Lege Artis Medicinae

[THE EPIDEMIOLOGY OF CEREBROVASCULAR DISEASES IN HUNGARY AFTER THE MILLENNIUM]

VOKÓ Zoltán, SZÉLES György, KARDOS László, NÉMETH Renáta, ÁDÁNY Róza

MARCH 21, 2009

Lege Artis Medicinae - 2009;19(klsz)

[INTRODUCTION - Here we present the descriptive epidemiology of stroke in Hungary including mortality, morbidity, functional limitation and inpatient care based on the most recent health statistical data. METHODS - Mortality data were analysed by direct and indirect standardisation, and geographical mapping based on empirical Bayesian smoothing. Morbidity data were obtained from the General Practitioners’ Morbidity Sentinel Station Program and the National Health Surveys. The latter also provided data on functional limitation. Data on inpatient service were taken from the European Hospital Morbidity Database of WHO. RESULTS - Hungarian stroke mortality continued to decrease in recent years, and the slope of the decrease was larger than in Western Europe. Stroke mortality was highest in the Northern- Hungarian Region, and in Somogy and Zala counties. The incidence of stroke was 1.5-2 times higher than in the developed countries in most age groups. Over 64 years of age, a decline of stroke incidence was observed, especially in men. In this age group approximately 10% of men and 7% of women had already had a stroke. Of these patients more than 10% needed assistance to get out of the bed, dress up, or eat. Hospitals reported more than 60 000 stroke cases in 2005. CONCLUSION - Despite the promising trends in stroke mortality and now also in morbidity, both indices are still rather high in Hungary compared to those in Western-Europe. The relatively favourable epidemiological changes, however, may be overridden by the increased stroke burden resulting from the aging of the population.]

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Lege Artis Medicinae

[STATE-OF-THE ART COMPLEX TREATMENT OF THYROID CANCERS]

LUKÁCS Géza

[Thyroid cancers derived from follicular epithelial cells are histologically classified as papillary, follicular and anaplastic. Cancers that originate from parafollicular, or C-cells, are termed medullary carcinomas. Their annual incidence is fairly low; 3 to 7 cases per 100 000 people. After the Chernobyl disaster, however, thyroid cancers have received much attention. They often occur at young age, and frequently and early give metastases. They typically grow slowly and have a good prognosis even in the metastatic stage. The main prognostic factors include age, tumour size and extent, the completeness of surgical removal, distant metastases and tumour grade. Based on these parameters, they are classified into high-risk and low-risk groups. There are no prospective randomized studies available on the optimal treatment of thyroid cancers. Their biological aggressiveness differs according to geographic location, which explaines why the management of thyroid carcinomas has not been standardized internationally. Contrary to America and Australia, in Europe there are several endemic goitre regions, and background radiation is higher. It is generally accepted that here the standard therapy of choice is total thyreoidectomy with adequate lymph node dissection followed by postoperative radioiodine ablation. It is a reasonable demand to minimize the higher morbidity associated with radical surgery (e.g., recurrent nerve palsy, postoperative hypoparathyroidism) below 1%. It is recommended that such operations are performed by experienced thyroid surgeons in centres with multidisciplinary endocrine teams.]

Lege Artis Medicinae

[STEM CELL THERAPY AFTER ACUTE MYOCARDIAL INFARCTION]

NYOLCZAS Noémi, GYÖNGYÖSI Mariann

[Left ventricular remodelling and chronic heart failure as a consequence of myocardial infarction is a major problem despite of the everimproving therapeutic options. The available treatment methods have fairly limited success in preventing the development of these changes. Myocardial regeneration with stem cell treatment is a promising therapeutic alternative. Although the results should still be confirmed in large, randomised, multicentric controlled trials, data from animal studies and small clinical trials suggest that therapy with stem cells after acute myocardial infarction is safe and feasible, is able to reduce the extent of necrosis, and may improve myocardial perfusion and left ventricular function. This review presents the types of cells that can be used, the ways of application, and the available results of clinical trials of stem cell therapy after acute myocardial infarction.]

Lege Artis Medicinae

[Axillar sentinel node biopsy and surgical treatment of the axilla in breast cancer patients - Evidences and open questions]

CSERNI Gábor

Lege Artis Medicinae

[THE REAL FACE OF JUVENILE POLYPOSIS SYNDROME - MALIGNANCY IN A DISEASE PREVIOUSLY THOUGHT TO BE BENIGN]

TAM Beatrix, SALAMON Ágnes, BAJTAI Attila, NÉMETH Annamária, KISS János, SIMON László

[INTRODUCTION - The majority of colorectal cancer cases is sporadic, but familial and autosomal dominant forms should also be considered. Juvenile polyposis syndrome is an autosomal dominant condition caused by mutations in the SMAD4 or the BMPR1A gene. Typically, numerous hamartomatous polyps develop in the upper gastrointestinal and the colorectal area. In contrast to earlier opinions, some of these polyps may transform malignantly, like in the case presented here, at the age of 34-35 years on average. CASE REPORT - During the eighteen-year continuous care of the young man treated for juvenile polyposis, more than a hundred polyps were resected from the gastrointestinal tract. After an eigth-year intermission of surveillance because of insufficient compliance, the patient presented in a severe clinical condition caused by metastatic colorectal cancer. He died after a short palliative therapy at the age of 31. Based on the family tree, all of his living adult first-degree relatives were subsequently examined and juvenile polyposis syndrome was also diagnosed in his older brother. Genetic testing revealed a mutation in the BMPR1A gene in the clinically affected brother, one of his daughters, and also in the deceased probands child. CONCLUSION - Genetic testing made it possible to relieve the mutation-free relatives of the anxiety and particularly of a number of unnecessary, mainly invasive examinations, while mutation carriers can be given the best possible clinical surveillance.]

