Lege Artis Medicinae

[Submucosal injection polypectomy]

DUBRAVCSIK Zsolt

SEPTEMBER 19, 2008

Lege Artis Medicinae - 2008;18(08-09)

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[Smoking and Alcohol Consumption: Motivation of Hungarian and American Secondary School Students]

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[The Discovery of Insulin]

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[Is continuous b-2 receptor agonist therapy safe in patients with chronic obstructive pulmonary disease?]

SOMFAY Attila

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[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.]

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[The impact of tiotropium on the respiratory function of smoking and non-smoking patients with COPD]

BÖSZÖRMÉNYI Nagy György

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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

Acute effect of sphenopalatine ganglion block with lidocaine in a patient with SUNCT

KOCATÜRK Mehtap, KOCATÜRK Özcan

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNCT/SUNA) is a rare severe headache. At the time of an attack, it can hinder a patient from eating and requires acute intervention. The sphenopalatine ganglion is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. Sphenopalatine ganglion block has long been used in the treatment of headache, particularly when conventional methods have failed. Here, we present a patient who was resistant to intravenous lidocaine, but responded rapidly to sphenopalatine ganglion block during an acute episode of SUNCT/SUNA.

Clinical Oncology

[Complications of infusion treatment with emphasis on extravasation of cytostatics]

HARISI Revekka

[The extravasation of cytostatics is the most signifi cant complication of infusion therapy in cancer treatment. Extravasation refers to the inadvertent infi ltration of cytostatic drugs into subcutaneous or subdermal tissues surrounding the intravenous or intraarterial administration site. According to literature data incidence estimates between 0,01-7%. Extravasated drugs are classifi ed according to their potential for causing damage as vesicant, irritant and nonvesicant. Knowledge of risk factors, the patientrelated and treatment-related ones is important to minimize the occurrence of extravasation. In order to reduce the risk of extravasation, the staff involved in the tumor infusion therapy must be specially trained to implement several preventive and therapeutical protocols. In 2012, ESMO-EONS has put together a new comprehensive treatment protocol on the topic of cytostatics extravasation. Protocol recommended that every oncological department, who administers chemotherapy have to have extravasation trained team and a standby extravasation kit. According to the new ESMO-EONS guideline subcutaneous corticoids are not recommended, anymore. In case of mechloretamine extravasation the recommendation is immediate subcutaneous injection of sodium thiosulfate. After extravasation of anthracyclines, mitomycin C and platin salts the best treatment opportunity is subcutan dimethyl sulfoxide administration. In case of anthracyclines’ extravasation intravenous dexrazoxane treatment is also effective. Hyaluronidase, injected into or under the skin, facilitates absorption of extravasated drugs because of increases connective tissue permeability, promotes the spreading and reduces the local concentration of the extravasated citostatic agents. Hyaluronidase might be effi cacious in preventing skin necrosis by extravasation due to vinca alkaloids. The treatment of unresolved tissue necrosis or pain lasting more than 10 days is surgical debridement. Because of the medical and juristic importance of the extravasation event, it is necessary to establish uniform guidelines for treatment of extravasation, in all Hungarian Oncological Centers.]

Lege Artis Medicinae

[The role of double-balloon endoscopy in the diagnosis and treatment of small intestinal disease compared with capsule endoscopy]

LAKATOS Péter László, HORVÁTH Henrik Csaba, ZUBEK László, PÁK Gábor, NÉMETH Artúr, RÁCZ István, PÁK Péter, FUSZEK Péter, NAGYPÁL Anna, GEMELA Orsolya, PAPP János

[INTRODUCTION - Until recently, only the proximal small bowel was accessible for diagnostic or therapeutic endoscopy. A new method, doubleballoon enteroscopy (DBE), provides high-resolution imaging and enables both diagnostic and therapeutic interventions in all segments of the gastrointestinal tract. Our aim was to report our experiences with the Fujinon EN-450 T5 therapeutic double-balloon endoscope and compare our findings with the results of earlier capsule endoscopy where this was available. METHODS - Between August 2005 and July 2009, 150 DBE procedures were conducted in 139 consecutive patients (M/F: 67/72, age: 51.1±18.6 years) who presented at our tertiary referral hospital. The examination was performed via the oral route in 112 patients, via the anal route in 16 patients, and via both routes in 11 patients. DBE was indicated due to obscure gastrointestinal bleeding in most cases (83), due to diagnosis or complication of IBD in 29 cases and due to polyposis syndrome or suspected neoplasia in 25 patients. In one patient we performed endoscopic retrograde cholangiopancreatography (ERCP). All procedures were performed using i.v. anaesthesia at our outpatient clinic. After the procedure, the patients were monitored in a recovery room for at least four hours. The results of previous capsule endoscopy were available in 27 patients. RESULTS - Small-bowel abnormalities ? mostly angiodysplasias, minor erosions or ulcers ? were detected in 50 (60.2%) of the patients with obscure gastrointestinal bleeding. Malignancy was found in 7,2% (6/83) of the patients who were examined because of bleeding (three gastrointestinal stoma tumour, one non-Hodgkin lymphoma, one previously undetected melanoma metastasis and one pancreatic adenomacarcinoma that involved the duodenum) Intervention was performed in 24 patients. IBD was diagnosed in five (38.5%) of the 13 patients in whom the disease was suspected. In patients with known Crohn-disease, DBE was indicated on the basis of the extent, behaviour and activity of the disease. Polypectomy was performed in eight patients with Peutz-Jeghers syndrome or familial adenomatous polyposis syndrome, whereas small-bowel adenocarcinoma was diagnosed in four patients. The concordance between the findings of capsule endoscopy and DBE was 51.8% (14/27), and in one patient DBE revealed malignancy that has not been detected by endoscopy. The average insertion length during the procedure was approximately 213 cm (range 50-480 cm, SD 111). CONCLUSIONS - On the basis of our results, DBE is a safe and useful method for assessing and treating small bowel disease, even if capsule endoscopy is contraindicated due to suspected strictures.]

Lege Artis Medicinae

[Efficiency and safety of biphasic aspart insulin therapy in clinical studies]

GERŐ László

[Six-to-eight years after the diagnosis of type 2 diabetes the majority of patients require insulin treatment. Premixed insulin therapy provides an insulin profile that is closer to the physiological profile than that achieved by basal insulin supplementation and, in some cases, may serve as an alternative treatment in patients for whom intensified insulin therapy is unsuitable. However, if premixed human insulins are used, nocturnal hypoglycaemia occurs relatively frequently. Furthermore, patients must keep a lag-time of 30-45 minutes between the injection of insulin and eating. In contrast, if premixed insulin analogues are used, there is no need for such lag-time and both nocturnal and severe hypoglycaemia are less frequent than with human premixed therapy. The superiority of premixed insulin analogues compared with premixed human insulin therapy has been confirmed by a number of prospective, randomised controlled trials and retrospective analyses. The author summarises the results of these studies, emphasising the beneficial effects of premixed insulin analogues in the therapy of type 2 diabetes.]