Apelin-13 as a Potential Biomarker in Critical Illness.

BACKGROUND: The adrenocortical system and copeptin as prognostic markers were intensively investigated in critical illness. The potential predictive power of apelin-13 as a biomarker is largely unknown. We aimed to investigate the prognostic role of apelin-13 in relation to free cortisol, aldosterone, CRH, and copeptin in critically ill patients. METHODS: In this prospective observational study, 124 critically ill patients (64 men, 60 women, median age: 70 (59-78) years) were consecutively enrolled at the time of admission. All routinely available clinical and laboratory parameters were evaluated and correlated to hormonal changes. RESULTS: Serum apelin-13 was 1161 (617-2967) pg/mL in non-survivors vs. 2477 (800-3531) pg/mL in survivors (p = 0.054). The concentrations of apelin-13 and CRH had strong positive correlations (r = 0.685, p < 0.001) and were significantly higher in surviving non-septic patients (Apelin-13 (pg/mL): 2286 (790-3330) vs. 818 (574-2732) p < 0.05; CRH (pg/mL) 201 (84-317) vs. 89 (74-233) p < 0.05). Apelin-13 and free cortisol were independent determinants of survival in the multivariate Cox regression analysis, while copeptin, CRH, or aldosterone were not. CONCLUSIONS: Beyond free cortisol, serum apelin-13 may also help refine prognostic predictions in the early phase of critical illness, especially in non-septic patients.

[The potential role of improvisation training to optimize communication in emergency care]. / Az improvizációs tréningek lehetséges szerepe a kommunikáció optimalizálására a sürgosségi ellátásban.

INTRODUCTION: One of the most common challenges in acute care is the time- and space-limited communication with patients, relatives and colleagues. There is ample evidence, however, that the quality of care, patient and staff satisfaction can be improved, measured and researched using simple communication tools (e.g., training). OBJECTIVE: This improvement was what we focused on when carrying out voluntary participation surveys with the staff of the Department of Emergency Medicine of the Clinical Centre of the University of Pécs. METHOD: With the help of a trained psychologist-actor and a senior specialist in medical communication, we investigated the potential impact of applied improvisation on medical communication by testing the participants in various situations simulating communication challenges after having completed an improv-based communication training full of exercises, games and tasks. After warm-up games taken from improv, the participants completed pre-defined tasks and finished every session with discussion and self-reflective feedback. Questionnaire (Interpersonal Confidence Questionnaire - ICQ) was used to check the potentially positive impact of improvisation on emergency communication. RESULTS: Our studies confirmed that the applied elements of medical improvisation, developing communication skills through play not only make participants more assertive and empathic, but also - after preparation - lead to a smoother and more effective exchange of information. Positive feedback from participants in the training sessions also confirms this. DISCUSSION: Our aim is to develop an improvisation-based communication training focused specifically on acute care providers, which, based on our initial experience, could optimize communication with patients, relatives and also between professionals. CONCLUSION: Application of improvisational techniques in this segment of acute care studied by us might open new perspectives to improve communication. Orv Hetil. 2023; 164(19): 739-746.

[Bedside ultrasound in adult primary care.] / Ágy melletti ultrahangvizsgálat az alapellátásban.

It is hard to imagine a modern hospital ward without a mobile ultrasound, bedside (point-of-care) sonography (POCUS) is a technique of the 21st century, which in emergency medicine settings (for example during primary survey) might replace the stethoscope at times. In emergency medicine - which is the hospital discipline closest to primary care - bedside ultrasound is part of the routine care by now, and its use is based on evidences of thorough research. Given that the emergency outpatient population is getting closer to primary care patients both in presentation and demography, we believe that the current POCUS evidences are probably applicable to primary care as well. Based on the clinical experience gained in emergency medicine, we assume that bedside ultrasound may also be helpful in general practice reliably diagnosing certain, potentially life-threatening pathologies, reducing the length of time until definitive treatment, increasing the success rate of certain interventions, improving patients' experience, and potentially alleviating staff burnout. The present article summarizes experiences with bedside sonography in the Anglo-Saxon world and tries to find its place in the Hungarian primary care. The widespread use of bedside ultrasound, however, in the Hungarian general practice is still lagging due to numerous barriers, the most pressing of those are training, legal responsibility and financing. Regardless, we believe, that even in this early, unregulated phase, it is worth considering to introduce bedside ultrasound into daily primary care. Competent use, however, requires continuous practice; based on the average adult patient turnover in an urban Hungarian "adult only" surgery, it might take six months to gain the necessary skills to provide high level, safe patient care. Orv Hetil. 2022; 163(52): 2067-2071.

