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The economic impact of second opinion in pathology

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The economic impact of second opinion in pathology

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... The Second Opinion Medical Network is a consultation referral web and outpatient office system enclosing a wide panel of specialists, to whom any patient with whatever illness or syndrome inadequately faced by the diagnosis and therapy can apply for an individual clinical audit [25][26][27][28]. ...
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Aim: We report an open spontaneous anecdotical retrospective survey of Corynebacterium parvum administration to 4000 fragile immune-depressed and multimorbid patients treated with a killed C. parvum strain to enhance innate immunity, integrating the adaptative immune response for long-standing antinfectious resistance. Methods: A total of 4000 patients (1900 men and 2100 women) with mild, moderate, or chronic disease, appealing to our Second Opinion Medical Consultation Network, signed an informed consent form and were injected subcutaneously with C. parvum. The treatment was followed up to 6 months, completing the short form of the medical outcome health survey questionnaire (SF-36) directly by the patients or their parents and monitoring their health status regularly via telemedicine (Skype, WhatsApp, mail, etc.) or outpatients visits. Results: The main efficacy endpoints, as assessed by the SF-36 questionnaire are: significant improvements in the mental and physical role functioning score (p < 0.02), better general health; social role performance (p < 0.02), vitality (p < 0.03), and a significant pain reduction (p < 0.03). A quick (48-72 hours) symptoms improvement and/or complete regression of the herpetic eruptions was observed in 1000 affected patients with disappearance or relieve of herpetic neuralgia (reduced in 80% of cases); also full recovery or frequency reduction (30%) of recurrent cystitis and prostatitis in 120 affected patients. Last but not least, a life quality improvement in 100 oncologic patients of overall 200 cases. A significant increase in the lymphocyte count (p < 0.01), mainly helper and killer lymphocytes, was noted 6 months after Parvulan injection vs. the baseline. The asymptomatic SARS-CoV-2 patients who were incidentally enrolled in our survey were tested at the sixth month for antibodies against SARS-CoV-2, and 14 patients had high levels of SARS-CoV-2 antibodies. The incubating COVID infections of the Parvulan-injected patients even if frail and multimorbid recovered in short term (48-96 hours) with a benign clinical course, without need of drugs administration except for the variants, such as Delta and Omicron, whose infections lasted on average one week and required some antipyretics and low-dose steroids for a few days. Conclusions: Our results confirm that C. parvum is quite safe and effective in supporting immune-compromised patients when epidemic or pandemic events increase the life risk and any kind of infection and complication rate. Further double-blind placebo evidence-based studies are urgently required, and our numerically substantial not sponsored spontaneous observation is exclusively intended to promote further evidence-based double-blind institutional studies.
... Our Second Opinion Medical Consulting Network was founded by one of us (B. Palmieri) a few years ago at the University of Modena medical school, it is a free of charge examination and counseling service dedicated to patients with comorbidity or unresolved health problems desperately trying to achieve positive results (health recovery or at least life quality improvement), through stubborn sometimes obsessive web screening, and contacts (the classic doctor google consultation) with often self-referral Doctors or Institutions (10)(11)(12). We have named such a patient's compulsory behavior "the Web Babel Syndrome" and obviously our mission has been to release promptly proper diagnostic and effective therapeutic options, relieving this frustrating situation (13). ...
