Lege Artis Medicinae

[The latest rules on prescribing medicines]

LÁSZLÓ András

JANUARY 29, 1992

Lege Artis Medicinae - 1992;2(01)

[No lists! Medical rights or economic constraints? We asked Béla Doktorics, Secretary General of the Hungarian Medical Chamber, whether the Ministry of Public Welfare had consulted the Chamber on the controversial legislative package, even if not with the Parliament's health committee?]

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Lege Artis Medicinae

[Biological and Pathological Significance of Apoptosis (Programmed Cell Death)]

SZENDE Béla

[Programmed cell death (apoptosis) basically differs from necrosis regarding its biological significance, the morphological signs and biochemical events. Apoptosis is the result of an active cell function, so-called cell-suicide and it is observable in several biological as well as pathological processes. Enhancement of apoptosis can be achieved in malignant tumors by hormonal treatment. This explains the mode of action of hormones in tumor therapy and also contributes to the alterations in gene regulation leading to apoptosis.]

Lege Artis Medicinae

[The use of BCG immunotherapeutic for the treatment of superficial bladder cancer (carcinoma in situ and papillary tumor)]

CSIZÉR Zoltán

[BCG Immunotherapeutic (BCG IT) is the first immunomodulator to be licenced in Canada, Germany and the United States for the use in the treatment of carcinoma of the urinary bladder. The product licence was granted following the conduct of a well designed efficacy study. The study was multicente red, independent and controlled with well defined end points and a long follow up period. The results clearly shows that BCG immunotherapy is significantly more effective than Adriamycin chemotherapy. There is no evidence to suggest a difference in severity of toxicities between BCG and Adriamycin treatment groups.]

Lege Artis Medicinae

[Transesophageal and transthoracic echocardiography in aortic dissection]

LENGYEL Mária

[ The severe prognosis of aortic dissection can only be improved by early diagnosis. The role of echocardiography was assessed. Echocardiographic findings were analysed in 32 patients in whom aortic dissection was confirmed by other methods between September 1984 and July 1991. In 19 of them only transthoracic echo (TTE), in 13 patients both TTE and transesophageal echo (TEE) was performed. Control group consisted of 21 patients in whom the clinical suspicion of dissection was ruled out. The DeBakey classification was used. Among 14 acute and 18 chronic cases type I was confirmed in 9, type II in 15 and type III in 8. The sensitivity of clinical suspicion, TTE, TEE and angiography was 34, 72, 92, 94% resp. TEE correctly identified the types, entry and reentry sites, false lumen and left coronary ostium. TTE was valuable in the detection of complications and of etiologic factors of dissection. Hypertension (12) and Marfan's syndrome (7) were the leading etiologic factors. As previously has been reported in the diagnosis of aortic dissection TEE was a safe and reliable technique. It was superior to TTE and was as correct as angiography. The combined use of TTE and TEE is recommended in each case of clinically suspected dissection. The importance of the echocardiographic detection of cardiac complications and etiologic factors is emphasized in the management and prevention.]

Lege Artis Medicinae

[Oral symptoms in the early diagnosis of leukaemias]

GYURKOVICS Csilla, BÁNÓCZY Jolán

[Diseases of the haemopoetic system are often preceeded and/or accompanied by clinical changes in the oral cavity, which, as first signs of the disease, might be of important diagnostic value. Primary oral findings are characteristic mainly of acute leukaemias, such as haemorrhagies, petechias, ecchymoses, ulcera, gingival hy pertrophy, painful gingiva, tooth mobility, candidiasis, herpes simplex infection, lymph node enlargements. Oral manifestations of chronic leukaemia may also arouse the suspicion of a haemopoetic disease. Applied cytostatic therapy might aggravate the condition of oral manifestations. ]

Lege Artis Medicinae

[Peritoneal dyalisis in hungary]