Plasma Levels and Renal Handling of Amino Acids Contribute to Determination of Risk of Mortality or Feed of Ventilation in Patients with COVID-19.

COVID-19 infection may lead to serious complications, e.g., need for mechanical ventilation or death in some cases. A retrospective analysis of patients referred to our COVID Emergency Department, indiscriminately, was performed. A routine lab analysis measured amino acids in plasma and urine of patients. Data of surviving and deceased patients and those requiring or not requiring mechanical ventilation were compared, and logistic regression analyses have been performed. Deceased patients were older, had higher blood glucose, potassium, AST, LDH, troponin, d-dimer, hsCRP, procalcitonin, interleukin-6 levels (p < 0.05 for all). They had lower plasma serine, glycine, threonine, tryptophan levels (p < 0.01), higher tyrosine and phenylalanine levels (p < 0.05), and higher fractional excretion of arginine, methionine, and proline (p < 0.05) than survivors. In a regression model, age, severity score of COVID-pneumonia, plasma levels of threonine and phenylalanine were predictors of in-hospital mortality. There was a difference in ventilated vs. non-ventilated patients in CT-scores, glucose, and renal function (p < 0.001). Using logistic regression, CT-score, troponin, plasma level, and fractional excretion of glycine were predictors of ventilation. Plasma levels and renal excretion of certain amino acids are associated with the outcome of COVID-19 infection beside other parameters such as the CT-score or age.

How to best handle vaccine decliners: scientific facts and psychological approach.

There is currently no curative drug therapy for COVID-19. The spread of the virus seems relentless despite the unprecedented epidemiological measures. Prevention remains the only feasible option to stop the pandemic; without population-level vaccination, we are unlikely to regain the quality of social life and the unrestricted economy/commerce we enjoyed before. Anti-vaxxers and conspiracy theorists are seemingly oblivious to the detrimental effect of COVID-19 both at an individual and societal level. These groups have (and probably will) continue to attempt to undermine efforts to eradicate the virus despite the fact that the major reduction in morbidity/and mortality of infectious diseases of the past century was achieved through the development of vaccines and improved hygiene. Conspiracy theories are directly associated with reduced vaccine uptake and unfortunately neither anti-vaxxers nor vaccine hesitants cannot be persuaded (debunked) with logical arguments; hence, prescribers must not only be aware of the truth underlying the dense web of misinformation but must fully understand the psychological aspects as well to be able to efficiently counsel about the potential benefits and harms. Such knowledge is pivotal to help the lay public to make informed decisions about SARS CoV-2 in general and vaccination in particular; as the COVID-19 situation can probably be best controlled with mass inoculation and novel immune therapies. The lessons learnt regarding the importance of efficient communication and the adherence to the proven epidemiological measures hopefully would be leaving us better prepared for the future if challenged by novel communicable diseases of pandemic potential.

Hypoalbuminemia affects one third of acute pancreatitis patients and is independently associated with severity and mortality.

The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Data from 2461 patients were extracted from the international, prospective, multicentre AP registry operated by the Hungarian Pancreatic Study Group. Data from patients with albumin measurement in the first 48 h (n = 1149) and anytime during hospitalization (n = 1272) were analysed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. The prevalence of hypoalbuminemia (< 35 g/L) was 19% on admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on admission was poor for severity and mortality. Severe hypoalbuminemia (< 25 g/L) represented an independent risk factor for severity (OR 48.761; CI 25.276-98.908) and mortality (OR 16.83; CI 8.32-35.13). Albumin loss during AP was strongly associated with severity (p < 0.001) and mortality (p = 0.002). Hypoalbuminemia represents an independent risk factor for severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure and length of stay.