Lege Artis Medicinae

[SEVERE NECROTISING PRIMARY VASCULITIS]

GRIGER Zoltán, SZÁNTÓ Antónia, SZABÓ Nóra Anna, SOLTÉSZ Pál, ZEHER Margit

[INTRODUCTION - Vasculitis is an inflammatory disorder of the vessels, often associates with necrosis. The primary (idiopathic) form caused by distinct immunological mechanisms, the secondary form caused by infection, tumor, drugs or systemic autoimmune disease. CASE REPORT - 57-year-old smoking female patient with a medical history of the left ankle fracture. Four days earlier had sore throat, at admission was febrile and generally weak and had severe pain in her lower extremities. Physical examination revealed numerous livid alterations in both lower extremities, necrotic change of some toes and new onset of diastolic hypertension. Elevated serum transaminase levels, severe thrombopenia, anemia, leukocytosis suggested the possibility of thrombotic thrombocytopenic purpura and vasculitis. Tests ruled out septic embolism, therefore we applied high dose steroid treatment and plasma exchange. Meanwhile the results fulfilled the classification criteria of polyarteritis nodosa (vasculitis, livedo reticularis, polyneuropathia and new onset of diastolic hypertension), accordingly we synchronized the treatment with fractionally administered intravenous cyclophosphamide. The process revealed responsive to therapy and the substantive function of the legs remained after surgical removal of the necrotic areas. CONCLUSIONS - Early rapid diagnosis of vasculitis is fundamental and we emphasize the significance of the efficient treatment.]

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[The Comprehensive Aphasia Test in Hungarian]

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[In this paper we present the Comprehensive Aphasia Test-Hungarian (CAT-H; Zakariás and Lukács, in preparation), an assessment tool newly adapted to Hungarian, currently under standardisation. The test is suitable for the assessment of an acquired language disorder, post-stroke aphasia. The aims of this paper are to present 1) the main characteristics of the test, its areas of application, and the process of the Hungarian adaptation and standardisation, 2) the first results from a sample of Hungarian people with aphasia and healthy controls. Ninety-nine people with aphasia, mostly with unilateral, left hemisphere stroke, and 19 neurologically intact control participants were administered the CAT-H. In addition, we developed a questionnaire assessing demographic and clinical information. The CAT-H consists of two parts, a Cognitive Screening Test and a Language Test. People with aphasia performed significantly worse than the control group in all language and almost all cognitive subtests of the CAT-H. Consistent with our expectations, the control group performed close to ceiling in all subtests, whereas people with aphasia exhibited great individual variability both in the language and the cognitive subtests. In addition, we found that age, time post-onset, and type of stroke were associated with cognitive and linguistic abilities measured by the CAT-H. Our results and our experiences clearly show that the CAT-H provides a comprehensive profile of a person’s impaired and intact language abilities and can be used to monitor language recovery as well as to screen for basic cognitive deficits in aphasia. We hope that the CAT-H will be a unique resource for rehabilitation professionals and aphasia researchers in aphasia assessment and diagnostics in Hungary. ]

Clinical Neuroscience

The applications of transcranial Doppler in ischemic stroke

FINNSDÓTTIR Herdis, SZEGEDI István, OLÁH László, CSIBA László

Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the in­crea­sed intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Micro­em­boli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast en­chan­ced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt.

Clinical Neuroscience

Hyperhomocysteinemia in female migraineurs of childbearing ages

ALEMDAR Murat, SELEKLER Macit Hamit

Background and purpose - Migraine is a risk factor for ischemic stroke in women of childbearing ages. Previous researches revealed a higher prevalence of hyperhomocysteinemia in migraineurs. Possible differences on the frequencies of hyperhomocysteinemia between migraine with aura and migraine without aura could contribute the established variances in stroke risk between these migraine types. Therefore, we aimed to search if the frequency of hyperhomocysteinemia was different between these subtypes of migraine or not. Methods - We analyzed the findings of serum homocysteine levels in female migraineurs of 16-49 years old who admitted to our outpatient clinic. Results - Homocysteine level was elevated in 13.3% of study population. There were not any significant differences on median serum homocysteine levels between migraine with aura (8.0 mikromol/L) and without aura (8.5 mikromol/L). (p=0.426) The frequencies of hyperhomocysteinemia were also similar (9.1% versus 16.7%, respectively; p=0.373). Correlation analyses did not reveal any linear correlation between ages and homocysteine levels either in group of migraine with aura or in group of migraine without aura (p=0.417 and p=0.647, respectively). Similarly, any linear correlation between disease ages and homocysteine levels either in group of migraine with aura or in group of migraine without aura was not detected (p=0.359 and p=0.849, respectively). Conclusion - The median serum homocysteine levels and the frequencies of hyperhomocysteinemia are similar between migraine with aura and without aura in women of childbearing ages. Therefore, the variances on stroke risk ratios between these types of migraine are probably not originated from the differences of serum homocysteine status.

Clinical Neuroscience

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Lege Artis Medicinae

[Holistic approach to cardiovascular prevention]

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[Cardiovascular diseases, primarily the organic manifestations of atherosclerosis, such as coronary artery disease, ischaemic stroke, and peripheral arterial diseases, represent the largest healthcare problem in the developed countries, since the mortality, disability, and need for hospitalisation caused by them constitute a bigger burden than that caused by all other diseases combined. A modern, holistic approach to cardiovascular prevention should consider the complete cardiovascular continuum, including genetic predisposition, social-economicalcultural background, environmental factors, the integrated effect of atherosclerotic risk factors, the inhibition of progression of functional and morphologic damages that have already developed, and, if possible, the promotion of regression. Besides targeting the individual, prevention at the public and social level is also important.]