Lege Artis Medicinae

[The End of the Story]

MAKÓ János

FEBRUARY 21, 2008

Lege Artis Medicinae - 2008;18(02)

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Lege Artis Medicinae

[The Nuremberg Doctors' Trial - The forever valid social message of the forced euthanasia programme]

KERPEL-FRONIUS Sándor

Lege Artis Medicinae

[Management of bleeding from oesophageal and gastric varices]

JÓZSA Andrea, SZÉKELY Iván, SIMON János, MÁHR Árpád, HORVÁTH László, HORVÁTH Andrea, FEJES Roland, SZÉKELY András, SZABÓ Tamás, MADÁCSY László

[INTRODUCTION – Variceal haemorrhage from the oesophageal or gastric wall is a major cause of death in patients with chronic liver disease. Over the past two decades many new treatment modalities have been introduced in the management of variceal bleeding, such as emergency endoscopy, band ligation and postintervention observation of the bleeding patients in subintensive care units. This study presents the results of state-of-the-art therapy applied in our department, comparing them to published data. PATIENTS AND METHODS – Clinical records of patients with variceal haemorrhage admitted to our department between January 1st 2001 and December 31st 2004 were reviewed. Six-week mortality, incidence of recurrent bleeding, transfusion requirement and length of hospital stay were the main parameters analysed. RESULTS – A total of 228 admissions (191 patients) due to variceal bleeding were recorded in the study period. Cirrhosis was of alcoholic origin in 92% of patients. Upper endoscopy was performed in 94% of patients within 4 hours and endoscopic therapy was also applied in all but 7 patients. Octreotide was administered in 4 patients, and portosystemic shunt was performed in 1 patient. Primary endoscopic haemostasis was achieved in 85% of cases, while rebleeding rate was 31%. The mean length of total hospital stay was 10.6 days, including an average of 2.6 days in subintensive care units. The mean transfusion requirement was 3.75 units of packed red cells. Six-week mortality rate was 14.9%. CONCLUSION – In comparison to international data, the six-week mortality rate among our patients was substantially lower than that in earlier reports, and nearly equals with recent leading results.]

Lege Artis Medicinae

[Pregnancy and insulin resistance: theoretical and clinical issues]

BARANYI Éva, WINKLER Gábor

[During pregnancy, metabolic changes occur physiologically, which are enhanced by the presence of gestational or praegestational diabetes. The basis of these changes is the increasing insulin resistance throughout pregnancy, which in diabetics may result in hyperglycaemia with undesirable clinical consequences and complications. These complications can be prevented in diabetic pregnant women by maintaining the physiological metabolic state typical of healthy pregnant women. Thus the aim of the treatment is to achieve a normoglycaemic state throughout pregnancy. In most cases this is only possible by the use of insulin, along with appropriate dietary measures. Intensive insulin regimes are successfully used in the metabolic control of pregnant diabetic women, and the use of insulin analogues and insulin pump may also be considered.]

Lege Artis Medicinae

[The diagnostics of changes in the mouth cavity]

BÁNÓCZY Jolán

Lege Artis Medicinae

[Microscopic colitis]

BARTA Zsolt

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Valproic acid associated pleuropericardial effusion: case report

DEMIR Figen Ulku

Introduction - Valproic acid is an effective antiepileptic and mood stabilizer used in the treatment of many neurological and psychiatric disorders. Although there are frequently seen side effects, effusions between layers of pleural and pericardial membranes are rare to be seen. Case - Pleuropericardial effusion was detected in a 23 years old woman who was under valproic acid treatment because of epileptic seizure. After 1 year of valproic acid treatment, patient complained of dyspnea. As all the researches intended on etiology were usual, valproic acid has been thought to be responsible for the matter. Control examination after 1.5 months regarding the end of treatment revealed complete recovery of pleuropericardial effusion. Discussion - Pleural and pericardial effusions are rarely seen complications related to the use of valproic acid. It must also be kept in mind that valproic acid causes a potential for such side effects which can be blamed etiologically when the other possibilities for patients are excluded.

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[Hungarian dialysis statistics: changing trends in the renal epidemiology]

KULCSÁR Imre, KISS István, SZEGEDI János

[In the last 30-35 years, dialysis care in Hungary has been a major development: both the incidence and prevalence of patients have increased year by year. Over the last decade, growth has slowed and is becoming more and more stabilized (similar trends can be seen in dialysis statistics in developed countries). Behind the dialysis indication the acute kidney injury (AKI) is more common than the end-stage renal disease (ESRD). The latter incidence has been stable for last 6 years (200-230 patient/million population). The annual average growth rate of prevalent dialysis patients was only 0.9%/year in the last 6 years. Among prevalent dialysis patients, the proportion of diabetic patients has remained unchanged for 10 years (26-27%), but those have increased who had hypertension nephropahty. The average age of incident and prevalent dialyzed patients has decreased gradually over the past 8 years (between 2009 and 2017 incident rate was from 67.1 to 63.0 years, prevalent rate was from 65.6 to 61.8 years). Unfortunately, just over half of the patients who dialyzed due to chronic kidney disease (CKD) have reached dialysis day 91. This is due to the high proportion of patient who was in urgent need of dialysis. In chronic hemodialysis (HD) program, the proportion of patients treated with arterovenous fistulas (AVF) decreases, while the rate of central venous catheter (CVC) users increases. The Hungarian peritoneal dialysis program in Europe is very good. The number of prevalent patients receiving renal replaement therapy (RRT) in Hungary in 2017 was 1005 for 1 million inhabitants.]