Glucose levels show independent and dose-dependent association with worsening acute pancreatitis outcomes: Post-hoc analysis of a prospective, international cohort of 2250 acute pancreatitis cases.

BACKGROUND: Metabolic risk factors, such as obesity, hypertension, and hyperlipidemia are independent risk factors for the development of various complications in acute pancreatitis (AP). Hypertriglyceridemia dose-dependently elicits pancreatotoxicity and worsens the outcomes of AP. The role of hyperglycemia, as a toxic metabolic factor in the clinical course of AP, has not been examined yet. METHODS: We analyzed a prospective, international cohort of 2250 AP patients, examining associations between (1) glycosylated hemoglobin (HbA1c), (2) on-admission glucose, (3) peak in-hospital glucose and clinically important outcomes (mortality, severity, complications, length of hospitalization (LOH), maximal C-reactive protein (CRP)). We conducted a binary logistic regression accounting for age, gender, etiology, diabetes, and our examined variables. Receiver Operating Characteristic Curve (ROC) was applied to detect the diagnostic accuracy of the three variables. RESULTS: Both on-admission and peak serum glucose are independently associated with AP severity and mortality, accounting for age, gender, known diabetes and AP etiology. They show a dose-dependent association with severity (p < 0.001 in both), mortality (p < 0.001), LOH (p < 0.001), maximal CRP (p < 0.001), systemic (p < 0.001) and local complications (p < 0.001). Patients with peak glucose >7 mmol/l had a 15 times higher odds for severe AP and a five times higher odds for mortality. We found a trend of increasing HbA1c with increasing LOH (p < 0.001), severity and local complications. CONCLUSIONS: On-admission and peak in-hospital glucose are independently and dose-dependently associated with increasing AP severity and mortality. In-hospital laboratory control of glucose and adequate treatment of hyperglycemia are crucial in the management of AP.

Assessment of the patients' quality of life visiting the emergency department with dizziness / A sürgosségi osztályon szédüléses panaszokkal megjelent betegek életminoségének vizsgálata.

