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Lege Artis Medicinae

SEPTEMBER 20, 2015

[Perioperative management of patients taking new oral anticoagulants - dabigatran in focus]

MÁRK László

[Appearance of new oral anticoagulants (NOAC) on the market requires a basically new approach from the doctors compared to vitamin K antagonists (VKA), the only oral anticoagulants used for several decades. These new drugs are at least as effective in the prevention of thrombotic events as the old ones and have the advantage that no regular laboratory monitoring is needed. Compared to the VKA a different management is required also in the perioperative care of patients taking NOAC. There is no need for bridge therapy, i.e. low-molecular-weight heparin (LMWH). The smaller surgical procedures can be performed 24 hours after the last dose of NOAC if it is administered once a day or 12 hours in case of agents administered twice a day. When a large surgical procedure is planned the drug should be stopped 24-96 hours before. The therapy should be resumed 6-8 hours after the procedure in low, 48-72 hours later in high bleeding risk cases. In a Canadian prospective study a protocol was used in which the stopping and resumption of dabigatran was recommended based on the bleeding risk and its half-life depending on the renal function. In 541 surgeries (60% with standard, 40% with increased bleeding risk) the occurrence of serious bleeding events was 1.8%, that of minor bleedings 5.2%. During the study one thrombotic event (TIA) occurred (0.2%). At the end of the article the author also makes a recommendation for stopping and resuming dabigatran therapy in case of tooth extraction, endoscopic biopsy and cholecystectomy.]

Clinical Neuroscience

SEPTEMBER 30, 2015

Turkish version Quality of Life in Essential Tremor Questionnaire (QUEST): Validity and reliability study

GULER Sibel, TURAN F. Nesrin

Background - Our aim was to translate the Quality of Life in Essential Tremor Questionnaire (QUEST) advanced by Troster (2005) and to analyse the validity and reliability of this questionnaire. Methods - Two hundred twelve consecutive patients with essential tremor (ET) and forty-three control subjects were included in the study. Permission for the translation and validation of the QUEST scale was obtained. The translation was performed according to the guidelines provided by the publisher. After the translation, the final version of the scale was administered to both groups to determine its reliability and validity. Results - The QUEST Physical, Psychosocial, communication, Hobbies/leisure and Work/finance scores were 0.967, 0.968, 0.933, 0.964 and 0.925, respectively. There were good correlations between each of the QUEST scores that were indicative of good internal consistency. Additionally, we observed that all of the QUEST scores were most strongly related to the right and left arms (p=0.0001). However, we observed that all of the QUEST scores were weakly related to the voice, head and right leg (p=0.0001). Discussion - These findings support the notion that the Turkish version of the Quality of Life in Essential Tremor (QUEST) questionnaire is a valid and reliable tool for the assessment of the quality of life of patients with ET.

Clinical Neuroscience

MAY 30, 2015

[Validation of the Hungarian Unified Dyskinesia Rating Scale]

HORVÁTH Krisztina, ASCHERMANN Zsuzsanna, ÁCS Péter, BOSNYÁK Edit, DELI Gabriella, PÁL Endre, KÉSMÁRKI Ildikó, HORVÁTH Réka, TAKÁCS Katalin, BALÁZS Éva, KOMOLY Sámuel, BOKOR Magdolna, RIGÓ Eszter, LAJTOS Júl

[Background - The Unified Dyskinesia Rating Scale (UDysRS) was published in 2008. It was designed to be simultaneous valid, reliable and sensitive to therapeutic changes. The Movement Disorder Society organizing team developed guidelines for the development of official non- English translations consisting of four steps: translation/back-translation, cognitive pretesting, large field testing, and clinimetric analysis. The aim of this paper was to introduce the new UDysRS and its validation process into Hungarian. Methods - After the translation of UDysRS into Hungarian and back-translated into English, it was reviewed by the UDysRS translation administration team. Subsequent cognitive pretesting was conducted with ten patients. For the large field testing phase, the Hungarian official working draft version of UDysRS was tested with 256 patients with Parkinson’s disease having dyskinesia. Confirmatory factor analyses (CFA) determined whether the factor structure for the valid Spanish UDysRS could be confirmed in data collected using the Hungarian Official Draft Version. To become an official translation, the Comparative Fit Index (CFI) had to be ≥0.90 compared to the Spanish-language version. Results - For the Hungarian UDysRS the CFI was 0.98. Conclusion - The overall factor structure of the Hungarian version was consistent with that of the Spanish version based on the high CFIs for the UDysRS in the CFA; therefore, this version was designated as the Official Hungarian Version Of The UDysRS.]

