[Neurosyphilis or not - a case of a differential diagnostic challenge]. / Neurosyphilis vagy nem ­ egy differenciáldiagnosztikai kihívás esete.

We report the case of a 42-year-old woman with paraparesis associated with transverse myelitis. For differential diagnostics detailed microbiological, cerebrospinal fluid (CSF) and neuroimaging examinations were performed. Syphilis was confirmed, but diagnosis of neurosyphilis was only probable based on the CSF microbiological test results. The beneficial treatment response to application of the therapeutic protocol for syphilis supported the supposed diagnosis of syphilis-associated myelitis in our case. In this case report we reviewed the differential diagnostic tools of myelopathies/myelitis.
Nowadays regarding to growing prevalence of syphilis worldwide physicians should face on its presence and medical consequences.

[Investigation of reading abilities of ischemic stroke patients with aphasia]. / Ischaemiás stroke-on átesett afáziás személyek olvasási folyamatainak elemzése.

Background and purpose: Reading is a part of the language processes; a strong interaction can be found between them so the damage of the one has a strong impact on the other. It is worth to put emphasis on the exploration of reading disorders which occur with aphasia to have a better outcome of the rehabilitation process. The aim of our study is to explore the main characteristics of aqcuired reading disorders to have a more specialized and individualized language therapy. Methods: 19 ischemic stroke patients with aphasia took part in our study. All participants were right-handed with a lesion of left arteria cerebri media infarct. Due to the Hungarian version of Western Aphasia Battery 10 mild and 9 moderate participated. Reading abilities were investigated with our reading battery which consisted four main tasks: grapheme-phoneme correspondence, reading words, lexical access and reading comprehension. Tobii X120 device was used for recording and analyzing patients' eye-movements. Results: Significant positive correlations were found between the four subscales of Western Aphasia Battery and some part of the reading tasks. Eye-movements were analyzed, especially fixation count and total fixation duration. The severity of language disorder had a strong impact on fixation count and fixation duration. The more serious the language disorder was the more eye movements were detected. Conclusion: Our data support the idea that the severity of aphasia had a strong impact on reading processes and eye-movements. Eye-tracking device can help to have a deeper insight in the background brain mechanisms during reading. Our results contribute to have a more accurate diagnostic process to have a more specialized language therapy with better outcome.

Effectiveness of a Three-Week Inpatient Pulmonary Rehabilitation Program for Patients after COVID-19: A Prospective Observational Study.

For COVID-19 patients who remain symptomatic after the acute phase, pulmonary rehabilitation (PR) is recommended. However, only a few studies have investigated the effectiveness of PR, especially considering the duration between the acute phase of COVID-19 and the onset of rehabilitation, as well as the initial severity. This prospective observational study evaluated the efficacy of PR in patients after COVID-19. A total of 120 still-symptomatic patients referred for PR after overcoming acute COVID-19 were asked to participate, of whom 108 (mean age 55.6 ± 10.1 years, 45.4% female) consented. The patients were assigned to three groups according to the time of referral and initial disease severity (severe acute; severe after interval; mild after interval). The primary outcome was dyspnea. Secondary outcomes included other respiratory disease symptoms, physical capacity, lung function, fatigue, quality of life (QoL), depression, and anxiety. Furthermore, patients rated the overall effectiveness of PR and their subjective change in health status. At the end of PR, we detected improvements with large effect sizes in exertional dyspnea, physical capacity, QoL, fatigue, and depression in the overall group. Other parameters changed with small to medium effect sizes. PR was effective after acute COVID-19 in all three groups analyzed.

Genetic epidemiological characteristics of a Hungarian subpopulation of patients with Huntington's disease.

