Lege Artis Medicinae

[Successful palliative therapy of metastatic breast cancer with fulvestrant]

SZENTMÁRTONI Gyöngyvér

JANUARY 20, 2011

Lege Artis Medicinae - 2011;21(01)

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Lege Artis Medicinae

[Anosmia in everyday clinical practice]

GERLINGER Imre

Lege Artis Medicinae

[The Key to Paradise – Hungarian Aspects to the Cultural History of Hashish ]

KISS László

Lege Artis Medicinae

[Effective adalimumab treatment of a steroid-dependent Crohns’ disease patient suffering from general, abdominal and joint symptoms of multiple etiology]

JUHÁSZ Márk, TÓTH Zsuzsanna, MIHELLER Pál, SZŰTS Ildikó, GAÁL Ramóna, PÁPAY Judit, PREGUN István, TULASSAY Zsolt, RÁCZ Károly, MŰZES Györgyi

[The 69-year-old male patient had been suffering from periodically relapsing rheumatological symptoms involving variable localisations (knee, ankle, MTP, sternoclavicular and hip joint) since 1964. On the basis of his joint symptoms, load-independent lower back pain, sacroileitis, recurrent iridocyclitis, urethroprostatitis and oral aphtous lesions, Reiter disease was diagnosed in 2000. The patient had Lyme-disease (confirmed Borrelia burgdorferi seropositivity) with peripheral facial paresis in 2003. The patients joint problems relapsed in 2006, accompanied by diarrhoea and fever, independent of any infecions. The possibility of IBD could not be confirmed either by macroscopic examination using colonoscopy or hystology. The patient was admitted to our department in March 2008 for the first time, presenting again with joint pain and disability of gait, 7-8 bowel movements a day, and fever. Taken together the clinical symptoms, the typical radiological findings and HLA-B27 positivity, Bechterew disease was diagnosed. Colonoscopy performed because of diarrhea revealed multiple segmental aphtoid lesions and irregular ulcers, suggesting Crohn disease that was confirmed by histology (cryptal abscess formation and microgranulomas). Sulfasalazin, 5-ASA, and other NSAIDs applied to treat rheumatological symptoms could not eliminate either the gastrointestinal or the rheumatological symptoms of the patient, which necessitated regular steroid therapy. Because of the patient’s steroid dependency, and considering his rheumatological symptoms, in June 2008 he was treated with adalimumab (ADA) induction therapy (80-40-40 mg s.c.). In two weeks, his gastrointestinal as well as extraintestinal symptoms substantially improved, and completely diminished through the course of maintenance ADA therapy (40mg weekly). The patient is still asymptomatic and is excercising (jogging) regularly.]

Lege Artis Medicinae

[Hypertension and twenty years of LAM]

FARSANG Csaba

[The author reviews significant results related to hypertension with special emphasis on papers published in the LAM during the past twenty years. The history of hypertensiology, important aspects of hypertension research, therapeutic guidelines, antihypertensive agents and their combinations are also discussed. A brief section is dedicated to the expected future development of hypertension research and new directions of antihypertensive therapy.]

Lege Artis Medicinae

[The Effects of Music Therapy on Stress and Immunity Levels ]

KOLLÁR János

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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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Delirium is a syndrome frequently encountered in intensive care and associated with a poor prognosis. Intensive care delirium is mostly based on general and palliative intensive care data in the literature. In this study, we aimed to investigate the incidence of delirium in coronary intensive care unit (CICU), related factors, its relationship with inhospital and follow up prognosis, incidence of age-related delirium and its effect on outcomes. This study was conducted with patients hospitalized in CICU of a tertiary university hospital between 01 August 2017 and 01 August 2018. Files of all patients were examined in details, and demographic, clinic and laboratory parameters were recorded. Patients confirmed with psychiatry consultation were included in the groups of patients who developed delirium. Patients were divided into groups with and without delirium developed, and baseline features, inhospital and follow up prognoses were investigated. In addition, patients were divided into four groups as <65 years old, 65-75 yo, 75-84 yo and> 85 yo, and the incidence of delirium, related factors and prognoses were compared among these groups. A total of 1108 patients (mean age: 64.4 ± 13.9 years; 66% men) who were followed in the intensive care unit with variable indications were included in the study. Of all patients 11.1% developed delirium in the CICU. Patients who developed delirium were older, comorbidities were more frequent, and these patients showed increased inflammation findings, and significant increase in inhospital mortality compared to those who did not develop delirium (p<0.05). At median 9-month follow up period, rehospitalization, reinfarction, cognitive dysfunction, initiation of psychiatric therapy and mortality were significantly higher in the delirium group (p<0.05). When patients who developed delirium were divided into four groups by age and analyzed, incidence of delirium and mortality rate in delirium group were significantly increased by age (p<0.05). Development of delirium in coronary intensive care unit is associated with increased inhospital and follow up morbidity and mortality. Delirium is more commonly seen in geriatric patients and those with comorbidity, and is associated with a poorer prognosis. High-risk patients should be more carefully monitored for the risk of delirium.

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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.

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