Perinatal testicular torsion and medicolegal considerations

Perinatal testicular torsion (PTT) is a very complex condition because of rarity of presentation and diagnostic and therapeutic difficulties. In presence of perinatal testicular torsion, the involvement of contralateral testis can be present also in absence of other indications which suggest the bilateral involvement; therefore, occurrences supported by literature do not exclude the use of surgery to avoid the risk of omitted or delayed diagnosis. The data on possible recovery of these testicles are not satisfactory, and treatment consists of an observational approach ("wait-and-see") or an interventional approach. The hypothesis of randomized clinical trials seems impracticable because of rarity of disease. The authors present a case of PTT, analyzing injuries due to clinical and surgical management of these patients, according to medicolegal profile. The delayed diagnosis and the choice of an incorrect therapeutic approach can compromise the position of healthcare professionals, defective in terms of skill, prudence and diligence. Endocrine insufficiency is an unfortunate event. The analysis of literature seems to support, because of high risk, a surgical approach aimed not only at resolution of unilateral pathology or prevention of a relapse, but also at prevention of contralateral testicular torsion.

Medical tourism: evidence from an Italian descriptive survey on pediatric neurorehabilitation treatment abroad

BACKGROUND

In recent years we have witnessed a rapidly-growing tendency to seek neurorehabilitation abroad.

AIM

This study aimed at better understanding this practice through a analysis of the authorizations for pediatric neurorehabilitation services issued by Italian Regions.

DESIGN

Descriptive retrospective survey study.

SETTING

Outpatient.

POPULATION

Italian children travelling abroad for neurorehabilitation.

METHODS

We analyzed the number of authorizations granted in the 2008-2011 period by local health agencies of Italian regions to children aged 0-18 years applying for neurorehabilitation services abroad. Information was obtained from the Ministry of Health database management systems.

RESULTS

Our analysis showed an extreme variability across Italian regions. This is probably suggestive of an unbalanced offer of pediatric neurorehabilitation services across regions, different mechanisms used to control the phenomenon.

CONCLUSION

Our study looked specifically at the practice of neurorehabilitation abroad in order to encourage further and larger studies, even at international level. A greater integration of health systems with common policies is to be achieved in order to control this phenomenon in a field as sensitive as pediatric neurorehabilitation.

CLINICAL REHABILITATION IMPACT

Our study, which is the only study so far focusing on pediatric neurorehabilitation, looked specifically at the practice of health tourism in order to encourage further and larger studies, even at international level. Health tourism is a critical issue for all Western welfare systems which are under a pressure to cut health-related expenses.

Topical promethazine side effects: our experience and review of the literature

Promethazine hydrochloride is a first-generation H1 receptor antagonist, antihistamine, and antiemetic medication that can also have strong sedative effects. The apparent ability of topical H1r/2r antagonists to target epidermal H1/2r was translated into increased efficacy in the treatment of inflammatory dermatoses, likely due to decreased inflammation and enhanced barrier function.

Overall survival for sorafenib plus interleukin-2 compared with sorafenib alone in metastatic renal cell carcinoma (mRCC): final results of the ROSORC trial

BACKGROUND

The ROSORC trial, a randomised, phase II trial comparing sorafenib plus interleukin (IL-2) versus sorafenib alone as first-line treatment of metastatic renal cell carcinoma (mRCC) failed to demonstrate differences in progression-free survival (PFS). Updated overall survival (OS) results are reported.

PATIENTS AND METHODS

In this study, 128 patients were randomised to receive sorafenib 400 mg twice daily plus subcutaneous IL-2 4.5 million international units (MIU) five times per week for 6 weeks every 8 weeks (arm A) or sorafenib alone (arm B). OS was estimated with the Kaplan-Meier method and compared with the two-sided log-rank test.

RESULTS

After a median follow-up of 58 months (interquartile range: 28-63 months), the median OS was 38 and 33 months in arms A and B, respectively (P = 0.667). The 5-year OS was 26.3% [95% confidence interval (CI) 15.9-43.5) and 23.1% (95% CI 13.2-40.5) for the combination- and single-agent arm, respectively. Most of the patients who were refractory to first-line treatment were subsequently treated with different targeted agents; they had a median survival greater than expected.