Clinical Oncology

[Treatment of hepatocellular carcinoma - today]

VÉGH Éva, DEMETER Gyula, BODOKY György

[The hepatocellular carcinoma (HCC) is one of the main causes of cancer-related death globally, and at the same time, it is the main event leading to death in cirrhotic patients. In the etiology of HCC, the non-alcoholic liver disease may be an important cause besides the viral cirrhosis. The HCC’s staging systems (Child-Pugh scores, Cancer of the Liver Italian Programme/CLIP, Barcelona Clinic Liver Cancer/ BCLC) play an important role in predicting the prognosis and determining the appropriate therapy. In Europe, the treatment strategy is based on the BCLC staging system. Screening of cirrhotic patient is also important because curative therapy is available only for the early-stage HCC. Several therapeutic options exist in the intermediate stage disease; among them the radiofrequency ablation (RFA), the transarterial chemoembolization (TACE) and the percutan ethanol injection (PEI) are most important. For the advanced disease, the only approved systemic therapy is sorafenib, which has been well-tolerated and yielded a substantially relative improvement in overall survival. For patient in end-stage disease with impaired liver function or a poor performance status, only supportive care is recommended.]

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[End of the line? Addenda to the health and social care career of psychiatric patients living in Hungary’s asylums]

KAPÓCS Gábor, BACSÁK Dániel

[The authors are focusing on a special type of long term psychiatric care taking place in Hungary outside of the conventional mental health care system, by introducing some institutional aspects of the not well known world of so called social homes for psychiatric patients (asylums). After reviewing several caracteristics of institutional development of psychiatric care in Hun­gary based on selected Hungarian and in­ternational historical sources, the main struc­tural data of present Hungarian institutional capacities of psychiatric health and social care services are shown. Finally, the authors based on own personal experiences describe several functional ascpects of the largest existing asylum in EU, a so­cial home for long term care of psychiatric pa­tients. By the beginning of the 20th century, Hungarian psychiatric institutions were operating on an infrastructure of three large mental hospitals standing alone and several psychiatric wards incorporated into hospitals. Nevertheless, at the very first session of the Psychiatrists’ Conference held in 1900 many professionals gave warning: mental institutions were overcrowded and the quality of care provided in psychiatric hospital wards, many of which located in the countryside of Hungary, in most cases was far from what would have been professionally acceptable. The solution was seen in the building of new independent mental hospitals and the introduction of a family nursing institution already established in Western Europe; only the latter measure was implemented in the first half of the 20th century but with great success. However, as a result of the socio-political-economic-ideological turn following the Second World War, the institution of family nursing was dismantled while different types of psychiatric care facilities were developed, such as institutionalised hospital and outpatient care. In the meantime, a new type of institution emerged in the 1950s: the social home for psychiatric pa­tients, which provided care for approximately the same number of chronic psychiatric patients nationwide as the number of functioning hospital beds for acute psychiatric patients. This have not changed significantly since, while so­cial homes for psychiatric patients are perhaps less visible to the professional and lay public nowadays, altough their operational conditions are deteriorating of late years. Data show, that for historical reasons the current sys­tem of inpatient psychiatric care is proportionately arranged between health care and social care institutions; each covering one third. Further research is needed to fully explore and understand the current challenges that the system of psychiatric care social- and health care institu­tions are facing. An in-depth analysis would significantly contribute to the comprehensive improvement of the quality of services and the quality of lives of patients, their relatives and the health- and social care professionals who support them. ]

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[Chronotherapy of hypertension - individualized treatment according to the circadian blood pressure profile]

SZAUDER Ipoly, UJHELYI Gabriella

[The circadian (24 h) rhythm shows great importance in the pharmacotherapy of hypertension. There is growing interest in how to best tailor the treatment of hypertensive patients according to the circadian blood pressure pattern of each individual. Significant administration-time differences are in the chronokinetics of antihypertensive medication. The therapeutic coverage and efficacy of different antihypertensive drugs are all markedly dependent on the circadian time of drug administration. Administration of ACE inhibitors, ARBs, doxazosin and aspirin at bedtime, as opposed to upon wakening, results in an improved diurnal/nocturnal blood pressure ratio (recommended for nondipper type of hypertension). Other antihypertensive medications: calcium channel blockers and β receptor blockers are non effective at the circadian blood pressure pattern. Chronotherapy provides a means of individualizing the treatment of hypertension according to the circadian blood pressure profile of patients and constitutes a new option to optimize blood pressure control and reduce the risk of cardiovascular disease and the risk of end organ injury.]