Összefoglaló. Bevezetés: A szédülés gyakori panasz, amellyel a betegek felkeresik a sürgosségi osztályt. Emellett fontos tünet, hiszen kihívást jelent mind a diagnosztika, mind a terápia szempontjából, és nagy hatással lehet a betegek életminoségére. Célkituzés: Kutatásunk célja annak vizsgálata, hogy mennyire befolyásolta a szédülés a betegek életminoségét a sürgosségi osztály elhagyását követoen. Módszer: A vizsgálat idotartama alatt 879, szédülést panaszoló beteg jelent meg a Semmelweis Egyetem sürgosségi osztályán. Részükre kérdoív került kiküldésre, amely tartalmazta a 'Dizziness Handicap Inventory' (DHI-) kérdoívet is. Megkeresésünkre 308 beteg (110 férfi, 198 no; átlagéletkor: 61,8 ± 12,31 SD) válaszolt, az általuk visszaküldött kérdoíveket részletesen elemeztük. Eredmények: A leggyakoribb diagnózisok közé a benignus paroxysmalis positionalis vertigo, a centrális egyensúlyrendszeri eltérések és a szédülékenység tartoztak. Az elemzés alapján különbség volt látható a fizikális, a funkcionális és az emocionális pontszámok között. Kiemelendo, hogy a legmagasabb értékeket a fizikális csoportban regisztráltuk. A részletes otoneurológiai kivizsgáláson átesett betegek DHI-értékeit összevetettük azokéival, akik nem jártak ilyen vizsgálaton, a két csoport értékei között azonban nem volt szignifikáns különbség (p = 0,97). Emellett a DHI-érték emelkedése volt látható a végleges diagnózisig eltelt ido függvényében. Következtetés: A végleges diagnózisig eltelt ido, illetve a megfelelo kivizsgálás hiánya jelentos hatással van a szédülo betegek életminoségére. Lényeges a kivizsgálás, a mielobbi diagnózis és a részletes egyensúlyrendszeri vizsgálat szerepe, ugyanakkor az utóbbi indokolt esetben kell, hogy történjen. Orv Hetil. 2021; 162(30): 1216-1221. INTRODUCTION: Dizziness and vertigo are among the most common complaints in the emergency department. This may require interdisciplinary cooperation due to their complex presentation in the department and the effects on the patients' quality of life. OBJECTIVE: Our study aimed to assess the effect of an acute vertigo episode on the quality of life after patients' discharge from the emergency department. METHOD: 879 patients examined at the Semmelweis University emergency department with vertigo and dizziness were included in the study. A questionnaire, including the Dizziness Handicap Inventory (DHI), was addressed to this population. We received 308 answered questionnaires back (110 males, 198 females; mean age 61.8 years ± 12.31 SD), which were further analyzed. RESULTS: The most frequent diagnoses were benign paroxysmal positional vertigo, central lesions and dizziness. According to the analysis of the DHI questionnaire, a difference between physical, functional and emotional scores was shown, whereas the highest scores were registered in the physical group. The DHI questionnaire scores of patients undergoing a neurotological examination and those who did not were further compared, whereas no significant statistical difference was indicated (p = 0.97). In addition, an increase in DHI scores was seen depending on the time elapse for the definitive diagnosis. CONCLUSION: The absence of adequate examination and a late diagnosis of the dizziness cause have a significant impact on the quality of life of patients. Therefore, substantial investigation, early diagnosis, and detailed vestibular examination are essential, but the latter should take place in justified cases. Orv Hetil. 2021; 162(30): 1216-1221.

Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit.

BACKGROUND: Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. CASE SERIES: Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. METHODS: To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital's electronic medical record system to reassess all consecutive adult chest pain patients. RESULTS: The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71-553.37], twenty times higher than suggested by prevalence data. DISCUSSION: In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. CONCLUSION: Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis.

BACKGROUND: Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings. METHOD: A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours. RESULTS: Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects. CONCLUSION: This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Cannabidiol in low back pain: scientific rationale for clinical trials in low back pain.

INTRODUCTION: The pooled worldwide prevalence of low-back pain-related presentations in primary care varies between 6.8% and 28.4% in the high-income countries rendering it a major healthcare/economy problem. To best manage this complex bio-psycho-social condition a 360-degree approach is needed, as the psycho-social components are often more important than the scant pathophysiology. Pattern analysis of cannabis users suggested that attempts to alleviate musculo-skeletal pain is often seen as a major drive to use cannabinoids. AREAS COVERED: Unlike NSAIDs/opioids, cannabidiol might directly affect more than one modality of pain signaling/perception. The 2019 guideline of the National Institute for Clinical Excellence recommended further studies with cannabidiol in pain medicine because of its excellent safety profile and presumed therapeutic potential. Therefore, we have researched relevant databases for pharmaco-physiological papers published between 2000 and 2021 to collate evidence in a narrative fashion to determine the clinical rationale for this cannabinoid in low-back pain. EXPERT OPINION: Observational research reported good results with CBD in pain and fear reduction, which are both key factors in low-back pain. Given the paucity of high-quality evidence, further research is needed to determine the efficacy/non-inferiority of CBD in primary/emergency care setting, using multimodal assessment of various patient-reported outcomes.

Severe Hypertriglyceridemia-Induced Acute Pancreatitis.

