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Lege Artis Medicinae

OCTOBER 20, 2019

[Medical therapy of peripherial artery disease]

BENCZÚR Béla

[Care of PAD (peripherial arterial disease) is one of the most negligent area of cardiovascular diseases: on one hand patients suffering from PAD are the most uncared, less educated and health-minded population (it’s enough to keep in mind the high rate of smoking and alcohol-abuse among them) in addition the number of angiologists is insufficient for the treatment of PAD. Although detection of PAD would be easy as a widely applicable, cheap screening method, the ankle-brachial index is available which is an obligatory screening investigation in general care. Therapeutic options are better and better since cilostazol was launched we have an evidence-based treatment which can solve the symptoms, slower the progression which is strongly recommended (IA recommendation) in both American and Hungarian guidelines. Cilostazol, a PDE3-inhibitor has complex pharmacological effect but contraindicated in several clinical conditions as pentoxiphylline is not totally excluded from the therapeutic arsenal of PAD. The place of antiplatelet agents is well-defined in the most recent European guidelines in the treatment of PAD. The jumping development of interventional radiology beyond medical therapy contributed a lot to prevent limb amputations in the case of early detection of PAD. ]

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. ]

Clinical Neuroscience

JULY 30, 2019

Attitude of spine surgeons towards the application of 3D technologies - a survey of AOSpine members

ÉLTES Endre Péter, KISS László, BARTOS Márton, EÖSZE Zsolt, SZÖVÉRFI Zsolt, VARGA Pál Péter, LAZÁRI Áron

Background - 3D technologies (3D virtual and physical model, 3D printing, computer aided engineering, finite element analysis based simulations) play an important role in personalized spine surgery. Objective - In collaboration with AOSpine a global, online survey-based study was performed in order to determine the acceptance rate and the factors which stand against the wider spread of 3D technologies. Methods - A survey containing 21 questions was developed and divided into five pages, every page corresponding to one chapter. Our analysis is based on the responses of 282 spine surgeons from 57 countries. To interpret our results in a global context, we used the Human Development Index of the respondent's countries in comparisons. Results - Significant difference between the AOSpine regions (p ≤ 0.05) was found, with the highest acceptance in Asia-Pacific region. There was no significant difference in acceptance score according to the field of spine surgery, or the surgical experience in years (p=0.77, and p=0.19). In the case of public practice, we found significantly higher acceptance compared to private and mixed (public and private) surgical practice (p ≤ 0.05). The acceptance of the technology varied based on the respondent’s resident country’s Human Development Index and was significantly different between „Medium” vs “Very high” (p = 0.0005) and „High” vs „Very high” (p=0.019) category. Significant positive correlation was found between the acceptance score and the HDI score (Spearman test, ρ = 0.37, p = 0.007). The main limitation factor was identified as the lack of information. Conclusion - There is high interest among spine surgeons towards the incorporation of 3D technologies into the clinical practice. Education, the healthcare system, and the economic environment plays a major role in acceptance. Our results provide the basis of a strategy to promote the application of 3D technologies.

Clinical Neuroscience

JULY 30, 2019

Restless leg syndrome frequency in health workers

ÖCAL Ruhsen, ATGÜDEN Gizem, AYCAN Cagri, BALABAN Zeynep, SENAR Seran, YAVUZ Sena

Introduction - Restless Leg Syndrome (RLS) is a disease, primarily composed of sensational symptoms, caused by the urge to move lower extremities especially at night, and characterized by undesired feelings of the legs. Decreasing of the dopaminergic effect at night is thought to be responsible from these symptoms. RLS patients suffer from low quality of sleep affecting their daily life activities even causing socio-economic loss. Although RLS is a common and treatable disease, it can not be diagnosed easily due to the variability of symptoms. Aim - The purpose of this study is to determine the frequency of RLS among health workers and to define the disease causing factors. Method - A questionnaire was applied to 174 randomly selected health workers at Baskent University Medical Faculty (KA17/285). The demographic information, history of illnesses or usage of drugs, socioeconomic status, working hours and daytime sleepiness were questioned. Included in the questionnaire were diagnostic criteria for RLS, frequency assessment scale, and survey of sleep quality. We used “the diagnostic criteria of international RLS working group” for the diagnosis, and “Pittsburgh sleep quality index survey” to determine the quality of sleep. Reliability and validity studies were performed on both tests. Results - A significant relationship between socio-economic status and RLS was found (p<0.05) as an increase of RLS frequency in parallel with decreased socio-economic status. RLS was found to be common among health workers. We suggest that health workers should be checked regularly, and they should be informed about the disease in order to raise an awareness and hence increase their quality of life.

Clinical Neuroscience

MAY 30, 2019

The prevalence of sarcopenia and dynapenia according to stage among Alzheimer-type dementia patients

YAZAR Tamer, YAZAR Olgun Hülya

Aim - In this study, the aim was to identify the prevalence of sarcopenia and dynapenia according to disease stage among Alzheimer-type dementia (AD) patients and collect data to suggest precautions related to reducing the disease load. Method - The study was completed with 127 patients separated into stages according to Clinical Dementia Rating Scale (CDR) criteria and 279 healthy volunteers aged 18-39 years and 70-80 years abiding by the exclusion criteria who agreed to participate in the research. Our prospective and cross-sectional study applied the CDR and mini mental test (MMSE) to patients with disorder in more than one cognitive area and possible AD diagnosis according to NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer’s Disease and Related Disorders Association) diagnostic criteria. The patient and control groups had skeletal muscle mass index (SMMI), muscle strength and physical performance assessed with sarcopenia diagnosis according to European Working Group on Sarcopenia in Older People (EWGSOP) diagnostic criteria. Results - In our study, in parallel with the increase in disease stage of AD patients, the prevalence of sarcopenia (led by severe sarcopenia) and dynapenia was higher compared to a control group of similar age. Conclusion - In chronic, progressive diseases, like AD, identification of changes in parameters, like muscle mass and strength and reductions in physical performance in the early period, is important for identification and to take precautions in the initial stages considering the limitations of the preventive effects of treatment applied after diagnosis of AD.

