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Clinical Oncology

FEBRUARY 28, 2020

[Opportunities and challenges in online support of cancer patients]

B. PAPP László

[The online support of oncological care may increase patients’ adherence, and by this it can contribute to the effectiveness of treatment, the improvement of quality of life and physician-patient communication as well as to a higher sense of control over the disease. With the online support of supportive care, patients and their relatives can get information on what they can do in order to improve their conditions, how they can recognize side effects and alarming symptoms of complications, what kind of changes they need to make in their lifestyle and how they can reduce the level of distress. Though the positive outcomes are feasible in many cases, quite considerable number of reports in the fi eld do not meet the requirements of evidence. The online support of oncological care may offer considerable opportunities, however, it may further increase inequality: the more educated and well-off patients with higher level of health awareness may benefi t more, meanwhile for the ones at the bottom of digital divide, the disadvantages may increase. The Hungarian internet coverage and accessibility make the broader online support technologically possible, however, its effectiveness may be hindered by the lack of human skills. Therefore, it is a real challenge to establish such platforms that can be used by the broadest spectrum of society, they are comprehensible for patients and their relatives with lower education, but also satisfying for patients and their relatives with higher level of literacy and expectations.]

Clinical Neuroscience

NOVEMBER 30, 2020

Positive airway pressure normalizes glucose metabolism in obstructive sleep apnea independent of diabetes and obesity

KABELOĞLU Vasfiye, SENEL Benbir Gulçin, KARADENIZ Derya

The relationship among obstructive sleep apnea syndrome (OSAS), type 2 diabetes mellitus (DM2) and obesity is very complex and multi-directional. Obesity and increased visceral fat are important perpetuating factors for DM2 in patients with OSAS. On the other hand, OSAS itself leads to obesity by causing both leptin and insulin resistance as a consequence of activation of the sympathetic nervous system. Risk for developing DM2 further increases in patients with OSAS and obesity. Data regarding effects of positive airway pressure (PAP) therapy, gold standard treatment for OSAS, on glycemic control were inconsistent due to variability in duration of and adherence to PAP therapy. In our cohort study we investigated effects of PAP treatment on glucose metabolism in normal-weighted non-diabetic OSAS patients, in obese non-diabetic OSAS patients, and in OSAS patients with DM2. We prospectively analyzed 67 patients diagnosed with OSAS and documented to be effectively treated with PAP therapy for three months. Apnea-hypopnea index was highest in the diabetic group, being significantly higher than in the normal-weighted group (p=0.021). Mean HOMA values were significantly higher in obese (p=0.002) and diabetic group (p=0.001) than normal-weighted group; the differences were still significant after PAP therapy. HbA1c levels were significantly higher in diabetic group compared to those in normal-weighted (p=0.012) and obese (p=0.001) groups. After PAP treatment, decrease in HbA1c levels were significant in normal-weighted (p=0.008), obese (p=0.034), and diabetic (p=0.011) groups. There was no correlation with the change in HbA1c levels and age (p=0.212), BMI (p=0.322), AHI (p=0.098) or oxygen levels (p=0.122). Our study showed that treatment of OSAS by PAP therapy offers beneficial effect on glucose metabolism, not only in diabetic patients, but also in obese and normal-weighted OSAS patients. Although data regarding overall effects of PAP therapy on glycemic control present contradictory results in the literature, it should be emphasized that duration and adherence to PAP therapy were main determinants for beneficial outcome of treatment.

Clinical Neuroscience

NOVEMBER 30, 2020

[The connection between the socioeconomic status and stroke in Budapest]

