Lege Artis Medicinae

[Verruca like terime in armpit with unusual location]

VERTSE Gergely, NAGY Jenő, SZELECZKY Márton, IVÁNYI András, SVASTICS Egon

SEPTEMBER 20, 2015

Lege Artis Medicinae - 2015;25(08-09)

[Authors present a case of a patient suffering from a verrucous lesion in the right armpit. The patient underwent a succesful operation. Histological report revealed verrucous carcinoma. The site of origin is uncommon, and there was no previous history of any inflammation at the involved region. General characteristic features of verrucous carcinoma are also shortly described.]

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Lege Artis Medicinae

[Evaluation of body image by means of body shape test and the priming phenomenon]

KOVÁCS Gyöngyvér Xénia, PRIEVARA Dóra Katalin, PIKÓ Bettina

[INTRODUCTION - Body image plays a significant role in the way how the individuals evaluate their own health and in the motivation for health promotion and disease prevention. Consumer culture provides controversial messages for the population, on one hand it motivates to try foods of high calories, on the other hand it also supports the thin body for the ideal. Not surprisingly, besides obesity, eating disorders and distorted body image disorders also tended to increase during the past decades. Therefore, it would be relevant to investigate the background variables of body image. METHODS - One hundred and sixty seven healthy working adults participated in our study that included a self-completed, voluntary and anonymous questionnaire with a focus on the so called body shape test. First, based on projecting figures on slides, the participants evaluated their own figure and the ideal one as perceived by them. Then we projected figures of skinny models. After this they re-evaluated themselves. The goal of this investigation was to detect the priming effect of projecting slim figures that is frequently used in the media. RESULTS - Based on the projection of the skinny models, there was a change in 55.6% of the sample in the evaluation of one’s own figure. On a Likert-type scale of 1-7 points, previously they had evaluated themselves with an average of 3.23 points (thinness scale) that turned into 3.35 after the projection of the skinny models. In addition, their view about their own ideal body (4.57 points), and about female and male ideal body also changed into a slimmer one. These changes were statistically significant (p < .001) by paired t-test both for men and women. Finally, men and women did not show significant difference in the evaluation of female and male ideal body. CONCLUSIONS - These results justified the role of the pictures’ priming effect in body image both in terms of the perception of one’s own figure and the ideal body. The change was particularly relevant in the case of evaluation of one’s own figure due to the choice of the slimmer body as compared to the view of the ideal body. Evaluation of female and male ideal body was similar to the first projection of the pictures as compared to what they would think as ideal for themselves. After the projection images of the female and male ideal body moved to the slimmer figures in a smaller account as compared to the own ideal body image. All these suggest that pictures projected by the media may have a significant role in the population’s body image. Clarifying the phenomenon may help in health promotion and dieting related disease prevention. ]

Lege Artis Medicinae

[In the Shadow of Death ]

FERENCZI Andrea

Lege Artis Medicinae

[A Gunshot in the Night, or the Death of Marat ]

GEREVICH József

Lege Artis Medicinae

[Perioperative management of patients taking new oral anticoagulants - dabigatran in focus]

MÁRK László

[Appearance of new oral anticoagulants (NOAC) on the market requires a basically new approach from the doctors compared to vitamin K antagonists (VKA), the only oral anticoagulants used for several decades. These new drugs are at least as effective in the prevention of thrombotic events as the old ones and have the advantage that no regular laboratory monitoring is needed. Compared to the VKA a different management is required also in the perioperative care of patients taking NOAC. There is no need for bridge therapy, i.e. low-molecular-weight heparin (LMWH). The smaller surgical procedures can be performed 24 hours after the last dose of NOAC if it is administered once a day or 12 hours in case of agents administered twice a day. When a large surgical procedure is planned the drug should be stopped 24-96 hours before. The therapy should be resumed 6-8 hours after the procedure in low, 48-72 hours later in high bleeding risk cases. In a Canadian prospective study a protocol was used in which the stopping and resumption of dabigatran was recommended based on the bleeding risk and its half-life depending on the renal function. In 541 surgeries (60% with standard, 40% with increased bleeding risk) the occurrence of serious bleeding events was 1.8%, that of minor bleedings 5.2%. During the study one thrombotic event (TIA) occurred (0.2%). At the end of the article the author also makes a recommendation for stopping and resuming dabigatran therapy in case of tooth extraction, endoscopic biopsy and cholecystectomy.]

Lege Artis Medicinae

[Masterworks and Medicine ]

NAGY Zsuzsanna

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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

Creutzfeldt-Jakob Disease: A single center experience and systemic analysis of cases in Turkey

USLU Ilgen Ferda, ELIF Gökçal, GÜRSOY Esra Azize, KOLUKISA Mehmet, YILDIZ Babacan Gulsen

We aimed to analyze the clinical, laboratory and neuroimaging findings in patients with sporadic Creutzfeldt-Jakob disease (CJD) in a single center as well as to review other published cases in Turkey. Between January 1st, 2014 and June 31st, 2017, all CJD cases were evaluated based on clinical findings, differential diagnosis, the previous misdiagnosis, electroencephalography (EEG), cerebrospinal fluid and cranial magnetic resonance imaging (MRI) findings in our center. All published cases in Turkey between 2005-2018 were also reviewed. In a total of 13 patients, progressive cognitive decline was the most common presenting symptom. Two patients had a diagnosis of Heidenhain variant, 1 patient had a diagnosis of Oppenheimer-Brownell variant. Seven patients (53.3%) had been misdiagnosed with depression, vascular dementia, normal pressure hydrocephalus or encephalitis. Eleven patients (87%) had typical MRI findings but only 5 of these were present at baseline. Asymmetrical high signal abnormalities on MRI were observed in 4 patients. Five patients (45.4%) had periodic spike wave complexes on EEG, all appeared during the follow-up. There were 74 published cases in Turkey bet­ween 2005 and 2018, with various clinical presentations. CJD has a variety of clinical features in our patient series as well as in cases reported in Turkey. Although progressive cognitive decline is the most common presenting symptom, unusual manifestations in early stages of the disease might cause misdiagnosis. Variant forms should be kept in mind in patients with isolated visual or cerebellar symptoms. MRI and EEG should be repeated during follow-up period if the clinical suspicion still exists.

