónika, STADLER Judit, BALÁZS Krisztina, EGYED Katalin, KECSKEMÉTI Judit, HOLLÓSI Lilla Eszter, DANIS Ildikó, GERVAI Judit, SZABÓ László

[In a three-part article series, we present (1) the clinical protocol used by the Early Childhood Eating and Sleep Disorders Outpatient Clinic of the Heim Pál National Pediatric Institute; (2) the follow-up monitoring methodology of treatment efficacy; and (3) the first results obtained by this moni­toring program in a three-part ar­ticle. The Clinic with in-patient background was the first in the Hungarian health care system to provide organized care by interdisciplinary methods for families of infants and young children struggling with early child­hood emotional and behavioural regulation problems. The present first article concerns the clinical protocol of our facility based on the international literature and our own prior experiences. In the literature review, we emphasize especially the early childhood range of care for eating and sleep disorders. Thus, we justify the rationale of structure and activities of our Outpatient Clinic launched in 2017 by a brief summary of the international literature. Our aim is to inspire further health care providers to set up similar interdisciplinary services by a detailed description of our facility. ]

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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

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.

Clinical Neuroscience

[The Comprehensive Aphasia Test in Hungarian]

ZAKARIÁS Lilla, RÓZSA Sándor, LUKÁCS Ágnes

[In this paper we present the Comprehensive Aphasia Test-Hungarian (CAT-H; Zakariás and Lukács, in preparation), an assessment tool newly adapted to Hungarian, currently under standardisation. The test is suitable for the assessment of an acquired language disorder, post-stroke aphasia. The aims of this paper are to present 1) the main characteristics of the test, its areas of application, and the process of the Hungarian adaptation and standardisation, 2) the first results from a sample of Hungarian people with aphasia and healthy controls. Ninety-nine people with aphasia, mostly with unilateral, left hemisphere stroke, and 19 neurologically intact control participants were administered the CAT-H. In addition, we developed a questionnaire assessing demographic and clinical information. The CAT-H consists of two parts, a Cognitive Screening Test and a Language Test. People with aphasia performed significantly worse than the control group in all language and almost all cognitive subtests of the CAT-H. Consistent with our expectations, the control group performed close to ceiling in all subtests, whereas people with aphasia exhibited great individual variability both in the language and the cognitive subtests. In addition, we found that age, time post-onset, and type of stroke were associated with cognitive and linguistic abilities measured by the CAT-H. Our results and our experiences clearly show that the CAT-H provides a comprehensive profile of a person’s impaired and intact language abilities and can be used to monitor language recovery as well as to screen for basic cognitive deficits in aphasia. We hope that the CAT-H will be a unique resource for rehabilitation professionals and aphasia researchers in aphasia assessment and diagnostics in Hungary. ]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

Atypical presentation of late-onset Sandhoff disease: a case report

SALAMON András , SZPISJAK László , ZÁDORI Dénes, LÉNÁRT István, MARÓTI Zoltán, KALMÁR Tibor , BRIERLEY M. H. Charlotte, DEEGAN B. Patrick , KLIVÉNYI Péter

Sandhoff disease is a rare type of hereditary (autosomal recessive) GM2-gangliosidosis, which is caused by mutation of the HEXB gene. Disruption of the β subunit of the hexosaminidase (Hex) enzyme affects the function of both the Hex-A and Hex-B isoforms. The severity and the age of onset of the disease (infantile or classic; juvenile; adult) depends on the residual activity of the enzyme. The late-onset form is characterized by diverse symptomatology, comprising motor neuron disease, ataxia, tremor, dystonia, psychiatric symptoms and neuropathy. A 36-year-old female patient has been presenting progressive, symmetrical lower limb weakness for 9 years. Detailed neurological examination revealed mild symmetrical weakness in the hip flexors without the involvement of other muscle groups. The patellar reflex was decreased on both sides. Laboratory tests showed no relevant alteration and routine electroencephalography and brain MRI were normal. Nerve conduction studies and electromyography revealed alterations corresponding to sensory neuropathy. Muscle biopsy demonstrated signs of mild neurogenic lesion. Her younger brother (32-year-old) was observed with similar symptoms. Detailed genetic study detected a known pathogenic missense mutation and a 15,088 base pair long known pathogenic deletion in the HEXB gene (NM_000521.4:c.1417G>A; NM_000521:c.-376-5836_669+1473del; double heterozygous state). Segregation analysis and hexosaminidase enzyme assay of the family further confirmed the diagnosis of late-onset Sandhoff disease. The purpose of this case report is to draw attention to the significance of late-onset Sandhoff disease amongst disorders presenting with proximal predominant symmetric lower limb muscle weakness in adulthood.