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Clinical Neuroscience

SEPTEMBER 30, 2020

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

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.

Lege Artis Medicinae

SEPTEMBER 30, 2020

[Case report about the choice of care at Olajág Elderly Home in Budapest during the COVID-19 epidemic in spring 2020]

PETRÓ Kata, PETKE Zsolt, RADNAI Zoltán, SZIRMAI Viktor

[During the COVID-19 pandemic caused by the SARS-CoV-2 virus, elderly people in long-term nursing homes were espe­cially risks exposed. In this study, the au­thors analyse the causes of local outbreak at the Olajág Elderly Home Vezér street facility in Budapest and the means and ways to curb the spreading of infection. They summarise the measures, which proved to be effective in isolation and treat­ing the patients. The number of infected residents as well as the course of the disease are demonstrated by statistical data. The authors consider as pre-eminently important to identify asymptomatic but in­fec­ted residents, further the rapid introduc­tion of screening tests, strict compliance with protocols, patient path regulation and the use of enhanced, supportive communication.]

Clinical Neuroscience

JANUARY 30, 2016

Long term follow-up of lesional and non-lesional patients with electrical status epilepticus in slow wave sleep

HEGYI Márta, SIEGLER Zsuzsa, FOGARASI András, BARSI Péter, HALÁSZ Péter

Objectives – A retrospective study has been done at the Bethesda Children’s Hospital Epilepsy Center with those patients whose EEG records fulfilled in one or more records the criteria of electrical status epilepticus in slow wave sleep (ESES) pattern, occupying at least 75% of NREM sleep with bilateral discharges, and had detailed disease history and long term follow-up data, between 2000 and 2012. Patients and methods – Thirty-three patients (mean 11.1±4.2 years of age) were studied by 171 sleep EEG records. Sleep was recorded after sleep deprivation or during spontaneous sleep at least for one hour length of NREM. From the 492 EEGs, 171 sleep records were performed (average five/patient). Average follow-up time was 7.5 years. Eighty-two ESES records have been analyzed in 15 non-lesional and 18 lesional (11 with dysgenetic and seven with perinatal - asphyxic or vascular origin) patients. Variability of seizure types, seizure frequency and frequency of status epilepticus was higher in the lesional group. Impairment of the cognitive functions was moderate and partial in the non-lesional, while severely damaged in the lesional group. Results – EEG records of 29 patients showed unihemispherial spike fields with a perpendicular axis (in anterior, medial and posterior variants) to the Sylvian fissure, regardless their lesional or non-lesional origin. Only three (1one non-lesional and two lesional) patients had bilateral synchronous spike-wave discharges with bilateral symmetric frontocentral spike fields. The individual discharges of the sleep EEG pattern were very similar to the awake interictal records except their extension in time and field, their increased number, amplitude, and continuity of them and furthermore in the increased trans-hemispheral propagation and their synchronity. Conclusions – Assumed circuits involved in the pathomechanism of discharges during NREM sleep in ESES are discussed based on our findings.

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. ]

Clinical Neuroscience

SEPTEMBER 30, 2019

Acute bilateral drop foot as a complication of prolonged squatting due to haemorrhoid

KOKSAL Ayhan, DOGAN Burcu Vasfiye

Drop foot is defined as difficulty of dorsiflexion of the foot and ankle due to weak anterior tibial, extensor hallucis longus and extensor digitorum longus muscles. Cauda equina syndrome, local peroneal nerve damage due to trauma, nerve entrapment, compartment syndrome and tumors are common etiologies. A 32-year-old male patient was applied with difficulty in dorsiflexion of both of his toes, feet and ankles after he had squatted in toilette for 6-7 hours (because of his haemorrhoid) after intense alcohol intake 2 weeks before. Acute, partial, demyelinating lesion in head of fibula segment of peroneal nerves was diagnosed by electromyography. This case was reported since prolonged squatting is an extremely rare cause of acute bilateral peroneal neuropathy. This type of neuropathy is mostly demyelination and has good prognosis with physical therapy and mechanical devices, but surgical intervention may be required due to axonal damage. People such as workers and farmers working in the squatting position for long hours should be advised to change their position as soon as the compression symptoms (numbness, tingling) appear.

