Lege Artis Medicinae

[The Mental Eyes of the Anatomist – Beáta Szabó’s Exhibition “The Wounds of Light, the Anatomy of Colours” in the Semmelweis Museum of Medical History ]

CZIGLÉNYI Boglárka

MAY 02, 2018

Lege Artis Medicinae - 2018;28(03)

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Lege Artis Medicinae

[The role of acupuncturists’ qualifications in randomized controlled trials of acupuncture]

ORAVECZ Márk, MÉSZÁROS Judit, YU Funian, HORVÁTH Ildikó

[BACKGROUND - Randomized controlled trials (RCT) of acupuncture show heterogeneity in several ways. Acupuncture interventions used for the same conditions are greatly variable and so are study designs. METHOD - We evaluated the most frequently cited randomized controlled trials of acupuncture based on traditional Chinese medicine by examining practitioner background using elements of the “STandards for Reporting Interventions in Clinical Trials of Acupuncture”. The extracted data was compared with international guidelines and standards of traditional Chinese medicine and acupuncture education. RESULTS - We identified 5 heterogenous educational systems with contact training hours ranging from 120 to 3000. The educational criteria set by 93.75% of the reviewed trials did not meet the standards of the World Health Organization guidelines for acupuncture education or the World Federation of Chinese Medicine Societies standard for Chinese medicine education. Education in traditional Chinese acupuncture is internationally heterogeneous and this heterogeneity was found to be underreported in 87.5% of these trials, not provided for in study design. DISCUSSION - The generalizability and external validity of the reviewed trials may be questioned regarding the participating practitioners’ training background. In the future, a similar evaluation of systematic reviews could help further elucidate the issue of educational heterogeneity in traditional Chinese medicine acupuncture trials.]

Lege Artis Medicinae

[The present and future of hypertension-care in Hungary]

SZEGEDI János, KÉKES Ede, KISS István

[Hypertension is a population disorder of a kind that basically affects the health status, morbidity, mortality, quality of life of the population. The decrease complications its prevalence is favorably influenced by the correct treatment -defined by guidelines-, effective care, reaching and its sustained maintenance of target blood pressure, successful patient-physician co-operation. The importance of cooperation between the patient- physician- assistants- pharmacist is emphasized by numerous international organizations. The general quality of the health care system, the extensive use of the unified information system and the modern tools of telemedicine are increasingly important. The degree of drug adherence is also extremely important. According to our own experience, 40% of patients did not take the prescribed drugs in the second to third months of therapy. The Home Blood Pressure Measurement, Blood Pressure Monitoring as well as the patient education and drug revenue check mediated by smartphones, increase adherence. Real progress would mean that, like the care of heart failure, hypertension outpatients clinic (within the university centers, and the hospital departments of the county) would provide the therapeutic controll and care of the hypertensive patients.]

Lege Artis Medicinae

[Therapy and examination of generalized anxiety disorder in general practitioner practice]

BECZE Ádám, HARGITTAY Csenge, KALABAY László, TORZSA Péter

[Anxiety disorders are the most common psychiatric conditions in primary care, but still the ratio of treated patients is low. Clinically significant anxiousness decreases work efficacy and quality of life, it can cause and often goes with somatic and other psychiatric comorbidities. Patients with anxiety disorders usually undergo many diagnostic tests and interventions turning out negative on all levels of the health system. The general practitioner has a significant role in diagnosing and assessing anxiety disorders, based on a focused history, tests for differential diagnosis and questionnaire screening tools. The generalised anxiety disorder (GAD) is highly prevalent in primary care, appr. 8- 10%, 2-4 times frequent in women. Treat - ment is complex, evidence-based methods are available as certain lifestyle modifications, psychotherapy and pharmacotherapy. A regular consultation with a psychiatrist colleague can improve the chronic care of patients with anxiety disorders.]

Lege Artis Medicinae

[‘Bánk Bán’, our National Opera – Historical Background, Preceding Works, Variants ]

WINKLER Gábor

Lege Artis Medicinae

[The realization of public health strategies and health-screening in the light of the results of the “comprehensive health screening of Hungary 2010-2017” program]

KISS István, BARNA István, DAIKI Tenno, DANKOVICS Gergely, KÉKES Ede

[The European Healthcare Consumer Index (EHCI) 2017 of Hungary is critically low. Hungarian’s EHCI evaulation are particularly bad in obesity, in nutrition and in physical activity. The ”Comprehensive Health Screening of Hungary 2010-2020" (MÁESZ), has been designed for 10 years, and the first eight years can be considered succesfull. In 2017, 23 931 people participated in a comprehensive screening test, which results 183 655 individuals over the eight years. In this paper, the authors summarize the main achievements of 2017 of MÁESZ. The eight years of the program has been demonstrating the lack of health-conscious behavior, and the deficiencies of health care in Hungary. ]

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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.

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

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery

ONDER Burcu, KELES Yavuz Betul

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.

Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

Clinical Neuroscience

Delirium due to the use of topical cyclopentolate hydrochloride

MAHMUT Atum, ERKAN Çelik, GÜRSOY Alagöz

Introduction - Our aim is to present a rare case where a child had delirium manifestation after instillation of cyclopentolate. Case presentation - A 7-year old patient was seen in our outpatient clinic, and cyclopentolate was dropped three times at 10 minutes intervals in both eyes. The patient suddenly developed behavioral disorders along with gait disturbance, and complained of visual hallucinations 20-25 minutes after the last drop. The patient was transferred to intensive care unit and 0.02 mg/kg IV. physostigmine was administered. The patient improved after minutes of onset of physostigmine, and was discharged with total recovery after 30 minutes. Conclusion - Delirium is a rare systemic side effect of cyclopentolate. The specific antidote is physostigmine, which can be used in severely agitated patients who are not responding to other therapies.