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Objectives: Our main aim was to investigate the short-term thera-peutic effects, safety/tolerability of natural compound, composed of melatonin (1,5 mg) and cannabis extracts (2.5 mg CBD) in patients with sleep disorders. Methods: In this spontaneous, anecdotal, retrospective, "compas-sionate-use," observational, open-label study, 20 patients (age 43-96 years) were appealed to our "Second Opinion Medical Consulting Net-work" (Modena, Italy), because of a variable pattern of sleep disorders and anxiety and were instructed to take sublingually the compound (20 drops) overnight for 3 months of treatment. Tolerability and adverse effects were assessed monthly during the treatment period through direct contact (email or telephone) or visit if required. Results: PSQUI and HAM-A scores evidenced reduction in mood alterations, including anxiety, panic, paranoia, depression (P < 0.03), in pain (P < 0.02) and good general health perceptions. Conclusions: These data suggest that the formula CBD-melatonin could be competitive with the classic hypnotic synthetic drugs, the antioxidant activity of melatonin offers a further benefit to the brain network, restoring the biological clock functions, while CBD, redu-cing chronic pain perception, helps to complete the neuromuscular relaxation and to relieve anxiety fulfilling a very balanced sensation of wellbeing during the sleep.
... "The Second Opinion Medical Network is a consultation referral web and outpatients O ce System enclosing a wide panel of specialists, to whom any patient with whatever illness or syndrome inadequately faced by the diagnosis and therapy can apply for an individual clinical audit (25)(26)(27)(28) The clinical data of the recruited patients is described in Table 2. ...
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AIM: We report an open spontaneous anecdotical retrospective survey of Corynebacterium parvum administration to 4000 fragile immune-depressed and multimorbid patients treated with a killed C. parvum strain to enhance the innate immunity integrating the adaptative immune response for a long standing antinfectious resistance. METHODS: 4000 patients (1900 men and 2100 women) with mild, moderate or chronic disease, appealing to our Second Opinion Medical Consultation Network, signed an informed consent and were injected subcutaneously with C.parvum. The treatment was followed up at 6 months after therapy, filling the short form of the medical outcome health survey questionnaire (SF-36), directly by the patients or its parents and monitoring the health regularly via telemedicine (Skype, WhatsApp, mail, etc) or physician’s visit. RESULTS: The main efficacy endpoints, as assessed by the SF-36 questionnaire, are significant improvements in the mental and physical role functioning score (p< 0.02), in general health, in social role functioning (p < 0.02), vitality (p < 0.03), and a significant reduction in bodily pain (p< 0.03). There was a quick (48-72 hours) symptoms improvement and/or complete regression of the herpetic eruptions observed in 1000 affected patients and of herpetic neuralgia (reduced in 80% of cases), also full recovery or frequency reduction (30%) of recurrent cystitis and prostatitis in 120 affected patients, and last, but not least, a life quality improvement in 100 oncologic patients of overall 200 cases. A significant increase in the lymphocyte count (p<0.01), mainly Helper and Killer lymphocytes, was noted after 6 months by Parvulan injection vs. the baseline. The asymptomatic SARS-CoV-2 patients, incidentally, enrolled in our survey, were tested at sixth months for antibodies against SARS-CoV-2 and 14 patients occurred high level of SARS-CoV-2 antibodies. The incubating Covid infections in the Parvulan injected patients even if rail and multi-morbid recovered in a short term (48-96 hours) and with benign clinical course, usually no need of further drugs administration except for the variants, which lasted on average one week and required some antipyretics, and low dose steroid for a few days. CONCLUSIONS: Our results confirm that C.parvum is quite safe and effective to support immune-compromised patients when epidemic or pandemic events rise the life risk and any kind of infections and complications rate. Further double-blind placebo evidence-based studies are urgently required, and our numerically substantial not sponsored spontaneous observation aims exclusively to promote further evidence based double blind institutional studies.
... The Second Opinion Medical Network is a consultation referral web and Medical Office System recruiting suddenly a wide panel of real-time available specialists, to whom any patient affected by any disease or syndrome and not adequately satisfied by the diagnosis or therapy can apply for an individual clinical audit (16). To help patients discontented with their psycho-physical condition, the Second Opinion Network aims to be a useful "problem-solving" support revisiting each diagnostic and therapeutic step and properly re-addressing tailored treatments and prognoses, as well as preventing unnecessary investigational procedures and unhelpful and expensive medical and surgical interventions (17). ...