Lege Artis Medicinae

SEPTEMBER 10, 2019

[What may hurt the patient’s leg? Lower extremity ischaemia]

FENDRIK Krisztina, BIRÓ Katalin, KOLTAI Katalin, ENDREI Dóra, TÓTH Kálmán, KÉSMÁRKY Gábor

[Peripheral artery disease (PAD) is of high prevalence, and one of the most common clinical manifestations of the atherosclerosis beside ischaemic heart disease and cerebrovascular disease. PAD should be considered as a systemic disease, PAD patients have two times higher ten-year cardiovascular mortality than the normal population. For these reasons, the early recognition of the disease, the appropriate secondary preventive medical and non-medical therapy are of great importance. Risk stratification, proper physical examination, ankle pressure, ankle-brachial index, toe pressure, transcutaneous partial tissue oxygen pressure measurement and duplex ultrasound are the cornerstones to an early diagnosis. This summary aims at calling attention to the fact that lower extremity pain can not only be caused by musculo­sceletal diseases but limb and/or life-threatening limb ischaemia can be revealed in the background. ]

Hypertension and nephrology

SEPTEMBER 10, 2019

[Kidney diet and the patient compliance issue ]

LADÁNYI Erzsébet

[There have been significant developments in the field of nephrology and dialysis as for the science and technology are concerned in the past decades. However, CKD patients still show high mortality and morbidity. From among the several factors determining the long-term outcome of CKD patients metabolic disorder and malnutrition play an important role. Malnutrition is often not diagnosed or is not paid enough attention to in the complex treatment of CKD patients. It is important to make both the patients and clinical staff more aware of proper nutrition and importance of prevention and treatment of malnutrition, respectively. The early diagnosis and treatment of malnutrition is of utmost importance in CKD patients. The long term renal failure and the accompanying malnutrition have a negative impact on their long term outcome and quality of life. Since the malnutrition causes a lot of complications, it is indispensable for dietitians and nephrologists to work closely together. Patient compliance is a determining factor in the successful implementation of renal diet.]

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).]

Lege Artis Medicinae

MAY 20, 2019

[Treating methods of obstructive sleep apnea syndrome and related difficulties in daily practice ]

MOLNÁR Márton, CSATLÓS Dalma, HARGITTAY Csenge, MOHOS András, TERRAY-HORVÁTH Attila, DOMBOVÁRI Magdolna

[Obstructive sleep apnea syndrome (OSAS) is the most common breathing disorder during sleep. Its incidence is between 2-4%, but in many cases, the disease is not recognized. It has many symptoms, but the most typical symptoms are loud snoring and daytime sleepiness. Treatment always consists of several elements depending on the patients’ specific needs. When deciding on which treatment to use efficiency and the patients’ compliance are the key factors. The necessity of the therapy can be determined by three criteria: clinical complaints (daytime discomfort), the severity of the breathing disorder and the accompanying cardiovascular diseases. Treating possibilities for the mild to moderate OSAS are lifestyle changes (losing weight, avoiding alcohol and sedative drugs), positional therapy, oral appliances, and varied surgical corrections. For patients with moderate to severe OSAS and mild OSAS with severe symptoms the first line therapy is continuous positive airway pressure. In addition to presenting new therapeutic options, the authors describe the role of the family physician in the care of apnea patients.]

Lege Artis Medicinae

MARCH 20, 2019

[Long-term CPAP compliance among Sleep Apnea Patients at the Sleep Laboratory of the Hungarian Defense Forces Medical Center ]

DOMBOVÁRI Magdolna, BERNÁT István, TERRAY-HORVÁTH Attila, CSATLÓS Dalma, HARGITTAY Csenge, TORZSA Péter

[Obstructive sleep apnea syndrome (OSAS) is the most common sleep disorder, with a prevalence of 2-4% in the overall popula­tion. It is a risk factor for cardiovascular diseases and its daytime symptoms significantly impair the patients’ quality of life and increase the risk of work and road accidents. Its first-line treatment is the CPAP device (Continuous Positive Airway Pres­sure) the effectiveness of which is significantly determined by the compliance of the patient. Although the issue of compliance in such treatment is a very important factor, long-term studies including a large number of patients have not been published yet, and there are no known data about it in Hungary. OBJECTIVE - Examining the long-term compliance of CPAP among OSAS patients in a sleep laboratory in Hungary. METHOD - 3403 OSAS patients were selected for our study between January 1, 2007, and September 30, 2017. The diagnosis and titration of effective CPAP pressure were determined by polysomnography. Patients were controlled after 2 months of therapy and then every 6 and 12 months. During the care, their compliance value was determined by data downloaded from their device's memory card. RESULTS - The mean age (± SD) of patients was 59.0 (± 10.5) years, most of them were male, 2676 (78.6%), their average body mass index (BMI) was 32.6 (± 5.25) kg/m2, their average Epworth Sleepiness Scale score was 11.4 (± 5.0), their average Apnea-Hypopnoe index was 51.0 (± 19.5) events/hour. The average usage time of the CPAP device was 5.0 (± 1.9) hours. 72.3% of the patients used the device for over 4 hours and 27.7% used it for less than 4 hours. 34.7% of the patients used the device for more than 6 hours. The Epworth Sleepiness Score showed a significant and dose-dependent improvement over CPAP treatment, with a greater improvement among patients who used the machine for longer hours. The highest score improvement was achieved by users who used CPAP between 6-7 hours, averaging 7.3 (± 3.2) points (p <0.001). CONCLUSIONS - Our present study shows that high average compliance can be achie­ved among well-adjusted and well-maintained patients. ]