BACKGROUND: Recent advances in therapeutic options may prevent deterioration related to Huntington's disease (HD), even at the pre-symptomatic stage. Be that as it may, a well-characterized patient population is essential for screening and monitoring outcome. Accordingly, the aim of this study was to describe the characteristics of a Hungarian subpopulation of HD patients and mutation carriers diagnosed at the University of Szeged. METHODS: We conducted a search for International Classification of Diseases (ICD) code G10H0 in the local medical database for the period of 1 January 1998 to 31 December 2018. RESULTS: We identified 90 HD cases (male: 45, female: 45) and 34 asymptomatic carriers (male: 15, female: 19). The median age of onset was 45 years (range: 16-79). There were 3 cases of juvenile onset (3.3%), and 7 of late disease onset (7.8%). The median repeat length was 43 (range: 36-70) for the pathological and 19 for the non-pathological alleles (range: 9-35). 17.5% of the pathological alleles were in the decreased penetrance range, while 7% of non-pathological alleles were intermediate. CONCLUSIONS: The genetic and clinical features of the population examined in the present study were in line with the previous Hungarian study, as well as with international literature. The exceptions were the higher ratio of reduced penetrance and intermediate alleles.

Determination of Reference Values of MDR-ABC Transporter Activities in CD3+ Lymphocytes of Healthy Volunteers Using a Flow Cytometry Based Method.

BACKGROUND: MDR transporters are important biomarkers of drug resistance in cancer and in autoimmune conditions. We determined the MDR1, MRP1 and BCRP activity in CD3+ lymphocytes using a flow cytometry based method from 120 healthy volunteers in order to describe normal reference values of the activity of these transporters. The effects of gender and age were also determined. METHODS: The Solvo MDQ Kit™ was used for measurements. In this assay, fluorescent reporter substrates (Calcein-AM for MDR1 and MRP1 and mitoxantrone for BCRP, respectively) are trapped in the cytoplasm and pumped out by MDR proteins depending on the presence or absence of specific inhibitors (verapamil for MDR1 and MRP1, indomethacin for MRP1 and KO134 for BCRP, respectively), allowing for quantitative, standardized assessment. Cell surface staining was applied to select CD3+ cells. RESULTS: MAF values of MRP1 and BCRP are independent from age. MAFC and MAF of MDR1 show negative correlation with the age of the studied subjects (P = 0.003, r = -0.27 and P = 0.0001, r = -0.34, respectively). No difference was detected in any of the four MAF values between men and women. Gender does not affect the presence or lack of correlation between MAF values and age. CONCLUSIONS: The determination of the functional activity of MDR-ABC transporters is achievable using a flow cytometry based standardized method. Having established the normal range of MAF values on CD3+ lymphocytes of a healthy population, our results allow for the development of novel flow cytometry based diagnostic tools. © 2018 International Clinical Cytometry Society.

Trunk alignment in different standing positions in healthy subjects and stroke patients -a comparative study with a simple method for the everyday practice.: Trunk alignment in healthy and stroke subjects.

OBJECTIVES: Weight-bearing (WB) on the lower extremities is an important outcome parameter in the rehabilitation of poststroke hemiparesis. However, the patients often regain this ability by compensatory movement patterns. METHODS: Our goal was to characterize with a simple method the trunk alignment of healthy subjects and stroke patients (n = 17 for both groups) during standing and following lateral weight shift (WS). To describe trunk alignment, five markers were placed on the subjects' back, and the angles of the trunk at both sides were defined by the lines drawn from the posterior angle of the acromion and the iliac crest on the same body side to the seventh thoracic spinal process. Weight distributions on the lower extremities during standing and lateral WS were determined with a force platform. RESULTS: The patients had significantly limited WB capacity on their paretic limb, which was accompanied with significant asymmetry in the trunk alignment during standing and following WS to the paretic side. DISCUSSION: Our results show that this patient population tends to use abnormal compensatory movement patterns to optimize weight shifting, and changes of trunk alignment play a key role in this. This should be taken into consideration during rehabilitation.

Membrane Assays to Characterize Interaction of Drugs with ABCB1.

