Lege Artis Medicinae

[The bell is cracked]

BONDÁR Éva

JANUARY 20, 2010

Lege Artis Medicinae - 2010;20(01)

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[The changing concept of the metabolic syndrome in the past two decades]

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[The introduction of the concept of the metabolic syndrome (MS) (1988) had a great significance from both a theoretical and a clinical point of view. The concept and the assesment of this syndrome has been widely criticized during the past two decades, however, many new components and even new diseases have been added to its defintion. These significant changes motivated us to complete and modify our previous review on this topic published in this journal more than ten years ago. In addition to the classical concept of MS, we discuss its various definitions, in which no consensus has been reached. Besides the two characteristic features, insulin resistance and hyperinsulinism, we discuss the etiological role of endothelial dysfunction, overactivity of the symphato-adrenal system, endocrine activity of the adipose tissue, and low-degree inflammation. We also discuss the roles of the Peroxisome- Proliferator Activated Receptor system and the ubiquitin proteasome system in certain metabolic and inflammatory processes. Recently, the causal unity of the syndrome has been questioned, which has generated an extended and still ongoing debate. For the clinicians, however, the most important fact is that individuals with the characteristic symptoms of the syndrome represent a significant number of the population and are at hight risk of severe cardiovascular conditions. Finally, we outline the newly discovered relationships of the syndrome with other diseases that have a great public health importance, such as cancers, Alzheimer disease, sleep apnoe, nonalcoholic fatty liver disease and chronic obstructive pulmonary disease. We also discuss the supposed common pathomechanisms of these conditions. These associations further increase the significance of MS in terms of both therapy and prevention.]

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[The role of transcranial magnetic stimulation in clinical diagnosis: facial nerve neurography]

ARÁNYI Zsuzsanna, SIMÓ Magdolna

[Facial nerve neurography involving magnetic stimulation techniques can be used to assess the intracranial segment of the facial nerve and the entire facial motor pathway, as opposed to the traditional neurography, involving only extracranial electric stimulation of the nerve. Both our own experience and data published in the literature underline the value of the method in localising facial nerve dysfunction and its role in clinical diagnosis. It is non-invasive and easy to perform. Canalicular hypoexcitability has proved to be the most useful and sensitive parameter, which indicates the dysfunction of the nerve between the brain stem and the facial canal. This is an electrophysiological finding which offers for the first time positive criteria for the diagnosis of Bell’s palsy. The absence of canalicular hypoexcitability practically excludes the possibility of Bell’s palsy. The technique is also able to demonstrate subclinical dysfunction of the nerve, which can be of considerable help in the etiological diagnosis of facial palsies. For example, in a situation where clinically unilateral facial weakness is observed, but facial nerve neurography demonstrates bilateral involvement, etiologies other than Bell’s palsy are more likely, such as Lyme’s disease, Guillain-Barré syndrome, meningeal affections etc. Furthermore, the technique differentiates reliably between peripheral facial nerve lesion involving the segment in the brain stem or the segment after leaving the brainstem.]

Clinical Neuroscience

[CLINICAL ANALYSIS OF PATIENTS WITH PERIPHERAL FACIAL PALSY]

ILNICZKY Sándor

[symptoms. In two thirds of the cases the cause is unknown, this is called “idiopathic peripheral facial palsy or Bell’s palsy”, but several different diseases have to be considered in the differential diagnosis. In this paper we reviewed the case histories of 110 patients treated for “peripheral facial palsy” in the Department of Neurology, Semmelweis University, Budapest in a five year period, 2000-2004. We studied the age, gender distribution, seasonal occurance, comorbidities, sidedness, symptoms, circumstances of referral to the hospital, the initial diagnoses and therapeutic options. We also discuss the probable causes and consequences of diagnostic failures. Results: the proportion of males and females was equal. There was no considerable difference between sexes regarding agedistribution. Of the 110 patients 106 was diagnosed with idiopathic Bell’s palsy, three cases with otic herpes zoster and one patient with Lyme disease. In our material, peripheral facial palsy was significantly more frequent in the cold period of late autumn, winter, and early spring. Diabetes mellitus and hypertension were more frequent than in the general population. 74% of the patients were admitted within two days from the onset of the symptoms. In 37% preliminary diagnosis was unavailable. In 15% cerebrovascular insult was the first, incorrect diagnosis, the correct diagnosis of “Bell’s palsy” was provided only in 16%. The probable causes of diagnostic failures may be the misleading symptoms and accompanying conditions. We examined the different therapies applied and reviewed the literature in this topic. We conclude that intravenous corticosteroid treatment in the early stage of the disease is the therapy of choice.]

Clinical Neuroscience

Facial virus inoculations infect vestibular and auditory neurons in rats

HELFFERICH Frigyes, LOURMET Guillaume, SZABÓ Rebeka Éva, BOLDOGKŐI Zsolt, PALKOVITS Miklós

Background and purpose – There is growing evidence for the viral origin of the Bell’s facial palsy, vestibular neuritis and sudden sensorineural hearing loss, however their exact pathophysiology is still unknown. We investigated the possibility of brainstem infections following peripheral viral inoculations in rats. Methods – Pseudorabies virus, a commonly used neurotropic viral retrograde tracer was injected into the nasolabial region of rats. Five and 6 days after injections, infected brainstem nuclei were demonstrated by immunohistochemical techniques. Results – Infected neurons were found in the motor facial, the medial vestibular, and the sensory trigeminal nuclei, as well as in the medial nucleus of the trapezoid body. Conclusion – Pseudorabies virus infects auditory and vestibular sensory neurons in the brainstem through facial inoculation. The possible routes of infections: 1. trans-synaptic spread constituted by facio-vestibular anastomoses: primarily infected motor facial neuron infects neurons in the medial vestibular nucleus, 2. via trigeminal sensory nerves: the sensory trigeminal complex innervated by GABAergic medial vestibular neurons, and 3. one bisynaptical route: infected facial motoneurons may receive indirect input from the medial vestibular nucleus and the trapezoid body via connecting neurons in the sensory trigeminal complex. We may assume that latent infections of these areas may precede the infections of the peripheral organs and the reactivation of the virus exerts the symptoms.