Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate--a randomized trial.

PURPOSE: To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision. MATERIALS AND METHODS: A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up. RESULTS: One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups. CONCLUSION: Morphine does not improve US-based diagnosis of appendicitis.

Balkan endemic nephropathy: still a mysterious disease.

Balkan endemic nephropathy (BEN) is an acquired, environmental, polytopical disease of the entire urinary tract, with long latency. Tubulointerstitial chronic nephritis, urotheliomas of all localities, and renal cell carcinoma occur with a significantly higher frequency in the affected population. These represent only clinical manifestations of one unique nosological entity. BEN occurs in focuses. Within them, it agglomerates in households, without any evidence of hereditary background. Patients with various clinical manifestations of the disease can be simultaneously found within one single household. BEN appears equally among members of different ethnic groups. Its aetiology is not clear enough. There is no evidence of a causal relationship with silicon compounds, heavy metals and viruses. Much attention has been recently focused on research of the aetiological role of mycotoxins, mainly ochratoxin A. Toxic and carcinogenic agents of natural origin are commonly accepted as the major cause of BEN.

[Primary tumors of the diaphragm. Apropos of a case]. / Les tumeurs primitives du diaphragme. A propos d'un cas.

The diagnosis of diaphragmatic tumours is complicated by their rarity and because they are often difficult to distinguish from the more frequent tumours of surrounding structures. We describe two cases: an invasive fibroma and a primary hydatid cyst. We discuss the differential diagnosis of diaphragmatic tumours and suggest a systematic approach to their radiological diagnosis, stressing the value of ultrasonography, CT scanning and diagnostic pneumoperitoneum.