ATP-binding cassette sub-family B member 1 (ABCB1) [P-glycoprotein (P-gp), multidrug resistance protein 1 (MDR1)] can affect the pharmacokinetics, safety, and efficacy of drugs making it important to identify compounds that interact with ABCB1. The ATPase assay and vesicular transport (VT) assay are membrane based assays that can be used to measure the interaction of compounds with ABCB1 at a lower cost and higher throughput compared to cellular-based assays and therefore can be used earlier in the drug development process. To that end, we tested compounds previously identified as ABCB1 substrates and inhibitors for interaction with ABCB1 using the ATPase and VT assays. All compounds tested interacted with ABCB1 in both the ATPase and VT assays. All compounds previously identified as ABCB1 substrates activated ABCB1-mediated ATPase activity in the ATPase assay. All compounds previously identified as ABCB1 inhibitors inhibited the ABCB1-mediated transport in the VT assay. Interestingly, six of the ten compounds previously identified as ABCB1 inhibitors activated the basal ATPase activity in activation assays suggesting that the compounds are substrates of ABCB1 but can inhibit ABCB1 in inhibition assays. Importantly, for ATPase activators the EC50 of activation correlated with the IC50 values from the VT assay showing that interactions of compounds with ABCB1 can be measured with similar levels of potency in either assay. For ATPase nonactivators the IC50 values from the ATPase inhibition and VT inhibition assay showed correlation. These results demonstrate the utility of membrane assays as tools to detect and rank order drug-transporter interactions.

The first identified Central-Eastern European patient with genetically confirmed dentatorubral-pallidoluysian atrophy.

AIMS: Dentatorubral-pallidoluysian atrophy (DRPLA) is an inherited neurodegenerative disorder characterized by a trinucleotide repeat expansion. The disease mainly occurs amongst the Japanese and is extremely rare in the European population. The characteristic clinical symptoms are cerebellar ataxia, dementia, choreoathetoid movements, epileptic seizures and myoclonus. The aim of this study is to present the first genetically confirmed Hungarian case of DRPLA. CASE REPORT: The middle-aged female patient developed the characteristic clinical symptoms except myoclonus over her late thirties with positive family history. The major finding in the skull magnetic resonance imaging was the atrophy of infratentorial brain structures with the consequential dilation of related cerebrospinal fluid spaces. A detailed neuropsychological examination was also performed and it revealed moderate cognitive dysfunctions, mild depression and anxiety. As underlying conditions, Huntington's disease and common spinocerebellar ataxia forms all came into consideration, but all the result of the respective genetic tests were negative. However, the test for mutation in the ATN1 gene revealed pathological heterozygous CAG repeat expansion. CONCLUSION: This case study serves as the first description of genetically confirmed DRPLA in the Central-Eastern region of Europe, the clinical features of which seems to be very similar to the previously reported cases.

The role of cognitive training in the neurorehabilitation of a patient who survived a lightning strike. A case study.

BACKGROUND: Lightning-related injuries most often involve impairment of the functions of the central and peripheral nervous systems, usually including cognitive dysfunctions. We evaluated the cognitive deficit of a patient who had survived a lightning strike and measured the improvement after her cognitive training. This therapeutic method appears to be a powerful tool in the neurorehabilitation treatment. OBJECTIVE: The aim of this case study was to prove the beneficial effects of cognitive training as part of the neurorehabilitation after a lightning strike. METHODS: Six neuropsychological functions were examined in order to test the cognitive status of the patient before and after the 2-month cognitive training: phonological short-term memory (digit span test and word repetitions test), visuo-spatial short-term memory (Corsi Block Tapping Test), working memory (backward digit span test and listening span test), executive functions (letter and semantic fluencies), language functions (non-word repetition test, Pléh-Palotás-Lörik (PPL) test and sentence repetition test) and episodic memory (Rivermead Behavioral Memory Test and Mini Mental State Examination). We also utilized these tests in aged-matched healthy individuals so as to be able to characterize the domains of the observed improvements more precisely. RESULTS: The patient exhibited a considerable improvement in the backward digit span, semantic fluency, non-word repetition, PPL, sentence repetition and Rivermead Behavioral Memory tests. CONCLUSIONS: The cognitive training played an important role in the neurorehabilitation treatment of this lightning injury patient. It considerably improved her quality of life through the functional recovery.

Structure and function of BCRP, a broad specificity transporter of xenobiotics and endobiotics.