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Objective: The aim of study is to evaluate the aesthetic outcome of specific formulated cosmeceutical product to mask and reduce the appearance surgical scars or unappealing skin tags in chronic diseases, such as cancer Methods: In a spontaneous, anecdotal, retrospective study, 26 patients with skin disorders appealed to Second Opinion Medical Network (Modena, Italy), required masking and improving the skin appearance. To evaluate the aesthetic improvement of skin imperfections, a gelcream containing 10% of acetyl hexapeptide-8 (registered trademark Argireline®) was selected, that can be applied directly upon the lesion, followed by a light massage in the treated area for a few minutes Results: The skin quality parameters (hydration, elasticity, sebum), photographs and investigators clinical assessment have been performed before and after the treatment and demonstrated that this cream significantly improved the skin values and the self-image expectation of each patient. No allergic reactions were documented during the period treatment Conclusions: The topical administration of this cosmeceutical cream is a safe and effective alternative to the invasive procedures, to improve the quality of life in patients with some skin disorders such as cancer, surgical scars, hidradenitis, aging wrinkles
... RICERCA SCIENTIFICA della qualità della vita, ricorrendo in tempo reale anche a consultare un panel di esperti specialisti, sotto una regia di coordinamento [9][10] . La continua e assillante ricerca autogestita e autoreferenziale, di risposte diagnostiche e terapeutiche da parte del paziente nel web, fa spesso precipitare l'interlocutore nella cosiddetta "sindrome di Babele del Web" 11 . ...
... Palmieri et al. [26] describe this borderline or even pathological behavior as the 'Web Babel Syndrome' -a psychological imbalance affecting young and elderly patients, especially those with multiple synchronous diseases who receive from their caregivers heterogeneous and misleading information or advices, including confused, contradictory statements and prescriptions [27]. To deal with this problem, the Second Opinion Medical Consulting Network aims to be a useful 'problem-solving' support, revisiting each diagnostic and therapeutic step and properly re-addressing tailored treatments and prognoses, as well as preventing unnecessary investigational procedures and unhelpful and expensive medical and surgical interventions [28]. ...
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Aim The aim of this study was to evaluate brain glucose metabolism by means of [18F]-fluoro-deoxygluycose (18F-FDG) PET in a group of patients presenting dysautonomic syndrome after human papilloma virus (HPV) immunization. Methods Medical records of patients, referred to the ‘Second Opinion Medical Consulting Network’ Medical Centre (Modena, Italy) diagnosed with dysautonomic syndrome were searched. Inclusion criteria were presence in the medical history of adverse drug reactions following HPV vaccine; a Montreal Cognitive Assessment score <25 and good quality of a 18F-FDG-PET brain scan performed within 12 months from the diagnosis of dysautonomic syndrome. 18F-FDG-PET images of patients (HPV-group) were compared to a control group, matched for age and sex, using statistical parametric mapping (SPM). Results The 18F-FDG-PET study was available for five female patients. The SPM-group analysis revealed significant hypometabolism (P < 0.05 false discovery rate corrected) in the right superior and medial temporal gyrus (Brodmann areas 22, 21) and insula (Brodmann area 13). At a threshold of P < 0.001 (uncorrected), further hypometabolic regions were revealed in the right superior temporal gyrus (Brodmann area 42) and caudate head and in the left superior temporal gyrus (Brodmann area 22), frontal subcallosal gyrus (Brodmann area 47) and insula (Brodmann area 13). Relative hypermetabolism (P = 0.001) was revealed in the right premotor cortex (Brodmann area 6). Conclusion This study revealed the possibility of altered brain glucose metabolism in subjects with dysautonomic syndrome post-immunization with HPV vaccine. These results could reinforce the hypothesis of a causal relationship between HPV vaccine, or some component included in the vaccine and the development of clinical manifestations.
