Lege Artis Medicinae

[The Newcastle University medical education system]

PETŐ Zoltán, PETŐ Tünde

JULY 27, 1994

Lege Artis Medicinae - 1994;4(07)

[In November 1993, I was invited to join the Institutes of Psychiatry, Neuropsychiatric Rehabilitation, Medical Biochemistry and Health Sciences at Newcastle University Medical School. In addition to all these university institutes, I was able to visit several medical rehabilitation centres, a social welfare centre, a social welfare institute, self-help clubs and a medical library. It was only during my visits that the strategic importance of education, which is fundamentally different from any other university education system I have ever known, became clear to me. ]

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[The authors summarize the relevant ultrasonic findings in case of suspected fetal chromosomal aberration. Some of these signs are detectable during routine ultrasonic screening examinations. In high-risk cases, prenatal chromosomal analysis is recommended. The following ultrasonic findings indicate a situation of high risk: disturbances of the lymphatic and amniotic fluids (e.g. hydrops, hygroma colli, polyhydramnios, nuchal edema), certain skull and brain alternations, abnormalities of the thorax and abdomen, and „minor” findings such as a single umbilical artery, choroid plexus cyst, pyelectasy, or changes in the size or shape of the long tubular bones, if these signs are accompanied by other anomalies or growth retardation.]

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[Advantages and limits of the open tube and flexible esophagoscopes]

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[The two types of endoscopes presently available for examination and treatment of the esophagus are the traditional open tube esophagoscope and the flexible endoscope. Despite the many advantages offered by the flexible endoscope, its limitations should not be forgotten. The open tube esophagoscope should not be thought of as out-of-date, since its new variations have important therapeutic applications. The authors examine the advantages and disadvantages of the two types of esophagoscopes as discussed in the literature. ]

Lege Artis Medicinae

[An update on obstructive sleep apnea]

METES Ágnes, HIRSCHBERG Andor

[Obstructive sleep apnea, which occurs in approximately 2% of the adult population, is the more common of the two major forms of sleep apnea. The conse quences and dangers of excessive daytime sleepiness are emphasized along with the other well-known characteristics of sleep apnea syndrome. Both the decreased upper airway muscle tone during sleep and the negative pressure due to breathing through the obstructed airways may cause upper air ways to collapse. The history has a very important role in the clinical assessment, while the role of the physical examination is limited. An exact and reliable diagnosis may be arrived at through laboratory evaluation, e. g. polysomnography (PSG), Multiple Sleep Latency Test (MSLT), or radiologic examinations. Among conservative treatments, reduction of the body weight is usually effective in mild to moderate cases. In severe apneas, nasal continuous positive airway pressure (nCPAP) is the current treatment of choice. The efficacy of surgical intervention is still controversial. According to most authors, uvulopalatopharyngoplasty (UPPP) has a 50% success rate. Most recently good results have been obtained with maxillo-facial surgery in a variety of selected patients. ]

Lege Artis Medicinae

[Electrophysiologic study versus electrocardiographic monitoring]

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Lege Artis Medicinae

[The role of echocardiography in the management of ventricular free wall rupture ]

PÁL Mátyás, LENGYEL Mária

[Our goal was to evaluate which diagnostic and therapeutic approaches could provide a better chance of survival. Between January 1, 1987, and December 7, 1992, 772 patients with acute myocardial infarction were treated in the Hungarian Institute of Cardiology. Cardiac rupture was investigated by the retrospective analysis of clinical data, electrome chanical dissociation, echocardiographic signs and autopsy findings. Ventricular free wall rupture was found in 28 cases. The diagnosis was confirmed by autopsy in 23, by intraoperative findings in 4 cases, and by echocardiography and pericardiocentesis in 1 case. Pericardial effusion was detected in 12 of 14 cases undergoing emergency echocardiography. Seven of these had pericardiocentesis and 2 patients underwent surgical pericardial fenestration. Following this 4 patients were referred to surgery. All 4 patients died: 2 during and 2 shortly after operation. The bleeding stopped in 1 case, after pericardiocen tesis and continous drainage and during the 12 month follow-up the patient is alive and well. In acute myocardial infarction, electromechanical dissociation or signs of tamponade are indications for emergency echocardiography, and if pericardial effusion can be visualized, pericardiocentesis should be performed. This can lead to a temporary haemodynamic improvement, providing sufficient time for emergency surgery.]

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We aimed to investigate the association between fluoxetine use and the survival of hospitalised coronavirus disease (COVID-19) pneumonia patients. This retrospective case-control study used data extracted from the medical records of adult patients hospitalised with moderate or severe COVID-19 pneumonia at the Uzsoki Teaching Hospital of the Semmelweis University in Budapest, Hungary between 17 March and 22 April 2021. As a part of standard medical treatment, patients received anti-COVID-19 therapies as favipiravir, remdesivir, baricitinib or a combination of these drugs; and 110 of them received 20 mg fluoxetine capsules once daily as an adjuvant medication. Multivariable logistic regression was used to evaluate the association between fluoxetine use and mortality. For excluding a fluoxetine-selection bias potentially influencing our results, we compared baseline prognostic markers in the two groups treated versus not treated with fluoxetine. Out of the 269 participants, 205 (76.2%) survived and 64 (23.8%) died between days 2 and 28 after hospitalisation. Greater age (OR [95% CI] 1.08 [1.05–1.11], p<0.001), radiographic severity based on chest X-ray (OR [95% CI] 2.03 [1.27–3.25], p=0.003) and higher score of shortened National Early Warning Score (sNEWS) (OR [95% CI] 1.20 [1.01-1.43], p=0.04) were associated with higher mortality. Fluoxetine use was associated with an important (70%) decrease of mortality (OR [95% CI] 0.33 [0.16–0.68], p=0.002) compared to the non-fluoxetine group. Age, gender, LDH, CRP, and D-dimer levels, sNEWS, Chest X-ray score did not show statistical difference between the fluoxetine and non-fluoxetine groups supporting the reliability of our finding. Provisional to confirmation in randomised controlled studies, fluoxetine may be a potent treatment increasing the survival for COVID-19 pneumonia.

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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

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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.

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Lege Artis Medicinae

[LAM 30: 1990–2020. Facing the mirror: Three decades of LAM, the Hungarian medicine and health care system]

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

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[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.]