The discovery and characterization of breast cancer resistance protein (BCRP) as an efflux transporter conferring multidrug resistance has set off a remarkable trajectory in the understanding of its role in physiology and disease. While the relevance in drug resistance and general pharmacokinetic properties quickly became apparent, the lack of a characteristic phenotype in genetically impaired animals and humans cast doubt on the physiological importance of this ATP-binding cassette family member, similarly to fellow multidrug transporters, despite well-known endogenous substrates. Later, high-performance genetic analyses and fine resolution tissue expression data forayed into unexpected territories concerning BCRP relevance, and ultimately, the rise of quantitative proteomics allows putting observed interactions into absolute frameworks for modeling and insight into interindividual and species differences. This overview summarizes existing knowledge on the BCRP transporter on molecular, tissue and system level, both in physiology and disease, and describes a selection of experimental procedures that are the most widely applied for the identification and characterization of substrate and inhibitor-type interactions.

A P-gp vesicular transport inhibition assay - optimization and validation for drug-drug interaction testing.

Accurate determination of potential drug-drug interaction mediated by efflux transporters (tDDI) is crucial to assess the risk of pharmacokinetic interaction and toxicity of drugs. Passive permeability and uptake transporter mediated transport are important covariates of cell-based inhibition assays that need to be taken into consideration when performing kinetic analysis of data. Vesicular uptake inhibition has been considered by regulatory agencies as a viable alternative for testing tDDI potential of low passive permeability drugs in particular. Membranes prepared from a P-gp overexpressing human cell line has superior transport properties over membranes prepared from Sf9 cells and cholesterol enriched Sf9 membranes. P-gp expressed in this membrane effluxes N-methyl-quinidine (NMQ) with high affinity (K(m) is 3.65 µM) and a high rate (V(max) is 656 pmol/mg protein/min). Digoxin, vinblastine and paclitaxel, established P-gp substrates inhibited transport of NMQ with estimated K(i) values of 250, 0.1 and 0.6 µM, respectively. A panel of 11 drugs that have been listed by regulatory agencies as reference inhibitors were used to validate the assay to predict clinical inhibition potential. All the drugs that have been implicated in P-gp mediated DDI were found to be inhibitors in a relevant concentration range.

MDR-ABC transporters: biomarkers in rheumatoid arthritis.

MDR-ABC transporters are widely expressed in cell types relevant to pathogenesis of rheumatoid arthritis. Many reports demonstrate the interaction of small molecule drugs with MDR-ABC transporters. Cell-based assays for disease relevant cell types can be easily gated and could reveal specific drug targets and may increase significance and utilisation of data in clinical practice. Many commonly used DMARDs (e.g. methotrexate, sulfasalazine, leflunomide/teriflunomide, hydroxychloroquine) are ABCG2 substrates. Consequently, the activity of this transporter in patients should be determined to understand the disposition and pharmacokinetics of the therapy. In addition, MDR-ABC transporters transport a variety of endobiotics that play important roles in cell proliferation, cell migration, angiogenesis and inflammation. Therefore, MDR-ABC transporters are important biomarkers in rheumatoid arthritis.

Synthesis and ABCG2 inhibitory activity of novel fumitremorgin C analogs--specificity and structure activity correlations.

The Ko family of fumitremorgin C analogs are potent and selective ABCG2 inhibitors. However, the most potent Ko compounds carry an ester linkage in their side-chain that makes them chemically and metabolically less stable. We have synthesized 16 tricyclic and 28 tetracyclic novel analogs devoid of ester linkages and tested them for ABCG2 inhibition potency and specificity. Unlike in the tricyclic analog group, potent ABCG2 inhibitory compounds were found among the tetracyclic analogs. The most potent compounds carried the 3S,6S,12aS configuration. We observed a marked stereospecificity as compounds with the 3S,6S,12aS configuration were at least 18-fold more potent inhibitors than their diastereoisomeric pairs with a 3S,6R,12aS configuration. This stereospecificity was not observed in ABCB1 and ABCC1 inhibition. Therefore, a single chiral center confers specificity for ABCG2 over ABCB1 and ABCC1. This is quite unexpected considering the large multivalent drug binding site these transporters harbor.

Prediction of Therapy Response and Prognosis in Leukemias by Flow Cytometric MDR Assays.

