[Second opinion clinic: is the Web Babel Syndrome treatable?]. / Ambulatorio del secondo parere: la Sindrome di Babele è curabile?

The term "second opinion" has been widely used, since the 70's in the American hospitals with the aim of reducing the skyrocketing costs of the patients' healthcare, improving their diagnosis, the patient's care and his healing process at the same time. In this paper, after a short review of the "second opinion" impact on different medical fields, we give the reasons why, nowadays, patients are strongly addressed towards a second opinion seeking behaviour. In fact, due to the spreading of the world wide web, the patient can obtain any kind of medical information, even if it is an unqualified one. This fact leads the patient to carry out an obsessive search that can result in confusion and disorientation. We have defined this psychological distress the "Web Babel Syndrome". Building upon these foundations, we strongly support a "second opinion medical clinic" that can face the patient's needs and help those patients with impending single or multiple unresolved illnesses. They need a multispecialty diagnostic or therapeutic medical or surgical approach in order to heal properly or achieve a better quality of life.

Microsatellite analyses of recurrence or second primary tumor in head and neck cancer.

BACKGROUND: In head and neck squamous cell carcinoma, distinguishing second primary tumours and recurrences may help to orient clinical decisions concerning therapy. PATIENTS AND METHODS: A panel of eight microsatellite markers was used to analyse the loss of heterozygosity and genomic instability in a selected group of 32 patients experiencing a recurrence after having undergone surgery for oral or oropharyngeal carcinoma, in order to establish the clonality and origin of the recurrence. RESULTS: Twenty-three patients showed genetic changes in primary and/or relapsing tumour DNA: clonally-related patterns were detected in six cases, whereas the different patterns between paired tumours indicated the presence of a second primary tumour in 17 cases. None of the markers was informative in nine cases. CONCLUSION: Our observations suggest that only a small proportion of patients have primary and secondary tumours developing from a single contiguous altered field (thus indicating a common clonal origin), whereas the metachronous tumour arises in unrelated fields in the majority of cases.

Prognostic significance of P27 and cyclin D1 co-expression in laryngeal squamous cell carcinoma: possible target for novel therapeutic strategies.

Tumour cells are characterised by uncontrolled growth due to alterations in the genes that play a key role in cell repair systems and apoptosis: pro-mitotic oncogenes such as cyclin D1, and tumour suppressor genes such as p27. Recent studies have demonstrated that these genes are involved in different epithelial neoplasms and that their expression is generally associated with prognosis. The aim of this immunohistochemical study was to analyse the clinical relevance of cyclin D1/p27 co-expression in a homogeneous series of 132 laryngeal squamous cell carcinomas. Multivariate analysis showed that cyclin D1 and p27 were the only statistically significant predictors of disease-free and overall survival. In relation to the simultaneous expression of p27 protein and cyclin D1, the patients with a cyclin D1+/p27-phenotype had the poorest disease-free and overall survival rates. On the basis of these immunohistochemical results, it was possible to select a subgroup of patients with a high risk of recurrence and poor prognosis to undergo more extended surgical treatment and/or combination antitumoral therapeutic procedures.

Analysis of user-satisfaction with the use of a teleconsultation system in oncology.

There is an increasing interest in assessing telemedicine as alternative method of delivering high quality cancer treatment to patients living in rural areas. In the Province of Trento (north-east Italy) a tele-oncology system was implemented to provide non-surgical oncological consultation to district general hospitals. The aim of this study was to explore user-satisfaction with the system after 6 months of experimentation. During the on-field validation two questionnaires with open and closed-response questions were distributed to 80 physicians and nurses 6 months apart to investigate the users' expected benefits vs. perceived ones. The two questionnaires were compared to assess how perceived benefits differed from expected ones. Significant differences were found regarding improvements in: the standardization of diagnostic-therapeutic procedures using the Electronic Patient Record (EPR)]; information sharing; data updating; consultation speed; and the possibility to diminish patients' travels through the use of teleconsultation (TC). Physicians' responses showed a significant difference regarding the EPR's effects on relationship with patient, the nurses' responses with regards to its effects on care quality. Physicians felt that both modalities of teleconsultation were useful in enhancing communication with colleagues (86% for the synchronous TC, 80% for the asynchronous TC). Responses indicated that the major difficulties encountered were in the introduction of the system into the daily routine. Despite this, user expectations for its future use in clinical field were considerably high.

Changing attitudes towards abortion in Europe.

