Motives for seeking a second opinion in orthopaedic surgery.

OBJECTIVES: The number of second opinions in orthopaedic surgery is increasing rapidly, yet the grounds on which patients and their doctors decide to seek a second opinion have been little studied. The goal of the study was to identify patient and consultant factors that appeared to contribute to a second opinion being sought. METHODS: Two thousand and seventy-nine consecutive new patients visiting an orthopaedic surgical outpatient clinic in 1996-1997 participated in the study. Patients were self-defined as seeking a second opinion if they had visited at least one other consultant for the same condition within the previous two years. Each of these patients completed a questionnaire before seeing the orthopaedic surgeon; this included details about the physician-patient relationship, reasons for seeking a second opinion and perceived health status. The first-opinion consultants were contacted by mail; their practice characteristics and the motives for seeking a second opinion were also obtained. RESULTS: Thirty per cent of the study population (n = 625) had sought a second opinion. Patients sought a second opinion because of disappointment concerning their original treatment, or because they wanted more information about their condition and/or its treatment. First-opinion consultants were usually unaware of these communication issues. Patients' inclination to initiate a second opinion was best predicted by their evaluation of their relationship with their first-opinion consultant. The propensity to initiate referrals for a second opinion varied widely among the first-opinion consultants (10-70%) and was inversely proportional to the size of the group they worked in and their distance from the referral centre. CONCLUSIONS: Patients did not seek a second opinion because they had doubts about the competence of their treating consultant, but because they were dissatisfied about the level of communication or about the results of their treatment. Medical educators should continue to increase their efforts to improve specialists' communication and relationship skills since these seem to generate referrals for second opinions, which occupy clinic space that could be used by other patients.

Neonatal infectious spondylitis of the cervical spine presenting with quadriplegia: a case report.

STUDY DESIGN: A case report.- OBJECTIVE: To highlight the evaluation and treatment of neonatal infectious spondylitis of the cervical spine. SUMMARY OF BACKGROUND DATA: Most authors advise intravenous antibiotics as first-choice treatment. The place of aspiration or operative drainage is debated, as is the position and duration of immobilization. METHODS: A 3-week-old neonate was presented with intermittent quadriplegia. RESULTS: Additional investigation demonstrated an osteolytic process in the body of C3 with a large epidural abscess compressing the spinal cord. Because an infectious spondylitis of C3 was suspected, aspiration of the abscess was performed, and antibiotic therapy was started. The patient improved to neurologically normal within 3 weeks and remains asymptomatic throughout a follow-up period of 7 years. CONCLUSIONS: Neonatal infectious spondylitis should be diagnosed early and treated promptly; otherwise, it may have devastating consequences.

[Rupture of the quadriceps tendon; cannot be missed?]. / Ruptuur van de quadricepspees; niet te missen?

In four patients, two men aged 59 and 68 years and two women aged 59 and 50 years, a unilateral rupture of the quadriceps tendon was diagnosed. In two patients the disease was initially misdiagnosed. A depression was palpable in all patients just on the proximal side of the patella. All patients were treated operatively and all recovered with satisfactory knee function. In order to obtain full recovery early aetiological diagnosis is important; quadriceps tendon rupture should be considered in patients with haemarthrosis and inability to stretch the knee.

Definition of subchromosomal intervals around the myotonic dystrophy gene region at 19q.

The localization to 19q of the gene causing myotonic dystrophy (DM) has been defined more precisely by refinement of the physical location of several linked markers. A somatic cell hybrid mapping panel from cells with t(1;19), t(12;19), and t(X;19) translocation products was constructed to define five different intervals across 19q. In addition, we have derived a series of cell hybrids by irradiation of a der(19)-only hybrid to further subdivide the cen-q13.1 region. Using an array of 36 cloned genes, anonymous DNAs, and enzyme markers, we have tested the location of the panel breakpoints and refined the regional assignment of several of these markers. All markers tightly linked to DM are localized mainly within 19q13.2, thus suggesting that the DM gene is also close to this region.

Isolation and characterization of alphoid DNA sequences specific for the pericentric regions of chromosomes 4, 5, 9, and 19.

We have cloned and characterized two distinct types of alphoid DNA elements. Probe pG-Xba 11/340 was obtained by random cloning of human satellite DNA and contains two basic units with overall 88% homology to the 171-bp consensus alphoid sequence. pG-Xba 11/340-like elements are represented about 2,000-4,000 times in the haploid genome and, by in situ hybridization, are found exclusively at the primary constrictions of chromosomes 4 and 9. Probe pG-A16 was cloned from a chromosome 19-specific cosmid library and represents a 2.25-kb higher-order DNA element which is present at roughly 75-150 copies per haploid genome and which hybridizes to the centromeres of chromosomes 5 and 19. Using the pG-A16 probe, further genetic and physical dissection of the central area of chromosome 19 can be envisaged.

Identical chromosome translocations involving the region of the c-myb oncogene in four metastases of a mediastinal teratocarcinoma.

A 39-year-old white male presented with a disseminated mediastinal teratocarcinoma. Karyotyping was performed on two mature residual metastatic lesions in the lungs immediately following chemotherapy, on a recurring lung lesion after 5 months, and on a metastasis in the right thigh 5 months after salvage chemotherapy. All four lesions were pseudoeuploid and showed identical chromosomal abnormalities: a translocation with the two chromosomes #6 and one chromosome #11 involved, resulting in 46, XY, t (6;6;11) (q21;q23;q13). The breakpoint in chromosome #6 is in the region to which the oncogene c-myb has been localized, and the breakpoint in chromosome #11 is at a known fragile and possibly oncogenic site, suggesting that the translocations in this case may have played a crucial role in the development of the malignancy.