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Chronic venous insufficiency has a high impact on the healthcare system due to its high incidence worldwide. We performed a study in 30 women with thigh and leg varices due to major saphenous vein valve incontinence with saphenous trunk reflux causing phlebo-lymphoedema to assess the efficacy of sclerofoam-assisted laser treatment combined with nutraceutical administration. The patients underwent endovascular combination sealing of the saphenous trunk with sclerofoam-assisted laser treatment technique into the major saphenous veins under low-volume tumescent anesthesia followed by intraoperative phlebectomies. Post-operatively, the patients received capsules containing Aesculus Hippocastanum , chondroitin sulphate, proanthocyanidins from Pinus pinaster Aiton , proanthocyanidins from Vitis vinifera L., hydrolysed marine collagen and carcinine dihydrochloride for 3 weeks. We evaluated the extracellular fluid volume of the lower limbs using bioimpedance spectroscopy pre- (T0) and post-surgery (T2) (impedance is a vector which is composed of two components, resistance [RES] and reactance [REA)]). In addition, we evaluated the following parameters pre- and post-surgery: pain, heaviness, paresthesia, itching, swelling, daily urine volume output and leg volume. Limb volume was significantly decreased at T2 compared to T0 ( p < 0.01). RES and REA were significantly increased at T2 compared to T0 ( p < 0.0001 and p < 0.01, respectively). A significant improvement in heaviness, paresthesia, pain, swelling and itch was also observed (all p < 0.0001) while no changes in terms of diuresis occurred. No adverse effects were observed. The present study shows a promising approach to the treatment of chronic venous insufficiency that warrants further clinical studies in larger cohorts of patients.
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OBIETTIVO: Lo scopo della nostra indagine retrospettiva, aneddotica e spontanea è stato di stimolare l’immunità innata, integrando la risposta immunitaria adattiva tramite la somministrazione di un batterio inattivato Corynebacterium parvum su pazienti fragili immunodepressi e con multimorbilità. METODI : Quattromila pazienti (1900 uomini e 2100 donne) si sono rivolti alla nostra rete di consulenza medica del Secondo Parere, perché affetti da patologie di lieve, moderata o cronica intensità e, una volta firmato il consenso informato, sono stati sottoposti a trattamento con C. parvum. Il follow-up è stato di 6 mesi, e si è svolto attraverso la compilazione di un questionario sulla salute in forma breve (SF-36), compilato direttamente dai pazienti o dai loro familiari, anche attraverso il regolare e periodico monitoraggio diretto della loro salute via telemedicina (Skype, WhatsApp, posta, ecc.) o visita medica. RISULTATI: I punteggi attribuiti alle variabili del questionario SF-36 hanno evidenziato un significativo miglioramento relativo: al benessere mentale e fisico (P<0,02), allo stato di salute generale, alla funzionalità sociale (P<0,02), alla vitalità (P<0,03), e alla riduzione del dolore fisico (P<0,03). È stato osservato un miglioramento significativo o una regressione completa delle eruzioni erpetiche in 1000 pazienti affetti, nonché una netta riduzione (80%) della nevralgia, una risoluzione o riduzione in frequenza (30%) delle cistiti e prostatiti ricorrenti in 100 casi sofferenti e, ultimo ma non meno importante, un miglioramento (2,5%) della qualità della vita in 100 pazienti oncologici su un totale di 200 casi. È stato osservato anche un aumento significativo della conta linfocitaria soprattutto delle cellule T helper (P<0,0001). CONCLUSIONI: Anche se il nostro studio non rispecchia appieno i parametri della evidence-based medicine, i risultati, data la numerosità del campione raccolto, meritano di essere presi in considerazione al fine di programmare indagini cliniche più approfondite
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La recente pandemia unitamente alle recrudescenze virali stagionali comporta la integrazione di procedure terapeutiche efficaci e urgenti: risulta infatti importante ricercare e implementare ottimali misure di prevenzione e di terapia farmacologica e immunologica. Negli ultimi mesi si è cercato di trattare l’infezione con chemioterapie mutuate da altri programmi antivirali o con farmaci off label. L’obiettivo ottimale sarebbe quello di praticare un trattamento sicuro, efficace, e sostenibile, fruibile da quante più persone possibile, tenendo in considerazione non solo le nuove terapie a bersaglio molecolare, ma quelle, recenti e non, attualmente disponibili. Due importanti riferimenti emergenti in quest’ottica sono, dunque, la stimolazione della immunità innata e della trained immunity oltre che della immunità adattiva. L’immunità innata rappresenta filogeneticamente (essendo prerogativa anche degli invertebrati), la più antica forma di pronta e rapida difesa degli esseri viventi da agenti e meccanismi patogenetici, con attivazione diretta della fagocitosi da parte di cellule capacitate ad attività macrofagica; la trained immunity è una più recente acquisizione (2000 anni dopo) ed evoluzione del sistema immunitario, dotata di più ampia memoria immunologica con produzione anticorpale al secondo contatto con la noxa infettante, potenzialmente in grado di coinvolgere anche altri agenti patogeni non direttamente correlati al primo.
