Lege Artis Medicinae

[Saving Lives at the Cost of the Physician’s Life?]

BARANYAI Zsolt

JANUARY 27, 2009

Lege Artis Medicinae - 2009;19(01)

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Lege Artis Medicinae

[Jubilee Meeting of the Hungarian Rheumatologists’ Association]

SZEKANECZ Zoltán

Lege Artis Medicinae

[Rivaroxaban: a new and efficient direct factor Xa inhibitor anticoagulant]

BLASKÓ György

[Rivaroxaban is a directly acting, orally administrable selective inhibitor of the activated blood clotting factor X, which could replace low molecular weight heparins and oral coumarintype anticoagulants. It was registered by European (EMEA) and US authorities (FDA) for the prevention of venous thrombotic events in orthopedic surgery. It is being investigated in phase III studies for the treatment of established, symptomatic venous thrombosis, surgical thromboprophylaxis, prevention and treatment of pulmonary embolism, as well as in ST-elevation and non-ST-elevation myocardial infarction. Until this time it was given to more than 24,000 patients. Its sideeffect profile is favorable, bleeding risk is similar to other drugs in its group, and other side effects are acceptable, although it may result in elevation of hepatic enzymes. The drug is investigated at present in the secondary prevention of stroke in atrial fibrillation and in the prevention of acute ischemic events in acute coronary syndromes. It could be one of the first alternative drugs for the presently used oral vitamin K antagonist anticoagulant products.]

Lege Artis Medicinae

[The Adventures of Haydn’s Skull]

GERLINGER Imre

Lege Artis Medicinae

[Relationships in recovery, recovery in relationships]

SZABÓ József, GEREVICH József

[INTRODUCTION - Some of the recent researches based on analyses of autobiographies pointed out, that the quality and the quantity of our social relations are in connection with our life longevity, and the frequency of words referring social roles and integration gives a respective measurement possibility of it. Conception of the term “social words” had been introduced. The influence of the degree of social support to the recovery from alcohol addiction is also a well-known phenomenon. Based on the above we supposed that examining their autobiography vocabularies we find special differences which can show the distinction between the social support of the relapsed and recovering addicted persons. We planned to prove the being of these special differences via revealing bias of the frequency and pattern of social word usage. PATIENTS AND METHODS - Two separate groups were created for purpose of the examination. The first consisted of relapsed alcohol dependent persons, who were treated in hospital (department of addiction psychiatry) diagnosed alcohol-dependent (F 10.2) (and nothing else) at least twice within a year (N=30). We chose earlier treated (because of alcohol-dependency, and nothing else mental disease) persons who had been being abstinent for at least 2 years into the second group (N=20). Beside the earlier diagnosis we used the parts of the ASI test to sreen any other mental diseases. We created similar groups with regards to gender, age and qualification. We collected autobiographies from the persons, and made two common documents of them. Afterwards we compared these documents by the Atlas.ti 5.0 (trial free version) content analysing software. We defined the frequency of the found social words in the rate of these words and the sum of the words in the whole text. We found the most prominent difference between the frequency of social words referring to the family and relatives, opposite the words dealing with friendship. RESULTS - In the latter case we could not detect any difference between the two groups. We got results confirming our hypothesis in the frequency of such words as “help”, “love”, “give” and “get”. We experienced in connection with the pattern that the words referring to social organisations, for example “team”, “community”, “company”, “club”, “meeting”, “collective” and the word “guest” practically did not appear (R<0.001) in the texts of relapsed persons, while they could be detected in the case of the recovering group (R=0.023). We did khisquare test to compare the frequency in the mentioned categories and we experienced significant differences between the social word usage of the two groups. CONCLUSION - Our results confirmed that the recovery from alcohol addiction was related to the quality and quantity of person's social relations, what we can get relevant information from the frequency of social words in the autobiographies about, so the high frequency of the social words can be considered as a good predictor of recovery.]

Lege Artis Medicinae

[Cost-effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes]

SIMON Judit, GRAY Alastair, CLARKE Philip, WADE Alisha, NEIL Andrew, FARMER Andrew

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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.

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[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.]

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Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

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