VASTAGH Ildikó, SZŐCS Ildikó, OBERFRANK Ferenc, AJTAY András, BERECZKI Dániel

[The well-known gap bet­ween stroke mortality of Eastern and Western Euro­pean countries may reflect the effect of socioeconomic diffe­rences. Such a gap may be present between neighborhoods of different wealth within one city. We set forth to compare age distribution, incidence, case fatality, mortality, and risk factor profile of stroke patients of the poorest (District 8) and wealthiest (District 12) districts of Budapest. We synthesize the results of our former comparative epidemiological investigations focusing on the association of socioeconomic background and features of stroke in two districts of the capital city of Hungary. The “Budapest District 8–12 project” pointed out the younger age of stroke patients of the poorer district, and established that the prevalence of smoking, alcohol-consumption, and untreated hypertension is also higher in District 8. The “Six Years in Two Districts” project involving 4779 patients with a 10-year follow-up revealed higher incidence, case fatality and mortality of stroke in the less wealthy district. The younger patients of the poorer region show higher risk-factor prevalence, die younger and their fatality grows faster during long-term follow-up. The higher prevalence of risk factors and the higher fatality of the younger age groups in the socioeconomically deprived district reflect the higher vulnerability of the population in District 8. The missing link between poverty and stroke outcome seems to be lifestyle risk-factors and lack of adherence to primary preventive efforts. Public health campaigns on stroke prevention should focus on the young generation of socioeconomi­cally deprived neighborhoods. ]

Hypertension and nephrology

SEPTEMBER 30, 2020

[Non-pharmacological treatment of hypertension and reducing cardiovascular risk in general practitioners’ clusters]

MOHOS András, KOZMA Anna, MARKÓ-KUCSERA Mária, MESTER Lajos

[Hypertension and cardiovascular diseases are major public health issues. In their treatment non-pharmacological methods have a role in every case either alone or as a complement. Patient adherence is a key factor. The role of primary care is very important in the management and with general practitioners’ cluster model and with the involvement of new primary care professionals (for example: dietetitian, physiotherapist) the opportunities are expanding. In the A GP Cluster and in the Marosmenti GP Cluster the analysis of the patients’ results who participated in an individual health status examination, in dietetic and in physiotherapy services. Assessing the professionals’ attitudes towards GP cluster model. In the A GP Cluster 2409 people, in the Marosmenti GP Cluster 1826 people participated in an individual health status examination. 14.6% and 19.9% of the participants were under the age of 18. 58.9% and 60.7% of the participants over the age of 18 were female. 1083 and 232 patients used physiotherapy services, 147 and 187 people used dietetic services. The age distribution of the individual health status examinations is correspond to the Hungarian age pyramid. In addition to the preventive approach came into view the community based local health care services. The GP cluster model was welcomed by the patients, the physiotherapy was more popular than dietetic among them. All professionals of the GP clusters had a positive opinion of the professional work done in the project. Conclusion: There is a demand both from the patients and the healthcare professionals for the GP cluster concept. The establishing of an appropriate monitoring system and creating long-term, sustainable operating conditions are essential for achieving lasting social health gains. ]

Hypertension and nephrology

SEPTEMBER 30, 2020

[Treatment and care of hypertensive patients during and after the Covid-19 pandemic. Possibilities and effectiveness of telemedicine]

KÉKES Ede, SZEGEDI János, VÁLYI Péter

[The course and outcome of an pandemic caused by coronaviruses are determined by many factors, such as the strength and dose of the infectious virus, the immune system of the affected individual, the underlying diseases, the speed of virus spread, age and environmental factors and methods of control. In old age, there is a significantly higher risk of developing severe cases and fatalities. The rate of loss of life is particularly high in social care and nursing homes. Hypertension as the underlying disease is the most common cause of death, but hypertension alone is not an independence risk factor, but the main reason is the co-morbidities and complications associated with viral infection. In the epidemic situation, the treatment and care of hypertensive patients poses special challenges for health and active primary and specialist care workers and, of course, for hypertonologists. The Hungarian Society of Hypertension expressed its opinions and recommendations to patients living at home and to doctors performing treatment and care during the Covid-19 virus epidemic and summarized the decision-making possibilities derived from the data obtained during the telemedicine consultation. We would like to present the details of the possibilities provided by telemedicine, the practical possibilities and advantages of the different methods of teleconsultation, and the models that can be implemented in a domestic environment. We have taken into account international experience to date, the new e-health strategy for chronic, non-communicable diseases and the WHO concept. Telemedicine, continuous teleconsultation ensures an optimal relationship between the patient and the doctor, increases the patient’s sense of security, improves drug adherence. The doctor receives reliable data about the patient’s condition and can send him instructions as well as information. The development of a harmonious balance between personal contact and telecommunications already shows the future, and the application of these methods must be developed in the epidemic-free period as well. Previous international (TASMINH-4, HOMED-BP etc.) and domestic (CONADPER-HU) studies have proved that telemonitoring of hypertensive patients can be successfully solved, improves patients’ drug adherence, increases the target blood pressure achievement rate and at the same time the patient will be the active part of the treatment. The method is especially useful in rural settlements without a doctor. Telemedicine monitoring of elderly and multimorbid patients is especially useful in social institutions and nursing homes. It is solved the continuous control of vital functions, ensures continuity of contact with the supervising physician and in urgent cases, allows for rapid intervention. Telemedicine is also of great importance due to the lack of human resources, as many things can be solved with such technology, there are no need so many personal encounters. In addition to influencing the course of this pandemic, it also plays an important role in efficiency, headcount, management and “convenience” in general practice and in all formes of medicine. The proposed models can not only be applied in an epidemic situation, but should continue to be part of everyday health work in future.]