Clinical Neuroscience

MAY 30, 2015

[Acoustic CR®-neuromodulation - first experiencies in Hungary with novel patented method in therapy of chronic subjectiv tinnitus]

BENCSIK Beáta, GÁBORJÁN Anita, HARNOS Andrea, LÁSZLÓ Klára, VÉGSŐ Péter, TAMÁS László

[Objective - Acoustic CR®-neuromodulation is a novel patented method for the therapy of chronic subjective tinnitus and has been tested in Hungary, as one of the first European countries introducing this procedure. It can be used for the treatment of monaural or binaural tonal tinnitus. Suitability of patients for this therapy was assessed by the help of an appropriate set of criteria. Aim of our study was to analyze 6-month therapy and related measurement data of patients first treated with this method in Hungary and evaluate the results. Method - 27 outpatients (20 males, seven females) with a minimum of 6-month long history of subjective tinnitus were assessed (four detected on the right side, six on the left side, 17 on both sides) who were treated for six months by Acoustic CR®-neuromodulation. On 44 treated ears (21 right, 23 left), changes of tinnitus frequency and loudness were measured and analysed, using Visual Analogue Scale (VAS) loudness/annoyance/pitch scores and Tinnitus Handicap Inventory tests, which were performed at defined intervals during the treatment period. Results - During this 6-month treatment period, significant decrease was detected in tinnitus frequency and loudness by tinnitometry (irrespective of the affected side), and an improvement in VAS annoyance/pitch scores and THI test results. VAS loudness did not show any significant changes. Conclusion - Acoustic CR®-neuromodulation therapy may be a useful treatment of subjective chronic tinnitus, but its efficacy should be proved in controlled clinical trials.]

Clinical Neuroscience

MARCH 25, 2015

[Measuring of functional impairment of lumbal spine]

VALASEK Tamás, VARGA Péter Pál, KLEMENCSICS István, SZÖVÉRFI Zsolt, BOZSÓDI Árpád, ÉLTES Péter Endre, LAZÁRY Áron

[Background and purpose - The purpose of our study was to outline the Hungarian validation process of the Oswestry Disability Index, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire and the Core Outcome Measurement Index, as well as to draw up recommendations regarding their future applications. Methods - The Hungarian versions were brought to life after a cultural and linguistic adaptation. Next to the above-mentioned questionnaires, the questionnaire booklet used for validation also contained the WHOQoL-BREF general quality of life questionnaire and a pain measuring Visual Analog Scale. The data of low-back pain patients were registered twice in two weeks. We determined the internal homogeneity (Cronbach alpha), reproducibility, standard error of measurement and the minimal detectable change of the questionnaires. Patients were assigned into different two subgroups (surgical / non-surgical, with / without affection of nerve roots) and differences between the subgroups were examined with the help of the questionnaires. We determined the physical subscale of the WHOQoL-BREF and the correlation between the pain and the studied questionnaires. Results - The value of Cronbach alpha was between 0.85 and 0.95. All four questionnaires showed significant differences (p<0.001) between the subgroups. The correlation studies brought strong and significant results (p<0.001, r>0.5) in every case. The values of reproducibility were between 0.93-0.92. The results of standard measurement error: 4.8 (Oswestry), 5.2 (Quebec), 1.6 (Roland-Morris), 0.59 (Core Index). The minimal detectable change was 13; 14; 4, and 2 points, respectively. Conclusion - The Hungarian versions of all four questionnaires are valid. They can be applied with scientific certainty to measure low back pain patients. From the studied questionnaires, we especially recommend the wide-raging application of the Oswestry Disability Index and the Core Outcome Measurement Index based on their psychometric and application features. ]

LAM Extra for General Practicioners

FEBRUARY 20, 2015

[Insertion of percutaneous peritoneal dialysis catheter using Seldinger technic with assistance of image amplifier ]

