Lege Artis Medicinae

[The Sixth Sense of China – Paintings of Qi Baishi ]

NAGY Zsuzsanna

JUNE 01, 2015

Lege Artis Medicinae - 2015;25(04-05)

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Lege Artis Medicinae

[Succesful 1,5 years long fulvestrant therapy in metastatic breast cancer]

MEZEI Klára, KÓRÓDINÉ Karászi Katalin

Lege Artis Medicinae

[Use of surgical checklists to improve the patient safety]

BENEDEK Zsófia, MOLNÁR-GALLATZ Zsolt

[In the millennium working groups were formed in several countries to create and implement control- or checklists to reduce the mortality rate and complications during surgical care. The research revealed that the use of checklists improved patient safety, reduced mortality and complication rate, and several additional positive effects were identified. The checklists improved teamwork and the communication in the surgery team. The starting financial and time costs of using checklist are low, and the maintaining costs are minimal. On the other hand, checklists result significant financial savings. These savings primarily are the costs of malpractice lawsuits and the costs of treatment complications. To ensure patient safety multiple checklists were developed. By the literature data three checklists are the most detailed and widely used: the World Health Organiza­tion’s checklist, the Universal Protocol and the Surgical Patient Safety System. Common characteristics are that they significantly reduce the complications and the mortality rate, improve patient safety, teamwork and communication. The main differences are in the using and timing. In this publication we present the most typical and used checklists, their advantages and possible disadvantages, and finally we give an overview of the examples of the Hungarian experience.]

Lege Artis Medicinae

[Role of roflumilast in chronic obstructive lung disease]

NAGY László Béla

[The phosphodiesterase 4 inhibitor roflumilast supresses the function of a range of inflammatory cells and mediators contributing in the pathogenesis of chronic obstructive lung disease (COPD). This article reviews the current status of roflumilast, focusing on the pharmacokinetics, efficacy and safety. Phase III clinical trials have demonstrated that roflumilast reduces exacerbation frequency with accompanying improvements in lung function. This effect appeared to be the greatest in the phenotypes of patients who have frequent acute exacerbations, or/and whose characteristic feature is chronic bronchitis. It can presumably also reduce systemic inflammation. Such effect has not been documented in COPD yet. It is generally well tolerated, but the most common adverse effects include diarrhea, nausea, and headaches. Roflumilast is a promising drug as a supplementary therapy when symptoms are not adequately controlled by conventional COPD therapy.]

Lege Artis Medicinae

[Survey on the dietary habits of children between the age of 4-10]

KISS-TÓTH Bernadett, BÍRÓ Lajos

[INTRODUCTION - The prevalence of overweightness and obesity among children is increasing in Hungary, while the inadequate or excessive intake of some nutrients is also representative. Keeping these inappropriate lifestyle habits in adulthood could significantly worsen the health status of the rising generation. METHOD - The sample is representative for the 4-10 year old children of Budapest and Kecskemét city. The dietary assessment was executed, using the internationally accepted 3 day dietary record method. Body mass index was also calculated from the measured body weight and height, creating BMI categories according to the Cole methodology. RESULTS - The ratio of overweightness and obesity resulted in 21% (19% for the 4-6 year old, 24% for the 7-10 year old), while 13% of them belonged to the underweight category. The nutritional problems, identified by adults, like the excessive fat intake, its inappropriate composition, the high sodium-, low calcium- and vitamin D intake already appears in the early stages of life. CONCLUSION - The results prove, that the education for healthy nutrition among children is in high priority, in which all stakeholders, like the parents, the governmental and non-governmental organisations, the educational institutes as well as the food industry plays an important role. ]

Lege Artis Medicinae

[Physician and Science 4. Medical Knowledge – As Seen from Mars ]

BÁNFALVI Attila

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Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Lege Artis Medicinae

[Donizetti's ailment: mood disorder, Barbaja, or luetic derailment?]

JANKA Zoltán, SZAKÁCS Réka

[The occurrence of specific forms of mood disorders is significantly higher among eminent creative persons, thus the talent and creative skills show some connections or may have common roots with mood swings. This phenomenon can be observed among composers as well. Our paper briefly summarizes several aspects of Gaetano Do­ni­zetti’s life (1797-1848), and some characteristic features of his operas. After his musical studies and initial successes Donizetti was hired by the opera impresario Domenico Bar­baja who pressed him under contract to write operas in a considerable number. Do­ni­zetti’s personal tragedy was that his wife and three children have died young. He composed more than 70 operas, wrote the librettos for some of them, had drawing skills, and a sense for theatre Gesamtkunst. His composing technique was incredibly fast, partly due to the external pressure (es­pecially by the impresario Barbaja). Beside the feverish speed (hypomania) he suffered of episodes with genuine fever, headache, and nausea. From 1845 onward full apathy, depression (occurred already earlier), and paralysis (progressiva?) developed hindering any creative power and meaningful interpersonal contact, so he was admitted to a closed mental facility. His illness was considered syphilis, but prevailing bipolar mood disorder may strongly be presumed today which is supported by early emerging creativity and hypomanic signs, transient mood swings, the composing technique, his multimodal talent, the abundance of his works (output of 3-4 operas a year), the vein (mood) streaming from the operas (’maddening scenes’ alongside lax and sparkling characters) and by certain circumstances (he was able to write opera buffas during his greatest personal tragedies). To all these com­ponents there can certainly be added an exogenous environmental pressure factor: Domenico Barbaja, the ’prince’ (and taskmaster) of opera impresarios. ]

