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Lege Artis Medicinae

APRIL 18, 2020

[Digitally-assisted treatment planning in precision oncology]


[The progress of molecular information based on personalized precision medicine has reached a new milestone. Actually, about 6 million mutations of 600 genes may be related to the development of cancer, and on average, 3-4 of these “driver” mutations are present in each patient. Due to the progress in molecular diagnostics, we can now routinely identify the molecular profile of tumors in clinical settings. By clinical translation, there are actually available more than 125 targeted pharmaceuticals and hundreds of such therapies are under clinical trial. As a result, we have many first-line and licenced treatment options to be elected by molecular information as the optimal one for every patient. There is an increasing need for complex informatics solutions by medical software. Geneticists, molecular biologists, molecular pathologists, molecular pharmacologists are already using bioinformatics and interpretation software on their daily work. Today, online digital tools of artificial intelligence are also available for physicians for assisted treatment planning. Telemedicine, videoconferencing provide solutions for interdisciplinary virtual molecular tumor boards, which democratizes the access to precision oncology for all doctors and patients. ]

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 Oncology

FEBRUARY 20, 2019

[The role of artifi cial intelligence in precision medicine]

MESKÓ Bertalan

[The essence of practicing medicine has been obtaining as much data about the patient’s health or disease as possible and making decisions based on that. Physicians have had to rely on their experience, judgement, and problem-solving skills while using rudimentary tools and limited resources. With the cultural transformation called digital health, disruptive technologies have started to make advanced methods available not only to medical professionals but also to their patients. These technologies such as genomics, biotechnology, wearable sensors, or artifi cial intelligence (AI) are gradually leading to three major directions. They have been (1) making patients the point-of-care; (2) created a vast amount of data that require advanced analytics; and (3) made the foundation of precision medicine. Instead of developing treatments for populations and making the same medical decisions based on a few similar physical characteristics among patients, medicine has shifted toward prevention, personalization, and precision. In this shift and cultural transformation, AI is the key technology that can bring this opportunity to everyday practice.]

Clinical Neuroscience

MARCH 30, 2019

[Sturge Weber type 3 presenting with occipital epileptic seizure: case report ]

SERİNDAĞ Cansu Helin, EREN Fulya, KARAHAN Gökçen Muazzez, GUL Gunay, SELCUK Hakan, KARA Batuhan, SOYSAL Aysun

[Sturge Weber syndrome is the third most common neurocutaneous syndrome after neurofibromatosis and tuberous sclerosis. Three distinct types were identified. Type 3 with leptomeningeal involvement alone is the rarest among other types. The reported case is a 21-years-old female patient without any known chronic disease. She admitted to the emergency department after visual symptoms and headache, followed by generalized tonic clonic seizure. EEG of the patient showed left occipital seizure activity. The contrast enhanced magnetic resonance imaging (MRI) showed left occipital leptomeningeal angioma. Digital substraction angiography (DSA) revealed minimal blushed contrast enhancement on late venous phase and lack of superficial cortical veins. Her focal seizures were under control with levatiracetam and lacosamide treatment. The reported case is unique because of the late onset presentation with focal seizure without mental retardation.]

Hypertension and nephrology

DECEMBER 10, 2018

[Prognostic role of arterial stiffness in IgA nephropathy]

SÁGI Balázs, KÉSŐI István, VAS Tibor, CSIKY Botond, KOVÁCS Tibor, NAGY Judit

[Background: Arterial stiffness has a prognostic role in chronic cardiovascular diseases. Pulse wave velocity (PWV) determined by the carotid-femoral pulse detection is accepted as a gold standard method. Further diagnostic procedures are in use to assess the arterial stiffness including the finger photoplethysmography. The prognostic role of this method is limited in chronic renal diseases. The goal of our investigation was to determine the prognostic significance of the stiffness index (SIDVP) measured by the photoplethysmographic method in IgA nephropathy. Patients and methods: One hundred and three histologically proved IgA nephropathy patients with chronic kidney disease stage 1-4 were investigated (67 male, 36 female, 45 ± 11 years) and followed for an average 65 (6-107) months. The stiffness index was determined by the volume alteration of the digital artery during the cardiac cycle (Pulse Trace system, Micro Medical, Gilingham, Kent, UK). The primary combined end point was total mortality, major cardiovascular events (stroke, myocardial infarction or cardiovascular procedure, for example revascularisation) plus achieving end stage renal disease. The secondary end points were cardiovascular and renal end points alone. Results: The patients with increased stiffness index (> 10 m/s) had significantly more combined primary end point events (10/60 vs. 19/43, P = 0.015). In case of the secondary end points the renal end points were significantly more frequent in patients with higher stiffness index. Stiffness index has also proved to be an independent predictor on survival from other cardiovascular risk factors (age, hypertension, diabetes, obesity, lipid disturbances and decrease of renal function) using the Cox regression model in IgA nephropathy. Every 1 m/s increase in stiffness index resulted a 17% gain in the occurrence of the combined primary end point. Conclusions: Stiffness index determined by finger photoplethysmography is an eligible parameter to assess the prognosis in IgA nephropathy. Increased stiffness index in IgA nephropathy seems to be a good prognostic tool for identification of higher risk patients.]