PETHŐ Ákos Géza, SZABÓ Réka, SZŰCS Attila, BALLA József

[INTRODUCTION - Continuous Ambula­tory Peritoneal Dialysis (CAPD) treatment is widespread used over the years as a result of technical progress. As with any renal replacement therapy, in hemodialysis patients in time made vascular access, also the success of the CAPD depends on the in time inserted catheter for peritoneal dialysis. PATIENTS AND METHOD - Inserting a catheter for chronic peritoneal dialysis in Hungary is currently exclusively surgical procedure. The successfully CAPD treatment is so essential to insert the peritoneal dialysis catheter by dedicated surgeon. The intervention is often not a priority in the surgical tender, and in many places queues delaying the surgery. Proposed as an alternative to the percutaneous technique introduction. If nephrologist are familiar with basic surgical procedures by providing appropriate means, the percutaneous catheter insertion technique can be performed. RESULTS - In the spring of 2014, we introduced in Hungary first this procedure, which reported in the international literature as percutaneous PD-catheter insertion method. The technique was modified to the primary entry point determined by the typical abdominal puncture site. Puncture of the abdomen is performed by physicians as a routine intervention, which is widely accepted. After selecting the appropriate patient population and detailed medical information, patients are prepeared, under x-ray fluoroscopy imaging the implants were made. So far 10 catheter were implanted under this technique, all of them successfully. Thanks to the minimal invasive intervention, the patients healing was significantly faster, after the day of catheter-insertion we were able to start drainage. By the traditional surgical implantation the recovery time is six weeks. CONCLUsiONS - In all cases, when a surgeon not willing to insert the peritoneal dialysis catheter, the percutaneous technique can be safe. All of the catheters made by us are working well. Of course, the surgical procedure is still indispensable, however, and this is the percutaneous technique’s advantage, the CAPD treatment can be started after the intervention. ]

Journal of Nursing Theory and Practice

AUGUST 28, 2014

[Examination of effects of the nurses shiftworks with application of Standard Shiftwork Index - pilot study]

FUSZ Katalin, KOVÁCS KALIC Károly, KÍVÉS Zsuzsanna, MÜLLER Ágnes, OLÁH András

[Aim of the study: Several physiological processes are disturbed in shift workers. The authors’s aim was to complete a pilot study as part of the validation process of Standard Shiftwork Index (SSI) and to examine the effects of shiftwork on the quality of sleeping and on psychical and somatic status. Sample and methods: The survey was implemented at the hospitals of the University of Szeged in 2011, with the participation of not randomly selected nurses working in shiftwork, night- or dayshifts (N=211). SSI was complemented with further respective questions. Results: Those working in dayshift suffer less from sleep disorders than nurses working in nightshift or shiftwork (p=0,002, p=0,005), and have better health status (p=0,001, p=0,003), furthermore feel themselves less tired (p=0,011, p=0,039). The nightshift workers had gastrointestinal complaints more frequently (p=0,044, p=0,006), as well as nurses working in nightshift suffer from more chronic diseases than dayshift workers (p=0,004) and shift workers (p=0,003). In case of shift workers the weekly amount of cigarettes having smoked (p=0,008) and the consumption of caffeinated refresher beverages (p<0,001) were significantly increased since the beginning of their shiftwork. Conclusion: Health status of nurses working in nightshifts and shiftwork are more relapsed, their health attitude is worse than in case of dayshift workers. As the continuation of this examination the authors try to find out which variations of shiftwork can be considered less exhausting.]

Clinical Neuroscience

JANUARY 30, 2015

[Role of modified open-door laminoplasty in the treatment of multilevel cervical spinal stenosis: a retrospective analysis of 43 cases]

VITANOVICS Dusan, BÁRÁNY László, PAPP Zoltán, PADÁNYI Csaba, BALOGH Attila, BANCZEROWSKI Péter

[Background and purpose - Symptomatic degenerative multilevel cervical spinal stenosis - beside other methods - is often treated using the open-door laminoplasty. This procedure aims to decompress the spinal cord and preserve the stability of the cervical spine. The efficiency and safety of the method was proved by numerous Japanese and American studies, also the technique related complications are well known. We treated 43 patients with symptomatic multilevel cervical spine stenosis using the open-door laminoplasty as a surgical procedure of choice in the National Institute of Clinical Neurosciences between 2009 and 2012. In this article we analyse our results and the related literature is discussed. Methods - Symptomatic patients with a minimum of three-segment cervical spine stenosis and radiologically proved myelopathy or with electrophisiologically verified subclinical myelopathy were selected for laminoplasty. Patients in whom cervical kyphosis was present were operated on using laminectomy and posterior fusion. Postoperative control CT, MRI and/or X-ray images were made after the surgery and at six weeks, three, six and 12 months after the operation and in the same time neurological evaluation was performed. The modified Japanase Orthopaedic Association (mJOA) scale value was assigned to patients preoperatively, six weeks, three, six and 12 months after the operation. The statistical difference between the groups of data was tested by chi square test. Results - The average follow-up time was 27 months (minimum seven, maximum 42). According to the mJOA scale, 26 patient’s condition (61%) improved, in 13 cases (30%) remained unchanged, and in one case (2%) we detected neurological deterioration. We lost three patients during the follow up period. The median of mJOA preoperatively was 12 (minimum eight, maximum 18), while six week postoperative mJOA was 14 (minimum 10, maximum 17). Three, six and 12 months mean value of mJOA was 14 which shows that the improvement in patients’ condition remained stable at one year after surgery. The difference was statistically significant (p<0.05). The canal’s average anteroposterior diameter on CT was 8.29±0.92 mm at the level of C III, while after the operation we measured 15.16±1.02 mm; 7.54±0.62 mm at the level of C IV before, and 15.29±0.2 mm after; 9.05±0.48 mm at the level of C V before and 17.23±0.4 mm after the surgery. The differences proved to be significant (p=0.0001). Conclusion - According to our experiences the modified open-door laminoplasty is an efficient and safe method for the treatment of symptomatic multilevel cervical spinal stenosis.]