Lege Artis Medicinae

[The impact of telemedicine on the development of doctor-patient relationship based on interviews conducted among physicians]

BÁN Attila

[Introduction - The doctor-patient relationship has always been an essential part of health care, however, in parallel with the integration infocommunication technologies in health care the doctor-patient communication is also transforming. Therefore, the aim of the study is to examine the effect of telemedicine on this relationship. Methods - During the study, we applied qualitative research methods and a total number of 58 semi-structured interviews (45 men, 13 women) were conducted among physicians having experience in telemedicine. The majority of the interviewees were radiologist, general practitioners, and internists. The interview questions concerned that what characterises the doctor-patient relationship in telemedicine. Results - The interviews pointed out that in teleradiology the doctor-patient relationship depersonalises and almost terminates. In this respect, the problem is often the incomplete clinical information about the patient. In turn, telemonitoring can bring a quality change in the doctor-patient communication and through remote contact the patients’ satisfaction, the sense of security, and the doctor-patient relationship will be further enhanced. Conclusions - In accordance with the academic literature - based on the research results - there is no clear evidence that telemedicine would affect doctor-patient communication only positively or only negatively. In some areas of telemedicine, this relationship is reducing (e.g. teleradiology) while in other areas it could be fur-ther strengthened (e.g. telemonitoring).]

Clinical Neuroscience

[Special concerns in medical care of severely demented patients suffering from Alzheimer disease]

RAJNA Péter

[While the expected life-time increases dementias will show a pandemic nature. Author analyses the special medical and social concerns of severe states of Alzheimer disease. Having introduced the epidemiologic, diagnostic data and forms of palliatíve therapies he concentrates on the hitherto unsolved problems of patients and caregivers. He belongs to the experts identifying the Alzheimer diseases as a forced aging process. Accepted the theory of L. Hayflick he evaluates the aging process in frame of an evolution model. He states that for aged human beings having already performed the task of reproduction further conditions of living circumstances and even that of death are no more programmed. This hypothesis may have a very negative content at the first sense. But the author rather considers the uncertainty of aging a positive message. He establishes that the occurrence of degenerative processes connecting the aging must be limited by preventive interventions far more efficient than the present possibilities. Concerning these steps we are still on the level of recommendations for preserving our general health and data of relevant science are quite contradictory. Although criteria of “healthy", “qualified” or “assumable” aging are getting defined, we still do not know exactly how we should live optimally and what should we do for this in different epochs of our life. Somatic and psychological parameters are lacking which would be able to signalize the actual level of the aging process in a given person. We, physicians, also do not have exact opinion on the level of severity of dementias at which the patient already lost his her features of personality and individuality on an irreversible way. We have no idea on the phase when the ratio of joy and suffer falls below the value of 1.0 because we still have no tool for its measure. The author pointed the necessity of acceptance of a new preventive attitude and application of new methods in the medical care of the forced or pathological aging, instead of the present approaches based on the “wait and treat” attitude. Because of the intensive increase of the patient population the identification and care of patients can be efficient with a much more involvement of the basic medical network. Financial background can be improved by new theoretical bases of criteria of the palliative treatments. But the direct professional programs can be planned after solution of the existing moral and social dilemmas.]

Hypertension and nephrology

[Covid-19 and the kidney]

PATÓ Éva, DEÁK György

[Covid-19 pandemy has emerged from Wuhan, China in December 2019. The infection affects not only the lung but other organs such as the kidney, as well. The relation between Covid-19 infection and the kidney is bidirectional. On one hand, Covid-19 infection may cause kidney damage in 50-75% of the cases resulting in proteinuria, haematuria and acute kidney injury (AKI). The etiology of AKI is multifactorial. Main pathogenic mechanisms are direct proximal tubular cell damage, sepsis-related haemodinamic derangement, citokine storm and hypercoagulability. The virus enters proximal tubular cells and podocytes via the ACE2 receptor followed by multiplication in the lysomes and consequential cell lesion. Histopathology shows acute tubular necrosis and acute tubulointerstitial nephritis. AKI is a strong predictor of mortality in critically ill patients. On the other hand, the risk of Covid-19 infection and mortality is substantially increased in patients with chronic kidney disease – especially in those with a kidney transplant or on dialysis – due to their immunocompromised status. Among haemodialysis patients, infection may spread very easily due to the possibility of getting contacted in the ambulance car or at the dialysis unit. The mortality rate of patients on renal replacement therapy with Covid-19 infection is 20-35%. In order to avoid mass infection it is obligatory to employ preventive measures and implement restricions along with (cohors) isolation of infected patients. In Hungary, every dialysis or kidney transplant patient with Covid-19 infection should be admitted to dedicated Covid-19 wards.]