OBJECTIVE: To understand how personal and social attitudes are changing regarding more available safe abortion in Europe. RESULTS: Abortion has been commonly practiced for a long time throughout most of the world, either in legal or illegal conditions, but it is a subject that arouses passion and controversy, because abortion raises two important issues, namely sex and life, sometimes mixed with religion and ethics. Over the past few years, we have observed changes in laws, and personal and professional attitudes towards abortion. Social needs modify the attitudes of the authorities and individuals. In many countries where the performance of abortion is illegal, statistics indicate that large numbers of abortions are carried out, but authorities are indifferent, ignore or tolerate it or even unofficially license clinics for the abortion. In some other countries where abortion is technically legal, access to authorized facilities and personnel may be limited, or resources to pay for the abortion may be lacking, resulting in more illegal abortions. There are, therefore, two categories of abortion: legal versus illegal, and safe versus unsafe. However, laws are changing, becoming even more liberal, even if, in certain nations, there are renewed attempts to question the right of women to decide. Practice is changing and in some cases becoming separate from the law. Basic ideas are changing, because, in a large number of European countries, we are moving from a culture of abortion to a culture of contraception and prevention of abortion, through an effort of governments, women, professionals, and non-governmental organizations. Certainly, important steps have been taken in the different ways of performing an abortion. For example, we have seen the arrival of medical abortion, with the use of mifepristone and misoprostol. Finally, there is also a change in the way of supporting women through humane and complete counseling, which includes attention to follow-up services offering a choice of contraceptive methods to help women avoid another unwanted pregnancy. CONCLUSIONS: There is some resistance at different levels, but attitudes are changing in a positive way throughout Europe, offering a good quality of service, good facilities, well-trained practitioners and more open minds.

Extracorporeal shockwave lithotripsy for salivary calculi in pediatric patients.

Salivary gland lithiasis is uncommon in pediatric patients. Color Doppler ultrasonography (US) enables an accurate diagnosis of lithiasis to be made without exposure to the radiation of traditional imaging techniques. The development of minimally invasive techniques in the ENT field has made salivary lithotripsy a feasible alternative to traditional invasive surgery. The safety and efficacy of shock wave lithotripsy for salivary calculi were evaluated in pediatric patients. Seven children (5 males; age 4-15 years) with single calculi (mean diameter 4.4 mm) of the submandibular (n = 4) and parotid glands (n = 3) underwent extracorporeal electromagnetic shock wave lithotripsy (EESWL). In four cases the stone was intraductal (two submandibular and two parotideal) and in the remaining three cases it was intraparenchymal (two submandibular and one parotideal). In one case sedative anesthesia was performed. The mean number of therapeutic sessions was five. Patients were followed up clinically and with US for 6-72 months (mean 32 months). Complete disintegration of the calculi was achieved in five cases while in two cases a residual fragment < 2 mm in diameter was observed. None of the patients had recurrence of calculi in the treated gland. Mild self-limited adverse effects (pain, swelling of the gland, self-limiting bleeding from the duct, cutaneous petechiae) were observed in four cases. Our data suggest that EESWL is effective, safe and well tolerated; the minimal invasiveness of the technique suggests that EESWL should be used as the primary approach to salivary calculi in pediatric patients. The continuous US monitoring enables the efficacy of EESWL to be evaluated during both treatment and follow-up, with only slight discomfort for the pediatric patient.

General anaesthesia, a risk factor for complication following induced abortion?

Of the 10,000 abortions performed at the Regional hospital at Modena in Italy between 1982 and 1986, 199 (2%) led to early complications. Investigation of the relationship between the risk of haemorrhage, injury, other complications and all complications and eight explanatory variables revealed that the adjusted odds ratio associated with the use of general anaesthetic compared with local anaesthetic was 4.6 (95% CI, 2.2-9.5) for haemorrhage, 1.3 (95% CI, 0.78-2.2) for injury, 1.6 (95% CI, 1.0-2.6) for other complications and 1.8 (95% CI, 1.4-2.5) for all complications. It is speculated that if the relationship between use of general anaesthetic and risk of complication is causal there could be about 40% fewer cases of complications and 75% fewer cases of haemorrhage following induced abortion if local anaesthesia were used rather than general anaesthesia.

PIP: Of the 10,000 abortion performed at the Regional Hospital at Modena, Italy between 1982-86, 199 (2%) led to early complications. Investigation of the relationship between the risk of hemorrhage, injury, other complications, and all complications and 8 explanatory variables revealed that the adjusted odds ratio associated with the use of general anesthetic compared with local anesthetic was 4.6 (95% CI, 2.2-9.5) for hemorrhage, 1.3 (95% CI, 0.78-2.2) for injury, 1.6 (95% CI, 1.0-2.6) for other complications, and 1.8 (95% CI, 1/4-2/5) for all complications. It is suggested that if the relationship between the use of general anesthetic and risk of complications is causal, there could be about 40% fewer cases of complications and 75% fewer cases of hemorrhage following induced abortion if local anesthesia were used rather than general anesthesia.

[Transvesical cesarean section]. / La césarienne par voie transvésicale.

On the basis of a clinical case the authors report the technique of laparotomic transvesical incision for cesarean section, which, nevertheless, has limited and special indications.