Lege Artis Medicinae

[Report from the 2004 Congress of the American Society for Cardiology]

PFLIEGLER György

JANUARY 20, 2005

Lege Artis Medicinae - 2005;15(01)

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Lege Artis Medicinae

[ALA (5-aminolevulinic acid)-induced protoporphyrin IX fluorescence in the endoscopic diagnostic and control of pharyngo-laryngeal cancer]

CSANÁDY Miklós, KISS G. József, IVÁN László, JÓRI József, CZIGNER Jenő

Lege Artis Medicinae

[EVIDENCE BASED ORAL ANTIDIABETIC THERAPY]

JERMENDY György

[Oral antidiabetic drugs are used in type 2 diabetic patients when diet and physical exercise have failed. The oral antidiabetic drugs available in Hungary can be classified according to their main effect. In this regard, antihyperglycaemic drugs with no hypoglycaemic potential (alfaglucosidase inhibitors, biguanides, thiazolidinedions) and drugs with a potential of insulin secretion (sulfonylureas, prandial glucose regulators) can be distinguished. Acarbose is mainly used in order to decrease the postprandial glucose excursion. Metformin is the drug of choice for obese, insulin resistant diabetic subjects while buformin is not preferable anymore since the availability of metformin. Rosiglitazone, the only thiazolidine-dion derivative in Hungary, can be used in combination therapy in diabetic subjects with clinical characteristics of the metabolic syndrome. The list of sulfonylureas contains five drugs in Hungary which enables differential therapeutical strategies to be performed. The prandial glucose regulators can be used either in monotherapy or in combination with other drugs at the relatively early stage of the disease. At present, the recommendations for treating diabetic patients with oral antidiabetic drugs can be based on clinical evidences.]

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MATOS Lajos

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[POST-CHOLECYSTECTOMY SYNDROME AND SPHINCTER OF ODDI DYSFUNCTION]

MADÁCSY László

[After cholecystectomy, recurrent biliary-like pain, alone or in association with a transient increase in liver enzymes may be the clinical manifestation of the sphincter of Oddi dysfunction (SOD). Most of the clinical information concerning SOD refers to postcholecystectomy patients who have been classified according to clinical presentation, laboratory results and endoscopic retrograde cholangio-pancreatography (ERCP) findings as: biliary type I, biliary type II, and biliary type III. The prevalence of SOD has been reported to vary from 9 to 11% in unselected patients having postcholecystectomy syndrome up to 68% in a selected group of patients without organic disorder and complaining of postcholecystectomy pain. Diagnostic work-up of postcholecystectomy patients for suspected SOD includes liver biochemistry and pancreatic enzyme levels plus negative findings of structural abnormalities. Usually this would include transabdominal ultrasound, gastroscopy and ERCP. Depending on the available resources, endoscopic ultrasound and magnetic resonance cholangiography may precede endoscopic retrograde cholangiopancreatography in specific clinical conditions. In SOD patients, the endoscopic sphincter of Oddi manometry is the gold-standard diagnostic method to evaluate the abnormal motor function of the sphincter of Oddi. Quantitative evaluation of bile transit with cholescintigraphy is valuable in the decision whether to perform sphincter of Oddi manometry or to treat. The standard treatment for SOD is sphincterotomy. In biliary type I patients, the indication for endoscopic sphincterotomy is straightforward without the need of additional investigations. Slow bile transit on cholescintigraphy in biliary type II patients is an indication to perform endoscopic sphincterotomy without sphincter of Oddi manometry. Positive Nardi or Debray evocative test in biliary type III patients is an indication to perform sphincter of Oddi manometry. Medical therapy with nitrosovasodilatators, Ca-channel blockers, theophyllin compounds, β2 receptor agonists and anticholinerg drugs can be useful in biliary type II and type III patients preceding endoscopic sphincterotomy. If medical therapy fails, one might proceed to perform ERCP and endoscopic sphincterotomy but only in patients with abnormal SO manometry results.]

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[CARCINOID TUMORS]

RÁCZ Károly

[Carcinoid tumors are rare neoplasms: they are traditionally divided into three subgroups (foregut, midgut and hindgut tumors). Despite their neuroendocrine cell origin and the similarities in their histological structure, the molecular background, pathogenesis, clinical features, diagnostic and therapeutic procedures, as well as the prognosis of carcinoid tumors located at different sites may be highly variable. Although sensitive biochemical markers (serum chromogranin A concentration, urinary 5- hydroxyindoleacetic acid excretion) and localization methods (somatostatin receptor scintigraphy, positron emission tomography) are available, a considerable number of patients are only diagnosed at the late stages of the disease. When surgical cure is not obtainable such as in cases with advanced metastatic disease, surgical procedures to reduce tumoral tissue should be still considered. At present, the most effective drugs for the symptomatic treatment of carcinoid tumors are somatostatin analogues (octreotide, lanreotide). In addition to their beneficial effect on clinical symptoms they may stabilize tumor growth for many years and rarely, tumor regression is produced. Radioisotope-labelled somatostatin analogues are presently under clinical evaluation, which may offer new therapeutic means for patients with carcinoid tumors.]

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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.

Lege Artis Medicinae

[COVID-19-cardiology at spring, 2020]

VÁLYI Péter

Clinical Neuroscience

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery

ONDER Burcu, KELES Yavuz Betul

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.

Clinical Neuroscience

Extraskeletal, intradural, non-metastatic Ewing’s sarcoma. Case report

OTTÓFFY Gábor, KOMÁROMY Hedvig

Intracranial localization of Ewing’s sarcoma is considerably very rare. Herein, we present clinical and neuroimaging findings regarding a 4-year-old boy with intracranial Ewing’s sarcoma. He was born prematurely, suffered intraventricular haemorrhage, posthaemorrhagic hydrocephalus developed, and a ventriculoperitoneal shunt was inserted in the newborn period. The patient endured re­gular follow ups, no signs of shunt malfunction nor increased intracranial pressure were observed. The last neuroima­ging examination was performed at 8 months of age. Upon reaching the age of 4 years, repeated vomiting and focal seizures began, and symptoms of increased intracranial pressure were detected. A brain MRI depicted a left frontoparietal space-occupying lesion infiltrating the superior sagittal sinus. The patient underwent a craniotomy resulting in the total excision of the tumour. The histological examination of the tissue revealed a small round blue cell tumour. The diagnosis was confirmed by the detection of EWSR1 gene translocation with FISH (fluorescent in situ hybridization). No additional metastases were detected during the staging examinations. The patient was treated in accordance to the EuroEwing 99 protocol. Today, ten years onward, the patient is tumour and seizure free and has a reasonably high quality of life.

Clinical Neuroscience

Valproic acid associated pleuropericardial effusion: case report

DEMIR Figen Ulku

Introduction - Valproic acid is an effective antiepileptic and mood stabilizer used in the treatment of many neurological and psychiatric disorders. Although there are frequently seen side effects, effusions between layers of pleural and pericardial membranes are rare to be seen. Case - Pleuropericardial effusion was detected in a 23 years old woman who was under valproic acid treatment because of epileptic seizure. After 1 year of valproic acid treatment, patient complained of dyspnea. As all the researches intended on etiology were usual, valproic acid has been thought to be responsible for the matter. Control examination after 1.5 months regarding the end of treatment revealed complete recovery of pleuropericardial effusion. Discussion - Pleural and pericardial effusions are rarely seen complications related to the use of valproic acid. It must also be kept in mind that valproic acid causes a potential for such side effects which can be blamed etiologically when the other possibilities for patients are excluded.