Lege Artis Medicinae

[Reports on events of Hungarian Conference of Medical Sciences]

DECEMBER 17, 2021

Lege Artis Medicinae - 2021;31(12)

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Lege Artis Medicinae

[Europe’s highest COVID-19 mortality experienced behind the former iron curtain]

RIHMER Zoltán

[While 11 out of the 15 first European countries with highest COVID-19 mortality rates are Post-Socialist countries (73%), and only 9 out of the 31 countries on place 16-46 (29%) are Post-Socialist. All of the top 17 European countries with the highest cumulative excess-mortality since the beginning of the COVID-19 pandemic era, are Post-Socialist countries (100%) as well as 19 out of the top 20 (95%). The dividing line between high and low COVID-19 mortality of European countries follows exactly the path of the former Iron Curtain. In addition, out of the 43 data reporting European countries, all the 18 with the lowest vaccination rate (100%) are Post-Socialist. The main cause of these differences in European COVID-19 mortality may be the traditionally disadvantageous physical and mental condition of the population of Post-Socialist countries, but this problem needs further, more intense investigations.]

Lege Artis Medicinae

[100 years of insulin]

WINKLER Gábor

[Insulin is 100 years old. Concerning this anniversary, this study reviews the main events before and after the insulin era, the wider range of insulin products and the chronology of main clinical innovations related to the insulin administration. It also presents the history of related devices as delivery pens, insulin pumps and automated treatment systems. It points out that, al­though insulin dosing is an external replacement for missing or insufficient endogenous hormone production as related to the actual demand, it is to this date the general treatment available for all types and stages of this condition.]

Lege Artis Medicinae

[Cardiovascular prevention 2021 – Guidelines of European Society of Cardiology 2021. Cardiovascular prevention at individual level]

VÁLYI Péter, KÉKES Ede

[In August 2021, the European Society of Cardiology (ESC) published its practical guidelines for cardiovascular prevention. In Part 1 of our publication, we discussed cardiovascular risk factors, risk assessment, cardiovascular risk assessment in presumably healthy individuals of different ages, people with proven atherosclerotic cardiovascular disease, people with diabetes mellitus, and factors influencing risk. In Part 2, conditions that influence cardiovascular risk were detailed. In the current Part 3 of this publication, we review personalised cardiovascular prevention, non-pharmaceutical and pharmaceutical treatment of specific risk factors, emerging treatment options, and par­ticipation in cardiovascular rehabilita­tion and prevention programmes based on ESC guidelines.]

Lege Artis Medicinae

[Insulin: alfa and omega]

KIS János Tibor, BALOGH Bernadett, KISS Zsófia, SCHANDL László

[Type 1 diabetes (T1DM) is caused by the autoimmune death of insulin-producing β-cells. In the background there is by all probability the primary antigen (if the theory of primary antigen is correct) the insulin itself or the proinsulin. However, treatment of T1DM is virtually equivalent to the insulin treatment. The earlier we recognize T1DM and start treatment, the better gly­caemic results we achieve, the more likely we can maintain all functional β-cell stocks. Insulin also plays a key role in the immunopathogenesis, development and treatment of T1DM, thus insulin is the alpha and omega in this condition.]

Lege Artis Medicinae

[Modern insulin therapy using insulin pump or insulin pump and sensor]

GERÔ László

[Insulin was discovered 100 years ago. At this anniversary the present study concerns the applications of insulin pumps and sensors, emphasising the latest options in Hungary. Since January 1, 2020 the above devices are provided with 98% coverage by the National Health Insurance Fund for underage Type 1 diabetics and high school students up to 24 years. Adults with Type 1 diabetes may also obtain an insulin pump and sensor with 80% coverage of the so­cial health insurance. A sensor distributed by an independent local company will also be available in the upcoming months. It should be suggested that more and more unstable Type 1 diabetics use the insulin pump and sensors since this treatment stabilise the metabolism reduces the glucose level excesses and minimise the glucose varia­bility. All these measures are lowering the probability of diabetes related comp­lica­tions.]

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Clinical Neuroscience

Fluoxetine use is associated with improved survival of patients with COVID-19 pneumonia: A retrospective case-control study

NÉMETH Klára Zsófia, SZÛCS Anna , VITRAI József , JUHÁSZ Dóra , NÉMETH Pál János , HOLLÓ András

We aimed to investigate the association between fluoxetine use and the survival of hospitalised coronavirus disease (COVID-19) pneumonia patients. This retrospective case-control study used data extracted from the medical records of adult patients hospitalised with moderate or severe COVID-19 pneumonia at the Uzsoki Teaching Hospital of the Semmelweis University in Budapest, Hungary between 17 March and 22 April 2021. As a part of standard medical treatment, patients received anti-COVID-19 therapies as favipiravir, remdesivir, baricitinib or a combination of these drugs; and 110 of them received 20 mg fluoxetine capsules once daily as an adjuvant medication. Multivariable logistic regression was used to evaluate the association between fluoxetine use and mortality. For excluding a fluoxetine-selection bias potentially influencing our results, we compared baseline prognostic markers in the two groups treated versus not treated with fluoxetine. Out of the 269 participants, 205 (76.2%) survived and 64 (23.8%) died between days 2 and 28 after hospitalisation. Greater age (OR [95% CI] 1.08 [1.05–1.11], p<0.001), radiographic severity based on chest X-ray (OR [95% CI] 2.03 [1.27–3.25], p=0.003) and higher score of shortened National Early Warning Score (sNEWS) (OR [95% CI] 1.20 [1.01-1.43], p=0.04) were associated with higher mortality. Fluoxetine use was associated with an important (70%) decrease of mortality (OR [95% CI] 0.33 [0.16–0.68], p=0.002) compared to the non-fluoxetine group. Age, gender, LDH, CRP, and D-dimer levels, sNEWS, Chest X-ray score did not show statistical difference between the fluoxetine and non-fluoxetine groups supporting the reliability of our finding. Provisional to confirmation in randomised controlled studies, fluoxetine may be a potent treatment increasing the survival for COVID-19 pneumonia.

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

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Lege Artis Medicinae

[LAM 30: 1990–2020. Facing the mirror: Three decades of LAM, the Hungarian medicine and health care system]

KAPÓCS Gábor

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.