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Lege Artis Medicinae

DECEMBER 18, 2012

[The altered role of coagulase-negative staphylococci]

SZALKA András

[Coagulase-negative staphylococci are differentiated from the more virulent Staphylococcus aureus by their inability to produce coagulase enzyme. Currently, more than 40 recognized species of coagulasenegative staphylococci are known. The great majority of these bacteria are normal inhabitants of the human skin and mucous membranes. Therefore, it is very difficult to distinguish isolates that are of clinical significance. Recently, coagulase-negative staphylococci have been increasingly detected to cause clinically significant infections. This is due in most cases to the increasing use of medical devices inserted or implanted in the human body. This overview discusses the various infections caused by these microbes, as well as their pathogenesis, epidemiology, and management.]

Lege Artis Medicinae

DECEMBER 18, 2012

[Cost minimization analysis of basal insulin analogues in the treatment of type 2 diabetes]

MERÉSZ Gergő, TABÁK Gy. Ádám, KALÓ Zoltán

[INTRODUCTION - Basal insulin analogues are essential drugs for the treatment of type 2 diabetes mellitus. Basal insulin analogues have been shown to reduce the frequency of hypoglycaemia versus NPH insulin, and thus may be beneficial in the treatment of type 2 diabetes. Here we present a cost-minimisation analysis of basal insulin analogues, comparing insulin glargine and insulin detemir available in Hungary. METHODS - A literature review was conducted to identify randomized, controlled clinical trials with a duration of 12 weeks or more in which a direct comparison of insulin glargine and insulin detemir was made in patients with type 2 diabetes. In a meta-analysis of the eligible trials, the following endpoints were investigated: metabolic status, body weight, frequency of hypoglycaemia, insulin doses administered and the number of insulin injections required. If a high heterogeneity (I2>75%) was found, meta-regression was performed to identify the underlying reasons. The funder’s perspective was applied in the cost-minimization analysis by taking into account the cost of the drug and of medical devices necessary for its administration, based on the daily number of insulin injections. RESULTS - No further studies were found in addition to those included in a metaanalysis published by The Cochrane Library. On the basis of three eligible studies, insulin detemir was injected more frequently compared with glargine (weighted mean difference: 0.42 95% CI 0.14-0.69 injections/day). High heterogeneity was present in case of two endpoints: the incidence of overall hypoglycaemia per patient-year (I2=83%), and daily basal insulin dose in units per body weight (I2=94%). The reason for the high heterogeneity in hypoglycaemia rates was not identified by meta-regression; however, the difference in insulin doses per body weight was negatively associated with body weight (-0.027 IU/kg per 1 kg, 95%CI: -0.051; -0.004). On the basis of the present meta-analysis and meta-regression, our calculations suggest that treating an average weight (90 kg) patient with type 2 diabetes with insulin glargine would result in an annual cost reduction of 93 452 HUF compared with insulin detemir by employing gross public drug prices. CONCLUSION - On the basis of the available clinical evidence, insulin glargine might be a cost-saving alternative of insulin detemir in an average-weight patient with type 2 diabetes. In an era of scarce resources, the role of therapeutic alternatives offering cost savings with the same efficacy become more important. The generalisability of our conclusions might be influenced by potential differences in the manufacturers’ claw-back rate of detemir vs glargine insulin.]

Lege Artis Medicinae

NOVEMBER 22, 2012

[The sensor-augmented insulin pump and its use in clinical practice]

KÁNTOR Irén

[Diabetes is one of the most common chronic diseases. Technological advances provide increasingly refined tools for clinicians to manage type 1 and type 2 diabetes. Continuous subcutaneous insulin infusion (CSII), also known as insulin pump, allows for a sophisticated delivery of basal as well as bolus insulin. Continuous glucose monitoring helps patients and clinicians understand and manage changes in blood glucose trends and minute-to-minute blood glucose variablitiy. The sensor-augmented insulin pump was created by the merging of these devices, which has been a revolutionary step towards self-regulatory, closed-loop insulin delivery or the creation of an artificial pancreas.]