Lege Artis Medicinae

APRIL 18, 2020

[Interrelations between antidepressants and diabetes]

HARGITTAY Csenge, GONDA Xénia, MÁRKUS Bernadett, VÖRÖS Krisztián, TABÁK Gy. Ádám, KALABAY László, RIHMER Zoltán, TORZSA Péter

[Diabetes and depression are frequent comorbidities. They are a heavy burden by themselves, however, as comorbidities increase additionally the number of diabetes-related complications, morbidity, and mortality. In the background of interrelations, there are both well-known and hypothetical mechanisms. The aim of the present review is to outline these interrelations between antidepressants and diabetes and to discuss the effect of medications on carbohydrate metabolism respectively. Anti­depressant treatment on the one hand may improve mood, cognitive function and medication adherence leading to an improved glucose metabolism, on the other hand through their metabolic side effects, they may worsen carbohydrate metabolism. Concerning metabolic side effects, selec­tive serotonin reuptake inhibitors are the sa­fest, while tricyclic antidepressants and mo­noamine oxidase inhibitors should be administered under close monitoring. Se­rotonin and noradrenaline reuptake inhibitors may deteriorate gly­cae­mic control via increased noradre­nergic activation. Novel antidepressants, how­ever, have a neutral or positive impact on gly­caemic measures. Screening for and temporally adjusted treatment of depres­sion may decrease the risk of comorbidities ge­nerated complications. While caring for diabetic patients with depression, one should consider metabolic side effects of antidepressants and close monitoring of carbohydrate metabolism.]

Hypertension and nephrology

FEBRUARY 20, 2020

[Thinking globally - the significance of the joint treatment of risk factors]

BENCZÚR Béla

[Hypercholesterolemia and hypertension - as the key risk factors of ischemic heart disease - are strongly linked to the increasing prevalence of cardiovascular mortality and morbidity. These risk factors are related to each other and half of the hypertensive patients have elevated cholesterol, as well. The recent European hypertension guidelines recommend statin treatment in dyslipidemic and/or subjects at high risk including diabetic or CKD-patients. Reaching blood pressure target if we can hold the patient under 1.8 mmol/l LDL-level results in 60% reduction of the risk of CAD and 17% reduction of stroke. This aim can only be reached if patients regularly take their prescribed medications although statinadherence is the poorest in our country. One of the main tools of improving adherence beyond education is the use of fix-dosed combination.]

Lege Artis Medicinae

NOVEMBER 15, 2019

[Hypertension in the elderly ]

BARNA István

[Elevated isolated systolic pressure is the most common and greatest cardiovascular risk factor with age. The prevalence of hypertension increases with age and ex­ceeds 60% over 70 years. Proper treatment of hypertension in the elderly, even in very old age (> 80 years), increases life expectancy and reduces the risk of cardiovascular events. For patients over 65 years of age, the target blood pressure range is between 130-139 / 70-80 mmHg if the patient tolerates the treatment. In elderly patients with poorer conditions, systolic blood pressure may be <150 mmHg. White-coat hypertension is common, nondipper ratio is increased, autonomic nervous system dysregulation is more common, and orthostatic decrease of blood pressure. The renal function is decreased or already impaired, often resulting in poorer therapeutic cooperation due to impaired cognitive function. The blood pressure lowering effect of targeted lifestyle changes may be the same as medication monotherapy, with the main disadvantage of decreasing adherence over time, for which a proper physician-patient relationship is essential. First-line agents for the treatment of elderly hypertension include angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), long-acting calcium channel blockers, and thiazide, thiazide-like diuretics. Beta-blockers should be used in the treatment of elderly hypertension if they have other indications (coronary heart disease, heart failure, arrhythmias). More than 70% of hypertensive patients should use combination therapy to achieve target blood pressure. Take advantage of fixed dose combination to improve compliance to optimize treatment. ]

