Pain catastrophizing in rheumatic diseases: prevalence, origin, and implications.

Pain is a crucial factor in rheumatic disorders, and reducing it is a primary goal of successful treatment. Adaptive pain-coping strategies can enhance this improvement, but maladaptive approaches such as pain catastrophizing may worsen overall patient well-being. This narrative review aims to provide a concise overview of the existing knowledge on pain catastrophizing in the most prevalent specific rheumatic disorders. The objective of this study was to improve understanding of this phenomenon and its implications, as well as to pinpoint potential directions for future research. We conducted searches in the MEDLINE/PubMed, SCOPUS, and DOAJ bibliography databases to identify articles related to pain catastrophizing in rheumatoid arthritis, psoriatic arthritis, axial spondylarthritis, systemic sclerosis, systemic lupus erythematosus, Sjögren's syndrome, juvenile idiopathic arthritis, and osteoarthritis (non-surgical treatment). Data extraction was performed on November 1, 2023. The investigators screened the identified articles to determine their relevance and whether they met the inclusion criteria. Following a bibliography search, which was further expanded by screening of citations and references, we included 156 records in the current review. The full-text analysis centred on pain catastrophizing, encompassing its prevalence, pathogenesis, and impact. The review established the role of catastrophizing in amplifying pain and diminishing various aspects of general well-being. Also, potential treatment approaches were discussed and summarised across the examined disorders. Pain catastrophizing is as a significant factor in rheumatic disorders. Its impact warrants further exploration through prospective controlled trials to enhance global patient outcomes.

Ultrasonographic Applications of Novel Technologies and Artificial Intelligence in Critically Ill Patients.

The diagnostic process in Intensive Care Units has been revolutionized by ultrasonography and accelerated by artificial intelligence. Patients in critical condition are often sonoanatomically challenging, with time constraints being an additional stress factor. In this paper, we describe the technology behind the development of AI systems to support diagnostic ultrasound in intensive care units. Among the AI-based solutions, the focus was placed on systems supporting cardiac ultrasound, such as Smart-VTI, Auto-VTI, SmartEcho Vue, AutoEF, Us2.ai, and Real Time EF. Solutions to assist hemodynamic assessment based on the evaluation of the inferior vena cava, such as Smart-IVC or Auto-IVC, as well as to facilitate ultrasound assessment of the lungs, such as Smart B-line or Auto B-line, and to help in the estimation of gastric contents, such as Auto Gastric Antrum, were also discussed. All these solutions provide doctors with support by making it easier to obtain appropriate diagnostically correct ultrasound images by automatically performing time-consuming measurements and enabling real-time analysis of the obtained data. Artificial intelligence will most likely be used in the future to create advanced systems facilitating the diagnostic and therapeutic process in intensive care units.

Artificial Intelligence-Supported Ultrasonography in Anesthesiology: Evaluation of a Patient in the Operating Theatre.

Artificial intelligence has now changed regional anesthesia, facilitating, therefore, the application of the regional block under the USG guidance. Innovative technological solutions make it possible to highlight specific anatomical structures in the USG image in real time, as needed for regional block. This contribution presents such technological solutions as U-Net architecture, BPSegData and Nerveblox and the basis for independent assisting systems in the use of regional blocks, e.g., ScanNav Anatomy PNB or the training system NeedleTrainer. The article describes also the systems integrated with the USG devices, such as Mindray SmartNerve or GE cNerve as well as the robotic system Magellan which substantially increases the patient's safety, time needed for the regional block and quality of the procedure. All the solutions presented in this article facilitate the performance of regional blocks by less experienced physicians and appear as an excellent educational tool which, at the same time, improves the availability of the more and more popular regional anesthesia. Will, therefore, artificial intelligence replace physicians in regional block procedures? This seems unlikely. It will, however, assist them in a significant manner, contributing to better effectiveness and improved safety of the patient.

Effective treatment of Clostridioides difficile infection improves survival and affects graft-versus-host disease: a multicenter study by the Polish Adult Leukemia Group.

Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea after allogeneic hematopoietic cell transplantation (allo-HCT). The impact of CDI and its treatment on allo-HCT outcomes and graft-versus-host disease (GVHD), including gastrointestinal GVHD (GI-GVHD) is not well established. This multicenter study assessed real-life data on the first-line treatment of CDI and its impact on allo-HCT outcomes. Retrospective and prospective data of patients with CDI after allo-HCT were assessed. We noted statistically significant increase in the incidence of acute GVHD and acute GI-GVHD after CDI (P = 0.005 and P = 0.016, respectively). The first-line treatment for CDI included metronidazole in 34 patients, vancomycin in 64, and combination therapy in 10. Treatment failure was more common with metronidazole than vancomycin (38.2% vs. 6.2%; P < 0.001). The need to administer second-line treatment was associated with the occurrence or exacerbation of GVHD (P < 0.05) and GI-GVHD (P < 0.001) and reduced overall survival (P < 0.05). In the multivariate analysis, the risk of death was associated with acute GVHD presence before CDI (hazard ratio [HR], 3.19; P = 0.009) and the need to switch to second-line treatment (HR, 4.83; P < 0.001). The efficacy of the initial CDI treatment affects survival and occurrence of immune-mediated GI-GVHD after allo-HCT. Therefore, agents with higher efficacy than metronidazole (vancomycin or fidaxomicin) should be administered as the first-line treatment.

Exploring 5-year changes in general and skin health-related quality of life in psoriatic arthritis patients.

Psoriatic arthritis (PsA) carries a severe disease burden, often leading to deterioration of health-related quality of life (HRQoL). Different comorbidities that are relatively prevalent in PsA are also responsible for compromised HRQoL. To assess real-world data of a 5-year follow-up cohort of PsA patients, focusing on changes in general HRQoL, skin HRQoL, and comorbidities. In this prospective observational study, 114 outpatients diagnosed with PsA were examined at baseline and after 5 years. Data collection included demographics, clinical disease activity measures, and patient-reported outcome measures (PROMs). General HRQoL was assessed with a 15D instrument, and skin HRQoL was assessed with the Dermatology Life Quality Index (DLQI). During the 5-year follow-up, no significant deterioration in HRQoL assessed by 15D (23.53 vs. 23.08, p = 0.85) and DLQI (3.48 vs. 2.68, p = 0.07) was observed. There was no observed decline in other PROMs. The mean total number of comorbidities increased (1.13 vs. 1.39, p < 0.01). A significant improvement in disease activity measures, including 66/68 swollen/tender joint count, Disease Activity Index for Psoriatic Arthritis (all p < 0.01), and Psoriatic Arthritis Severity Index (p = 0.04) was seen. A higher proportion of patients at 5 years were treated with b/tsDMARDs (37.7% vs. 46.5%, p = 0.03). Despite an increased number of comorbidities over 5 years, our PsA cohort showed no decline in HRQoL. This can be attributed to the widespread adoption of modern treatments, leading to improved disease control and the preservation of baseline HRQoL.

The Human Centromedial Amygdala Contributes to Negative Prediction Error Signaling during Appetitive and Aversive Pavlovian Gustatory Learning.