KARÁTSON András, MAKÓ János

[Traditional intermittent peritoneal dialysis in patients with chronic uremia lasts for 8 to 10 hours three times a week. In 1976 Popovich et al. outlined the principle of CAPD (Continu ous Ambulatory Peritoneal Dialysis), a technique giving good results in the removal of water and toxic substances. The procedure is used in 19 000 patients in US and in 9600 patients in Europe. In early 1991 the technical conditions and the number of patients receiving peritoneal dialysis were surveyed in the Hungarian nephrological and dialysing units. Not only the number of patients with chronic uraemia (those undergoing dialysis + transplantation) is lower in this country as compared to the European average (106 versus, 236 per million people, respectively) but the distribution of patients according to the type of treatment they receive is also different. In Hungary intermittent peritoneal dialysis has been used in more than 10% of the cases for several years whereas the number of those receiving continuous peritoneal dialysis has been under 2%. (In Europe < 2% and 4–43%, respectively). The survey also included the types of solution, desinfection and connecting devices used in peritoneal dialysis, as well as the incidence of peritonitis and the administration of antibiotics . The principles of biocompatibility, the function of interleukin as well as the effectiveness and the conditions of home treatment are summarized. ]

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[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

Clinical Neuroscience

[The importance of patient reported outcome measures in Pompe disease]

MOLNÁR Mária Judit, MOLNÁR Viktor, LÁSZLÓ Izabella, SZEGEDI Márta, VÁRHEGYI Vera, GROSZ Zoltán

[In recent decades it has become increasingly important to involve patients in their diagnostic and treatment process to improve treatment outcomes and optimize compliance. By their involvement, patients can become active participants in therapeutic developments and their observations can be utilized in determining the unmet needs and priorities in clinical research. This is especially true in rare diseases such as Pompe disease. Pompe disease is a genetically determined lysosomal storage disease featuring severe limb-girdle and axial muscle weakness accompanied with respiratory insufficiency, in which enzyme replacement therapy (ERT) now has been available for 15 years. In our present study, patient reported outcome measures (PROMs) for individuals affected with Pompe disease were developed which included questionnaires assessing general quality of life (EuroQoL, EQ-5D, SF36), daily activities and motor performance (Fatigue Severity Score, R-PAct-Scale, Rotterdam and Bartel disability scale). Data were collected for three subsequent years. The PROM questionnaires were a good complement to the physician-recorded condition assessment, and on certain aspects only PROMs provided information (e.g. fatigue in excess of patients’ objective muscle weakness; deteriorating social activities despite stagnant physical abilities; significant individual differences in certain domains). The psychological effects of disease burden were also reflected in PROMs. In addition to medical examination and certain endpoints monitored by physicians, patient perspectives need to be taken into account when assessing the effectiveness of new, innovative treatments. With involvement of patients, information can be obtained that might remain uncovered during regular medical visits, although it is essential in determining the directions and priorities of clinical research. For all orphan medicines we emphasize to include patients in a compulsory manner to obtain general and disease-specific multidimensional outcome measures and use them as a quality indicator to monitor treatment effectiveness.]

Clinical Neuroscience

Cyanocobalamin and cholecalciferol synergistically improve functional and histopathological nerve healing in experimental rat model

ALBAY Cem, ADANIR Oktay, AKKALP Kahraman Asli, DOGAN Burcu Vasfiye, GULAEC Akif Mehmet, BEYTEMUR Ozan