Lege Artis Medicinae

MARCH 20, 2019

[Physiological-pathological muscle atrophy in elderly - interventions potencially inhibiting this progressive process ]

SZÉKÁCS Béla, MOLNÁR Andrea, BESENYEI Attila, MARTONY Zsuzsanna

[In old and very old age, one of the most prevalent signs of aged body’s decline is the progressive loss of muscle mass and function. First itself the physiological aging process can be dominant in the complex causative background but later it is usually intertwined with pathological mechanisms. The importance of muscle system is extremely high in the physiological regulation of various vital life processes The paper also points out the far-reaching consequences of sarcopenia syndrome that leads to general weakness, falls, traumas, acceleration of co-morbidities, rapidly declining self independence, ultimately frailty syndrome, and death. The initial body mass index has been recently replaced by a more adequate, more complex diagnostic approachment of sarcopenia that evaluates both muscle mass/strength and physical performance. Prevention or breaking the process of sarcopenia needs complex intervention which includes special fast protein rich diet with leucin and vitamin D combined with frequent physical exercise. ]

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. ]

Clinical Neuroscience

MARCH 30, 2019

[Rehabilitation possibilities and results after neurosurgical intervention of brain tumors ]

DÉNES Zoltán, TARJÁNYI Szilvia, NAGY Helga

[Objectives - Authors examined the rehabilitation possi­bi­lities, necessities, and results of patients after operation with brain tumor, and report their experiences. Method - Retrospective, descriptive study at the Brain Injury Rehabilitation Unit, in National Institute for Medical Rehabilitation. Patients - Patients were admitted consecutively after rehabilitation consultation, from different hospitals, following surgical intervention of brain tumors, between 01 January 2001 and 31 December 2016. Patients participated in a postacute inpatient rehabilitation program, in multidisciplinary team-work, leaded by Physical and Rehabilitation Medicine specialist included the following activities: rehabilitation nursing, physical, occupational, speech, psychological and neuropsychological therapy. Results - At the rehabilitation unit, in the sixteen-year period 84 patients were treated after operation with brain tumor. Patients arrived at the unit after an average of 41 days to the time of the surgical intervention (range: 10-139 days), and the mean length of rehabilitation stay was 49 days (range: 2-193 days). The mean age of patients was 58 years (20-91), who were 34 men and 50 women. The main symptoms were hemiparesis (64), cognitive problems (26), dysphagia (23), aphasia (16), ataxia (15), tetraparesis (5), and paraparesis (1). The mean Barthel Index at the time of admission was 35 points, whereas this value was 75 points at discharge. After the inpatient rehabilitation, 73 patients improved functionally, the status of 9 patients did not show clinically relevant changes, and 2 patients deteriorated. During the rehabilitation 10 patients required urgent interhospital transfer to brain surgery units, 9 patients continued their oncological treatment, two patients continued rehabilitation treatment at another rehabilitation unit, and after rehabilitation 73 patients were discharged to their homes. Conclusions - Inpatient rehabilitation treatment could be necessary after operation of patients with brain tumor especially when functional disorders (disability) are present. Consultation is obligatory among the neurosurgeon, rehabilitation physician and the patient to set realistic rehabilitation goals and determine place and method of rehabilitation treatment, but even at malignancies cooperation with oncological specialist also needed. Authors’ experience shows benefits of multidisciplinary rehabilitation for patients after brain tumor surgery. ]

Clinical Neuroscience

JANUARY 30, 2019

Is isolated hand weakness associated with subtypes of stroke?

YILDIRIM Ahmet, GÜNGEN Dogan Belma

Background and aim - Isolated hand weakness is an uncommon condition in stroke patients. It is frequently confused with peripheral nerve system (PNS) pathologies; misdiagnosis may delay identification of the etiology and treatment of stroke. Herein, we aimed to underline the necessity of keeping the diagnosis of stroke in mind in case of patients with isolated hand weakness and to assess the etiology of stroke. Materials and methods - A total of eight patients (four females and four males), who are presented with isolated hand weakness and had acute cortical infarction documented via cranial MRI, were enrolled in the study. Demographic characteristics, physical and radiological findings of the patients, as well as the lateralization and etiology of infarction were evaluated. Results - The mean age of the patients was 61.8 ± 12 years. Isolated hand weakness was in the dominant hand in four patients. According to the etiology and clinical signs, the stroke was cardioembolic in three patients and they had predominant radial-side (thumb and index) finger weakness. Large vessel atherosclerosis was present in three patients; two patients with predominant ulnar-side (little and ring) finger weakness and one patient with uniform finger weakness; there were two patients with stroke of undetermined etiology and they had uniform finger weakness. Conclusion - Keeping stroke in mind together with PNS pathologies in case of isolated hand weakness is critical for early diagnosis and treatment of the patients. In addition, cardioembolic focus should be considered in case of predominant radial-side finger weakness, whereas particular attention should be paid to carotid artery diseases in case of predominant ulnar-side finger weakness.

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.]