Lege Artis Medicinae

[The effect of tiotropium on exacerbation and airflow in patients with COPD]

MOLDVAY Judit

OCTOBER 18, 2006

Lege Artis Medicinae - 2006;16(10)

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Lege Artis Medicinae

[A Work that Fills a Gap Elemér Nemesánszky MD, Klára Werling MD: Infectious Inflammations of the Liver – Possibilities for Prevention and Management]

GERVAIN Judit

Lege Artis Medicinae

[SIMULTANEOUS PRESENCE OF GIST AND MALT-LYMPHOMA OF THE STOMACH IN A HELICOBACTER PYLORI NEGATIVE PATIENT]

KOVÁCS Ferenc, GYÖKERES Tibor, TAKÁCS Imre Géza, PADÁNYI István, FEKETE Csaba, OROSZ Zsolt, PAP Ákos

[INTRODUCTION - The simultaneous presence of gastric mucosa-associated lymphoid tissue lymphoma (MALT) and a gastrointestinal stromal tumor (GIST) is an extremely rare finding that has not been published until now. CASE REPORT - The authors report on a 78- year-old man who was referred to their department with an emergency upper gastrointestinal bleeding. Urgent gastroscopy revealed a bleeding ulcer in the middle third of the stomach. On the follow-up endoscopy 6 weeks later, an umbilicated polypoid lesion was found proximal to the healed ulcer, which was subsequently removed by elective surgery. Histology and immunohistochemical staining of the specimen for c-Kit confirmed the diagnosis of gastrointestinal stromal tumour. A few weeks later the patient was readmitted because of haematemesis. Upon detailed histological examination of the biopsy specimens taken from the multiple superficial ulcers found near the previous lesion, MALT-lymphoma was diagnosed. The absence of Helicobacter pylori was confirmed by repeated histological examinations, serology and urea breath test. CONCLUSION - This is the first report on a patient with simultaneous presence of a gastrointestinal stromal tumour and gastric mucosaassociated lymphoid tissue lymphoma with H. pylori negativity. Several observations suggest that the development of malignant tumours of the stomach is also associated with H. pylori infection. In view of the reported case, the possibility of a common aetiology of these two neoplasms other than H. pylori infection is discussed.]

Lege Artis Medicinae

[Recommendation for Counselors László Török: The Diagnostic Significance of Skin Symptoms]

NEBENFÜHRER László

Lege Artis Medicinae

[ENTERAL ADMINISTRATION OF N-3 POLYUNSATURATED FATTY ACIDS IN ACUTE PANCREATITIS]

LÁSZTITY Natália, HAMVAS József, BÍRÓ Lajos, NÉMETH Éva, MAROSVÖLGYI Tamás, DECSI Tamás, PAP Ákos, ANTAL Magda

[BACKGROUND - The main determinant of outcome in acute pancreatitis is the extent of inflammation and pancreatic necrosis. Early administration of n-3 polyunsaturated fatty acids (PUFAs) may prevent the development of severe complications through modulation of eicosanoid synthesis and cytokine release. PATIENTS AND METHODS - In the prospective, randomised clinical trial 14 patients with acute pancreatitis received n-3 PUFAs (3.3 g/day for 5- 7 days) as a supplement to their enteral formula in the form of fish oil, and another 14 patients receiving enteral nutrition served as a control group. Measurements of erythrocyte superoxidedysmutase activity, serum total antioxidant status, C-reactive protein and praealbumin concentrations were performed at admission and at day 3, 7 and 14. Beside routine laboratory and imaging examinations, the fatty acid and vitamin A and E concentrations of the serum lipid fractions were also determined at admission and at day 7 of the jejunal nutrition. The endpoints of the study were the duration of hospitalisation, the duration of jejunal nutrition and the frequency of complications. RESULTS - A significantly higher superoxidedysmutase activity was observed in patients receiving n-3 fatty acids at day 3 of the treatment. The n-3 to n-6 long chain PUFA ratio increased significantly in the serum lipids of the patients receiving n-3 PUFA supplementation, whereas remained unchanged in the controls. Supplementation resulted in a significant decrease in the length of hospitalisation (13.1±6.7 vs. 19.3±7.2 days, p<0.05) and jejunal feeding (10.6±6.7 vs. 17.6±10.5, p<0.05). Complications developed in 6/14 (42%) of the treated group and in 9/14 (64%) of the control patients. CONCLUSION - Enteral administration of n-3 PUFAs in acute pancreatitis may promote earlier recovery by moderating inflammation.]

