[Guideline 'Organ donation following euthanasia"]. / Richtlijn 'Orgaandonatie na euthanasie'.

- The multidisciplinary guideline 'Organ donation following euthanasia' was published in March 2017 at request of the Minister of Health, Welfare and Sport.- This guideline provides recommendations for the organisation and implementation of a request to donate organs expressed by a patient who asks for euthanasia.- It is vital to avoid any conflict of interest while the patient requesting organ donation following euthanasia is still alive.- The person who carries out the euthanasia procedure is responsible for assessing the degree of unbearable suffering and for guaranteeing that potential organ donation is well-considered and voluntary.- During the procedure everything possible must be done to ensure a minimal burden for the patient and the family.

What do medical students experience as moral problems during their obstetric and gynaecology clerkship?

This article reports on moral problems that were raised by medical students as the basis for an ethical case-conference in an obstetrics and gynaecology clerkship. After introducing the issue of teaching clinical ethics, the method of our case-conference is explained. Next, the variety of topics and related moral problems are presented. The article continues with a discussion of three distinct and challenging aspects that characterise obstetrics and gynaecology as a domain for teaching clinical ethics. The conclusion puts forward three significant points our review raises.

Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer.

A (modified) radical mastectomy (RM) was compared with breast-conserving therapy (BCT) in stage I and stage II breast cancer patients. Treatment of the study arm comprised lumpectomy, axillary clearance and radiotherapy to the breast (50 Gy in 5 weeks external irradiation and a boost with iridium implant of 25 Gy). 902 patients were included. There were 734 TNM stage II patients. Patients with microscopically incomplete excision of the tumour were not excluded. After a median follow-up of 6 years, overall survival and local recurrence rates do not differ significantly between the two study arms. Actuarial survival at 8 years was 73% after RM and 71% after BCT; actuarial local recurrence at 8 years was 9% and 15%, respectively. In the mastectomy group tumour size did not affect local relapse, but after BCT the incidence of local recurrences was higher for tumours of 2-5 cm (16%) than for smaller tumours (7%) (at 8 years, P = 0.08). Results of salvage treatment for local recurrence so far were similar in both the BCT and the mastectomy group.

Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial.

In a prospective randomized clinical trial conducted by the European Organization for Research and Treatment of Cancer (EORTC), mastectomy was compared with breast-conserving therapy in 903 stage I and stage II breast cancer patients entering the study between 1980 and 1986. The main participating centers were: Guy's Hospital, London; The Netherlands Cancer Institute, Amsterdam; University Hospital, Leuven; Radiotherapy Institute, Rotterdam; Breast Unit, Tijgerberg, S.A. The data were collected in the EORTC Data Center, Brussels. Treatment in the study arm consisted of lumpectomy, axillary clearance, and radiotherapy to the breast (50 Gy external irradiation in 5 weeks followed by boost with iridium implant of 25 Gy). Important in this study is the large number of TNM stage II patients (755). Most patients were stage II because of the size of the tumor (2-5 cm). The patient and tumor characteristics in the study and control groups were well balanced. So far the survival curves and local recurrence rates are not statistically different for the two study arms. Tumor size was found in univariate analysis to be a significant risk factor for local recurrence in the breast-conserving therapy group but not in the mastectomy group. Results of salvage treatment for local recurrence were not better for the breast-conserving therapy group compared with the mastectomy group. Measurements of quality of life and cosmesis show a clear benefit for the breast-conserving therapy group.

Immediate versus delayed shoulder exercises after axillary lymph node dissection.

A total of 144 evaluable patients with breast cancer were enrolled in a multicenter, randomized, prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection. Patients in group 1 (n = 78) started active shoulder exercises 1 day postoperatively. Patients in group 2 (n = 66) started on the eight postoperative day, following 1 week of immobilization of the arm. Patients in group 2 had 14% less wound drainage volume than those in group 1 (600 +/- 436 mL versus 701 +/- 398 mL); this difference, however, was not significant. Also, no differences could be established between the two groups when duration and volume of wound drainage, number and volume of seroma aspirations, wound complication rates, and shoulder function were compared 6 months after surgery.

Reconstructive approach of chronic oedema of the lower limb.

The results are presented of 22 reconstructive operations in 22 patients with venous and/or lymphatic oedema of the leg, after a maximum follow-up of three years. An overall patency rate of venous anastomoses of 92% and symptomatic improvement in 75% after lymphovenous anastomoses, indicates that there is a place for reconstruction in a highly selected group of cases. Deep venous insufficiency is diagnosed by transbrachial descending phlebography and direct venous pressure determination. Mixed forms of oedema, i.e. combined venous and secondary lymphatic, frequently occur in patients who have undergone tumour resections and radiotherapy. Both non-invasive plethysmography and routine phlebography via venipuncture on the dorsum of the foot are not reliable in diagnosing mixed oedema. For adequate visualization, direct puncture of the femoral vein in the groin is recommended.

Decreased venous outflow without venous obstruction--an analysis of three cases.

Three patients without prior thrombosis or varicosities presented with decreased venous outflow. They suffered from venous complaints, such as oedema and pain in the leg after prolonged standing. Phlebograms showed no obstruction or hypoplasia. Normal function of calf muscle pump and valves was present at venous pressure determination. The theoretical basis of venous emptying is discussed and a hypothesis is postulated that decreased emptying is due to a change in elastic properties of the venous vessel wall.

Dosimetry in isolation perfusion of the limbs by assessment of perfused tissue volume and grading of toxic tissue reactions.

The optimal single dosage of melphalan in isolation perfusion of the limbs for malignant melanoma was assessed. For this purpose a method to determine the volume of the isolated region in the individual patient and a grading system for the reaction of the normal tissues were introduced. A strictly standardized pharmacosurgical routine was developed that permitted an analysis of the correlation between dosage and the grade of toxic reaction in 90 perfusions. The optimal dosage of a cytostatic drug was considered to be the highest amount tolerated at an acceptable risk. Melphalan at 10 mg/l perfused tissue was determined as the likely optimum. This dose provoked remarkably little variation in toxicity, all reactions falling within a safe range. No exception to the applicability of this dosage was encountered.

[Intestinal lesions after radiotherapy (author's transl)]. / Darmbeschadiging door roentgenstralen.

The authors present a series of 50 patients for which a laparotomy was performed following a lesion of the intestines due to radiotherapy. Resection and anastomosis is indicated only in localized lesions in patients with a good general state. In more extensive bowel lesions it is safer to perform by-pass procedures as the morbidity and postoperative mortality are lower. However, by-pass is inadequate to stop profuse haemorrhages: in such cases resection is mandatory.