The prevalence of familial hypercholesterolemia (FH) is about 1 in 200-500 in the general population, but approximately less than 1% of those affected are actually diagnosed. One of the most promising approaches to treat FH is utilizing human monoclonal antibodies. This is a case study describing a 47-year-old male patient who presented to the Emergency Department with acute abdominal pain caused by severe hypertriglyceridemia (HTG)-induced acute pancreatitis (AP). We report the steps necessary for establishing the right diagnosis and the management of HTG-induced AP, which are inevitable for the reduction of severity and mortality. This case study shows that hypercholesterolemia is an underdiagnosed and potentially lethal disease. Once diagnosed, all measures should be considered to control blood cholesterol and lipid levels. The decision to administer PCSK9 inhibitors should not be solely based on economical calculation, but rather individual factors should also be considered to weigh the risk/benefit ratio.

The role of vitamin E acetate (VEA) and its derivatives in the vaping associated lung injury: systematic review of evidence.

Small scale observational evidence suggested that Vitamin E (VE) might play beneficial role in human and animal respiratory conditions of various origin by stabilizing surfactant functions. The intra-aleveolar VE level is directly proportionate to the lung's response to inflammation. Electronic cigarette or vaping associated lung injury was a dominantly respiratory syndrome in the United States with seemingly strong association between potential Vitamin E acetate inhalation exposure and the onset of symptoms. This systematic review intended to assess if there was previous evidence of any potential respiratory/gastrointestinal toxicity associated with Vitamin E acetate or any of its derivatives. A systematic review was constructed and prospectively registered at PROSPERO to search important clinical databases between 2000 and 2020 for full text human articles investigating the effect of VEA or any of its derivatives administered via any route (oral/parenteral/aerosolised) in adults with any respiratory conditions. Out of 363 records investigating the effect of VEA and/or its derivatives/isomers in (any) lung injury (inflammatory, oxidative, infective, asthma/COPD) seven articles qualified. The papers reported various surrogate outcomes (APACHEII score, spirometry, etc) with equivocal results. There was one case report of harmful exposure to both Vitamin E (intramuscular) and Vitamin E acetate (topical). The present review found evidence of neither harm nor any significant clinical improvement associated with the administration of VEA or any derivatives via any route in adult inflammatory lung conditions however, the articles were of low-level evidence. Further studies are needed to correct flaws in research to explore the role of Vitamin E in pulmonology.

Acid suppression therapy, gastrointestinal bleeding and infection in acute pancreatitis - An international cohort study.

BACKGROUND: Acid suppressing drugs (ASD) are generally used in acute pancreatitis (AP); however, large cohorts are not available to understand their efficiency and safety. Therefore, our aims were to evaluate the association between the administration of ASDs, the outcome of AP, the frequency of gastrointestinal (GI) bleeding and GI infection in patients with AP. METHODS: We initiated an international survey and performed retrospective data analysis on AP patients hospitalized between January 2013 and December 2018. RESULTS: Data of 17,422 adult patients with AP were collected from 59 centers of 23 countries. We found that 23.3% of patients received ASDs before and 86.6% during the course of AP. ASDs were prescribed to 57.6% of patients at discharge. ASD administration was associated with more severe AP and higher mortality. GI bleeding was reported in 4.7% of patients, and it was associated with pancreatitis severity, mortality and ASD therapy. Stool culture test was performed in 6.3% of the patients with 28.4% positive results. Clostridium difficile was the cause of GI infection in 60.5% of cases. Among the patients with GI infections, 28.9% received ASDs, whereas 24.1% were without any acid suppression treatment. GI infection was associated with more severe pancreatitis and higher mortality. CONCLUSIONS: Although ASD therapy is widely used, it is unlikely to have beneficial effects either on the outcome of AP or on the prevention of GI bleeding during AP. Therefore, ASD therapy should be substantially decreased in the therapeutic management of AP.

Actual questions about the electronic cigarette associated lung injury / Égeto kérdések. Merre tartunk az e-cigarettázással összefüggésbe hozható tüdobetegséggel?