Lege Artis Medicinae

[STUDY OF PARAOXONASE ACTIVITY IN MIXED CONNECTIVE TISSUE DISEASE]

BODOLAY Edit, SERES Ildikó, JAKAB Zsanett, CSÍPŐ István, SZILÁGYI Anna, SZEGEDI Gyula, PARAGH György

[INTRODUCTION - Mixed connective tissue disease (MCTD) is an inflammatory autoimmune disease with multiple organ involvement. Immune- inflammatory processes play a crucial role in the pathogenesis of atherosclerosis. The connection between inflammatory parameters and atherosclerosis in MCTD has not yet been studied. Lipid abnormality is an important risk factor of atherosclerosis. Among the lipids, HDL is protective, which is in part due to the antioxidant effect of paraoxonase. In this paper, the lipid profiles and paraoxonase activities of MCTD patients were studied and the factors causing abnormalities were investigated. PATIENTS AND METHODS - Thirty-seven patients with MCTD, who had not taken any lipid lowering drugs in the past 2 months, were enrolled in the study. Thirty healthy individuals served as controls. At the time of the study the mean age of the MCTD patients was 51.2 ± 9.5 years, and the mean disease duration was 11.0 ± 7.2 years. Paraoxonase activity was determined by spectrophotometry, lipid profiles were determined by a Cobas Integra 700 Analyser, the von Willebrand factor antigen (vWFAg) was measured by turbidimetry in platelet-poor plasma and the thrombomodulin and anti-endothelial cell antibody (AECA) measurements were carried out by ELISA methods. RESULTS - Paraoxonase activity in the MCTD patients was lower than in the control population (118.5 ± 64.6 U/l vs. 188.0 ± 77.6, p<0.001). The arylesterase activity was also significantly lower in the patients (p<0.001). The reduction of paraoxonase activity was in correlation with the age of the patients, the duration of the disease and with vascular (eye, cardiac, cerebral) disorders. The total cholesterol and triglicerid levels of the patients were significantly increased compared to the control group, while in the apoA1 levels a significant reduction was seen. A very strong correlation was observed between the reduction of paraoxonase activity and the increase of endothelial cell activation markers (thrombomodulin, vWFAg, AECA). There was no difference in the values of patients with or without corticosteroid treatment. CONCLUSIONS - The results suggest that in MCTD there is an increased risk for atherosclerosis. Apart from an elevated cholesterol and triglicerid level, a reduced paraoxonase level and activity may also play a role in the development of atherosclerosis,. Therefore, in patients with MCTD, due to the increased oxidative processes and the impaired elimination of free radicals, a sustained damage to the endothelial cells occurs, which is indicated by increased levels of thrombomodulin, vWFAg, and anti-endothelial antibody.]

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Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

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.

Hypertension and nephrology

[About the care of patients with hyperuricaemia and gout]

[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

[The role of sleep in the relational memory processes ]

CSÁBI Eszter, ZÁMBÓ Ágnes, PROKECZ Lídia

[A growing body of evidence suggests that sleep plays an essential role in the consolidation of different memory systems, but less is known about the beneficial effect of sleep on relational memory processes and the recognition of emotional facial expressions, however, it is a fundamental cognitive skill in human everyday life. Thus, the study aims to investigate the effect of timing of learning and the role of sleep in relational memory processes. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. Our results suggest that the timing of learning and sleep plays an important role in the stabilizing process of memory representation to resist against forgetting.]