Respect for illiterate or unconscious patient's autonomy as a requirement for the legality of medical procedures in the polish healthcare system: a case report and review of the literature

According to the Polish law, each patient has the right to refuse to consent to a medical procedure, even if the refusal concerns a life-saving procedure. It may be difficult for a physician to accept this kind of decision. In each case, however, medical intervention requires patient’s consent. Its lack makes physician’s actions illegal. Such a situation becomes more complicated when the patient who is intellectually incompetent, unconscious or illiterate is unable to express a consent to a medical procedure. Then, the possibility and the need to document and prove the patient’s consent becomes crucial from the point of view of the legality of medical personnel’s conduct. In this article, two representative clinical cases are discussed in the context of the legal assessment of the physician’s conduct in the event of legal complications related to the process of consenting to medical treatment. The authors analyze ethical dilemmas and legal risks that doctors may face in the process of consenting to risky medical procedures by unconscious and illiterate patient.

Mycorrhizal frequency, physiological parameters, and yield of strawberry plants inoculated with endomycorrhizal fungi and rhizosphere bacteria

Due to the impoverishment of agricultural and horticultural soils and replant diseases, there is a need to use bioproducts and beneficial microorganisms in order to improve the quality of soils and growth substrates. For this reason, research was undertaken to assess the impact of arbuscular mycorrhizal fungi and rhizosphere bacteria on changes in soil microbiology, the degree of colonization of plant roots by mycorrhizal fungi, selected physiological parameters, and fruit quality and yield of the strawberry cultivar "Rumba." The plants were inoculated with the mycorrhizal preparation Mykoflor (Rhizophagus irregularis, Funneliformis mosseae, Claroideoglomus etunicatum), MYC 800 (Rhizophagus intraradices), and the bacterial preparation Rhizocell C (Bacillus amyloliquefaciens IT45). The applied preparations increased the total number of bacteria and fungi in the soil and mycorrhizal frequency in the roots of the strawberry plants. They increased the chlorophyll "a" and total chlorophyll concentrations in the leaves as well as the rate of transpiration and CO₂ concentration in the intercellular spaces in the leaves. The plants treated with Rhizocell C and MYC 800 exhibited a higher CO₂ assimilation rate than control plants. The biopreparations increased chlorophyll fluorescence parameters such as maximum fluorescence (F_M) and the maximum potential photochemical reaction efficiency in PS II (F_V/F_M). The influence of the species of rhizosphere bacteria and mycorrhizal fungi used in the experiment on the physiological traits of strawberry plants contributed, especially in the second year of the study, to increase the yield and mean weight of strawberry fruit.

Can the matrix metalloproteinases 2 and 9 predict the course of acute pancreatitis in previously healthy patients?

BACKGROUND

It was confirmed that during the inflammatory process development, granulocytes are among the main groups of cells responsible for the course of acute pancreatitis. One of these substances produced by them are extracellular matrix enzymesmetalloproteinases. In the presented study, we undertook an attempt to investigate whether they may be used as an instrument to predict the course of acute pancreatitis in previously healthy patients.

METHODS

The study included 72 patients with the first-time episode of acute pancreatitis. The 2012 Atlanta classification was used in order to divide them into 3 groups. The patients were assessed according to the most popular multifactor scoring systems and single laboratory markers. The levels of metalloproteinases 2 and 9 were determined by the ELISA method. The diagnostic value of the commonly applied scoring systems and single diagnostic markers was compared with the value of matrix metalloproteinases levels.

RESULTS

A mild form of AP developed in 42 patients, a moderate form in 16, and severe in 14. All multifactor prognostic systems have high specificity and rather low sensitivity. Single laboratory markers have higher sensitivity but lower specificity than multifactor tools. The determination of the level of MMP-2 shows specificity of 98.3%, while MMP-9-100%.

CONCLUSION

The determination of a single laboratory marker, which is the level of metalloproteinase-2 or metalloproteinase-9, is characterized by sensitivity and specificity comparable to that of multifactor prognostic scoring systems.

Validation of the Joensuu risk criteria for primary resectable gastrointestinal stromal tumour - the impact of tumour rupture on patient outcomes

BACKGROUND

Approval of imatinib for adjuvant treatment of gastrointestinal stromal tumours (GIST) raised discussion about accuracy of prognostic factors in GIST and the clinical significance of the available risk stratification criteria.

METHODS

We studied the influence of a new modification of the NIH Consensus Criteria (the Joensuu risk criteria), NCCN-AFIP criteria, and several clinicopathological factors, including tumour rupture, on relapse-free survival (RFS) in a prospectively collected tumour registry series consisting of 640 consecutive patients with primary, resectable, CD117-immunopositive GIST. The median follow-up time after tumour resection was 39 months. None of the patients received adjuvant imatinib.

RESULTS

The median RFS time after surgery was 50 months. In univariable analyses, high Joensuu risk group, tumour mitotic count >5/50 HPF, size >5 cm, non-gastric location, tumour rupture (7% of cases; P = 0.0014) and male gender had adverse influence on RFS. In a multivariable analysis mitotic count >5/50HPF, tumour size >5 cm and non-gastric location were independent adverse prognostic factors. Forty, 151, 86 and 348 patients were assigned according to the Joensuu criteria to very low, low, intermediate and high risk groups and had 5-year RFS of 94%, 94%, 86% and 29%, respectively.