Multidrug resistance (MDR) is an unwanted phenomenon, that may cause therapy failure in several neoplasms including hematological malignancies. The purpose of any type of laboratory MDR assay is to reliably identify such patients and to provide useful data to clinicians with a relatively short turnaround time. MDR can be multicausal and several previous data identified a group of transmembrane proteins - the ATP-binding casette (ABC) proteins - that may be involved in MDR in various hematological malignancies. The prototype of these proteins is the P-glycoprotein (Pgp, MDR1, ABCB1) that is a seven-membrane spanning transmembrane protein capable of extruding several cytotoxic drugs that are of key importance in the treatment of hematological disorders. Similarly other ABC proteins - Multidrug resistance associated protein 1 (ABCC1) and breast cancer resistance protein (ABCG2) are both capable of pumping out cytotoxic drugs. Here, we present flow cytometric methods to identify MDR proteins by antigen and activity assays. The advantage of flow technology is the short turnaround time and its relative easiness compared to nucleic acid based technologies. However, for the activity assays, it should be noted, that these functional tests require live cells, thus adequate results can only be provided if the specimen transport can be completed within 6 hours of sample collection. Identification of MDR proteins provides prognostic information and may modulate therapy, thus signifies a clinically useful information in the evaluation of patients with leukemias.

[The role of marginal donors in liver transplantation. The Hungarian experience]. / Marginális donorok szerepe a magyar májátültetési programban.

UNLABELLED: Availability of suitable donor organs has always limited liver transplantations. Use of marginal donors (Extended Donor Criteria) for liver transplantation is an alternative to overcome the organ shortage. The aim of this study was to analyze the characteristics of organ donation in Hungary with special regard to marginal donors. METHODS: We reviewed data from donors and recipients between January 2003 and December 2008 retrospectively. Extended donor criteria were adopted from international recommendations. RESULTS: During this period, 1078 donors were reported to the clinic. 835 (77.4%) donors were excluded from liver transplantation and 243 (22.6%) were implanted. From the 243 transplantations 40 recipients (16%) received marginal graft, 203 (84%) received non-marginal graft. Extended Donor Criteria status had no negative impact on the patient and graft survival, postoperative graft dysfunction, and other complications. Recurrence of Hepatitis C occurred earlier in those patients who received marginal graft. CONCLUSION: There is an increasing number of patients waiting for liver transplantation in Hungary. There is no significant difference in morbidity and mortality of patients receiving marginal or non-marginal graft. Use of marginal grafts should be avoided in Hepatitis C virus positive recipients. Acceptance of older donors for liver transplantation should be considered.

[Biliary complications following orthotopic liver transplantation. The Hungarian experience]. / Epeúti szövodmények májtranszplantáció után.

INTRODUCTION: The authors summarize the characteristics of biliary complications following liver transplantation in the Hungarian liver transplant program. Aims were to analyze the frequency and the types of biliary complications as well as their effect on the patient and graft survival. The authors observed the known risk factors in the Hungarian practice, and they also try to find unknown risk factors for biliary complications. They review the therapy of biliary complications. METHOD: In the retrospective study, patients were divided into two groups, with and without biliary complication after liver transplantation. These two groups were compared with many factors, and with the survivals. The biliary complication group was divided into two parts: those who had an early and those with a late biliary complication. These two new groups were also compared with the controls. The results are summarized in tables and statistical figures. Categorical variables are evaluated by chi 2 -test, continuous ones are with Levine Test (for homogenicity of means), Student T test and Mann-Whitney U-test. Cumulative survivals are computed with Kaplan-Meier log rank analysis. RESULTS: Biliary complication appeared in 25% of the patients. The most frequent complications were stenosis (18%), biliary leakage (9%), biliary necrosis (6%), and ischaemic type of biliary lesions (3%). The 5-year survival is worse when biliary complications were diagnosed (55%) than without such a complication (66%). In the biliary complication group the retransplantation rate was higher (15%). The most frequent treatments were interventional radiologic methods (69%), surgical methods (17%), and the ERCP. CONCLUSIONS: The rate of biliary complications met the international reviews. Risk factors for biliary complications were cholangitis, hepatic artery thrombosis and stenosis, high rate of intraoperative blood transfusions, and acute rejection. Biliary complications frequently associated with the initial poor function of the transplanted graft. Early biliary complications have a negative impact on patient survival, while late complications influence a decreased quality of life. Biliary complications were treated mostly by interventional radiologic procedures.

Extensive flow cytometric characterization of plasmacytoid dendritic cell leukemia cells.