CONCLUSIONS

This outcome suggests a synergistic effect of the subsequent therapies following sorafenib failure.

CLINICALTRIALSGOV IDENTIFIER

NCT00609401.

[Legal medical considerations on a case of erectile dysfunction]

The primary obstruction of the bladder neck is a condition which is diagnosed in many young people with symptoms of lower urinary tract, such as obstructive symptoms (difficulty in the initial phase of urination and urinary retention) and irritative symptoms (pollakiuria, dysuria and nocturia). These tests are needed for the diagnosis: uroflowmetry, urodynamics, rx urethrocystography. For the treatment are used alpha-blockers or surgery. The main diagnostic test is the urodynamic study. Even though the alpha-blockers are effective and safe drugs, sometimes the treatment is surgical. The gold standard is the transurethral incision of the prostate or bladder neck (TUIP), a technique with good results, but with some complications, including retrograde ejaculation, that is the most dangerous, and erectile dysfunction, that occurs in a lower percentage of patients. In this work was studied, in terms of forensic medicine, the case of a patient who is 35 years old and reported erectile dysfunction after an intervention of transurethral incision of the prostate or bladder neck. Although there is a limited possibility, documented in the literature, of erectile dysfunction as a result of TUIP, there is no sufficient evidence to confer the responsibility of patient's organic nature impotence to the health professional civil conduct which is directly related to the transurethral incision of the bladder neck, considering the presence of a lumbo-sacral disc disease in the patient, documented by CT two years before the surgery.

[Medico legal considerations on prosthesis surgery of the erectile dysfunction in a La Peyronie disease case]

Peyronie's disease is characterized by the presence of an inelastic fibrous plaque of the penile tunica albuginea affecting 3-10% of the male population. The fibrous scar causes the curvature of the erect penis, which prevents the penetration. In the stabilization phase the plaque can cause a variable degree of erectile dysfunction (20-54%). In the treatment of the chronic disease, surgery is the gold standard and in case of concomitant erectile dysfunction the placement of a penile prosthesis is indicated. This surgery is loaded with an increase of the variables which can affect the outcome, such as individual clinical features and functionality of the device. The present case concerns a patient suffering from erectile dysfunction associated with Peyronie's disease who underwent surgery for implantation of hydraulic three-component penile prosthesis. After surgery a malfunction of the prosthesis was detected, which required unloading measures under sedation and a surgical revision of the scrotal pump. The latter was followed by the displacement of the prosthesis' cylinder and by a new surgical treatment for the reintegration of the prosthesis and the repair of the left corpus cavernosum. After two months a wrong positioning of the two cylinders inserted into the corpora cavernosa, with the left cranial extreme positioned 2 cm below the contralateral, was detected. In this case the failure of surgical treatment highlights a negligent behavior and the responsibility of the doctors by failing to examine adequately the variables, both clinical and not clinical, that might affect the outcome of the intervention.

Absence from work and the medical sickness certificate

Internet and dematerialization have greatly facilitated the medical profession. Contractual physicians and national health service doctors now have efficient tools for the electronic management of their routine administrative workload. A recent innovation is the medical sickness certificate issued by primary care providers and national health service physicians. Following postponements and uncertainties, procedures for the electronic completion and online transmission of the sickness certificate are now complete. The changes introduced by the so-called "Brunetta decree", however, have made its application difficult and continuous improvement to the system is needed, considering also the severe penalties imposed for violations. In the light of serious legal repercussions for health care professionals, this article examines various critical issues, highlighting the pitfalls and the network's enormous potential for ascertaining evidence of irregularities. The overheated debate on absenteeism due to illness, the diverse roles of national health physicians and self-employed doctors responsible for issuing a sickness certificate, and problems related to circumstances in which a doctor operates, are the key topics in this discussion. Computerization is an effective tool for optimizing public resources; however, it also seeks to ferret out, through the traceability of certification, abuse of medical certification, with severe penalties applied if certificates are discovered to contain misleading or untrue information.