CONCLUSION

The Joensuu criteria, which include 4 prognostic factors (tumour size, site, mitotic count and rupture) and 3 categories for the mitotic count, were found to be a reliable tool for assessing prognosis of operable GIST. The Joensuu criteria identified particularly well high risk patients, who are likely the proper candidates for adjuvant therapy.

Influence of nutritional treatment on the postoperative course in patients with gastric cancer

PURPOSE

Malnutrition occurs in ca. 60% of all patients with gastric cancer. The obligatory standard for a curative radical oncological procedure is gastrectomy inclusive of regional lymph nodes. Nutritional treatment is expected to decrease possibilities of postoperative complications in patients subjected to curative surgery. The study is aimed at comparing treatment results in patients with gastric cancer subjected to radical surgery, nutritional and non-nutritional treatment respectively.

MATERIAL AND METHODS

The study included 176 patients qualified for curative surgery of a total or subtotal gastrectomy. Analysed were 2 groups of patients: group I--not subjected to nutritional treatment, group II--subjected to nutritional treatment, both in the circumoperative period. The groups were compared in respect to: 1) age, 2) sex, 3) nutritional condition, 4) degree of clinical cancer development, 5) histopathological cancer type, 6) kind of surgical procedure performed, 7) antibiotic and antithrombotic prevention. All complications observed in the patients were divided into four kinds: surgical of a high or low risk and general of a high or low risk.

RESULTS

Given the above-mentioned estimation parameters, no statistically significant differences between both groups were recorded. Of 176 patients, 27% showed surgical complications and 40% had general complications. No difference (p = 0.60) in the incidence of a high and low risk surgical complications between groups I and II in the circumoperative period was observed, a significant difference (p = 0.03) was recorded in the incidence of general complications. Low risk general complications (respiratory infections) were shown to occur significantly more often (p = 0.005) in patients receiving either parenteral or enteral nutrition after surgery.

CONCLUSIONS

A significant part of the patients with a medium degree and a medium to heavy degree of malnutrition subjected to a curative gastrectomy can pass through the postoperative period without using either parenteral or enteral nutrition and with no violations of all the other principles of the postoperative procedure as well as without provoking any significant increase of surgical complications. In case surgical complications should occur and delay resuming natural feeding, it is necessary that parenteral and/or enteral nutritional treatment be undertaken according to clinical circumstances and condition of the patient concerned; such proceedings increase chances of cure.

Effects of truncal or highly selective vagotomy on the electron microscopic feature of the rabbit pancreas

PURPOSE

To perform a comparative study of two types of vagotomy: trunctal vagotomy (TV) and highly selective vagotomy (HSV) effects on pancreatic morphology assessed with light microscope and ultrastructural changes assessed with electron microscope in rabbits 30, 90 and 180 days after the vagotomy.

MATERIAL AND METHODS

The experiments were carried out on 89 male Popielno white rabbits, aged 4-6 months, 2.5 to 3.0 kg of body weight. On the 30th, 90th and 180th day after the vagotomy, rabbits were sacrificed and the pancreases were taken for the light and electron microscopic evaluation.

RESULTS

The regressive changes coexisting with adaptive like renewal of epithelial cells and mild interstitial fibrosis resulting from vagotomy were more pronounced in the early post-operative period and tended to normalize in the later post-operative one. All the changes seen in post-operative period were more prominent after TV than after HSV.

CONCLUSIONS

Both truncal and highly selective vagotomy affects evidently the morphology and ultrastructure of the pancreas in rabbits however the changes after the first procedure were more advanced than after the latter one. The intensity of the changes is highest early after these operations and tend to normalize in the later post-operative period.

[Prevention and principles of management in case of cardiac tamponade after catheterisation of the subclavian vein in parenteral nutrition]

The authors described different complications after the subclavian vein catheterisation, focusing on the cardiac tamponade. The authors presented the prevention and treatment principles respectively in case of the cardiac tamponade and reported experiences in this field.

[Bilateral breast cancer]

Rare case of women with inflammatory neoplasma in the right breast and left gigantic breast is presented. Detailed examination of the left breast showed neoplastic process, too.

Morphology of canine pancreas in electron microscopy following truncal and highly selective vagotomy

The purpose of the study was evaluation of morphological changes in canine pancreas on days 30, 90 and 180 after truncal vagotomy (VT) and highly selective vagotomy (HSV). On the 30th day after VT in some cells zymogen granules and lysosomes were disintegrated, vacuolization was moderately expressed, and fibrosis was present in the exocrine part. On the 30th day after HSV the structure of the exocrine part showed no important changes, but in the endocrine part in about one-third of cells in the islets deformed nuclei and trinucleated cells were found, along with changes of mitochondrial structure. beta cells contained very numerous insulin-containing granules. On the 90th day some changes observed on the 30th day after VT or HSV were no longer seen. On the 180th day after HSV the EM changes were negligible, less intense than after VT. The electron microscopic changes after VT and HSV were most pronounced early after the operation, particularly after VT. In later stages of the experiment a part of the changes regressed, but then more structural changes were seen after VT than after HSV.

[Experience with surgical treatment of liver neoplasms]

Six cases of primary and metastatic hepatic tumors are reported. The diagnoses, surgical treatment and the possibilities of complications after rarely performed liver resection are presented.