Clinical Neuroscience

SEPTEMBER 23, 2011

[Prolonged EEG-monitoring]

HALÁSZ Péter

[Prolonged EEG monitoring and video-EEG monitoring are basic methods on the level of epilepsy centers. These methods are able to make differences between epilepsy and non epileptic paroxysmal manifestations like psychogenic non epileptic seizures, parasomniac phenomena, narcolepsy. The application of the method, at least the video-EEG variant, needs team work, high level organisation, highly educated staff and high tech electrographic devices. Running the method even with these requirements is beneficial from the cost-benefit aspect as well.]

SEPTEMBER 22, 2011

The Fallacy of Neuroscience and the Error of Radical Reductionism

FRECSKA Ede

The following article is a reflection to Tallis-Buda-Halasz debate on Neuromania. From my perspective the problem is not the materialistic approach, but the radical reductionism, a mistake what every party can fall into. The fallacy of neuroscience is the assumption that every human experience results from the activity of one network, the neuroaxonal. As Francis Crick (1995) put it: “You’re nothing but a pack of neurons!” He spelled out his radical reductionistic vision as follows: “You, your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules.” My usual, disrespectful response to such kind of statements is: “You, but not me!” This rudely radical reductionism is not a characteristic of the neuroscientific field only. A behavioral psychologist would state that you are not more than a package of adaptive behavioral patterns, a radical social psychologist would say that you are not more than the sum of social roles, or a classical psychoanalyst would suppose that you are a bunch of complexes. Richard Dawkins has moved in another direction stating that we are vessels of selfish genes. Science writer John Horgan (2000) criticized such narrow views: “In a sense, Crick is right. We are nothing but a pack of neurons. At the same time, neuroscience has so far proved to be oddly unsatisfactory. Explaining the mind in terms of neurons has not yielded much more insight or benefit than explaining the mind in terms of quarks and electrons. There are many alternative reductionisms. We are nothing but a pack of idiosyncratic genes. We are nothing but a pack of adaptations sculpted by natural selection. We are nothing but a pack of computational devices dedicated to different tasks. We are nothing but a pack of sexual neuroses. These proclamations, like Crick’s, are all defensible, and they are all inadequate.” Buda Béla stated that he had not been aware of any representatives of the psychosocial field ruling out the role of the biological level. That is probably true nowadays. However, the first findings of biological psychiatry have met a huge resistance from the psychosocial/psychoanalytical field. For example, the first brain imaging findings of schizophrenia elicited a furious response from those who supposed it to be “functional”. In sum, no representative of any field is vaccinated against radical reductionism. The other fallacy (not of the neurosciences but its representatives) is the acknowledgment of the bottom-up effects with ignorance of the top-down relationships. In his book, The Blank Slate: The Modern Denial of Human Nature, Steven Pinker (2003) writes, “culture is crucial, but culture could not exist without mental faculties that allow humans to create and learn culture to begin with.” The effect of culture in shaping brain structure and neuroaxonal function is also permitted. This means that bottom-up and top-down interactions are at work bidirectionally. To avoid the trap of radical reductionism, one must assume that all levels of organization (Table 1) are at work with bidirectional inter-related causative effects. Contemporary psychiatry suffers from identity crisis: it tries hard to catch up to other medical fields in being objective, biological. However, by doing this overzealously it has been losing its essence the “psyche”, and deserves to be called “brainiatry”. In order to relieve the “inferiority complex” of my colleagues and to avoid the sarcastic disdain of other medical professionals, I may say for encouragement that psychiatrists deal with something more complex than they are themselves. No other professionals of the medical field can come up with a claim like that. Or can you imagine a proctologist stating something similar (i.e. the rectum is above them)? Table 1. Levels of organizations relevant to the conscious experience Just in brief about consciousness. The neurological correlates of consciousness can only solve the “easy problem” (Chalmers 1995), what is related to the content of conscious experience but not to its subjective feature, to the phenomenological experience. That is the “hard problem” which is out of the reach of the objective scientific approach per definitionem (since it is subjective). What more is necessary for solving the “hard problem” of consciousness, what other networks may be involved in mediating human experiences – I have addressed in the book Inner Paths to Outer Space (Strassman et al. 2007). Ede Frecska References Chalmers, David (1995). Facing up to the problem of consciousness. Journal of Consciousness Studies, 2(3):200-19. Crick, Francis (1995). Astonishing Hypothesis: The Scientific Search for the Soul. New York, NY: Scribner Publishing. Horgan, John (2000). The Undiscovered Mind: How the Human Brain Defies Replication, Medication, and Explanation. New York, NY: Free Press. Pinker, Steven (2003). The Blank Slate: The Modern Denial of Human Nature. New York, NY: Penguin Group. Strassman, Rick; Wojtowicz-Praga, Slawek; Luna, Luis Eduardo; Frecska, Ede (2007). Inner Paths to Outer Space, Rochester, VT: Inner Traditions. Original lecture:

Related materials (in Hungarian):
Halász Péter:Vajon megváltozik-e az agyunk különböző behatásokra?

Buda Béla: Bezárkózott a biológiai szemlélet

Halász Péter:Vajon megváltozik-e az agyunk különböző behatásokra?

Buda Béla: Tények és értelmezések az agykutatás terén

Raymond Tallis: Neurománia

Hungarian Radiology

MARCH 20, 2007

[Transcranial Doppler monitoring of distal embolism during of carotid stenting]

SZIKRA Péter, VÖRÖS Erika, SZTRIHA László, SZÓLICS Alex

[INTRODUCTION - Reducing the risk of embolisation during endovascular treatment of internal carotid artery stenosis is very important. The rate of embolisation is affected by the different steps of stenting manipulation. Using transcranial Doppler equipment we studied the embolic signals during the different phases of carotid dilatation and stenting. MATERIAL AND METHOD - 50 patients (33 male, 17 female; mean age 64 years) were intraproceduraly monitorized with transcranial Doppler. Predilatation was necessary in nine cases, postdilatation was performed in 39 cases. The number of emboli were measured in seven different steps of endovascular treatment of carotid stenosis. Different type of commercial available endovascular devices were used. RESULTS - Intraprocedural embolisation was observed in every case. In different phases of carotid stenting the rate of embolisation showed marked differences in each phase of carotid stenting. Crossing the stenosis with stent delivery system were accompanied by a low rate of embolism (5.3) compared to the level during stent opening (9.16) and balloon dilatation (9.96). The highest level of embolisation was observed during predilatation (15.9) without the protection of the stent. CONCLUSIONS - We detected embolisation in all of the cases, however the number of embolic signals varied in different phases of carotid artery stenting. Embolisation can be reduced if the most dangerous steps (i.e. pre- and postdilatation) are avoided. Using TCD monitorisation the physician can be informed by the degree of embolisation that may alarm the interventionalist to perform the procedure more carefully, furthermore it can be employed during the training of carotid stenting.]

Clinical Neuroscience

AUGUST 20, 2003

[Positron emission tomography in presurgical localization of epileptic foci]

JUHÁSZ Csaba

[The success of cortical resection for intractable epilepsy of neocortical origin is highly dependent on the accurate presurgical delineation of the regions responsible for generating seizures. In addition to EEG and structural imaging studies, functional neuroimaging such as positron emission tomography (PET) can assist lateralization and localization of epileptogenic cortical areas. In the presented studies, objectively delineated focal PET abnormalities have been analyzed in patients (mostly children) with intractable epilepsy, using two different tracers: 2-deoxy-2-[18F]fluoro-D-glucose (FDG), that measures regional brain glucose metabolism, and [11C]flumazenil (FMZ), that binds to GABAA receptors. The PET abnormalities were correlated with scalp and intracranial EEG findings, structural brain abnormalities, as well as surgical outcome data. In patients with extratemporal foci and no lesion on MRI, FMZ PET was more sensitive than FDG PET for identification of the seizure onset zone defined by intracranial EEG monitoring. In contrast, seizures commonly originated from the border of hypometabolic cortex detected by FDG PET suggesting that such areas are most likely epileptogenic, and should be addressed if subdural EEG is applied to delineate epileptic cortex. In patients with cortical lesions, perilesional cortex with decreased FMZ binding was significantly smaller than corresponding areas of glucose hypometabolism, and correlated well with spiking cortex. Extent of perilesional hypometabolism, on the other hand, showed a correlation with the life-time number of seizures suggesting a seizurerelated progression of brain dysfunction. FMZ PET proved to be also very sensitive for detection of dual pathology (coexistence of an epileptogenic cortical lesion and hippocampal sclerosis). This has a major clinical importance since resection of both the cortical lesion and the atrophic hippocampus is required to achieve optimal surgical results. Finally, the author demonstrated that in patients with neocortical epilepsy, FDG PET abnormalities correctly regionalize the epileptogenic area, but their size is not related to the extent of epileptogenic tissue to be removed. In contrast, complete resection of cortex with decreased FMZ binding predicts good surgical outcome suggesting that application of FMZ PET can improve surgical results in selected patients with intractable epilepsy of neocortical origin.]

