Search results

Hypertension and nephrology

SEPTEMBER 30, 2020

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

[Frequency and risk factors of “de novo” tumors after kidney transplantation ]

BORDA Bernadett, HÓDI Zoltán, SZEDERKÉNYI Edit, OTTLAKÁN Aurél, SEREGÉLY Edit, LÁZÁR György, KERESZTES Csilla, VIRÁG Katalin

[After kidney transplantation, the administration of immunosuppressive therapy not only renders the patient susceptible to infections, but it may also damage the function of tumor cell recognition and elimination. Our study was performed at the Department of Surgery, University of Szeged. After establishing the inclusion criteria, 570 patients were involved in the study. We examined the age, sex, immunosuppressive therapy of the patients, and searched for the rela­tionship between the different immunosuppressive agents and the type of the tumor. In 81 cases, de novo cancer was diagnosed. Among patients treated with cyclosporin and tacrolimus there was no significant difference in the mean age (p = 0.734) and body mass index (p = 0.543). There was no significant difference in graft function between the two groups of patients (Tac vs Cyc; 44 vs 20). Related to the time passed since the trans­plantation to diagnosing the tumors the earliest were prostate and cervix cancers however without significant difference. Skin cancers are the most frequent followed by post-transplant lym­pho­prolife­ra­tive diseases. The increasing risk of developing tumors is mainly due to immunosuppressive therapy. ]

Lege Artis Medicinae

JULY 01, 2020

[Sarcopenia – muscle loss – pathomechanism, clinical presentation and metabolic comorbidities]

VERECKEI Edit, HODINKA László

[Sarcopenia, or the age-related involution of muscle strength and muscle mass, is a serious public health concern, due to the growing number of elderly population caused by nowadays demographic changes i.e. prolonged life expectancy. By ageing, the muscle tissue is shrinking gradually, leading to the loss of muscle strength and masses. This condition is called sarcopenia. Sar­co­penia is the simultaneous decrease of muscle mass, muscle strength and functional independence. In parallel the physical performance deteriorates (weakness, slowness and poor physical balancing). Fatigue, el­derly behaviour and weight loss are the consequences of these accumulating deficits, which associate with cognitive decline and result in increasing social isolation. The primary form of sarcopenia is the decrease of the energy production of muscle cells and then the death of muscle cells. Se­con­dary, endocrine dysfunctions, diseases of the nervous system, decreased physical activity, malnutrition or malabsorption, chronic infection accelerate the process and aggravate the patient’s condition. Complex genetic, biochemical and endocrine mechanisms take part in the development of sarcopenia. This involution is due to the impaired balance of restoring and depleting processes of muscles. A questionnaire and algorithm have been developed to recognize, screen and diagnose the risks of sarcopenic condition; these separate the sarcopenic and non-sarcopenic patients with specific cut-off values. Sar­co­penia can be diagnosed based on walking speed, decreased handgrip strength and measured or calculated muscle mass in persons over 65. Sarcopenia can be considered as a phenomenon of “physiological” aging, however, it becomes a disease when diagnostic cut-offs are exceeded and the patient experiences functional disability and declining quality of life. Prevention and treatment of sarcopenia and reducing the risk of falling are based on regular active resistance and coordination exercises. Options for pharmaceutical treatments are limited since despite of identified molecular targets there are no convincingly effective innovative therapy on the horizon. Nevertheless, there are some weak evidence for efficacy of the application of amino acids stimulating muscle cell differentiation, such as leucine or the analogue of beta-hydoxy-methylbutyrate beside exercise therapy.]

Hypertension and nephrology

JUNE 24, 2020

[Comparison of kidney transplant patients with IR-tacrolimus and LCP-tacrolimus]

BORDA Bernadett

[Tremor is the most common adverse event of tacrolimus, and it correlates with the peak concentration of the drug. LCP-tacrolimus is a prolonged release formulation of tacrolimus to be administered once daily and has a dec - reased Cmax value. Hand tremors are evaluated by the Fahn-Tolosa-Marin (FTM) scale used by the neurologists. In case of hand tremor, tacrolimus is switched to LCP-tacrolimus. Tremor improved significantly in accordance with the STRATO cli - ni cal study, which confirmed that switching to LCP-tacrolimus resulted in clinically significant improvement in hand tremor.]

Hypertension and nephrology

JUNE 24, 2020

[Not all young, athletic university students have optimal blood pressure. Results of the May 2019 Measurement Month (MMM19)]

PATÓ Anna, NÉMETH Zoltán, JÁRAI Zoltán, KOLLER Ákos

[For about 100 years, it has been known that persistently high blood pressure (hypertension) is the leading cause of cardiovascular disease deaths, such as major risk factors for heart failure, myocardial infarction, stroke, kidney and eye disease. Unfortunately, one of the characteristics of hypertension is that it remains undetected for a long time until damage to one or more organs has already occurred. Therefore, it is very important that systemic blood pressure is monitored from time to time, especially above 45 years of age. The prevalence of hypertension is more than 35% in the Hungarian population. Recent data have pointed out that hypertension may occur at a younger age, although at a lower frequency. Our studies were conducted in the context of the May 2019 Measurement Month (MMM19), an international campaign that draws attention to hypertension and the lack of systematic screening at population level. We hypothesized that hypertension may occur in young, apparently healthy university students. The studies were conducted among students of the University of Physical Education (n = 33; 25 males, 8 females). The mean age was 24.3 years (20–34 years). To measure blood pressure, an automatic blood pressure monitor (Omron MIT5) was used, placed on individuals’ upper arms, as specified in the guidelines, in a relaxed, sitting position. The measurements were repeated three times at one-minute intervals and the average of the three measurements was statistically analyzed. Blood pressure values (mean ± SEM, averaged over 3 measurements) in the student population were systolic 121.9 ± 14.4 mmHg, diastolic 75.1 ± 9.1 mmHg, mean 90.7 ± 10.9 mmHg, and heart rate: 46.8 ± 5.3 mmHg. Although mean blood pressure was within the normal range, higher values were also found in some individuals. Systolic blood pressure fell by 33% due to elevated normal blood pressure, respectively of Grade 1 hypertension. These data confirmed our hypothesis that hypertension may occur at a young age, despite the fact that members of the study population exercise regularly, which is an important preventive factor in the development of cardiovascular disease. These results underscore the importance of regular blood pressure measurement in adolescents, which may reduce the global spread of hypertension and prevent the development of a number of cardiovascular diseases, including stroke, heart attack, renal failure and mental decline.]