Introduction - Peripheral nerve injury (PNI) is a frequent problem among young adults. Hopefully, regeneration can occur in PNI unlike central nervous system. If nerve cut is complete, gold standard treatment is surgery, but incomplete cuts have been tried to be treated by medicines. The aim of the study was to evaluate and compare clinical and histopathological outcomes of independent treatment of each of Vitamin B12 (B12) and Vitamin D3 (D3) and their combination on sciatic nerve injury in an experimental rat model. Materials and methods - Experimental animal study was performed after the approval of BEH Ethics Committee No. 2015/10. 32 rats were grouped into four (n=8) according to treatment procedures, such as Group 1 (controls with no treatment), Group 2 (intraperitoneal 1 mg/kg/day B12), Group 3 (oral 3500 IU/kg/week D3), Group 4 (intraperitoneal 1 mg/kg/day B12+ oral 3500 IU/kg/week D3). Sciatic Functional Index (SFI) and histopathological analysis were performed. Results - SFIs of Group 2, 3, 4 were statistically significantly higher than controls. Group 2 and 3 were statistically not different, however Group 4 was statistically significantly higher than others according to SFI. Axonal degeneration (AD) in all treatment groups were statistically significantly lower than in Group 1. AD in Group 4 was significantly lower than in Group 2 and 3; there was no significant difference between Group 2 and 3. There was no significant difference between Group 1,2 and 3 in Axonolysis (A). But A of Group 4 was significantly very much lower than all others. Oedema- inflammation (OE-I) in all treatment groups were significantly lower than in Group 1; there was no significant difference between Group 2 and group 4. OE-I in Group 2 and 4 were significantly lower than in Group 3. There were no significant differences between Group 1, 2 and 3 in damage level scores; score of Group 4 was significantly lower than of Group 1. Conclusions - B12 and D3 were found effective with no statistically significant difference. But combined use of B12 and D3 improve nerve healing synergistically. We recommend combined use of B12 and D3 after PNI as soon as possible.

Clinical Neuroscience

[Sleep habits among preschool- and schoolchildren]

FUSZ Katalin, RITECZ Bernadett, BALOGH Brigitta, TAKÁCS Krisztina, SOMLAI Eszter, RAPOSA L. Bence, OLÁH András

[Objective - Our aim is to evaluate sleep habits, sleep quality and influencing factors among preschool- and schoolchildren. Method - Two questionnaires were recorded. Questionnaire 1 dealt with sleeping habits, breastfeeding and health behavior of preschool children and infant, and it contained the abbreviated version of the Children’s Sleep Habits Questionnaire. Questionnaire 2 dealt with health behavior and the application of sleep hygiene rules, as well as it contained the Athens Insomnia Scale. Subjects - We assessed a total of 1063 questionnaires: 516 kindergarten children participated in our online survey across the country; 547 primary and secondary school students participated in the 2nd questionnaire survey in Szolnok. Results - Parents’ observation shows that the average nighttime sleeping time of kindergarten children is 10 hours 20 minutes on weekdays and 10 hours 36 minutes on weekends. The most popular sleeping habits in kindergarten age: teal reading (65.1%) and co-sleeping (42.8%). Parents of infants used breastfeeding (50.4%) and rocking (43.2%) most frequently before sleep. Co-sleeping has a positive influence on the length of lactation. Among the preschool sleeping habits we have proved a number of positive effects of teal reading, while watching television have negative effects. The sleep quality of school-age children according to the Athens Insomnia Scale is 6.11 points (SD: 4.11), 19% of the children are insomniac. Their sleep time is 7 hours 31 minutes on weekdays and 9 hours 30 minutes on weekends. The usage of good health behavior and sleep hygiene rules positively influence sleep quality and sleep duration. Conclusions - With our results, we would like to draw the attention of children and parents to the importance of sleeping and using sleep hygiene rules.]

Clinical Neuroscience

[Personalised epilepsy treatment]

ALTMANN Anna

[Epilepsy is one of the most common chronic neurological disease in childhood. Patients with epilepsy – even with so-called benign epilepsy – need medication for years. During this time, children go through a very big change, not only gaining weight and height, but also changing hormonal and metabolic processes. Maturation processes in different brain areas also take place at different rates depending on age. All of these should be considered when preparing a therapeutic plan. In everyday practice after the diagnosis of epilepsy, the applied drug is most often selected based on the shape and type of seizure. However, a number of other factors need to be considered when designing a therapeutic strategy: 1. efficacy (form of epilepsy, type of seizure), 2. age, gender, 3. pharmacological properties of the drug, 4. adverse drug reaction profile, 5. lifestyle (community), figure (skinny, corpulent, obese), 6. other comorbidities (nutrition, behavioral and learning problems, circulatory disorders, kidney or liver disease), 7. expected interactions with other drugs already used, 8. genetics, 9. other aspects (drug registration and prescription rules). The purpose of this article is to help to decide which antiepileptic drugs are expected to have the least side effects in a particular child with different comorbidities and which medications should be avoided if possible.]