Prediction error (PE) is the mismatch between a prior expectation and reality, and it lies at the core of associative learning about aversive and appetitive stimuli. Human studies on fear learning have linked the amygdala to aversive PEs. In contrast, the relationship between the amygdala and PE in appetitive settings and stimuli, unlike those that induce fear, has received less research attention. Animal studies show that the amygdala is a functionally heterogeneous structure. Nevertheless, the role of the amygdala nuclei in PE signaling remains unknown in humans. To clarify the role of two subdivisions of the human amygdala, the centromedial amygdala (CMA) and basolateral amygdala (BLA), in appetitive and aversive PE signaling, we used gustatory pavlovian learning involving eating-related naturalistic outcomes. Thirty-eight right-handed individuals (19 females) participated in the study. We found that surprise with neutral feedback when a reward is expected triggers activity within the left and right CMA. When an aversive outcome is expected, surprise with neutral feedback triggers activity only within the left CMA. Notably, the BLA was not activated by those conditions. Thus, the CMA engages in negative PE signaling during appetitive and aversive gustatory pavlovian learning, whereas the BLA is not critical for this process. In addition, PE-related activity within the left CMA during aversive learning is negatively correlated with neuroticism and positively correlated with extraversion. The findings indicate the importance of the CMA in gustatory learning when the value of outcomes changes and have implications for understanding psychological conditions that manifest perturbed processing of negative PEs.SIGNIFICANCE STATEMENT A discrepancy between a prediction and an actual outcome (PE) plays a crucial role in learning. Learning improves when an outcome is more significant than expected (positive PE) and worsens when it is smaller than expected (negative PE). We found that the negative PE during appetitive and aversive taste learning is associated with increased activity of the CMA, which suggests that the CMA controls taste learning. Our findings may have implications for understanding psychological states associated with deficient learning from negative PEs, such as obesity and addictive behaviors.

Exploring pain catastrophizing and its associations with low disease activity in rheumatic inflammatory disorders.

Pain catastrophizing is a maladaptive mechanism associated with the exaggerated experience of pain, increased rumination and feelings of helplessness. The main objective of this study was to explore whether increased pain catastrophizing is independently associated with a lower proportion of low disease activity (LDA) in rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondylarthritis (axSpA). Demographics, comorbidities, treatment, disease activity measures and patient-reported outcome data were recorded in RA, PsA and axSpA patients. Pain catastrophizing score (PCS) was assessed using a standardised questionnaire. For each diagnosis, composite disease activity scores with distinct cut-off values for LDA, i.e. DAS28-CRP (RA), DAPSA (PsA) and ASDAS-CRP (axSpA) were calculated and used as the dependent variable in logistic regression reflecting LDA achieved. A total of one thousand two hundred and twenty nine patients were included: 580 with RA, 394 with PsA and 255 with axSpA. In the multivariable analysis, pain catastrophizing was independently associated with LDA rates in axSpA (OR 0.33, 95% CI [0.12, 0.88]) amongst tested groups. In RA (OR 0.90, 95% CI [0.64, 1.28]) and PsA (OR 0.77, 95% CI [0.55, 1.07]), a statistically significant association was not observed. Higher PCS was independently associated with not achieving LDA in axSpA. Our data, however, indicate that pain catastrophizing, which also reflects a patient's personality traits and coping abilities, plays a less important role for the patient than general pain perception.

Long-term drug effectiveness and survival for reference rituximab in rheumatoid arthritis patients in an ordinary outpatient clinic.

To explore the long-term drug effectiveness and survival of reference rituximab (ref-RTX)-treated rheumatoid arthritis (RA) patients in an ordinary outpatient clinic. Second, we explored baseline predictors of drug effectiveness and survival, and third, we clarified reasons for stopping treatment. RA patients treated with ref-RTX between 2006 and 2020 in Norway were examined and monitored using recommended measures for disease activity and patient-reported outcomes (PROs). Drug effectiveness was assessed with random intercept linear mixed models; drug survival was assessed with Kaplan-Meier survival analysis. Reasons for discontinuation were ascertained. Baseline predictors of drug effectiveness and survival were estimated. Among 246 RA patients, at baseline, 17.1% were biologic disease-modifying anti-rheumatic drugs (bDMARDs) naïve, and 51.6% were currently using conventional synthetic DMARDs (csDMARDs). During the five-year follow-up, all disease activity and PRO measures improved significantly (p < 0.01), with more substantial changes noted in the second year. Drug survival was 83% after one year and declined to 34% after five years. The two most frequently reported reasons for discontinuation were the doctor's decision (36.2%) and lack or loss of effectiveness (19.2%). No significant difference was found between naïve and previous users of bDMARDs or between concomitant and nonconcomitant users of csDMARDs when analysing drug effectiveness and survival. Our real-life data show that ref-RTX-treated RA patients had satisfactory treatment responses; drug survival declined linearly over time. There was no significant difference between naïve and previous users of bDMARDs or between concomitant and nonconcomitant users of csDMARDs, both for drug effectiveness and survival.