Hypertension and nephrology

JUNE 24, 2020

[Covid-19 and the kidney]

PATÓ Éva, DEÁK György

[Covid-19 pandemy has emerged from Wuhan, China in December 2019. The infection affects not only the lung but other organs such as the kidney, as well. The relation between Covid-19 infection and the kidney is bidirectional. On one hand, Covid-19 infection may cause kidney damage in 50-75% of the cases resulting in proteinuria, haematuria and acute kidney injury (AKI). The etiology of AKI is multifactorial. Main pathogenic mechanisms are direct proximal tubular cell damage, sepsis-related haemodinamic derangement, citokine storm and hypercoagulability. The virus enters proximal tubular cells and podocytes via the ACE2 receptor followed by multiplication in the lysomes and consequential cell lesion. Histopathology shows acute tubular necrosis and acute tubulointerstitial nephritis. AKI is a strong predictor of mortality in critically ill patients. On the other hand, the risk of Covid-19 infection and mortality is substantially increased in patients with chronic kidney disease – especially in those with a kidney transplant or on dialysis – due to their immunocompromised status. Among haemodialysis patients, infection may spread very easily due to the possibility of getting contacted in the ambulance car or at the dialysis unit. The mortality rate of patients on renal replacement therapy with Covid-19 infection is 20-35%. In order to avoid mass infection it is obligatory to employ preventive measures and implement restricions along with (cohors) isolation of infected patients. In Hungary, every dialysis or kidney transplant patient with Covid-19 infection should be admitted to dedicated Covid-19 wards.]

Hypertension and nephrology

JUNE 24, 2020

[Hypertension and Covid-19 – Part I. Significance of age, underlying diseases, and ACEI/ARB therapy in hypertension and co-morbidities during SARS-Cov2 infection]

KÉKES Ede, SZÉKÁCS Béla, NAGY Judit, KOVÁCS Tibor

[The appearance of the Covid-19 epidemic in different continents shows specific clinical features. Confirmed infected patients are detectable from approximately 30 years, with a maximum between 40 and 70 years of age. At the same time, however, a significant proportion of those who die from the infection come from patients over 65 years. The prevalence and mortality rates of the hypertensive population show a very similar formation. Based on the data collected, it is not surprising that hypertension as the underlying disease in the Covid- 19 epidemic is the first in all analysis. A more precise analysis clarified that it is not hypertension per se, but co-morbidities and complications of hypertension that play a primary role behind large-scale mortality in old age, such as diabetes, coronary heart disease, stroke, heart failure, and chronic kidney disease. Data from China, North America, and Italy suggest that hypertension and diabetes – and in North America, pathological obesity – in infected patients actually only reflect the prevalence of these diseases in a given population. The presence of comorbidities (coronary artery disease, stroke, heart failure, arrhythmia, chronic kidney disease) – based on multivariate logistic regression analysis – presents a more risk for severe clinical course and mortality. Some recent analyses have provided strong evidence that ACEI/ARB treatment does not pose a higher risk for the course or outcome of infection. Their administration is constantly needed in hypertension and comorbidities due to their organ protective and slowing the progression of diseases.]

Clinical Neuroscience

MAY 30, 2020

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

Clinical Neuroscience

NOVEMBER 20, 2015

[Novel strategy in the radiotherapy of metastatic brain tumors: simultaneous whole brain radiotherapy and integrated stereotactic radiosurgery]

KALINCSÁK Judit, LÁSZLÓ Zoltán, SEBESTYÉN Zsolt, KOVÁCS Péter, HORVÁTH Zsolt, DÓCZI Tamás, MAGNEL László

[Background and purpose – Treatment of central nervous system (CNS) tumors has always played an important role in development of radiotherapy techniques. Precise patient immobilisation, non-coplanar field arrangement, conformal treatment, arc therapy, radiosurgery, application of image fusion to radiation planning or re-irradiation were first introduced into clinical routine in the treatment of brain tumors. Methods – A modern multifunctional radiation instrument, Novalis TX has been installed at the University of Pécs two years ago. New methods, such as real time 3D image guided therapy, dynamic arc therapy and ultra-conformity offer further progress in treatment of CNS tumors. Whole brain irradiation and simultaneous fractionated stereotactic radiosurgery or integrated boost seem to be an optimal method in the treatment of not only soliter or oligo, but even a higher number (4-9) and not typically radiosensitive brain metastases. The new treatment strategy is illustrated by presentation of four case histories. Results – Treatment protocol was completed in all cases. Treatment period of 1.5 to 3 weeks, and treatment time of only a few minutes were not stressful for the patients. A quite remarkable clinical improvement as to general condition of the patients was experienced in three cases. Follow-up images confirmed either remission or a stable disease. Conclusions – Simultaneous whole brain radiotherapy and integrated stereotactic radiosurgery is a reproducible, safe method that offers an effective irradiation with delivery of definitive dosage even in cases with radio-insensitive brain metastasis.]