Lege Artis Medicinae

[SUCCESSFUL TREATMENT OF WHIPPLE'S DISEASE IN A PATIENT WITH LYMPH NODE ENLARGEMENT]

SOMOGYI Ágota, SZABÓ Tamás, KISHÁZI Péter, KISS Erika, ARATÓ Gabriella, PÁL Katalin, MADÁCSY László

OCTOBER 20, 2004

Lege Artis Medicinae - 2004;14(10)

[INTRODUCTION - Intestinal lipodystrophy, Whipple’s disease is an uncommon, chronic, systemic bacterial infection. It occurs predominantly in Caucasian males older than 40 years. The gastrointestinal tract is the most frequently involved organ, with clinical manifestations such as abdominal pain, malabsorption syndrome with diarrhea and weigth loss. Patient may present with low grade fever or fever of unknown origin, arthritis, lymphadenopathy, skin hyperpigmentation, endocarditis, pleuritis and peripheral and central neurological manifestations. Due to the wide variability of symptoms, the clinical diagnosis is very difficult and it is often made only years or even decades after the initial presentation. CASE REPORT - A 51-year-old Caucasian race man was admitted to the hospital with weigth loss and signs of subileus, referred for suspected lymphoma. After the exploratory laparotomy and lymphadenectomy the histological and the electron microscopical diagnosis was Whipple’s disease which was confirmed with histology from deep duodenal biopsy. Trimethoprim and sulfamethoxazole therapy for 6 months resulted in complete clinical and molecular biological healing. CONCLUSION - Clinical signs of Whipple’s dease are non-specific and may mimic Crohn’s disease, coeliac disease, amyloidosis, macroglobulinaemia, histoplasmosis, infection with non-tuberculotic mycobacterium in AIDS patients and lymphomas. Therefore, differential diagnosis is of critical importance. The natural evolution of the disease without treatment is always fatal. Trimethoprim and sulfamethoxazole for at least 1 year is usually considered adequate to eradicate the infection.]

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[SCIENTIFIC DIGEST]

Lege Artis Medicinae

[LONG-TERM RESULTS OF ENDOSCOPIC SPHINCTEROTOMY - EFFECTS OF THE TRANSECTION OF BILE PAPILLA]

DÖBRÖNTE Zoltán

[The abolishment of the choledochoduodenal pressure gradient due to endoscopic sphincterotomy results in the enhancement of the enterohepatic circulation of the bile salts, in the reduction of the cholesterol saturation index and in the modification of the gallbladder function: the reduced gallbladder storage time and the increased ejection fraction facilitates gallbladder emptying. On the contrary, bacterial colonisation of the bile ducts due to duodenobiliary reflux plays a causative role in the increased risk of pigment stone formation. However, when the biliary tree is well-drained, no clinically relevant chronic inflammation develops, furthermore there is no evidence for an increased cancer risk caused by the duodenobiliary reflux. Long-term complications may occur in about 12%, as the recurrence of common bile duct stones, post-EST papillary stenosis, and biliary symptoms caused by retained gallbladder stones. Risk factors for recurrence of bile duct stones are juxtapapillary duodenum diverticulae and persistently dilated bile ducts being the main reason for papillary restenosis and sphincterotomies are mainly performed because of papillary stenosis. In cases of retained gallbladder with stones patency of the cystic duct and contractility of the gallbladder are important predictive factors of late gallbladder complications as it was confirmed by our investigations. Accordingly, small gallbladder stones may pass spontaneously after EST. The indication of a cholecystectomy following EST should be considered individually, particularly in elderly patients. As 30-year-experience confirms, EST is a safe and effective treatment of choledocholithiasis and papillary stenosis even in the long term, and also in young patients. Regular follow-up of patients with high risk for recurrent biliary symptoms is recommended to detect late complications and treat them endoscopically in time.]

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UDVARHELYI Iván, HANGODY László

Lege Artis Medicinae

[CURRENT PRACTICAL VACCINOLOGY]

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[The author deals with the current situation and new trends of vaccinology by focusing on the interests of practitioners. The main topics are the changes of antigens (such as pertussis, measles, or poliomyelitis) to provide better efficacy and milder reactogenity or less adverse events. Purifying the vaccines, like thiomersal and human proteins free vaccines is another proven method to achieve better safety. New antigens e.g. Rota, Lyme, meningococcus B are in the pipeline of vaccinology. The aim of producing a combined vaccine is to achieve immunity against more diseases with less inconvenience for the patient, while achieving higher vaccine coverage (DPT-Hib-HBV-IPV). The epidemiological and clinical experiences will influence the current vaccine schedule such as revaccinations of MMR, and remove the need for revaccinations of BCG and hepaB. The special target groups of immunizations are the elderly and patients with chronic disease. Groups of specialists are working on the vaccine recommendation guidelines for certain risk groups. At the same time, with the successful eradication of polio in Europe the practitioners now have to face the antivaccination movement, as well. The main tools to convince people about the benefit of vaccinations are health education and information.]

Lege Artis Medicinae

[COST-EFFECTIVENESS OF PIMECROLIMUS CREAM - A NEW TREATMENT FOR ATOPIC DERMATITIS IN HUNGARY]

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[OBJECTIVE - To assess the costs, consequences and cost-effectiveness of pimecrolimus cream 1% in the treatment of children with atopic dermatitis in Hungary. METHODS - A Markov-model for atopic dermatitis developed by the Erasmus University (Rotterdam, the Netherlands) was adopted to the Hungarian health care setting. The model is based on a double-blind, multicenter, randomized, parallelgroup study. Patients were randomised (2:1) to receive pimecrolimus treatment (i.e. emollients, pimecrolimus, medium potency topical corticosteroids) or standard of care (emollients, vehicle, medium potency topical corticosteroids). The study was conducted in children and adolescents (2 to 18 years of age). Hungarian cost vectors were calculated by linking severity of disease as defined by Investigator’s Global Assessment (IGA) to average resource use. Resource use was multiplied by drug costs and unit costs as published in official databases. RESULTS - Pimecrolimus treatment has an incremental cost of HUF 143 897 over standard care. This additional cost of care resulted in an incremental 0.05 QALY gain over the 6 months period. The incremental cost effectiveness ratio was 2 863 913 HUF/QALY for the pimecrolimus therapy. CONCLUSION - Pimecrolimus is more costeffective than many other health care interventions currently reimbursed by the Hungarian National Health Fund.]

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