The Exstrophy-epispadias complex

Exstrophy-epispadias complex (EEC) represents a spectrum of genitourinary malformations ranging in severity from epispadias (E) to classical bladder exstrophy (CEB) and exstrophy of the cloaca (EC). Depending on severity, EEC may involve the urinary system, musculoskeletal system, pelvis, pelvic floor, abdominal wall, genitalia, and sometimes the spine and anus. Prevalence at birth for the whole spectrum is reported at 1/10,000, ranging from 1/30,000 for CEB to 1/200,000 for EC, with an overall greater proportion of affected males. EEC is characterized by a visible defect of the lower abdominal wall, either with an evaginated bladder plate (CEB), or with an open urethral plate in males or a cleft in females (E). In CE, two exstrophied hemibladders, as well as omphalocele, an imperforate anus and spinal defects, can be seen after birth. EEC results from mechanical disruption or enlargement of the cloacal membrane; the timing of the rupture determines the severity of the malformation. The underlying cause remains unknown: both genetic and environmental factors are likely to play a role in the etiology of EEC. Diagnosis at birth is made on the basis of the clinical presentation but EEC may be detected prenatally by ultrasound from repeated non-visualization of a normally filled fetal bladder. Counseling should be provided to parents but, due to a favorable outcome, termination of the pregnancy is no longer recommended. Management is primarily surgical, with the main aims of obtaining secure abdominal wall closure, achieving urinary continence with preservation of renal function, and, finally, adequate cosmetic and functional genital reconstruction. Several methods for bladder reconstruction with creation of an outlet resistance during the newborn period are favored worldwide. Removal of the bladder template with complete urinary diversion to a rectal reservoir can be an alternative. After reconstructive surgery of the bladder, continence rates of about 80% are expected during childhood. Additional surgery might be needed to optimize bladder storage and emptying function. In cases of final reconstruction failure, urinary diversion should be undertaken. In puberty, genital and reproductive function are important issues. Psychosocial and psychosexual outcome depend on long-term multidisciplinary care to facilitate an adequate quality of life

Primary Care Physicians’ Decisions About Discharging Patients from Their Practices

OBJECTIVE: There are few data available about factors which influence physicians' decisions to discharge patients from their practices. To study general internists' and family medicine physicians' attitudes and experiences in discharging patients from their practices.DESIGN: A cross-sectional mailed survey was used.PARTICIPANTS: One thousand general internists and family medicine physicians participated in this study.MEASUREMENTS AND MAIN RESULTS: We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p= 48 years old) were more likely to discharge actual patients from their practices (p=0.005) as were physicians practicing in rural settings (p=0.003).CONCLUSIONS: Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient-physician relationship and their fiduciary obligations to the patient

Psychosomatic and Biopsychosocial Medicine: Body-Mind Relationship, Its Roots, and Current Challenges

The basis of psychosomatic medicine is a fundamental philosophical debate between mind (a subjective phenomenon that is linked to a sense of consciousness) and body (which is empirically demonstrable). Starting from the Greek tradition to the Cartesian res cogitans-res extensa dichotomy, the chapter illustrates the role and importance of a biopsychosocial approach in all the spheres of medicine as a way to contrast the still evident modern medicine reductionism. The evidence coming from biological, psychological, and social science, merging in biopsychosocial (or psychosomatic) integrated view in medicine, is also discussed. Although the term psychosomatic can be misleading, since, as Alexander underlined in the first issue of the journal Psychosomatic Medicine in 1939, it may imply dichotomy between psyche and body (soma). If however we understand psychic phenomena as nothing but the subjective aspect of certain bodily (brain) processes, this dichotomy disappears, becoming medicine of the whole person, away from scientistic reductionism and toward the embrace of the complex in clinical practice