Lege Artis Medicinae

DECEMBER 20, 2014

[Insertion of percutaneous peritoneal dialysis catheter using Seldinger technic with assistance of image amplifier]

PETHŐ Ákos Géza, SZABÓ Réka, SZŰCS Attila, BALLA József

[INTRODUCTION - Continuous Ambula­tory Peritoneal Dialysis (CAPD) treatment is widespread used over the years as a result of technical progress. As with any renal replacement therapy, in hemodialysis patients in time made vascular access, also the success of the CAPD depends on the in time inserted catheter for peritoneal dialysis. PATIENTS AND METHOD - Inserting a catheter for chronic peritoneal dialysis in Hungary is currently exclusively surgical procedure. The successfully CAPD treatment is so essential to insert the peritoneal dialysis catheter by dedicated surgeon. The intervention is often not a priority in the surgical tender, and in many places queues delaying the surgery. Proposed as an alternative to the percutaneous technique introduction. If nephrologist are familiar with basic surgical procedures by providing appropriate means, the percutaneous catheter insertion technique can be performed. RESULTS - In the spring of 2014, we introduced in Hungary first this procedure, which reported in the international literature as percutaneous PD-catheter insertion method. The technique was modified to the primary entry point determined by the typical abdominal puncture site. Puncture of the abdomen is performed by physicians as a routine intervention, which is widely accepted. After selecting the appropriate patient population and detailed medical information, patients are prepeared, under x-ray fluoroscopy imaging the implants were made. So far 10 catheter were implanted under this technique, all of them successfully. Thanks to the minimal invasive intervention, the patients healing was significantly faster, after the day of catheter-insertion we were able to start drainage. By the traditional surgical implantation the recovery time is six weeks. CONCLUsiONS - In all cases, when a surgeon not willing to insert the peritoneal dialysis catheter, the percutaneous technique can be safe. All of the catheters made by us are working well. Of course, the surgical procedure is still indispensable, however, and this is the percutaneous technique’s advantage, the CAPD treatment can be started after the intervention. ]

Clinical Neuroscience

NOVEMBER 28, 2014

[Tailored cranioplasty using CAD-CAM technology]

VITANOVICS Dusan, MAJOR Ottó, LOVAS László, BANCZEROWSKI Péter

[Objective - The majority of cranial defects are results of surgical intervention. The defect must be covered within resonable period of time usually after 4-6 week given the fact that the replacement of bone improve the brain circulation. Number of surgical techniques and materials are available to perform cranioplasty. Due to favorable properties we chosed ultra high molecular weight polyethylene as material. In this paper the authors show a procedure which allows tailored artificial bone replacement using state of art medical and engineering techniques. Methods - between 2004 and 2012, 19 patients were operated on cranial bone defect and a total of 22 3D custom- designed implants were implanted. The average age of patients was 35.4 years. In 12 patients we performed primary cranioplasty, while seven patients had the replacement at least once. Later the implants had to be removed due to infection or other causes (bone necrosis, fracture). All patients had native and bone- windowed 1 mm resolution CT. The 3D design was made using the original CT images and with design program. Computer controlled lathe was used to prepare a precise-fitting model. During surgery, the defect was exposed and the implant was fixed to normal bone using mini titanium plates and screws. All of our patients had control CT at 3, 6 and12 months after surgery and at the same time neurological examination. Results - Twenty-one polyethylene and one titanium implants were inserted. The average follow-up of the patients was 21.5 months, ranged from two to 96 months. We follow 12 patients (63.15%) more than one year. No intraoperative implant modifications had to be made. Each of the 22 implant exactly matched the bone defect proved by CT scan. No one of our patients reported aesthetic problems and we did not notice any kind of aesthetic complication. We had short term complication in three cases due to cranioplasty, subdural, epidural haemorrhage and skin defect. Conclusion - Polyethylene is in all respects suitable for primary and secondary cranioplasty. Combined with 3D CADCAM method excellent aesthetic and functional result was achieved. In our study no case of infection occured. Proper preoperative preparation is important.]