OBJECTIVES: Accumulating evidence suggests that non-T, non-B cell CD4+CD56+ neoplasms with lymphoblastic morphology include clinically and immunophenotypically diverse entities. Although their cells of origin or classification are still controversial several entities clearly represent a distinct type of neoplasms that are clinically aggressive. METHODS: In this work we present the immunophenotypic and genotypic features of bone marrow (BM), peripheral blood (PB), lymph node and skin lymphocytes from a patient diagnosed as plasmacytoid dendritic cell leukemia involving the skin, BM, PB, lymph nodes, liver and spleen. For determination of immunophenotypic characteristics of malignant plasmacytoid dendritic cells 73 monoclonal antibodies detecting lineage markers, chemokine receptors, cytokine receptors, activation, and co-stimulatory molecules were used. RESULTS AND CONCLUSION: The malignant cells proved to express CD4+, CD56+ lineage negative leukemia phenotype characteristically positive for CD36, CD38, CD40, CD45, CD45RA, CD68, CD123, CD184, HLA-DR, BDCA2, and granzyme-B corresponding to the preplasmacytoid dendritic cell developmental stage. The presence of CD11a/CD18, CD84, CD91, CD95, alphavbeta5, CDw197, and the absence of CD52 and CD133 in this case can be regarded as additional features of malignant cells. Completing the immunophenotypes with multidrug resistance function can provide additional information for characterizing pDC leukemia.

Perceptual categorization is impaired in Huntington's disease: an electrophysiological study.

Recent evidence raised the possibility that the neostriatum and the corticostriatal circuits could play an important role in semantic categorization. In this study, we examined the electrophysiological correlates of natural scene categorization in Huntington's disease (HD) patients and their asymptomatic relatives who were Huntington's disease mutation carriers (HDC). Event-related potentials were recorded in HD patients, HDC subjects, and age-matched control subjects using a natural scene categorization task. The subjects had to decide whether a briefly presented image contained animals or no animals. Concerning the N1 component (150-250 ms), the mean amplitudes were more negative for nonanimal scenes as compared with stimuli containing animals at all electrode sites in the control group and at all but the lateral temporal electrode sites (T3, T4) in the HD group. Between-group comparison demonstrated that the N1 amplitudes were significantly smaller for both kinds of stimuli in the HD group in spite of a normal primary occipital component (P100). The HDC subjects were not significantly different from the controls concerning the N1 amplitudes. These results suggest that perceptual (N1) processes related to the categorization of natural scenes are specifically impaired in HD. The findings are in agreement with the hypothesis emphasizing the importance of neostriatal mechanisms in human categorization functions.

Somatosensory evoked potentials correlate with genetics in Huntington's disease.

Abnormalities of somatosensory evoked potentials (SEPs) have been reported in Huntington's disease, a neuropsychiatric disorder caused by the expansion of a CAG trinucleotide repeat. The aim of our study was to determine the relationship between these electrophysiological changes and the length of the nucleotide repeat. We found a striking correlation between the decrease in the early component amplitudes (N20 and N30) of the median nerve SEP and the repeat length, suggesting that these SEP alterations are indeed related to the genetically determined pathological process. The cortical components of the tibial nerve SEP exhibited a dramatic alteration in the patient group and were the only SEP changes found in the group of asymptomatic carriers of the mutation, being more sensitive than the median nerve SEPs.

"Pros and cons" on how to measure multidrug resistance in leukemias.

Drug resistance is one of the most significant challenges in the treatment of various types of malignancies, however most of the experimental and clinical data in multidrug resistance (MDR) has been obtained in leukemias. MDR is the term that describes innate or acquired resistance of tumor cells to a wide range of anticancer drugs. As its presence determines treatment outcome in several forms of leukemias, it is imperative that clinical laboratories provide the most useful data on its expression. Here, a brief review is provided on the pathomechanism and diagnostics of MDR. From the diagnostic point of view it is fortunate that MDR proteins display similar effluxing activity towards many dissimilar agents some of which can be used in fluorescent assays. These tests mimic the real clinical problem i.e. the extrusion activity of MDR proteins towards xenobiotics. Thus, we believe that functional assays when carried out in a standardized way and particularly combined with labeling for various surface markers can be recommended as a front-line test in MDR measurement.