Lege Artis Medicinae

[The Scientific Rationale of Balneology]

VARGA Csaba, BENDER Tamás

APRIL 21, 2006

Lege Artis Medicinae - 2006;16(04)

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Lege Artis Medicinae

[COMETS]

MATOS Lajos

Lege Artis Medicinae

[The True Salieri]

MALINA János

Lege Artis Medicinae

[METABOLIC “X” SYNDROME: “XYNDROME” - POSITIONS AND OPPOSITIONS]

MATOS Lajos

[The idea of a constellation of abnormalities linked to insulin resistance as a key component was pioneered and summarized by Reaven in 1988 under the name of “X” syndrome. Based on the various elements of the syndrome, several synonyms have been proposed, including “deadly trio”, “deadly quartet”, “central fat syndrome”, “insulin resistance syndrome”. To avoid the confusion of this entity with “cardial X syndrome”, an established syndrome in cardiology, and instead of the rather long “metabolic X syndrome”, I have proposed the term “Xyndrome”. Irrespective of how it is called, this syndrome has come into the focus of clinical research; using the keyword “metabolic syndrome” to search in the index of the National Library of Medicine, 15.661 citations pop up, and in February 2006 only, 168 papers were published in this field. In spite of this, several international scientific organizations have recently claimed that metabolic syndrome has not been unambiguously defined, its diagnostic criteria are contradictory, and finally, the syndrome as an entity has no more value in predicting cardiovascular risk than the sum of its individual components has, therefore, the use of this notion in the clinical practice is not recommended. There are, however, opposing opinions emphasizing the importance of abdominal obesity - today considered to be most essential element -, data from recent research, and the didactic advantage that the use of this notion has improved complex treatment of its various components. It is crucial to understand that “syndrome” is not more - and not less, either - than a clustering of symptoms and findings, and should not be treated as a distinct disease. The emergence of the notion of metabolic syndrome, however, has been a step forward in the medical concept in that metabolic and cardiovascular diseases are now dealt with in a more complex way, which warrants the maintenance of this notion and the increase of our understanding by continuing research in this field.]

Lege Artis Medicinae

[Gastrointestinal bleeding in infancy and childhood - Recommendation of the College of Paediatrics]

ARATÓ András, VERES Gábor, DEZSŐFI Antal

Lege Artis Medicinae

[THE LONG ACTING INSULIN ANALOGUE DETEMIR IN THE DIABETOLOGICAL PRACTICE: EVIDENCE AND POTENTIALS]

TAMÁS GYULA, KERÉNYI ZSUZSA

[Insulin detemir is a neutral, soluble, long-acting insulin analogue in which the amino acid threonineB30 has been removed and the LysB29 acylated with a 14-carbon fatty acid. The fatty acid modification allows insulin detemir to dihexamerisate and reversibly bind to human albumin upon administration. This brand new principle (self association and albumin binding) ensures slow absorption and a prolonged and consistent metabolic effect without a marked peak for up to 24 hours in patients both with type 1 and type 2 diabetes mellitus. Results of large clinical trials have shown that detemir can be efficiently used as basal insulin, supplemented with human regular insulin or aspart insulin taken before the main meals, in both type 1 and type 2 diabetes. Available data clearly demonstrate that the use of this insulin is associated with decreased variability of the fasting blood glucose values. In some of the studies the risk of (mostly nocturnal) hypoglycaemic episodes also dropped. It is important to note that patients using insulin detemir gained less or no weight compared to the group of patients treated with neutral protamine Hagedorn (NPH) insulin. Evaluation of long-term and wide-spread application of detemir needs further observations. Such trials are being conducted worldwide.]

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NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

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[Background – Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose – To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods – Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results – There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology – including genetic background –, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion – Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions. ]

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SZUPERA Zoltán

Clinical Neuroscience

[Neurology! Adieau? (Part 1)]

SZIRMAI Imre

[The neurological practice suffered considerable changes during the last twenty years. The recent therapeutic methods and the acceptance of the ideology of evidence based medicine, which is based on confidence in statistics, changed the reasoning of the neurologists. Therapy protocols intrude into the field of individual medicine, and doctors accept treatment schemes to alleviate responsibility of their decisions. In contrast with this, recent achievements in pharmacogenetics emphasize the importance of individual drug therapies. The protocol of intravenous cerebral thrombolysis does not require defining the origin of cerebral ischaemia in the acute stage, therefore, this procedure can be regarded as human experiment. According to the strict protocol thrombolysis might be indicated only in 1-8% of patients with cerebral ischaemia. According to the Cohrane database more trials are needed to clarify which patients are most likely to benefit from treatment. Because of the change in therapeutic principles transient ischaemic attack has been newly defined as “acute neurovascular syndrome”. Multiplication of neurological subspecialties has been facilitated by the development of diagnostic tools and the discovery of effective new drugs. The specialization led to narrowing of interest and competency of clinicians. Several new neurological scientific societies were founded for the representation of specific disorders. In Hungary, between 1993 and 2000 nine scientific societies were grounded within the field of clinical neurology. These societies should be thankful to the pharmaceutical industries for their existence. In some European countries in 2007 only three neurological subspecialties were accepted, which are neurophysiology, neuro-rehabilitation and childneurology. Neuro-radiology is in the hands of general radiologists, the specialization is not granted for neurologists. Because of the subspecialization the general professionalism of neurologists has diminished. Among young neurologists the propedeutic skills suffered most seriously. Subspecialisation of teachers also interferes with the practice oriented teaching of medical students and residents.]

Hypertension and nephrology

[Training, Postgraduate Training and Scientific Activities in the B. Braun Avitum Dialysis Network]

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