Lege Artis Medicinae

[Treatment of gallstone disease]

MAY 27, 1992

Lege Artis Medicinae - 1992;2(05)

[Cholecystectomy is the most common operation performed in surgical departments in Hungary. In Hungary, 17,000 cholecystectomies are performed every year. The mortality of the operation without opening the bile ducts is 0.4 - 0.7%.]



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Lege Artis Medicinae

[Treatment of endodermal thyroid cancers]

ÉSIK Olga, NÉMETH György

[Following staging procedures, differentiated thyroid cancers i. e. papillary and follicular carcinomas, are surgically treated with intra- or extracapsular total thyroidectomy (depending on the anatomical extent of the disease) and selective lymphnode dissection. Postoperative complementary use of adjuvant external and systemic radiotherapy is the general practice. External irradiation decreases local/regional relapses in all cases. Radioiodine treatment decreases local/regional/ distant recurrences in cases of tumour cells capable of iodine uptake. Life-long thyroxine medication is required, with a TSH-suppressive dose for relapse prevention and hormone substitution. This treatment regimen, a careful follow-up, and adequate rescue therapy are the prerequisites of the generally excellent patient prognosis, i. e. a survival probability measurable in decades. In anaplastic carcinoma following extracapsular total thyroidectomy and lymph node dissection, external irradiation is always indicated. Chemotherapy has a benefical effect on survival. Hormone replacement therapy is necessary to substitute for the missing metabolic effect of the thyroid. This combined modality treatment leads to some improvement with regard to the prognosis of this poor-risk type of cancer. ]

Lege Artis Medicinae



["Programmed cell death" I read with great interest and attention Dr. Béla Szende's excellent communication on the biological and pathological significance of programmed cell death (apoptosis). Although the phenomenon of apoptosis (albeit under a different name) has been described for more than twenty years, its importance in the regulation of tissue homeostasis has only been recognized in the last few years. In 1991, for example, Jean Claude Ameisen and Andre Carpon of the Pasteur Institute in Lille put forward their hypothesis that apoptosis explains the qualitative and quantitative deficiency of helper T cells in HIV-infected patients.]

Lege Artis Medicinae

[Malnutrition syndrome in childhood part II.]

BAKSAI László, PHILIP W. H. Esker

[Malnutrition is a chronic nutritional disorder resulting from insufficient intake of caloric energy and/or some fundamental nutrients. Since it is the most common public health problem in the world it has a great impact on pediatric morbidity and mortality. The etiology is extremely complex. When one considers the less severe symptoms and signs caused by vitamin-, mineral-, and trace element deficiencies, it is apparent that not only children living in underprivileged countries are affected. In the course of making the diagnosis an assess ment of the nutritional status should also be made, especially considering the above-mentioned marginal nutritional deficiencies. The most common manifestation of nutritional disorders is anemia, which is mostly caused by lack of iron, vitamin B12, folic acid and can be complicated by infections. Nutritional requirements can be affected by several drugs. That is why this medication-nutrition interaction has to be kept in mind during treatment. The interaction of malnutrition and infection is very important, primarily for three reasons: mechanisms by which infection complicates the metabolic and nutritional status of the host; importance of suboptimal nutritional status on susceptibility and severity of intercurrent infections; clinical and therapeutic implication of these interactions. ]

Lege Artis Medicinae

[Operative Hysteroscopy]


[Many thousands of hysterectomies are perfor med each year in women suffering from menorrhagia resistant to medical treatment but having, no demonstrable uterine abnormality. Hysteroscopy, the up to date diagnostic and therapeutic method can help to get advance in the diagnosis and therapy in these situations. In addition to permitting more precise diagnoses to be made, hysteroscopy allows the endometrium to be treated selectively under direct vision. The full thickness of the endometrium may be ablated using laser or resectoscope. The benefits of selective endometrial destruction versus hysterectomy are enormous. Patients undergoing endometrial ablation are frequently delighted with the short hospital stay, and the cost of this procedure is lower than the cost of hysterectomy. Many Müllerian fusion defects are amenable to hysteroscopic treatment. Patients with certain types of Müllerian defects undergoing hysteroscopic septotomy will enjoy as high a rate of reproductive success as those receiving more traditional procedures while avoiding the risks, the subsequent caesar sections, and the high cost. ]

Lege Artis Medicinae

[Transvaginal ultrasonography of embryo development in prematurity, sono-embryology I. The embryo and its appendages]

CSABAY László, SZABÓ István, NÉMETH János, PAPP Zoltán

[The authors performed serial examinations by a high resolution transvaginal transducer during the first trimester of pregnancy to show the most important stages of the early embryonal development. This is a preliminary study to a prospective, detailed screening programme in the first trimester of pregnancy. The earliest sign of pregnancy can be detected at the 29–31st days of menstrual age using vaginal transducer. During the 5th week the (secondary) yolk sac can be seen, which is an unambiguous evidence of an intrauterine pregnancy. The living embryo can be de monstrated on 36–38th days with the help of the pulsation of the embryonic heart tube. Certain embryonic structures appear in a defined order (developmental „calendar"). The physiologic midgutherniation can be observed during 7–11th weeks. Transvaginal sonography has gained popularity only recently due to technical advances. The main fields of use became gynaecology and early pregnancy, for there is no need to have a full bladder, for the lack of disturbing tissue layers. This method is essentially a combination of the bimanual gynaecological and the ultrasound examination. ]

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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

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

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

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

ÜNSAL Ünlü Ülkün, ŞENTÜRK Salim

Microdiscectomy (MD) is a stan­dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in­terlaminar lumbar discectomy (PELD) is another surgical op­tion that has become popular owing to reports of shorter hos­pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD). Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups. The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist’s costs), hospital stay, anesthetic drugs and materials, laboratory wor­kup, nur­sing care, and postoperative me­dication diffe­red significantly among the two main groups (PELD-MD) (p<0.01). This study demonstrated that PELD is less costly than MD.