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Lege Artis Medicinae

NOVEMBER 30, 2020

[Lung cancer – a review of thirty years. Thoughts about the past struggles, the present results and promises of the future]

OSTOROS Gyula

[In the past thirty years there was a huge development in the complex treatment of lung cancer. This development is due mostly to the last decade. Nihilism of lung cancer treatment is over and it is a reality that even patients in advanced stage turn out curable by appropriate therapy and their condition may be changed for a chronic disease while using anti-tumour therapy. Thirty years ago, the realistic life expectancy of six to eight months in advanced stage mounted nowadays significantly, and may surpass even five years in a number of cases. It required adequate diagnostic background, which provided the biomarker based treatment. In early stage surgical resection has a fundamental role, coupled with modern complex neoadjuvant and adjuvant treatment, while new surgical techniques also contributed to the improvement of therapeutic results. The same is true for radiation therapy. The same complex strategy is prevailing also in pharmaceutical options, which are dominated by modalities of cytotoxic chemotherapies and targeted immunothe­rapies. Multidisciplinary teams play a significant role in strategic decisions of lung cancer treatment. The future ways are indicating repeated innovations of tar­geted therapies and extended indica­tions of immunotherapy in terms of precision medicine. However, we must keep in mind also the primary and secondary prevention with effective smoking cessation programs and low-dose chest CT scree­ning applied as usual soon in the risk groups. ]

Lege Artis Medicinae

NOVEMBER 30, 2020

[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

Lege Artis Medicinae

NOVEMBER 30, 2020

[Economic features of rewarding physicians – changing for fair incomes in Hungary ]

BALÁZS Péter

[Since ages, rewarding physicians was a crucial problem. Among true professionals (priests, legal experts, physicians and teachers) only medical doctors are necessarily working in physical terms, which generates permanent uncertainty about their remuneration. Old Age manual services (surgery, obstetrics) were paid by artisans’ standards while patients of faith-healing (by priest-doctors) presented religious offers according to their capacities. Hippocrates’ business ethics transformed this pattern as price elasticity for profane providers. During the Medieval Ages, governments issued also for physicians fee schedules or in some countries like Hungary they agreed free on remuneration with their patients. Thus, Hungary’s physicians experienced 1891 the implementation of the Bismarck type social health insurance as a real shock-wave generated by the depressed fee proposals. After the first hit, during the following 100 years Hungary committed all possible financial failures down to the fall of Communism in 1989. After the age (1949–1989) of socialism in the health care, general practitioners returned to the self-employed business however under heavy custody of a single payer public fi­nan­cing. Specialist in out and in-patient care (if they used this opportunity) were “li­cenced” for earning money on the quasi pri­vate market of the under-the-table informal business. Actually, only the private dentistry preserved its legal free market share and by the cross-border “dental-tourism” Hungary joined also the competitive international dental market. All other specialists demonstrate income discontent by requiring higher wages, working abroad or fuelling debates on accepting informal payments of “thankful” patients. Contrasted to dentistry, there are actually no economic standards to ponder physicians’ income expectations and compare them with purchasing power of public and private financing. This study shows first the historic evidence of the relevant golden standard and its continuity un-der the present circumstances however supressed for political reasons. It would be able to settle debates about the public employees’ wages of doctors caught out of the thin air. ]

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

DECEMBER 30, 2019

[Systemic anticancer therapy in patients undergoing hemodialysis]

VÉGH Éva, LAKATOS Gábor, TOKODI Zsófia

[The number of cancer patients receiving regular dialysis treatment is increasing. These patients could benefi t similarly from the regular anticancer therapies. Data of the use of antineoplastic therapies in this vulnerable patient population mainly come from case reports and small case series. The lack of knowledge and lack of practical experiences in this patient group may lead to suboptimal cancer treatment. Defi ning the indication for antineoplastic treatment and choosing the appropriate drug is a challenging task and the patients’ prognosis and quality of life aspects should be evaluated carefully. The timing of anticancer treatment and the dialysis is also an important issue in this decision-making process. Close cooperation between the oncologists and nephrologists is essential in the proper antineoplastic treatment of the dialysed patients.]

Clinical Oncology

DECEMBER 30, 2019

[Prevention and treatment of venous thromboembolism in cancer patients]

[Venous thromboembolism (VTE) is a common and severe complication of cancer. Deep vein thrombosis and pulmonary embolism are the second most common cause of death in cancer patients. Cancer, tumor-related factors as well as patient’s general condition and comorbidities are responsible for the increased risk of VTE. Chemotherapy is one of the most important risk factors for VTE, increasing incidence of VTE by 6.5-fold. In my paper, current guidelines for cancer VTE prevention and treatment are reviewed. Hospitalized patients with active tumor are at higher risk for VTE, and thrombosis prophylaxis is recommended in all cases. Extensive, routine prophylaxis for advanced cancer patients receiving chemotherapy is not recommended, but may be considered in high-risk ambulatory cancer patients (Khorana-score ≥ 3). Risk factors may change during the course of cancer disease, and the score should be continually reviewed and prophylactic treatment changed as necessary. LMWH is the recommended agent for both primary and secondary prophylaxis/treatment. Direct oral anticoagulants (DOACs) are knocking on our door, but results from further clinical trials are pending to determine their exact role.]

