Lege Artis Medicinae

[The principle of "informed consent" to medical interventions in modern medical ethics Part II]

KOVÁCS József

JULY 28, 1993

Lege Artis Medicinae - 1993;3(07)

[A patient who is of age and has capacity has the right to refuse any medical intervention or treatment. However, in Hungary, an exception to this rule is made for interventions necessary to prevent imminent danger to life, for which the patient's consent is not required. This exception is not generally recognised in the Anglo-Saxon legal system.]

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Lege Artis Medicinae

[Features of chronic alcoholic liver and pancreatic diseases]

NEMESÁNSZKY Elemér, DÖNGÖLŐ László

[The most common organ pathologies caused by alcohol abuse are chronic liver disorders and chronic pancreatitis. The incidence of these diseases has not yet been fully established but both are considered to be widespread in Hungary. Since there are forms which frequently occur without symptoms, clinicians might have difficulties in recognizing them. The diagnosis should be based on the results of laboratory screening tests and the findings of the physical examination. A variety of specific and functional tests should be performed. Morphologic damage of the organ can be assessed by analysing the tissuesample obtained by biopsy. In the course of the disease progression, well characterised clinical entities (syndromes) develop. Features of the most advanced stage are as follows: fibrosis of the gland causing functional insufficiency which manifests itself in marked laboratory and clinical alterations.]

Lege Artis Medicinae

[Bronchological possibilities to treat the main airway stenosis]

STRAUSZ János, BÖLCSKEI Pál

[The review summerizes the recent broncholo gical possibilities to treat the main airway stenosis. The most of the patient have inoperable central endobronchial or endotracheal tumor. However these methods are of considerable palliativ value for recanalization of the main airway and these way for amelioration of the quality of life. The three methods: the LASER phototherapy, the afterloading irradiation and the stent implantation can be available yet in Hungary. ]

Lege Artis Medicinae

[Antineutrophil cytoplasmic autoantibodies and their pathogenic and diagnostic role in different diseases]

SZŰCS Gabriella, SZEGEDI Gyula

[Antineutrophil cytoplasmic autoantibodies (ANCAs) are found in the circulation of patients with systemic vasculitic syndromes, including Wegener's granulomatosis, polyarteritis nodosa, Churg-Strauss syndrome, and other disorders within the spectrum of autoimmune diseases. ANCAs have specificity for different proteins in the cytoplasmic granules of neutrophils. Two major patterns of ANCA staining are observed by indirect immunofluorescence as say: cytoplasmic (C-ANCA) and perinuclear (P-ANCA). There is in vitro evidence that antineutrophil cytoplasmic autoantibodies are directly involved in the pathogenesis of antineutrophil cytoplasmic autoantibody-as sociated vasculitides. Antineutrophil cytoplasmic autoantibody titers may be useful in modulating treatment regimens.]

Lege Artis Medicinae

[Cutaneous symptoms and reactive arthritis in giardia lamblia infection]

RIESZ Tamás, VÁLYI-NAGY István, TEMESVÁRI Erzsébet, WINKLER Valéria, KASZÁS Ilona

[ The authors discuss reactive arthritis and cutaneous symptoms as two infrequent complications of giardiasis. The incidence of reactive arthritis and cutaneous symptoms in 569 patients with giardiasis with simultaneous characte risticbiliary and gastrointestinal manifestation was investigated. In the majority of cases, parasitic infection was detected from fresh (warm) bile or, in a smaller proportion of patients, from fresh stool. Nine patients presented with reactive arthritis, 59 with chronic urticaria, 17 with rosacea, 8 with prurigo nodularis, and 2 with erythema nodosum. In all cases, initial therapy consisted of metroni dazol (Klion), using a daily dose of 0.75-1.5 g for 10–15 days. Only those patients whose symptoms were eliminated or substantially diminished and whose duodenal aspirate and stool was devoid of the parasite one month following treatment were considered cured. Sixty seven patients remained Giardia positive after metronidazol treatment. A detailed description of the curative therapeutic combinations in the cases of 64 patients is presented in the paper. Despite repetitive and combination therapy, three patients remained Giardia positive and continued to present with the symptoms of the parasitic disease. The authors emphasize that in patients having cutaneous allergic symptoms, reactive arthritis, or erythema nodosum with simultaneous gastrointestinal symptoms (even of the gastroin testinal symptoms are mild or absent), biliary or gastrointestinal Giardia infection must be considered. ]

Lege Artis Medicinae

[Color doppler imaging of the eye and orbit]

BARTA Miklós, DANIEL A Merton , BARRY B Goldberg, ROBERTA M Sandy

[Color Doppler Imaging (CDI) has added new dimension to orbital sonography. The indications of this method are basically the vascular and neoplastic diseases of the eye and orbit. After demonstrating the scan technique and normal findings the authors present some pathologic entities, such as reversed flow in ophthalmic artery as a result of occlusion of the internal carotid artery, lack of blood flow in central retinal artery in another ocular ischemic syndrome and the blood flow within a choroidal melanoma. The authors' experience reveals that CDI with pulsed Doppler spectral analysis is a promising new technique for the evaluation of vascular structures of the normal orbit as well as ocular and orbital vascular pathology.]

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Fluoxetine use is associated with improved survival of patients with COVID-19 pneumonia: A retrospective case-control study

NÉMETH Klára Zsófia, SZÛCS Anna , VITRAI József , JUHÁSZ Dóra , NÉMETH Pál János , HOLLÓ András

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.

Clinical Neuroscience

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

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

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.]

Lege Artis Medicinae

[A short chronicle of three decades ]

KAPRONCZAY Katalin

[Hungarian professional periodicals started quite late in European context. Their publish­ing, editing and editorial philosophy were equally influenced by specific historical and political situations. Certain breaking points of history resulted in termina­tion of professional journals (War of In­de­pendence 1848-1849, First and Se­cond World Wars), however there were pe­riods, which instigated the progress of sciences and founding of new scientific journals. Both trends were apparent in years after the fall of former Hungarian regime in 1990. The structure of book and journal publishing has changed substantially, some publishers fell “victim” others started successfully as well. The latters include the then-established publishing house Literatura Medica and its own scientific journal, Lege Artis Me­di­cinae (according to its subtitle: New Hun­garian Medical Herald) issued first in 1990. Its appearance enhanced significantly the medical press market. Its scientific publications compete with articles of the well-established domestic medical journals however its philosophy set brand-new trends on the market. Concerning the medical community, it takes on its problems and provides a forum for them. These problems are emerging questions in health care, economy and prevention, in close interrelation with system of public health institutions, infrastructure and situation of those providing individual health services. In all of them, Lege Artis Medicinae follows consequently the ideas of traditional social medicine.]