Lege Artis Medicinae

[SCIENTIFIC DIGEST]

FEBRUARY 20, 2005

Lege Artis Medicinae - 2005;15(02)

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Lege Artis Medicinae

[THE TREATMENT OF ACUTE ISCHEMIC STROKE BASED ON CURRENT GUIDELINES]

SZEGEDI Norbert, MAY Zsolt, ÓVÁRY Csaba

[Cerebrovascular diseases are third among the most frequent causes of mortality in developed countries and represent the most common cause of disability in adulthood. 80% of all acute stroke cases are of ischemic origin. The proven significant efficacy of intravenous thrombolysis with rt-PA in the NINDS rt-PA Stroke Trial was the cornerstone of the treatment of acute ischemic stroke, followed by several recommendations. From this time on, the attention shifted to early and appropriate recognition of symptoms and to organizing a quickly reacting emergency medical system in order to maximize the number of those patients transported immediately to the nearest stroke center to have the opportunity to be treated within three hours after their symptom onset. Specialized stroke facilities have documented benefit over other forms of stroke management concerning survival rates, but they need coordinated continuous multidisciplinary care for the patients, availability of CT scanner, laboratory examinations including tests of hemostasis, intensive care unit and well-trained stroke neurologists on 24-hours-a-day basis. Thrombolysis in these stroke centers with intravenous 0,9 mg/kg rt-PA improves the outcome of acute stroke with 30%. Although new guidelines strongly recommend the thrombolysis of selected ischemic stroke patients, the only evidence-based treatment of this condition has not yet become a part of the routine stroke management in Hungary. Regarding other specific antithrombotic therapeutic approaches, anticoagulation has the most contradictory status: in spite of well-defined theoretic considerations there are no evidence-based data in favour of routine anticoagulation in acute ischemic stroke, neither with heparin nor with low molecular weight heparins or heparinoids, while aspirin given within 24-48 hours after stroke onset was shown to have a significant but modest benefit. No data support the treatment with hemodilution or the administration of neuroprotective drugs. Evidence accumulating continuously determine the principles of general care including the methods and the targets in the acute phase of ischemic stroke regarding respiratory and cardiac care, management of blood pressure and blood glucose levels and body temperature.]

Lege Artis Medicinae

[The importance of the determination of auto-antibodies in diabetes mellitus - As recommended by the EASD 2004 Congress]

HOSSZÚFALUSI Nóra, PÁNCZÉL Pál

Lege Artis Medicinae

[ALDOSTERONE AT THE BEGINNING OF THE 21ST CENTURY]

GLÁZ Edit, SZŰCS Nikolett, VARGA Ibolya

[The discovery of aldosterone as the principal mineralocorticoid hormone led to a new era in the study of the regulation and the pathological/clinical relevance of the fluid-salt homeostasis and blood pressure. Here, we discuss briefly the history of the discovery of aldosterone, its biosynthesis, the mechanism of action, regulation and the diseases which are associated with its pathologically increased production and hypertension: primary and secondary hyperaldosteronisms. Considering their clinical significance, we focus on primary hyperaldosteronisms as they represent a considerable portion of secondary hypertensions that can be definitively cured. Differential diagnosis issues related to other forms of hypertension of different origins are discussed in detail. Recent findings of the past fifteen years indicate that besides its classical genomical actions aldosterone has much more diverse non-genomic actions as well including proinflammatory and profibrotic effects even in physiological concentrations. Based on these observations, aldosterone can be regarded as a risk hormone in the aetiology of cardiomyopathies, vasculopathies and neuropathies and therapeutical consequences are also discussed.]

Lege Artis Medicinae

[LONG-TERM OXYGEN TREATMENT]

SOMFAY Attila

[Long-term oxygen therapy is the only treatment that has been shown to significantly improve life expectancy in patients with severe chronic obstructive pulmonary disease (COPD) exhibiting marked hypoxemia. There has been sginificant advances in the longterm oxygen therapy in the last two decades caused by the technological improvements in oxygen delivery systems as well as our better knowledge of the beneficial effects of the longterm oxygen therapy including better quality of life, exercise tolerance and pulmonary hemodynamic effects. This expansive therapy requires the documentation of chronic arterial hypoxemia by arterial blood gas analysis or pulsoximetry which should be reassesed during chronic care of these patients. Besides hypoxaemia, the consequences of tissue hypoxia induced by different problems in the oxygenation chain should also be considered. Indication of long-term oxygen therapy is optimally based on evidence and pathophysiology, thereby the undesirable placebo effect or psychological addiction to oxygen can be reduced. Late laboratory diagnostics and poor patient compliance are the main determinants of undertreatment. The real value of the long-term oxygen therapy in indications other than hypoxaemic COPD requires more controlled studies.]