Pain catastrophizing in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: biopsychosocial perspective and impact on health-related quality of life.

Pain catastrophizing (PC), defined as tendency to describe pain in more exaggerated terms, to ruminate more or to feel helpless about it. Main objective was to illuminate PC in rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), revealing its prevalence and associations from a biopsychosocial perspective, including its association with health-related quality of life (HRQoL). Measures reflecting the biological, social and psychological perspective were recorded in RA, PsA and axSpA outpatients. Biological variables including demographics, disease activity and patient reported outcomes (PROs) along with variables reflecting psychological and social domains were collected. RAND12 questionnaire was used to explore HRQoL and standardized questionnaire was used to reveal pain catastrophizing score (PCS). 1229 patients were recruited (RA 580, PsA 394, axSpA 255). Mean (SD) PCS were for RA 1.88 (1.39), PsA 2.06 (1.45) and axSpA 2.27 (1.37). Proportion of pain catastrophizers (score ≥ 4) was not statistically different between RA (10.5%), PsA (12.7%) and axSpA (15.3%). Across all diagnoses, variables reflecting biological subjective domain explained more PCS variability (adjusted R2 35.3-49.9%) than psychological (28.4-33.6%), social (22.4-28.4%) and biological objective (4.3-9.9%) domains. HRQoL was significantly lower in pain catastrophizers across all diagnoses. No substantial differences in proportion of pain catastrophizers between RA, PsA and axSpA patients were found. Higher PCS (score ≥ 4) was best explained by biological subjective measures and corresponded with inferior HRQoL in all diseases. Several biological objectives, psychological and social measures were also associated with higher PCS.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) with probable mesentery involvement with associated hemophagocytic syndrome (HPS) - how to treat it?

Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is a rare, cutaneous lymphoma involving subcutaneous adipose tissue. SPTL is associated in less than 20% with hemophagocytic syndrome (HPS). A 5-year overall survival rate is inferior in patients with SPTL and HPS (46%) as compared with 91% in patients without HPS. No standardized therapy for SPTCL has yet been established. This is a case of 35-year-old Caucasian man with a one-month history of B symptoms with the suspicion of Still's disease, at admission with leucopenia, high LDH, ferritin, sIl-R2, and triglycerides levels, hepatosplenomegaly, small right supraclavicular nodule, and irregular thickening of trunk subcutaneous tissue. The abdomen MRI showed generalized thickening of mesentery and colonic mucosa. In the patient, diagnosis of SPTCL was established with secondary HPS. CHOEP chemotherapy and modified HLH 2014 protocol were applied with subsequent high dose chemotherapy (BEAM) supported by autologous stem cells transplantation. Treatment was complicated by pancytopenia and pneumonia. The outcome of the disease treated by intensive protocol seems to be good.

An empirical study of affective and cognitive functions in Compulsive Sexual Behavior Disorder.

BACKGROUND AND AIMS: Despite the inclusion of the Compulsive Sexual Behavior Disorder (CSBD) in the International Classification of Diseases, very little is known about the underlying affective and cognitive processes. To fill this gap, we compared CSBD subjects and Healthy-Controls (HC) across negative/positive valence, cognitive and sensorimotor systems, as proposed by the Research Domain Criteria framework. METHODS: 74 heterosexual CSBD and 66 matched HC males were studied with 10 questionnaires and 8 behavioral tasks. Analyses were conducted with frequent and Bayesian statistics. RESULTS: CSBD individuals showed significantly higher (than HC) punishment sensitivity, anxiety, depression, compulsivity, and impulsivity symptoms. Frequentist statistical analysis revealed significant interaction between subject group and condition in Incentive Delay Task, concerning the strength of motivation and hedonic value of erotic rewards. Bayesian analysis produced evidence for the absence of group differences in Facial Discrimination Task, Risk-Ambiguity Task, and Learning Task. Also, Bayesian methods provided evidence for group differences in the Emotional Stroop Task and the Incentive Delay Task. Sexual Discounting Task, Attentional Network Task, and Stop Signal Task produced mixed results. CONCLUSIONS: Higher punishment sensitivity and impulsivity among CSBD subjects, along with significant interaction between these groups and erotic vs. non-erotic reward processing is in line with previous findings on negative/positive valence alterations in CSBD patients. This result shows that there are similarities to substance and behavioral addictions. The absence of group differences and mixed results related to cognitive and sensorimotor systems raise concerns to what extent CSBD resembles a wide spectrum of impairments observed in disorders, and demand further research.