The electronic cigarette and vaping associated lung injury (EVALI) syndrome was first described in the United States (US) and was presumably strongly associated with cannabinoid vaping and exposure to vitamin E acetate, an oily additive used to dilute/cut cannabinoids vape liquids. As the case numbers were relatively low (epidemiologically) and the available data was inconsistent, several assumptions were made to explain the phenomenon. The lack of standardization of sampling, the self-reported, inhomogeneous user habits, the huge number of potential etiologies, and certain trade/legal loopholes (such as online distribution, black market penetration, or the inefficient regulatory control regarding the quantity and/or quality of ingredients/cutting agents) might question the validity of the data and the consequent conclusions. Furthermore, an interesting but by no means negligible question is the fact why no EVALI cases have been registered outside the US when electronic cigarettes and vapes have become increasingly popular worldwide. The present review seeks to answer whether vitamin E acetate is indeed the cause of this complex syndrome, what potentially non-healthcare related factors might have contributed to the rapid increase and decline in EVALI cases, and last but not least the minimum standards of safe vaping (as potential for drug delivery route for cannbinoids). Orv Hetil. 2020; 161(31): 1281-1285.

[What happens to vertiginous population after emission from the Emergency Department?] / Mi történik a szédülô beteggel a sürgôsségi osztály elhagyása után?

Background - Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose - The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods - 879 patients were examined at the Semmel-weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results - Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion - The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion - Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.

The first experiences with the palliative tumor board discussions in the University of Pécs / Az elso tapasztalatok a palliatív onkoteamrendszer muködésével kapcsolatban a Pécsi Tudományegyetemen.

INTRODUCTION: Palliative, symptomatic and end-of-life care of advanced and metastatic cancer patients is a great challenge for every health care system. With the initiation and establishment of the multidisciplinary palliative tumor board (MPTB), our aims were the timely referral of patients to palliative care, and the avoidance of multiple unnecessary emergency visits and over-diagnostics without further treatment consequences. METHOD AND RESULTS: The MPTB meetings were held biweekly. The core members of the team were: palliative care consultant, medical oncologist, internal medicine physician, psychologist, psychiatrist, and oncology and palliative medicine nurses. From May 2019 till January 2020, we discussed the medical history of 97 cases of 93 cancer patients with advanced disease states; in one meeting the team usually discussed over 6-10 complex patient histories. In every case we determined the actual form of the necessary palliative care, e.g., outpatient clinic, home care, or institutional referral, and we decided on further possible and realistic oncology treatment regimes. A few months after the introduction of the new MPTB, we detected a decrease of the unnecessary emergency unit referrals considering the patients whose histories were discussed. CONCLUSIONS: Although the initial MPTB discussions had an intense emotional tone, they shortly became thoughtful and operational expert meetings. We believe that the MPTB system fully promotes the early and timely access of advanced cancer patients to appropriate palliative care and facilitates gradual changes in the medical oncologists' approach from the absolute curative determination to a supportive medical attitude. Orv Hetil. 2020; 161(34): 1423-1430.

Management of acute gastrointestinal bleeding. Multidisciplinary guideline proposal. / Heveny gastrointestinalis vérzések ellátása. Multidiszciplináris útmutató javaslat.

Gastrointestinal bleeding has a profound impact on public health due to its high prevalence and severity. With the elderly population taking more anticoagulants/antiaggregants/non-steroid anti-inflammatory drugs, the digestive bleeding will certainly raise more and more challenges in quantity as well as in severity for the public healthcare system. The emergency medicine specialists and gastroenterologists have a central role in the management of patients presenting with gastrointestinal bleeding. In certain cases, radiologists, invasive radiologists, intensive care specialists and surgeons should also be involved in the decision making process and management of patients. Therefore, Hungarian experts felt the need to elaborate a comprehensive, multidisciplinary, practical local guideline reflecting the frequently arisen aspects based on current international guidelines. This guideline proposal covers topics of basic requirements, initial assessment of patients, risk evaluation, laboratory tests, hemodynamic resuscitation in the case of gastrointestinal bleeding followed by its consecutive steps of diagnosis and therapy sorted by location of the source of the hemorrhage. The authors give practical instructions for unsuccessful hemostasis or rebleeding. Finally, the role of surgery is also summarized in the management of gastrointestinal bleeding. Orv Hetil. 2020; 161(30): 1231-1242.