Clinical Neuroscience

MARCH 30, 2018

A case with angiographic demonstration of isolated anterior spinal artery occlusion

DOGAN Burcu Vasfiye, KARA Batuhan, SELCUK Hatem Hakan, DIRICAN Ceyhan Ayten, KOKSAL Ayhan

Anterior spinal artery syndrome (ASAS) is a rare syndrome which occurs due to thrombosis of anterior spinal artery (ASA) which supplies anterior two thirds of the spinal cord. A 27-year-old female patient was admitted to emergency clinic with sudden onset neck pain, sensory loss and weakness in proximal upper extremities which occurred at rest. Thrombophilia assessment tests were negative. Echocardiography was normal. Serum viral markers were negative. In cerebrospinal fluid (CSF) examination, cell count and biochemistry was normal, oligoclonal band was negative, viral markers for herpes simplex virus (HSV) type-1 and type-2, Brucella, Borrellia, Treponema pallidum, Tuberculosis were negative. Diffusion restriction which reveals acute ischemia was detected in Diffusion weighted MRI. Digital subtraction angiography (DSA) was performed. Medical treatment was 300mg/day acetilsalycilic acid. Patient was discharged from neurology clinics to receive rehabilitation against spasticity.

Hypertension and nephrology

SEPTEMBER 10, 2017

[Thought about renovascular hypertension by a special case report]

GAJDÁN Nikolett, LÉGRÁDY Péter, BAJCSI Dóra, MORVAY Zita, NAGY Endre, LETOHA Annamária, KYPROS Constantinou, FEJES Imola, SONKODI Sándor, ÁBRAHÁM György

[Renovascular hypertension is a well-known form of secunder hypertension. Two thirds of cases are caused by atherosclerotic plaque and one third are caused by fibromuscular dysplasia. The prevalence of it is less than 1%. Digital subtraction angiography is considered the goldstandard diagnostic method. The 58-year old female patient was hospitalized with resistant hypertension. Duplex ultrasonography showed fibromuscular stenosis the in left renal artery. Percutaneous transluminal angioplasty and stenting were performed. Her blood pressure normalized. The patient did not attend the control examinations. Next time in 2001, she was referred to our emergency department with increased blood pressure of 210/140 mmHg. Following control ultrasonography angiography showed total occlusion of the left renal artery and significant stenosis of the right renal artery. Left nephrectomy was necessary due to shrunken kidney and dilatation and stenting of the right renal artery. The blood pressure normalized again. Since 2004 until 2014 despite of the regular visits, we detected in stent restenosis of the right renal artery almost in each year. Even so, renal function was preserved all the time. In autumn of 2014, the patient suffered severe stroke, and few months later at the age of 74 she died. There are many open questions to discus concerning the right treatment of renovascular hypertension yet. Even so by performing 12 intravascular interventions we could ensure her acceptable quality of life for 16 years.]

Hypertension and nephrology

MAY 20, 2017

[Prognostic significance of stiffness index determined by digital volume pulse method in polycystic kidney disease]

SÁGI Balázs, KÉSŐI Bence, KÉSŐI István, VAS Tibor, CSIKY Botond, NAGY Judit, KOVÁCS Tibor

