[Refraining from futile medical treatment in clinical practice. Directives of the Polish pediatric society]. / L'astensione dall'accanimento terapeutico nella pratica clinica. Linee-guida della società polacca.

The continuous development of medicine increases the possibility of sustaining life functions, which frequently leads to prolonging the patient's agony or exposing him/her to unnecessary suffering. The application of some medical procedures, technical equipment and pharmacological measures that prolong the process of dying in terminally ill children may be a sign of therapeutic obstinacy. Such actions are not an outcome of concern for the welfare of young patients and violate their dignity. In the interest of incurable and terminally ill children and considering the needs of physicians who have to make difficult clinical decisions, the Polish Pediatric Society (PPS) ratified the guidelines concerning abandoning and withdrawal of overzealous therapy. The objective of this article was to present the Italian medical society, Polish rules for refraining from overzealous therapy in pediatrics. The commentary to the Directive include the remarks on the dubious concept of "therapeutic obstinacy". Following fragments of the article characterize Polish ideas on terminally ill children's rights, the current situation of these children in medical care, and the origins and character of the document approved by the PPS. The complementation of the commentary are remarks made by a team of experts that develop guidelines which apply to specific clinical problems associated with the care of terminally ill children. This article is yet another voice in the wide debate on the moral imperative of refraining from therapeutic obstinacy in medical practice.

Effect of pamidronate on skeletal morbidity in myelomatosis. Part 1. The results of the first 12 months of pamidronate therapy.

BACKGROUND: Osteolytic bone destruction caused by increase of osteolytic activity is a major manifestation of multiple myeloma (MM). Pamidronate (3-amino-1-hydroxypropylidene)-1,1-bisphosphonate) inhibits osteoclastic activity and reduces bone resorption. METHODS: Since October 1995 the efficacy of pamidronate is evaluated in MM patients all receiving anti-myeloma chemotherapy acc. to VMCP/VBAP alternating regimen. 46 patients with stage III myeloma and osteolytic lesions were randomized to receive either pamidronate (Aredia; Novartis) 60 mg i.v. in 4-hour infusion monthly (n = 23) or chemotherapy alone (control group n = 23). Estimation of performance status, quality of life, pain score, analgesic consumption, serum calcium concentration and twenty four-hours Calcium excretion, urine Calcium/creatinine ratio is done at least once a month (before pamidronate administration) while X-ray skeletal survey--before treatment and then every six months. RESULTS: In the first months of treatment apparent reduction of bone pain occurred. Hypercalcaemia was revealed in 6 patients at entry into the study. In 5 of these patients pamidronate restored and maintained normocalcaemia for a median 6 months. In 3 patients an aggressive plasma cell proliferation was accompanied by reoccurrence of hypercalcaemia. At skeletal X-ray examination performed after 6 and 12 cycles of pamidronate and by comparing each of consecutive imaging with previous one the progression of osteolysis was respectively found in 67% and 39% of patients. In the control group corresponding figures were: 79% and 70%. The mean number of skeletal events (pathologic fracture, radiation to bone and spinal cord compression) per year was lower in the pamidronate group (1.82) than in control-patients (2.72), p < 0.013. The proportion of patients who developed skeletal event (excluding vertebral fractures) was lower in the pamidronate group -34% v 52%. Adverse events of pamidronate: hypocalcaemia (< 2 mmol/l) observed in 7 patients occurred in particular patients beginning from 2 to 7 days after drug administration. In 2 patients hypocalcaemia that appeared in 24 hours after drug infusion was accompanied by blood pressure decrease; in one case systolic blood pressure dropped up to 60 mmHg, in the other one--to 90 mmHg. Muscular pain and fever up to 39 degrees C (transient and self-limiting "influenza like syndrom") occurred in 5 patients, in two patients after several hours and in three other--after some dozens of hours from drug administration. In one case hypertransaminasaemia was observed. CONCLUSIONS: In the first year of treatment monthly intravenous pamidronate administration as an adjunct to chemotherapy in patients with advanced multiple myeloma with osteolysis is an efficient approach in prevention and treatment of hyperacalcaemia, hypercalciuria and bone pain. It also shows some preventive effect on bone lesion occurrence.

[The value of phlebography, USG-doppler and intraoperative tests in diagnosis of perforating venous insufficiency in the calf]. / Skutecznosc badan flebograficznych, USG-doppler i sródoperacyjnych w wykrywaniu niewydolnych zyl przeszywajacych goleni.

Accuracy of phlebography, color duplex sonography and intraoperative findings have been compared in a group of 29 patients operated for postphlebitic syndrome. The highest number of perforating veins was identified during the operation, fewer on phlebography and the fewest on color duplex sonography. However in the upper part of the calf both the latter were found to be inaccurate.

A rationale for treating hepatic adenoma.

Hepatic adenomas are being seen in young women taking oral contraceptives with alarming frequency. In the United States it is estimated that at least five million women are taking oral contraceptives. Physicians should consider hepatic adenoma in the differential diagnosis of all menstruating females with right upper quadrant pain. An early diagnosis and proper treatment could be life-saving.

PIP: Since the 1st cases were reported, hepatic adenomas are being seen in young women using oral contraceptives at increasing and alarming levels. Although some cases have appeared in patients on pills for as short a time as 6 months, most occur after pill usage of more than 2 years. Older women taking estrogen therapy and young women taking anabolic steroids occasionally development hepatic adenomas also. These benign heaptic adenomas have a propensity for necrosis, rupture, and massive intraperitoneal hemorrhage. 2 case studies are cited; photographs are included. 3 clinical profiles can be observed with these adenomas: 1) extreme right upper quadrant pain followed by shock and, possibly, mortality; 2) right upper quadrant pain with no hemorrhaging; and 3) an asymptomatic mass palpable on examination. Treatment of these lesions is controversial. Any incident of right upper quadrant pain should be investigated for a possible case of hepatic adenoma.

The value of the barium enema in the diagnosis of acute appendicitis.

Contrary to popular belief, the barium enema is a safe diagnostic tool in the management of acute appendicitis. This is a survey of our experience over three years with 489 cases of suspected acute appendicitis. Two hundred eighteen barium enema examinations were done. The barium enema has a high degree of pathological correlation (97.14%). It has reduced negative surgical exploration in women between 11 and 40 years of age. This group traditionally represents the greatest diagnostic challenge in appendicitis. As a result, our negative exploration rate has been reduced to a figure below the average for this disease. We recommend its performance in all patients who pose a diagnostic dilemma.