[THE PROSPECTS OF SURGICAL TREATMENT OF END-STAGE EMPHYSEMA (COPD): THE LUNG VOLUME REDUCTION SURGERY]
KECSKÉS László
APRIL 21, 2004
Lege Artis Medicinae - 2004;14(04)
KECSKÉS László
APRIL 21, 2004
Lege Artis Medicinae - 2004;14(04)
[On the basis of relevant international literature the author presents the indications, contraindications, risks and results of the lung volume reduction surgery applicable in cases of therapyresistant end-stage COPD. These interventions, which require strong interdisciplinary cooperation of a pneumonologist, a thoracic surgeon, an anaesthesiologist and a physiotherapeutist were introduced in 1995 as a result of Cooper's study. A multicentric prospective study analysed the efficiency of this new surgical procedure. The results were evaluated in 2003 and it is important to be emphasised that in short term (3-6 months) and medium term (2-4 years) an improvement of lung function and of the quality of life can be observed in those patients who have heterogeneous emphysema, mainly in the upper lobe. Also, in case of homogenous emphysema this surgical procedure can be effective but perioperative mortality is higher and a deterioration in the health-state can occur as soon as six month after the intervention. The follow-up analyses of COPD patients with alpha- 1 antitrypsin deficiency show similarly moderate results. In Szombathely, Hungary 67 such interventions were carried out on 55 patients between 1997 and 2002, with a 4.4 % mortality rate which corresponds the international standard. Our own experience also supports the fact that in short and medium term the FEV1, RV, paO2, paCO2 and the quality of life take a positive change, the continuous O2-demand of patients will cease to exist and they regain parts of the former activity. The LVRS bears remarkable cost due to the use of staplers and surgical materials as well as longer hospital stay with the need of intensive care unit. Today in Hungary the LVRS is a realistic alternative in case of severe COPD to lung transplantation. The cost of an LVRS is maximum 10% of a lung transplantation. Patients having undergone an LVRS as well as patients unacceptable for LVRS may be suitable for lung transplantation.]
Lege Artis Medicinae
Lege Artis Medicinae
[Dendritic cells represent important components of the innate and adaptive immune responses. Human dendritic cells can be divided into two major subsets: myeloid and plasmacytoid (lymphoid) dendritic cells. The unique function of the dendritic cells is to capture antigens, present and to activate the antigenic peptides to the T lymphocytes. Dendritic cells go through a maturation process both in vitro and in vivo. By the use of pathogenrecognition- receptors the immature dendritic cells sense diverse pathogens or their various components, or cellular factors produced by the infected neighboring non-dendritic cells, and maturation signals are transduced for the dendritic cells. The heterogeneity of the pathogen-recognition-receptors and the microbial stimuli initiate a broad range of interactions between dendritic cells and infectious agents. Dendritic cells infected with certain viruses produce only a few infectious particles, but express and present viral antigens to T lymphocytes and immune response is initiated (influenza virus). Dendritic cells infected with certain pathogens not only initiate immune response but also disseminate the pathogen (human immunodeficiency virus, Mycobacterium tuberculosis). Some pathogens are killed in the dendritic cells, but the antigens are presented to the T cells, and immune responses are induced (Chlamydia trachomatis and Chlamydia psittaci). Dendritic cells capture antigens produced by infected neighbouring cells and present them to T lymphocytes, thus immune response is initiated (human cyto-megalovirus, herpes simplex virus). Dendritic cells are responsible for virus-induced immunosupp-ression; dendritic cells infected with certain pathogens form syncytia with T cells, thereby contribute to the suppression of T cell functions directed against opportunistic infections (measles virus). Dendritic cells can present not only foreign antigens but also self-antigens and when immature dendritic cells become mature upon exposure to inflammatory processes or to pathogens capable of activating them they can induce autoimmunity.]
Lege Artis Medicinae
[The widespread application of the LMW heparins promoted the prevention and therapy of the thromboembolic diseases in Hungary. Their propagation is mainly due to their simple clinical application and the active promotion of the producing pharmaceutical companies. However, the recommended “unnecessary” (in the reality the lack of) laboratory control may cause severe complications (bleeding, thromboembolism etc.) sometimes especially at the therapeutic application. For this reason, unfractionated (UF) heparin is advised in case of acute deep vein thrombosis when a patient is in the particular danger of bleeding because of its better controllability and the opportunity to stop anticoagulation immediately. In recent years, the indication of the long-term anticoagulation therapy expanded significantly. The number of patients is ever growing who need continuous anticoagulation because of atrial fibrillation or venous thromboembolic episode taken place earlier. Large randomised multicenter trials proved the efficacy of prolonged coumarin therapy in the prevention of recurrence of thromboembolic episodes in these diseases. Due to its advantageous pharmacological characteristics warfarin is especially suitable for the attainment of continuous anticoagulation. The direct thrombin inhibitor melagatran (and its orally applicable form, ximelagatran) may open a new era in the prophylaxis and therapy of the thromboembolic diseases. Its advantageous pharmacological characteristics and its simple application may make them to the antithrombotics of the future in case of a reasonable price and/or subsidisation.]