[Introduction: It is known from previous studies, that in chronic renal failure cardiovascular mortality and morbidity are more frequent than in the general population. The prognostic significance of arterial stiffness on cardiovascular outcomes trials was first demonstrated in end-stage renal disease patients by epidemiological longitudinal studies. Our aim was to assess the prognostic significance of arterial stiffness in polycystic kidney disease. Methods: 55 patients with polycystic kidney disease (PKD) were examined and followed in our clinic. Pulse wave velocity was determined by digital volume pulse (DVP) method, and a so-called stiffness index (SI DVP) was calculated. MDRD formula was used for estimating the glomerular filtration rate (eGFR, mL/min/1.73 m2) to determine renal function. Patients were observed regularly, in every 3-6 months, and we checked lab tests, which assessed the patient’s renal function and cardiovascular events occurred in patients were collected in our outpatient department. Results: Our study involved 55 patients, 21 were male, the mean age was 45±12 years. The average follow-up was 63±32 months. The average value of the stiffness index was 11.11±2.22 m/s. We divided the patients by 11 m/s as cut off point of SI values into two groups and analysed their outcome. In the increased arterial stiffness group (SI >11 m / s) the probability of the combined endpoint occurrence was signi - fi cantly higher than in the group with flexible arteries (χ-square: 4.571; p=0.033). Between the two groups we did not found significant difference in cardiovascular endpoint, but we found a statistically significant difference between the two groups in renal outcomes (χ-square: 5.591; p=0.018). Conclusion: In polycystic kidney disease the increased arterial stiffness may predict the onset of end-stage renal failure. Digital Pulse volume as determined by Pulse Trace system appears an appropriate method for making prognosis in chronic kidney disease.]

Lege Artis Medicinae

DECEMBER 15, 2015

[Actual questions of the longterm anticoagulant therapy]

SAS Géza

[In the last few years we have witnessed some changes in the area of the chronic oral anticoagulant therapy. The nomenclature of the anticoagulant drugs has been modified and concern has arisen about the possible vascular calcification in patients on long-term warfarin therapy. Because of the novelty of the “new” anticoagulants (dabigatran etc.) has been lost, instead of their previous acronym (NOAC) the DOAC (direct oral anticoagulants) term has been accepted for their marking. Experimental and clinical data suggested that vitamin K-antagonists (VKA) in addition to the coagulation factors disturb the production of other proteins, too. By inhibiting the matrix Gla protein (MGP), the chronic warfarin therapy promotes the calcification in media of the arteries as it was shown in women participating in routine mammography. However, the clinical importance of this observation is dubious, because the incidence of acute coronary events is not increased in cases of warfarin therapy in patients with atrial fibrillation. Notwith­standing, in addition to the bleeding complications we have to take into account of the possible harmful vascular calcification, too, at the indication of chronic coumarin therapy. Therefore, this therapy should be applied only in proper cases, such as non-valvular atrial fibrillation with a high risk of ischaemic stroke or unprovoked venous thromboembolic disease with a high risk of recurrence. The results of the Swedish anticoagulant register show that the efficacy and safety of the well-managed coumarin therapy may be superior to the treatments with DOACs. However, DOACs are indispensable in certain cases in which a previous “probe” coumarin treatment is unfounded.]

Clinical Neuroscience

NOVEMBER 28, 2014

[The interactive neuroanatomical simulation and practical application of frontotemporal transsylvian exposure in neurosurgery]


[Background and purpose - There is an increased need for new digital education tools in neurosurgical training. Illustrated textbooks offer anatomic and technical reference but do not substitute hands-on experience provided by surgery or cadaver dissection. Due to limited availability of cadaver dissections the need for development of simulation tools has been augmented. We explored simulation technology for producing virtual reality-like reconstructions of simulated surgical approaches on cadaver. Practical application of the simulation tool has been presented through frontotemporal transsylvian exposure. Methods - The dissections were performed on two cadaveric heads. Arteries and veins were prepared and injected with colorful silicon rubber. The heads were rigidly fixed in Mayfield headholder. A robotic microscope with two digital cameras in inverted cone method of image acquisition was used to capture images around a pivot point in several phases of dissections. Multilayered, high-resolution images have been built into interactive 4D environment by custom developed software. Results - We have developed the simulation module of the frontotemporal transsylvian approach. The virtual specimens can be rotated or tilted to any selected angles and examined from different surgical perspectives at any stage of dissections. Important surgical issues such as appropriate head positioning or surgical maneuvers to expose deep situated neuroanatomic structures can be simulated and studied by using the module. Conclusion - The simulation module of the frontotemporal transsylvian exposure helps to examine effect of head positioning on the visibility of deep situated neuroanatomic structures and study surgical maneuvers required to achieve optimal exposure of deep situated anatomic structures. The simulation program is a powerful tool to study issues of preoperative planning and well suited for neurosurgical training.]