Clinical Neuroscience

NOVEMBER 30, 2020

[New results of neuroscience research – the background of symptomatological and etiological diversity of mental disorders]

OSVÁTH Péter

[Nowadays, the focus of genetic, neurobiological, neuropsychological and psychosocial research is on a more accurate discovery of the etiology of mental illnesses, especially with regard to the role and complex interactions of certain risk factors. It is increasingly challenging to interpret the results of different aspects and methodologies in a coherent theoretical framework, as this can only lead to a more accurate understanding of the complexity and mechanism of the psychiatric disorders. The main aim of this paper to overview recent studies on etiological background of mental disorders and to present the most important aspects of the Research Domain Criteria (RDoC) system. Review of reports from comprehensive studies published in the most important psychiatric journals over the past five years summarizing new findings on the etio­logy of mental disorders. Although current classifications indicate that mental disorders are strictly distinct diagnostic categories, new findings suggest that these marked differences in symptomatic, genetic, and neurobiological backgrounds are not detectable, as many mental disorders have been identified as having common molecular genetic risk factors, which may indicate common neurobiological pathomechanisms. Research results support the need for a rethinking of psychiatric nosology on an etiological basis and represent an important step forward in the more accurate exploration of the neurobiological background factors of mental disorders and thus in the development of more targeted therapeutic approaches. The development of the RDoC system can be a great help in this, as this dimensional approach offers the possibility of integrating the - often diffuse or even contradictory - neuroscientific research findings into a unified theoretical framework for the etiology, nosology and treatment of mental disorders. ]

Clinical Oncology

AUGUST 30, 2019

[Electrochemotherapy]

KIS Erika Gabriella

[Tumors with standard electrochemotherapy (ECT) has raised over the past decade from skin cancers to locally advanced or metastatic tumors. The procedure became a reliable alternative of other local tumor ablation methods, because of its patient tolerability, effi cacy across histotypes, and repeatability. ECT is based on the physical phenomenon of reversible electroporation; short electric pulses are applied to tumor nodules to achieve transient cell membrane permeabilization to otherwire poorly permeant chemotherapy drugs, which consequently increases cytotoxicity. At present recognized indications include superfi cial metastases of malignant melanoma, breast cancer, head and neck skin tumors, Kaposi sarcoma, primary and recurrent nonmelanoma skin cancers, and in well-selected patients mucosal oropharyngeal cancers. Emerging applications include skin metastases from visceral or hematological malignancies, vulvar cancer, certain benign skin lesions, and the combination of ECT with systemic immunotherapy. Thanks to the technical developments, the new ECT indications are deep-seated tumors, including bone metastases, liver malignancies, pancreatic and prostate cancers with the use of long needle variable geometry electrodes. Herein we review the present status of ECT from the basic principles to emerging applications, and report the effi cacy of standard ECT across histotypes.]

Clinical Oncology

AUGUST 30, 2019

[Beyond second line therapy in patients with metastatic colorectal cancer: a systematic review]

D. Arnold, G. W. Prager, A. Quintela, A. Stein, S. Moreno Vera, J. Taieb

[Background: The optimal chemotherapeutic regimen for use beyond the second line for patients with metastatic colorectal cancer (mCRC) remains unclear. Materials and methods: We systematically searched the Cochrane Database of Systematic Reviews, EMBASE and Medline for records published between January 2002 and May 2017, and cancer congress databases for records published between January 2014 and June 2017. Eligible studies evaluated the effi cacy, safety and patient-reported outcomes of monotherapies or combination therapies at any dose and number of treatment cycles for use beyond the second line in patients with mCRC. Studies were assessed for design and quality, and a qualitative data synthesis was conducted to understand the impact of treatment on overall survival and other relevant cancer-related outcomes. Results: The search yielded 938 references of which 68 were included for qualitative synthesis. There was limited evidence to support rechallenge with chemotherapy, targeted therapy or both. Compared with placebo, an overall survival benefi t for trifl uridine/tipiracil (also known as TAS-102) or regorafenib has been shown for patients previously treated with conventional chemotherapy and targeted therapy. There was no evidence to suggest a difference in effi cacy between these treatments. Patient choice and quality of life at this stage of treatment should also be considered when choosing an appropriate therapy. Conclusions: These fi ndings support the introduction of an approved agent such as trifl uridine/tipiracil or regorafenib beyond the second line before any rechallenge in patients with mCRC who have failed second line treatment.]

Clinical Oncology

AUGUST 30, 2019

[Prevention of drug-related neuropathy in the clinical practice]

VAJDICS Tímea

[There was a revolution of oncological treatments in the last fi ve years caused by introduction of immuncheckpoint inhibitors. Platinum and taxane based chemotherapies are the standard of care of the most frequent malignancies such as colon and breast cancer. Signifi cant improvement was achieved concerning side effects of chemotherapy in the few past decades. Preventive treatment of vomiting, neutropenia, aneamia are now based on clinical evidences. Meanwhile, there remained side effects (including chemotherapy induced neuropathy) which are diffi cult to treat. This article provides overwiev of the pharmacological therapies, vitamins and non-pharmacological procedures aimed to prevent chemotherapy induced neuropathy. Unfortunately still there are no drugs that are highly effective of preventing of chemotherapy induced periferial neuropathy validated in randomized clinical trials.]