Lege Artis Medicinae
[Stroke is a highly prevalent disorder worldwide; it is the third main cause of death and the leading cause of severe disability. Recent data showed that 72-86% of cerebrovascular disorders are of ischaemic type. Arterial hypertension is the most prevalent risk factor for both haemorrhagic and ischaemic stroke, it is present in approximately 70% of cases. All forms of hypertension, isolated systolic or diastolic and combined hypertension increase stroke risk about 3-4 times and the relationship with systolic blood pressure may even be stronger than with diastolic blood pressure. Hypertension is very common after acute stroke. In this phase the cerebral autoregulation is disturbed in the region of focal brain ischaemia or haemorrhage such that cerebral blood flow is directly dependent on systemic blood pressure. It is therefore essential to avoid systemic hypotension in acute stroke patients and the reduction of high blood pressure may lower cerebral blood flow in the ischemic penumbra. Evidence from clinical data shows that control of blood pressure leads to lower risk of first or reccurent stroke and patients have shown beneficial effects especially of ACE inhibitors and diuretics. In the PROGRESS study both hypertensive and non-hypertensive cerebrovascular patients benefited from antihypertensive therapy. Previous results suggests that there may be additional beneficial effects of the ACEinhibitor therapy not related to blood pressure lowering in the prevention of stroke.]
Clinical Neuroscience
[Background - The deleterious effect of primary headaches on the sufferers’ quality of life (QOL) has been abundantly documented using both generic and headache-specific instruments. The currently used questionnaires focus on a limited number of factors and therefore may not be sensitive enough to detect the effect of headache type and headache characteristics on QOL, despite the obvious clinical differences. We have devised a comprehensive questionnaire that may be more sensitive to the burden of headache. Objective - To assess the psychometric properties of the new questionnaire on a group of migraineurs. Patients and method - We studied 117 migraineurs who completed the validated Hungarian version of the SF-36 generic QOL measure and our new, 25-item questionnaire. Reliability was assessed by internal consistency, measured by Cronbach’s a of all items. Content validity was exam- ined by calculating the correlation of the items with subscales of the SF-36 measure. The correlation of the patients’ migraine characteristics with the questionnaire’s items was used to assess criterion validity. Results - The questionnaire was quick and easy to administer. The questionnaire demonstrated good reliability, with Cronbach’s alpha being 0.893. Content validity was adequate; most “physical” items of the new questionnaire showed significant correlations with the bodily pain and role physical SF-36 subscales and most “psychical” and “social” items were correlated with mental health and social functioning SF-36 subscales. Criterion validity was adequate, with headache severity being correlated with most of the items. Discussion - In this study the new headache-specific quality of life instrument showed adequate psychometric properties.]
Clinical Neuroscience
[Background – The recently published “EarlyStim” study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson’s disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. Methods – We reviewed the data of 39 young (<60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job (“Job+” group, n=15) and retired patients (without active job, “Job-” group, n=24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. Results – As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p<0.01, McNemar test). Conclusion – Although our retrospective study has several limitations, our results fit well with the conclusions of “EarlyStim” study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.]