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Background: The nonalcoholic fat liver disease (NAFLD) progresses in 30% of the patients to not alcoholic steatohepatitis (NASH) and subsequently in liver fibrosis and even primary cancer and death. Due to the complex physiopathology of the liver steatosis, NASH is an area orphan of specific drugs, but many authors suggest an integrated treatment based upon diet, lifestyle change, and pharmacology. Methods: Our clinical study selected from a wider patient cohort, 13 subjects, appealing to the Second Opinion Medical Consulting Network, for liver and nutritional problems. The diet was integrated with regular prescription of an herbal derivative based on Chrysanthellum americanum and Pistacia lentiscus L. extracts. Clinical data of the recruited patients including body weight, Body Mass Index, were recorded before and after treatment. Each patient underwent pre-post accurate clinical examination and lab exams. The liver stiffness and liver steatosis were evaluated by a trained hepatologist with FibroScan®. Results: A significant reduction of anthropometric parameters was detected in all the patients at the end of the study; liver fibrosis and steatosis were instrumentally decreased in 8 subjects, but not significant changes in lab exams and no adverse effects were reported. Conclusions: Chrysanthellum americanum and Pistacia lentiscus L. extracts were absolutely safe and effective and gave a substantial contribution to the life quality benefit, metabolic balance and gut function in patients with hepatic steatosis.
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To evaluate the importance of inter-institutional second opinion surgical pathology review of lymphoma, and identify the lymphoma pathologic mimics. The surgical pathology material of patients referred to 2 tertiary care hospitals in the western region of Saudi Arabia (King Faisal Specialist Hospital and Research Centre and King Abdulaziz University Hospital, Jeddah, Saudi Arabia), for evaluation or therapy for lymphoma over a 10-year period (August 2001 to August 2011), were reviewed. This study included only cases in which the patient referred with a diagnosis previously made at the primary institution. Of 560 cases, the second opinion diagnosis differed significantly from the initial diagnosis in 39 cases (7%). These include changing the diagnoses from lymphoma to non-lymphoma lesions, change the type of lymphoma with major clinical impact, and change from reactive/non-diagnostic to lymphoma. Second opinion surgical pathology for lymphomas can result in major therapeutic and prognostic modifications. Thus, review of the original histologic material is recommended prior to a major therapeutic decision, and to maximize the discovery of clinically relevant major disagreements. Stringent adherence to institution's second opinion policy is an important quality assurance measure in surgical pathology.