Hungarian Radiology

OCTOBER 10, 2005

[The force transmission of the distal endings of stent delivery systems]

SZIKRA Péter, VÖRÖS Erika, SZTRIHA László, SZÓLICS Alex, CSIKÁSZ Tamás

[INTRODUCTION - In cases of endovascular treatment of internal carotid artery stenosis, one of the most important aspects is to minimise embolic complications. Dislodging emboli may be influenced by the shape and size of tapered endings of stent delivery systems. Our team performed measurements and calculations on the emergence of force of the various tapered endings. MATERIAL AND METHOD - Five different commercially available stent dilivery systems were investigated. The thickness of the devices were measured and taking 5 mm normal artery diameter, the lumen size was calculated, above which the delivery system should dilate the lumen mechanically. By means of geometrical computer-constructions and measurements, we analysed the forces directed ahead and laterally, emerging on the surface of tapered endings during the passing through the stenosis. RESULTS - The stent delivery systems were between 5.0 and 5.9 F in diameter, and even the stent delivery system of lowest profile would dilate a stenosis of over 89%. The different endings are tapered with variable lengths. The force transmission on the vessel wall of different directions was distinct at the various points of the cone surfaces. The forces directed ahead were less than those directed laterally on the larger part of a cone surface. Irregularity of the cone surfaces distributed the forces unfavorably. Considering the features of tapered endings, the atraumatic introduction of the devices required a range of upper limits of stenoses between 89.76-98.04%, which are more feasible values than those deternined by shaft sizes. CONCLUSIONS - Our experimental work suggests, that the shape and size of the endings of stent delivery systems influence the forces affecting vessel wall plaques, and in this manner, embolic complications, during carotid stenting. The lowest risk of embolisation could be induced by using the longest and smoothest tapered endings.]

Lege Artis Medicinae

MAY 20, 2003

[Conservative treatment of female urinary incontinence]

MATÁNYI Sándor

[Conservative treatment - lifestyle interventions, physical therapies, bladder retraining and devices - should be included in the counselling of incontinent women regarding treatment options. Obesity is an independent risk factor for the prevalence of urinary incontinence and weight loss would appear to be an acceptable treatment option for morbidly obese women. Chronic straining may also be risk factor for the development of urinary incontinence. Further research is needed to evaluate the effect of heavy exertion/exercise, smoking, caffeine and fluid intake on incontinence and whether their cessation can alleviate or prevent this condition. Specific pelvic floor muscle training targeted at women with genuine stress incontinence may optimise effectiveness and for those women with mixed and urge incontinence, it may be appropriate to offer pelvic floor muscle training in combination with bladder retraining. There is insufficient evidence to determine whether electrostimulation is better than no treatment for women with stress, mixed, or urge incontinence while bladder retraining is an effective treatment in these cases. The anti-incontinence extraurethral or intraurethral occlusive, and intravaginal supportive devices may be employed for initial and/or long term management and be used prior to or simultaneously with other forms of conservative therapy and if after other forms have failed in order to postpone or avoid surgery or following unsuccessful surgical intervention.]

Lege Artis Medicinae

MARCH 20, 2004

[THE PROBLEM OF SMOKING]

RODÉ Magdolna

[Smoking causes a health catastrophy all over the world. Its importance is increasing in the less developed countries. More and more young people (especially women) have started smoking recently. Its devastating effect on women carries on to the next generations. Prevention should already begin in childhood. In Hungary, there is a wide network to assist for those who want to give up smoking - especially in the national network of lung health care clinics. Peer supporters have a prominent role in helping these patients. The market-strategy and publicity campaign of major tobacco producers also deserves intensive attention.]