Lege Artis Medicinae
[The authors are focusing on a special type of long term psychiatric care taking place in Hungary outside of the conventional mental health care system, by introducing some institutional aspects of the not well known world of so called social homes for psychiatric patients (asylums). After reviewing several caracteristics of institutional development of psychiatric care in Hungary based on selected Hungarian and international historical sources, the main structural data of present Hungarian institutional capacities of psychiatric health and social care services are shown. Finally, the authors based on own personal experiences describe several functional ascpects of the largest existing asylum in EU, a social home for long term care of psychiatric patients. By the beginning of the 20th century, Hungarian psychiatric institutions were operating on an infrastructure of three large mental hospitals standing alone and several psychiatric wards incorporated into hospitals. Nevertheless, at the very first session of the Psychiatrists’ Conference held in 1900 many professionals gave warning: mental institutions were overcrowded and the quality of care provided in psychiatric hospital wards, many of which located in the countryside of Hungary, in most cases was far from what would have been professionally acceptable. The solution was seen in the building of new independent mental hospitals and the introduction of a family nursing institution already established in Western Europe; only the latter measure was implemented in the first half of the 20th century but with great success. However, as a result of the socio-political-economic-ideological turn following the Second World War, the institution of family nursing was dismantled while different types of psychiatric care facilities were developed, such as institutionalised hospital and outpatient care. In the meantime, a new type of institution emerged in the 1950s: the social home for psychiatric patients, which provided care for approximately the same number of chronic psychiatric patients nationwide as the number of functioning hospital beds for acute psychiatric patients. This have not changed significantly since, while social homes for psychiatric patients are perhaps less visible to the professional and lay public nowadays, altough their operational conditions are deteriorating of late years. Data show, that for historical reasons the current system of inpatient psychiatric care is proportionately arranged between health care and social care institutions; each covering one third. Further research is needed to fully explore and understand the current challenges that the system of psychiatric care social- and health care institutions are facing. An in-depth analysis would significantly contribute to the comprehensive improvement of the quality of services and the quality of lives of patients, their relatives and the health- and social care professionals who support them. ]
Clinical Neuroscience
[Introduction - Cluster headache (CH), which affects 0.1% of the population, is one of the most painful human conditions: despite adequate treatment, the frequent and severe headaches cause a significant burden to the patients. According to a small number of previous studies, CH has a serious negative effect on the sufferers’ quality of life (QOL). In the current study, we set out to examine the quality of life of the CH patients attending our outpatient service between 2013 and 2016, using generic and headache-specific QOL instruments. Methods - A total of 42 CH patients (16 females and 26 males; mean age: 39.1±13.5 years) completed the SF-36 generic QOL questionnaire and the headache- specific CHQQ questionnaire (Comprehensive Headache- related Quality of life Questionnaire), during the active phase of their headache. Their data were compared to those of patients suffering from chronic tension type headache (CTH) and to data obtained from controls not suffering from significant forms of headache, using Kruskal-Wallis tests. Results - During the active phase of the CH, the patients’ generic QOL was significantly worse than that of normal controls in four of the 8 domains of the SF-36 instrument. Apart from a significantly worse result in the ‘Bodily pain’ SF-36 domain, there were no significant differences between the CH patients’ and the CTH patients’ results. All the dimensions and the total score of the headache-specific CHQQ instrument showed significantly worse QOL in the CH group than in the CTH group or in the control group. Conclusion - Cluster headache has a significant negative effect on the quality of life. The decrease of QOL experienced by the patients was better reflected by the headache-specific CHQQ instrument than by the generic SF-36 instrument. ]
Clinical Neuroscience
[Background - Bilateral pallidal deep brain stimulation (DBS) is an established treatment option for primary generalized and segmental dystonia. In the present study we evaluated the results of our dystonia patients treated by DBS. Methods - The surgical results of forty consecutive dystonia patients underwent DBS implantation were analyzed (age: 43.7±17.7 years; sex: 22 men; etiology: 24 primary and 16 secondary dystonia; topography: 24 generalized, 12 segmental and four hemidystonia; disease duration: 16.1±9.3 years). Severity of dystonia measured by Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and health-related quality of life measured by EQ-5D scale were obtained preoperatively and compared to the scores obtained at postoperative six months and subsequent yearly follow-ups. The average follow-up lasted 2.5 years (median, 0.5-8 years). In all cases the BFMDRS scores were re-evaluated by a rater blinded to the treatment. Treatment responsiveness was defined as an at least 25% improvement on the BFMDRS scores. Non-parametric Mann-Whitney, McNemar and Kruskal-Wallis tests were applied to test statistical significance. Results - Severity of dystonia improved from 31 to 10 points (median, 68% improvement, p<0.01) in the primary dystonia group, whereas in secondary dystonia these changes were statistically insignificant (improvement from 40 to 31.5 points, 21.2%, p>0.05). However, the health-related quality of life significantly improved in both groups (primary dystonia: 0.378 vs. 0.788 and secondary dystonia: 0.110 vs. 0.388, p<0.01). Significantly more patients in the primary dystonia group responded to DBS treatment than those in the secondary dystonia group (83.3% vs. 37.5%, p<0.01). Conclusion - Our results are in accordance with previously published international findings demonstrating that DBS is a highly effective and long-lasting treatment option for primary dystonia. DBS is considerably less efficient in secondary dystonia; however, it still has a high impact on the quality of life presumably due to its pain-relieving effect.]
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Clinical Neuroscience
Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease3.
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Clinical Neuroscience
Cases of inborn errors of metabolism diagnosed in children with autism2.
Clinical Neuroscience
[The first Hungarian patient with Guillain-Barre syndrome after COVID-19]3.
Clinical Neuroscience
Retinal morphological changes during the two years of follow-up in Parkinson’s disease4.
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