Adjuvant chemotherapy seems beneficial for invasive intraductal papillary mucinous neoplasms

AIMS

The incidence of intraductal papillary mucinous neoplasm (IPMN) is rising and these neoplasms now represent up to 25% of resected pancreatic neoplasms. The optimal postoperative management of resected invasive IPMN is still debated in the absence of large prospective clinical trials and of validated prognostic factors in this setting. The objective of our study was to identify potential prognostic factors and to investigate the role of adjuvant therapies for patients radically resected for invasive IPMN.

METHODS

We retrospectively reviewed clinical and pathological data regarding a large series of patients with invasive IPMN who underwent surgical resection in the last six years at University Hospital of Pisa.

RESULTS

Sixty-four patients were considered for the analysis, thirty-three of whom received adjuvant chemotherapy with gemcitabine. In our series node involvement and high tumoral grade emerged as the major pathologic prognostic factors. Patients treated with adjuvant chemotherapy with gemcitabine experienced a longer disease-free survival than those who received surgery alone.

CONCLUSIONS

Gemcitabine-based chemotherapy seems beneficial as adjuvant treatment for patients with resected invasive IPMN.

[Investigation on a group of autistic children: risk factors and medical social considerations]

AIMS

The aim of this work is to study the association between autism in a group of autistic children and risk factors for specific familiar diseases and developmental disease in the early years of life, through a medical social investigation.

MATERIALS AND METHODS

For this study, we have submitted an anamnestic questionnaire to 29 autistic children and their families in a South Italy region (Basilicata), collecting data about children and their parents.

RESULTS

The results show that many children have a family history of autoimmune diseases (psoriasis, rheumatoid arthritis, celiac disease, Takayasu's arteritis), allergies and food intolerances, suggesting a putative involvement of the immune system in autism etiopathogenesis. Analyzing residences areas of patients, Potenza and Matera, with their environmental factors (radioactive waste repositories, incinerators, intensive farming), we demonstrate that the particular territorial characteristics don't affect autism.

CONCLUSIONS

Autistic disorder is a spectrum of neurologic disorders complex both in etiopathogenesis and healthcare. So we aim to continue the study already undertaken on cytokines of autistic subjects serum and to extend it through biomolecular approaches assessing the presence of specific genetic polymorphisms in order to identify the physiopathogenetic mechanisms underlying the disease and to evaluate the predictive risk with the aim to improve care interventions.

Levetiracetam versus carbamazepine in patients with late poststroke seizures: a multicenter prospective randomized open-label study (EpIC Project)

BACKGROUND

Strokes are the leading cause of epileptic seizures in adults and account for 50% of seizures in those over the age of 65 years. The use of antiepileptic drugs to prevent recurrent poststroke seizures is recommended.

METHODS

One hundred and twenty-eight patients with poststroke seizures were randomly allocated to treatment with either levetiracetam (LEV) or sustained-release carbamazepine (CBZ) in a multicenter randomized open-label study. After a titration study phase (2 weeks), the optimal individual dose of trial medication was determined and treatment was continued for another 52 weeks. The primary endpoint was defined as the proportion of seizure-free patients; the secondary endpoints were: evaluation of time recurrence to the first seizure, EEG tracings, cognitive functions and side effects.

RESULTS

Of 128 patients, 22 discontinued the trial prematurely; thus a total of 106 patients (52 treated with LEV and 54 treated with CBZ) were included in the analysis. The results of the study were as follows: no significant difference in number of seizure-free patients between LEV and CBZ (p = 0.08); time to the first recurrence tended to be longer among patients on LEV; there was no correlation between the therapeutic effect and the EEG findings in either treatment group; LEV caused significantly fewer (p = 0.02) side effects than CBZ; attention deficit, frontal executive functions and functional scales (Activities of Daily Living and Instrumental Activities of Daily Living indices) were significantly worse in the CBZ group.

CONCLUSIONS

This trial suggests that LEV may be a valid alternative to CBZ in poststroke seizures, particularly in terms of efficacy and safety. In addition, our results show that LEV has significant advantages over CBZ on cognitive functions. This trial also indicates that LEV in monotherapy is a safe and effective therapeutic option in elderly patients who have suffered epileptic seizures following a stroke.