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Interinstitutional consultation in pathology has shown to improve patient safety by detecting interpretive errors that may significantly impact clinical management. We conducted a study of 922 cases of thyroid FNAC slides, referred to our institution over a 2-year period, to assess the magnitude of discrepancies and determine the clinical impact of second opinion. Disagreements were categorized as none, minor or major, the latter two defined as one- or two-step deviations respectively on the NCI diagnostic categories scale. There were 122 disagreements (13%), including 44 major and 78 minor. Seventy-five patients underwent a change in management based on second opinion, in conjunction with clinical and radiologic findings (age, size of nodule, family history, ultrasonographic appearance, and solitary versus multiple nodules). The second opinion was supported on follow-up in 57% of major discrepancies, and the initial diagnosis was concurrent with the surgical diagnosis in 7% cases. The remainder (36%) of major discrepancy cases did not undergo surgery, precluding tissue confirmation. Critics have alleged increased costs due to interinstitutional consultations. However, cost avoidance from lost wages, potential surgical complications, and litigation is not easily quantified. Using a simplified calculation to objectively measure the costs associated with changed diagnoses, we estimate that second opinion of these 922 cases resulted in potential cost saving of $940,166 based on current Medicare reimbursement codes. Our study indicates the need for a quality-control program of outside thyroid FNA slides, especially in "high discrepancy categories" as discussed in the article.
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To investigate the morphology of cultured fibroblasts derived from abnormal scars and compare it to those of human normal skin. This study was carried out in the Surgical Clinic, Faculty of Medicine, King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia between December 2008 and March 2010. Fifty-two samples of hypertrophic and keloid scar were collected. An in vitro study was conducted in which fibroblasts from normal foreskin; abnormal scars were cultured, studied morphologically and morphometrically. There was a highly significant increase in the length and breadth of fibroblasts from the hypertrophic and keloid scars, and highly significant decrease in the bipolarity index compared to control. There was a significant increase in the mean cell area, mean nuclear area and nuclear/cytoplasmic ratio of fibroblast of hypertrophic and keloid scars compared to control. There was a significant decrease in the mean cell area and mean nuclear area of the fibroblast of the treated keloid scar (with all used modalities) compared to untreated ones. Morphologically, abnormal scar fibroblasts has abundant spreading cytoplasm with numerous processes and large nuclei. The cytoplasm, of some cells, contained clumped granules in the peri-nuclear region, numerous vacuoles, and dense vesicles. Morphological and morphometric study showed that hyperactive cultured fibroblasts was a characteristic feature of abnormal scars and the studied modalities of treatment reduced, but not completely nullify this activity.
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Despite numerous studies evaluating second-opinion surgical programs, we are unaware of work evaluating the cost effectiveness of a second opinion for pathology prior to surgery. One of six pathologists reviewed the pathology of the outside needle biopsies of 535 consecutive men referred to Johns Hopkins Hospital for radical prostatectomy over a 12-month period (from October 1993 until October 1994) before the men underwent surgery. Of the 535 needle biopsies initially diagnosed on the outside as adenocarcinoma of the prostate, seven (1.3%) were reclassfied as benign upon pathology review at Johns Hopkins Hospital. The most common lesion misinterpreted as adenocarcinoma was adenosis or less pronounced examples of adenosis consisting of foci of crowded glands (five cases). Foci of atrophy in the remaining two cases were misdiagnosed as adenocarcinoma of the prostate. Upon subsequent clinical work up, six of seven men were considered not to have adenocarcinoma, and their surgery was cancelled. The cost for reviewing all 535 preoperative needle biopsies was $44,883, which included the cost of immunohistochemical studies for high-molecular-weight cytokeratin and repeat biopsies and ultrasounds in men whose diagnoses were reversed. The total cost of the radical prostatectomies had the six men undergone surgery was estimated at $85,686, including hospitalization, anesthesia, radical prostatectomy pathology, and surgery. This cost savings did not include other costs resulting from lost wages, morbidity, or potential litigation. Second-opinion pathological evaluation of prostate biopsy before radical prostatectomy is cost effective and has a major impact on clinical treatment for a subset of patients.