Hypertension and nephrology

SEPTEMBER 10, 2019

[Hungarian Hypertension Registry. Different methods and effects of increasing physician-patient cooperation on target blood pressure]

SZEGEDI János, KÉKES Ede, KISS István

[The life expectancy, the mortality and the development of complications of hypertensive patients are fundamentally influenced by the treatment, the effectiveness of care and physician-patient cooperation, the achievement of target blood pressure. Based on the database of the Hungarian Hypertonia Registry, we present three examples of the effect of different solutions for physician-patient cooperation on increasing the blood pressure target. During the two years between 2005 and 2007, we used a complex, versatile method of increasing the patient’s adherence in treated hypertensive patients (17,114 males and 21,772 women), with information, education, home-blood pressure diary, and continuous, regular physician- patient communication (sms, green phone line, website). The target blood pressure was significantly increased from 38.8% to 43.9%, and the rate of growth was higher in women. The increase was also significant in the elderly (over 70 years). In the first quarter of 2011, we launched a wide-ranging education and patient support campaign for 28,018 hypertensive patients under the ‘Everywhere Good, Best Home!’ subprogram for promoting of home blood pressure measurement and its use in therapy. 81.3% of the patients had completed the diaries under ther observation period, the full completion of the diaries was 91.3%. At the end of the third month, the target blood pressure of 135/85 mmHg for HBPM increased from baseline 21.2% to 48.8%. Growth was significant (P <0.001). In the year 2015-2016 we started a one-year, multicentric, prospective, observational study, in which 7735 patients aged 18-64 years were included from the database of Hungarian Hypertension Registry. In the non-active group (3313 people), treated hypertensive patients were controlled according to the traditional care program so far, while the active group members (4422) participated in an intensive care program with telemedicine (smart phone application) and other helping opportunities. The control was done at the end of 3, 6, 9, and 12 months after the start. In the active group, blood pressure dier was done by smart phone and every month, in the non-active group, paper logging was done every 3 months. In the active group, the blood pressure dieries were filled with smart phone every month and in nonactive group the paper dieries only every 3 months. Patient adherence was high in both groups (around 70%) and in the active group was greater than in the nonactive group. Target blood pressure (<140/90 mmHg) in the active group increased from 53.8% to 73.4% and in the non-active group from 49.9% to 68.1%. Studies have shown that patient interaction is determined by good communication between the care team and the patient, success of home blood pressure monitoring. The communicative ability of the care team (physician-nurse pharmacist) greatly influences the achievement of the therapeutic target. Modern telecommunications is another useful option.]

Lege Artis Medicinae

JULY 20, 2019

[How many cardiovascular events can be avoided by a lipid lowering therapy based on preventive guidelines?]

MÁRK László

[The lipid lowering therapy became one of the most important elements in the cardiovascular prevention, yet it is not appropriately evaluated neither by the doctors, nor by the patients. The lipid goal attainment should to be improved according to Hungarian and international data. Using a recommendation guided lipid lowering therapy the most benefit can be expected in the patients at very high risk who alrea­dy had a cardiovascular event, where the LDL-cholesterol goal is 1.8 mmol/L. Calculating upon the data of 170000 patients of Cholesterol Treatment Trialists’ Collaboration a decrease of LDL-cholesterol level from 2.5 mmol/L to 1.8 in 100 patients in 10 years would avoid 3 myocardial infarctions, strokes or death, lowering that from 3.5 mmol/L to the goal would prevent these 3 events within 5 years. Using the traditional LDL-cholesterol lowering medication, high dose statin and ezetimibe, if the attitude of doctors and the compliance of patients would be ideal, the 1.8 mmol/L goal attainment rate would be over 80%. Unfortunately, up to now the reimbursed administration of ezetimibe in Hungary is still bound to a specialist’s recommendation, adding it to any dose of any statin an additional 20% LDL-cholesterol can be expected. The reimbursed administration of PCSK9-inhibitors is possible only based on a special request to National Health Insurance Fund. To achieve a better national cardiovascular morbidity and mortality the attitude of the doctors and the adherence of the patients to the lipid lowering therapy should be improved (it’s the goal of the present paper as well).]