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TLR4 (Toll-like receptor-4) expression and frontal-cingulate volumes in schizophrenia

LI Hua, KÉRI Szabolcs

Evidence suggests that pathogen-associated pattern recognition receptors (Toll-like receptors, TLRs) are implicated in the pathophysiology of schizophrenia. TLRs are important in both peripheral immune responses and neuronal plasticity. However, the relationship between peripheral TLR expression and regional brain volumes is unknown in schizophrenia. We therefore assessed 30 drug-naïve, first-episode patients with schizophrenia. TLR4+/TLR1+ monocytes were measured using flow-cytometry. High resolution magnetic resonance images (T1 MRI) were obtained and analyzed with FreeSurfer. Results revealed significant negative correlations between the percentage of TLR4+ monocytes, mean fluorescent intensities, and brain volumes in frontal and anterior cingulate regions. The measures of TLR1+ monocytes did not show significant relationships with regional brain volumes. These results raise the possibility that abnormal TLR-activation is associated with decreased brain volumes in schizophrenia.

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[LADA type diabetes, celiac diasease, cerebellar ataxia and stiff person syndrome. A rare association of autoimmune disorders]

SOÓS Zsuzsanna, SALAMON Mónika, ERDEI Katalin, KASZÁS Nóra, FOLYOVICH András, SZŰCS Anna, BARCS Gábor, ARÁNYI Zsuzsanna, SKALICZKI József, VADASDI Károly, WINKLER Gábor

[Celiac disease - in its typical form - is a chronic immunemediated enteropathy with typical clinical symptoms that develops against gliadin content of cereal grains, and is often associated with other autoimmune diseases. In cases of atypical manifestation classic symptoms may be absent or mild, and extra-intestinal symptoms or associated syndromes dominate clinical picture. The authors present a longitudinal follow-up of such a case. A 63-years old woman was diagnosed with epilepsy at the age of 19, and with progressive limb ataxia at the age of 36, which was initially thought to be caused by cerebellar atrophy, later probably by stiff person syndrome. At the age 59, her diabetes mellitus manifested with type 2 diabetic phenotype, but based on GAD positivity later was reclassified as type 1 diabetes. Only the last check-up discovered the celiac disease, retrospectively explaining the entire disease course and neurological symptoms. By presenting this case, the authors would like to draw attention to the fact that one should think of the possibility of celiac disease when cerebellar ataxia, progressive neurological symptoms and diabetes are present at the same time. An early diagnosis may help to delay the progression of disease and help better treatment.]

Clinical Neuroscience

Investigation of risk factors, topographic location and stroke mechanisms of unilateral isolated and posterior cerebral ARTERY thalamic infarcts

GÖKCAL Elif, SENGUL Yildizhan, USLU Ilgen Ferda

Aim - In this study, we aimed to examine the risk factors, topographic features and stroke mechanisms of acute ischemic unilateral infarcts of thalamus. Methods - Patient with isolated thalamic infarct and those with posterior cerebral artery (PCA) infarction who were admitted to our hospital between January 2014 and January 2017 with acute unilateral thalamic infarction (TI) were included in this study (isolated thalamic infarction/ isolated TI; thalamic and posterior cerebral artery infarction/PCA+TI). Demographic characteristics and vascular risk factors of the patients were determined. Thalamic infarct areas were recorded topographically as anterior, posteromedial, ventrolateral, posterolateral, more than one area, and variant areas. Stroke mechanism was determined according to the criteria of „Trial of Org 10172 in Acute Stroke Treatment” (TOAST). Patients with isolated TI and PCA TI were compared according to risk factors, stroke mechanism and infarct topography. Results - Forty-three patients with a mean age of 63.3 ± 14.5 years were included in the study. Twenty-eight patients (60.1%) were found to have isolated TI and the remaining 15 patients (34.9%) had PCA+TI. 32.1% of patients with isolated TI had sensory symptoms on presentation, and 60% of patients with PCA-TI had sensorimotor symptoms. The mean age, the mean score on National Institutes of Health Stroke Scale (NIHSS) and the mean frequency of atrial fibrillation were higher in PCA+TI patients than in isolated-TI patients (p: 0.04, p: 0.004, p: 0.02 respectively). 32.6% of the patients had ventrolateral, 30.2% had posteromedial involvement. Ventrolateral topography was seen in 46.7% of the PCA+TI patients, while posteromedial topography was seen in 39.3% of the isolated-TI patients. 53.6% of the isolated-TI had small vessel disease etiology, while 40% of the PCA+TI had cardioembolic etiology, and the other 40% had large artery atherosclerosis. Conclusion - Our study showed that the most ommon stroke mechanism in patients with thalamic infarction is the small vessel disease. Isolated TI and PCA+TI patients differ in terms of etiologic mechanism and infarct topography. Variant territorial involvement and multiple area involvements can be quite common in thalamic infarcts.