Smouldering fire in a nutrient-limited wetland ecosystem: Long-lasting changes in water and soil chemistry facilitate shrub expansion into a drained burned fen.

Wildfires are natural phenomena which regulate functioning and stability of fire-adapted ecosystems. However, their occurrence may impair the functioning of fire-susceptible ecosystems by disturbing nutrient cycling and biodiversity. This work aimed to identify environmental factors shaping post-fire patterns of shrub expansion in a drained, burned peatland. This research was conducted in a fire-susceptible drained rich fen, located in Biebrza National Park (Poland), which was subjected to a large-scale smouldering fire in 2002. In 2014, water and soil chemistry were studied alongside with foliar nitrogen (N), phosphorus (P) and potassium (K) contents of a native shrub (Salix cinerea) in four vegetation types present after the fire. Unburned areas were dominated by herbaceous plants. Willows present were sparse and low, with chloroses and necroses. Their foliar nutrient content indicated strong K limitation. Moderately burned areas were dominated either by willows or nitrophilous plants. Willows in moderately burned areas had high chlorophyll content in leaves and their foliar nutrient content indicated a lack of evident nutrient limitation. In the moderately burned areas, relatively high contents of phosphates (P-PO43-) were recorded in soil and water. In areas with high fire severity, willows were withdrawing and their foliar nutrient content indicated N limitation. Decreased content of P-PO43- and ammonium (N-NH4+) in soil and water was also observed there. Thus, fire-induced changes in fen geochemistry were recorded twelve years after a disturbance which shaped the long-term dynamics of shrub expansion. The fire ceased K limitation in burned areas and increased P availability. Strong K limitation, which is typical in degraded fens, appeared to be critical for keeping unmanaged fen meadows with low shrub cover. The occurrence of strong K limitation in drained fen ecosystems may reduce the need for investment in conservation practices used to restrict shrub expansion (e.g. regular mowing or shrub removal).

Recovery of fen peatland microbiomes and predicted functional profiles after rewetting.

Many of the world's peatlands have been affected by water table drawdown and subsequent loss of organic matter. Rewetting has been proposed as a measure to restore peatland functioning and to halt carbon loss, but its effectiveness is subject to debate. An important prerequisite for peatland recovery is a return of typical microbial communities, which drive key processes. To evaluate the effect of rewetting, we investigated 13 fen peatland areas across a wide (>1500 km) longitudinal gradient in Europe, in which we compared microbial communities between drained, undrained, and rewetted sites. There was a clear difference in microbial communities between drained and undrained fens, regardless of location. Community recovery upon rewetting was substantial in the majority of sites, and predictive functional profiling suggested a concomitant recovery of biogeochemical peatland functioning. However, communities in rewetted sites were only similar to those of undrained sites when soil organic matter quality (as expressed by cellulose fractions) and quantity were still sufficiently high. We estimate that a minimum organic matter content of ca. 70% is required to enable microbial recovery. We conclude that peatland recovery after rewetting is conditional on the level of drainage-induced degradation: severely altered physicochemical peat properties may preclude complete recovery for decades.

Are we restoring functional fens? - The outcomes of restoration projects in fens re-analysed with plant functional traits.

