[Withdrawal of artificial nutrition and hydration in severe stroke: medical, legal and ethical considerations]. / Aspects médicaux, législatifs et éthiques de l'arrêt de la nutrition et de l'hydratation artificielles dans l'accident vasculaire cérébral grave.

In the majority of cases, severe stroke is accompanied by difficulty in swallowing and an altered state of consciousness requiring artificial nutrition and hydration. Because of their artificial nature, nutrition and hydration are considered by law as treatment rather basic care. Withdrawal of these treatments is dictated by the refusal of unreasonable obstinacy enshrined in law and is justified by the risk of severe disability and very poor quality of life. It is usually the last among other withholding and withdrawal decisions which have already been made during the long course of the disease. Reaching a collegial consensus on a controversial decision such as artificial nutrition and hydration withdrawal is a difficult and complex process. The reluctance for such decisions is mainly due to the symbolic value of food and hydration, to the fear of "dying badly" while suffering from hunger and thirst, and to the difficult distinction between this medical act and euthanasia. The only way to overcome such reluctance is to ensure flawless accompaniment, associating sedation and appropriate comfort care with a clear explanation (with relatives but also caregivers) of the rationale and implications of this type of decision. All teams dealing with this type of situation must have thoroughly thought through the medical, legal and ethical considerations involved in making this difficult decision.

Adjuvant perioperative portal vein or peripheral intravenous chemotherapy for potentially curative colorectal cancer: long-term results of a randomized controlled trial.

BACKGROUND AND AIMS: The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349-353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival. MATERIALS AND METHODS: Stages I-III colorectal cancer patients (n = 753) were randomized to receive either surgery alone (control arm), surgery plus postoperative portal venous infusion of 5-FU 500 mg/m(2) plus heparin given for 24 hours for seven consecutive days plus mitomycin C 10 mg/m(2) given on the first day (arm 2), or surgery and the same chemotherapy regimen administered by peripheral venous route (arm 3). RESULTS: The 5-year disease-free survival for the three treatment groups were 65% (control group), 60% (portal vein infusion, hazard ratio 1.18, p = 0.23), and 64% (intravenous infusion, hazard ratio 1.04, p = 0.76); the 5-year overall survival was 72% (control group), 69% (portal vein infusion, hazard ratio 1.21, p = 0.2), and 74% (intravenous infusion, hazard ratio 1.03, p = 0.86), respectively. A significant accumulation of early deaths were observed in the portal vein infusion group (p = 0.015). CONCLUSIONS: The present prospective randomized multicenter trial provides compelling evidence that short-term perioperative chemotherapy does not improve disease-free and overall survival in patients with potentially curative colorectal cancer. In contrary, the chemotherapy regimen administered in the present investigation seems to have potentially harmful effects, a finding which should be carefully considered in the planning of future trials. Postoperative short-term administration of 5-FU plus mitomycin C either through portal infusion or a central venous catheter is not recommended for routine use in patients with potentially curable colorectal cancer.

Early asymptomatic recurrence of cervical artery dissection: three cases.

Cervical artery dissection (CAD) recurrences are rare but the risk could be higher during the first month. Twenty-seven consecutive patients admitted for an acute CAD were investigated using a standardized imaging protocol. An early asymptomatic recurrence was observed in three patients 49 to 53 days after the initial diagnosis. Anticoagulation was maintained and the prognosis remained good. Early CAD recurrences may have been underestimated previously, because asymptomatic recurrences seem to be more frequent than symptomatic ones.

[Cecum volvulus--a frequently misdiagnosed disease picture. Results of a retrospective study of 26 patients and review of the literature]. / Zoekumvolvulus--ein diagnostisch häufig verpasstes Krankheitsbild. Ergebnisse einer retrospektiven Studie von 26 Patienten und Literaturübersicht.

BACKGROUND: Cecal volvulus represents a rare disease which causes acute or chronic intermittent mechanical obstruction. Diagnosis of the acute form of cecal volvulus is often established too late with resulting high morbidity and mortality. This study characterizes the typical clinical symptoms, radiological signs and the frequent concomitant diseases, based on a rather large number of patients. We specifically evaluated possible differences concerning clinical presentation, therapy and postoperative course of patients with vital bowel as opposed to necrotic cecum. PATIENTS AND METHODS: 26 consecutive patients hospitalised with cecal volvulus from January 1984 until February 2000 were retrospectively evaluated. Patients with vital intestine (n = 14) were compared to those with necrotic cecum (n = 12). RESULTS: 38% of patients underwent previous abdominal surgery, 34% suffered from other acute disease, in 38% cecal volvulus was associated with a neuropsychiatric disorder. 58% of the patients showed symptoms of intestinal obstruction. The clinical pattern of patients with necrotic cecum was not significantly different from those of patients with vital intestine. Diagnosis of cecal volvulus could be established in 77% by plain abdominal X-ray alone or by an additional contrast enema. CONCLUSIONS: Knowledge of the characteristic pattern of history, physical findings, plain abdominal X-ray and the frequently with cecal volvulus associated diseases most often allows to establish diagnosis of cecal volvulus without delay and other diagnostic procedures. Astonishingly we found no major difference between vital and necrotic cecum with regard to clinical presentation and postoperative course.

[The Advanced Breast Biopsy Instrumentation (ABBI) for evaluation of mammographically suspicious, non-palpable findings of the breast: a reliable diagnosis with minor therapeutic potential]. / Die Advanced Breast Biopsy Instrumentation (ABBI) für die Evaluation mammographisch verdächtiger, nicht-palpabler Befunde der Brustdrüse: Eine zuverlässige Diagnostik mit geringem therapeutischen Potential.

BACKGROUND: Stereotactic biopsy techniques supersede conventional hook-wire localization followed by open excision to clarify the dignity of nonpalpable mammographic lesions. The advanced breast biopsy instrumentation (ABBI) allows stereotactically guided excision of a specimen up to 20 mm in diameter on an outpatient basis under local anaesthesia. METHODS: Demographic information, mammographic and pathological findings, complications, subsequent interventions and sensitivity as well as efficiency of a series of 144 planned ABBI procedures were documented (largest published single institution series). RESULTS: The ABBI procedure was successfully performed in 93.8% (135/144); accurate diagnosis was made in 99.3% (134/135), sensitivity for malignant lesions was 96.9% (31/32) and morbidity was 1.5%. Consistent with other published series margins of the biopsy cylinder containing a malignant lesion were involved in 83.9% (26/31). CONCLUSIONS: Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low incidence of morbidity. The therapeutic use is of limited potential.

[Emergency diagnosis of cecal volvulus]. / Notfalldiagnostik bei Zäkumvolvulus.

Twelve cases of coecal volvulus have been analysed. Given typical signs, plain radiography of the abdomen should assure diagnosis. Chronic volvulus requires a colon contrast enema for confirmation of diagnosis.. Immediate laparotomy is mandatory.