Lege Artis Medicinae

[THE IMMUNPATHOGENESIS OF VASCULITIDES]

ZEHER Margit

[The vasculitides are clinicopathologic entities characterized by the inflammation and damage to blood vessels. Most vasculitic syndromes are mediated by immunopathogenic mechanisms. Most immune vasculitides are idiopathic (“primary vasculitis”) and systemic. The “immune vasculitides” are classified according to their hypersensitivity reaction types: allergic angiitis, antineutrophil cytoplasmic antibody (ANCA) -associated vasculitis, immunecomplex vasculitis, and vasculitis associated with T cell-mediated hypersensitivity. Immunological features: eosinophilia plus elevated IgE are characteristic of allergic angiitis and granulomatosis (Churg-Strauss syndrome). No immune deposits can be found in situ in ANCA associated vasculitis (“pauci-immune vasculitis”). Immune complex deposits, by contrast, are the hallmark of immune-complex vasculitis, which is frequently associated with low complement levels. Inflammatory infiltration induced by Th1 cells distinguishes vasculitis associated with T cell-mediated hypersensitivity (granulomatous arteritis). This article is dealing with the immunological mechanisms which may play a central role in the development of vasculitides.]

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Related contents

Hypertension and nephrology

[Association between cyclothymic affective temperament and hypertension]

NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[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.]

Clinical Neuroscience

[Decisional collisions between evidence and experience based medicine in care of people with epilepsy]

RAJNA Péter

[Background – Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose – To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods – Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results – There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology – including genetic background –, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion – Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions. ]

Lege Artis Medicinae

[SIGNIFICANCE OF MICROCIRCULATION IN ARTERIAL DISEASES]

FARKAS Katalin

[The microvascular bed is an anatomical entity, which constitutes of blood vessels smaller than 50 μm (i.e. arterioles, capillaries and venules), and its major function is the nutritive perfusion of organs and tissues. In search of cardiovascular diseases, there are growing evidences that impaired microcirculation plays an important role in the patophysiology of arterial diseases. Beside the well known consequence of diabetic microangiopathy in the development of diabetic complications, new data support the role of microcirculation in the pathogenesis of hypertension and atherosclerosis, as well. There are different non-invasive methods for the investigation of the microcirculation. Capillarmicroscopy, laser doppler flowmetry and transcutaneous oxygen pressure measurement are used not only in the scientific research, but also in the clinical practice. Laser doppler flowmetry gives us the possibility to assess microvascular endothelial function and other early microcirculatory disturbances. Capillarmicroscopy is particularly useful in the diagnosis of different autoimmune diseases. Transcutaneous oxygen pressure measurement is mostly used in the diagnosis of critical limb ischemia, because it has proven prognostic relevance. Vascular specialist should prescribe all investigations. General practitioners play key role in the early diagnosis of vascular diseases that can be achieved through the screening of patients at risk for vascular disease. In case of suspected vascular disease, the patient should refer to angiology outpatient clinic, to decide further investigations and prescribe therapy. The conservative treatment includes the complex cardiovascular risk management supplemented with medication, acting on the microcirculation.]

Lege Artis Medicinae

[SCIENTIFIC DIGEST]

Clinical Neuroscience

[Status epilepticus and its treatment - Update 2013]

GYIMESI Csilla, JUHOS Vera, HORVÁTH Réka, BÓNÉ Beáta, TÓTH Márton, FOGARASI András, KOMOLY Sámuel, JANSZKY József

[Our study provides an overview of the results and guidelines published on the treatment of status epilepticus in the last five years. In recent years, as a result of scientific observations and collected data, the definition of and treatment approach to status epilepticus have been refined and novel therapeutic methods have been developed. The updated guidelines provide guidance in everyday medical practice. However, only a relatively small number of randomized studies are available on status epilepticus, especially in second-line treatment and third-line treatment, thus it is difficult to transfer the newest methods into clinical practice and into updates to treatment protocols. Due to the nature and epidemiology of the disease, the treatment of status epilepticus remains a daily challenge for healthcare providers. The key points of an effective treatment are: expeditiously initiating appropriate therapy, concurrent causal treatment and anticonvulsant therapy, early detection of nonconvulsive status epilepticus, as well as avoiding "overtreatment" and side effects.]