In peatland restoration we often lack an information whether re-established ecosystems are functionally similar to non-degraded ones. We re-analysed the long-term outcomes of restoration on vegetation and plant functional traits in 38 European fens restored by rewetting (18 sites) and topsoil removal (20 sites). We used traits related to nutrient acquisition strategies, competitiveness, seed traits, and used single- and multi-trait metrics. A separate set of vegetation records from near-natural fens with diverse plant communities was used to generate reference values to aid the comparisons. We found that both restoration methods enhanced the similarity of species composition to non-degraded systems but trait analysis revealed differences between the two approaches. Traits linked to nutrient acquisition strategies indicated that topsoil removal was more effective than rewetting. After topsoil removal competitive species in plant communities had decreased, while stress-tolerant species had increased. A substantial reduction in nutrient availability ruled out the effect of initial disturbance. An ability to survive and grow in anoxic conditions was enhanced after restoration, but the reference values were not achieved. Rewetting was more effective than topsoil removal in restricting variation in traits values permitted in re-developing vegetation. We found no indication of a shift towards reference in seed traits, which suggested that dispersal constraint and colonization deficit can be a widespread phenomena. Two functional diversity indices: functional richness and functional dispersion showed response to restoration and shifted values towards reference mires and away from the degraded systems. We concluded that targeting only one type of environmental stressor does not lead to a recovery of fens, as it provides insufficient level of stress to restore a functional ecosystem. In general, restoration efforts do not ensure the re-establishment and long-term persistence of fens. Restoration efforts result in recovery of fen ecosystems, confirmed with our functional trait analysis, although more rigid actions are needed for restoring fully functional mires, by achieving high and constant levels of anoxia and nutrient stresses.

Potential eolian dust contribution to accumulation of selected heavy metals and rare earth elements in the aboveground biomass of Tamarix spp. from saline soils in Kazakhstan.

In arid and semi-arid zones, atmospheric dust of different origins influences soil chemistry and plant biomass composition. Thus, studies on plant accumulation of heavy metals and rare earth elements (RREs) should include some assessments of potential eolian deposition. Here, we proposed the use of fractionation of metals in soils as an indirect method to assess potential atmospheric dust input to metal content in plant biomass. Our research was performed on individuals of Tamarix spp. growing on saline automorphic and hydromorphic soils in Kazakhstan. Studied soils could be, in general, classified as polluted, especially in industrial areas of Karaganda and Chromtau. However, concentrations of heavy metals and RREs in biomass remained low, as most of the studied elements were present in plant-inaccessible forms. Nevertheless, we recorded a high accumulation of Cd in biomass (70% of this element present in soils as plant-inaccessible fractions), which indicates the impact of Cd atmospheric deposition.

"Pornographic binges" as a key characteristic of males seeking treatment for compulsive sexual behaviors: Qualitative and quantitative 10-week-long diary assessment.

Background and aims Compulsive sexual behaviors (CSBs) are an important clinical and social issue. Despite the increasing number of studies, some of CSB's aspects remain under-investigated. Here, we explore the nature of CSB, such as binge pornography use and masturbation (PuM), and verify the correspondence between self-perceived factors leading to such behavior with its measures obtained in a diary assessment. Methods Semi-structuralized interviews with nine treatment-seeking males aged 22-37 years (M = 31.7, SD = 4.85) were followed by a questionnaire and a 10-week-long diary assessment, allowing us to acquire real-life daily patterns of CSB. Results Six out of nine subjects experienced binge (multiple hours or times a day) PuM. All subjects presented a high level of anxiety and perceived PuM as a way to regulate mood and stress. Data collected in the diary assessment uncovered a high diversity in the patterns of sexual behaviors (such as frequency of regular and binge PuM) and its correlates. Binge PuM was related to decreased mood and/or increased stress or anxiety. The causal relation between these correlates remains undetermined. Discussion and conclusions Binge PuM seems to be one of the most characteristic behavior among males who are seeking treatment for CSB and is related to the feeling of losing control over one's sexual activity. CSB individuals indicate a variety of binge triggers. Also, diary assessment data indicate that specific correlates of binge PuM (decreased mood, increased stress, and anxiety) differ between subjects. It suggests the existence of significant individual differences in binge PuM behaviors, and a need to study these differences, as it may help guide personalized treatment.

[Giving medico-legal opinions in cases with suspicion of medical mistake. part 2. Expert evidence in cases with suspicion of medical mistake - expectations, possibilities, threats ].

Problems of medical mistake and therapeutic failure are inextricably linked with realization of medical services. In recent years, mostly by the media and increasing demanding attitude, a rapid increase of initiated cases opened by judicial body in conjunction with medical mistake made by medical staff is observed. Making medico-legal opinions is not easy task and often face many difficulties. These consist of lacks in medical documentation, time rigor, formal tightening and need to create team that consist of both forensic medicine specialist and clinicians, who together shall write complex medico-legal opinion. This article touches the essence of the opinion-making problem in the aspect of medical mistake. It shows specifics of the role of forensic medicine specialist, his challenges and difficulties in creating opinions. The article confronts real possibilities of court experts with expectations of judicial body, outlining new challenges and dangers which court experts have to face.

[The teaching of medical ethics in medical school].

Medical ethics constitutes some kind of core, which enables the physicians to decide in complicated clinical situations. This subject is taught during medical studies through only one semester. Number of teaching hours designed for this crucial in later physician's practice subject is insufficient. Additional problem in teaching process is inconsistence between the Law and the Code of Medical Ethics. As a result it causes alarmingly weak preparation of students to take practical decisions according to ethical and moral values of the Code of Medical Ethics. What is also important, in 2012 a medical studies schedule was changed, which in author's opinion had very negative effect on medical ethics teaching. In our opinion it is vital to increase number of teaching hours spent on medical ethics, create a model of gradual ethical knowledge transfer to students on every year of studies, which should be based on clinical subjects in master-student relations. Authors of this article discuss in a complex way problems of medical ethics teaching at medical studies supporting their thesis with author's survey carried out on large group of students of Medical University of Silesia in Katowice.

[Giving medico-legal opinions in cases with suspicion of medical mistake.part 1. between medicine and justice.]

Creating medico-legal opinion is a sophisticated investigative, analytical, decision-making and creative process. Forensic medicine specialist in cooperation with clinical medicine consultants, on the basis of evidence analysis, which was gathered during procedures and contained in the acts has to create an objective and essential opinion. This opinion is a vital, very important and irreplaceable proof in every case. Judicial body consults with forensic medicine specialist or specialists if there are circumstances for settlement of which there is a need of classified informations - art. 193 of Penalty Code. Forensic medicine specialists face many difficulties which may have effect on quality, positiveness of opinion, compliance with the deadline, increasing expectancy of judicial body or sides. It is very difficult to find clinical specialists which except their clinical knowledge have basic knowledge about law, the role and duties of an court expert. In this article we discuss creating-opinion problems, role and position of court expert in confrontation with expectations of judicial body and the Justice with particular emphasis on medical mistakes and assessment of medical proceedings. We show the complexity of creating of medical opinions, especially these institutional.

[Euthanasia - an attempt to organize issue].

This article is an attempt to complete and holistically discuss problem of euthanasia, especially its ethical and legal aspects, comparing to Polish law. The subject of euthanasia arouse interest of the society because it touches one of the most important aspects of life, which is the death. Even bigger emotions are aroused amongst physicians. They are forced to put on the line the life as biggest value on the one side and autonomy of human being on the other. It also touches the empathy for suffering. The euthanasia was divided into three forms: active euthanasia, passive euthanasia and assisted suicide. Any form of euthanasia is illegal in Poland according to both the Penal Code and Code of Medical Ethics. Range of possible penal consequences perpetrator is very wide from waiver of punishment to life imprisonment and it comes from different penal qualification of the euthanasia. Qualification of the euthanasia is based on terms of intent of perpetrator's act, request of patient, strong empathy for suffering if the patient and decision based on up-to-date medical knowledge. It is valuable to mention "do-not-resuscitate" DNR procedure, which in case of medical futility is legally accepted in Poland, but in other form may be qualified as passive euthanasia.