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Fetus-in-fetu (FIF), also known as endoparasitic twin, is a form of asymmetric fetal duplication in which the abnormal developing embryo parasitizes the normal co-twin by attaching internally. Here, we report a case of FIF presented as an intra-abdominal cystic mass, which was first detected during an antenatal ultrasound examination of a 32-year-old Saudi mother. At 34 weeks and 4 days of gestation, she had spontaneous labor and delivered a baby boy. The x-ray and CT examination of the baby boy clearly suggested the presence of limbs, vertebral column, and anomalous blood supply to the mass. After laparotomy and surgical removal, the intra-abdominal mass was subjected to detailed pathological examination. Microscopic studies further showed the presence of brain tissue, gut-like structures, fingers, and limbs. The mass was finally confirmed as FIF.
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Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.
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To retrospectively analyze the extraordinary pathologic entities inside the concha bullosa (CB). Surgical interventions were performed on 136 patients (234 CB) at the Department of Ear, Nose, and Throat, and Head and Neck Surgery, Izmir Tepecik Training and Research Hospital, Izmir, Turkey between January 2002 and December 2007. Radiological and histopathological findings of these cases were reviewed retrospectively. In 203 (86.8%) of the 234 cases, only a pneumatized cavity was observed. The cavity was filled with purulent secretion in 13 (5.6%) cases. A bony septum, pyocele, polyp, ossifying fibroma, fungus ball, and cholesteatoma were the other extraordinary pathologies associated with CB. Although most of the CB cases have pneumatized cavity, it should be kept in mind that some extraordinary pathologies can be associated with CB.
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This study evaluates a mandatory second-opinion consultation program administered on behalf of a large Taft-Hartley welfare fund providing medical care coverage for 120,000 beneficiaries and covered dependents. During a two-year intake period (1977-1978), 2,284 individuals received second-opinion consultations for an elective surgical procedure recommended by a first-contact physician or surgeon. Of this group, 366 received a nonconfirmation of their need for surgery. Medical claims data were available for 342 individuals in this group, and they constitute the base for the current analysis. A comparable number of individuals who received a positive confirmation were randomly selected and served as a control for estimating program savings. Both groups were followed for a one-year period from the date of their consultations. Total program savings were estimated at $534,791. Of this amount, medical care utilization savings were $361,756 and productivity savings were $173,035. The cost of the program was $203,300, yielding a benefit-cost ratio of 2.63. These findings indicate that mandatory second-opinion consultation programs, which are consumer oriented and intervene before care is rendered, are clearly cost-effective.
Article
Despite numerous studies evaluating second-opinion surgical programs, we are unaware of work evaluating the cost effectiveness of a second opinion for pathology prior to surgery. One of six pathologists reviewed the pathology of the outside needle biopsies of 535 consecutive men referred to Johns Hopkins Hospital for radical prostatectomy over a 12-month period (from October 1993 until October 1994) before the men underwent surgery. Of the 535 needle biopsies initially diagnosed on the outside as adenocarcinoma of the prostate, seven (1.3%) were reclassified as benign upon pathology review at Johns Hopkins Hospital. The most common lesion misinterpreted as adenocarcinoma was adenosis or less pronounced examples of adenosis consisting of foci of crowded glands (five cases). Foci of atrophy in the remaining two cases were misdiagnosed as adenocarcinoma of the prostate. Upon subsequent clinical work up, six of seven men were considered not to have adenocarcinoma, and their surgery was cancelled. The cost for reviewing all 535 preoperative needle biopsies was $44,883, which included the cost of immunohistochemical studies for high-molecular-weight cytokeratin and repeat biopsies and ultrasounds in men whose diagnoses were reversed. The total cost of the radical prostatectomies had the six men undergone surgery was estimated at $85,686, including hospitalization, anesthesia, radical prostatectomy pathology, and surgery. This cost savings did not include other costs resulting from lost wages, morbidity, or potential litigation. Second-opinion pathological evaluation of prostate biopsy before radical prostatectomy is cost effective and has a major impact on clinical treatment for a subset of patients.
Article
To determine the effect of routine second review of pathologic material that was sent to Ohio State University before initiation of therapy. All the gynecologic-oncologic histopathology review diagnoses made during a 1-year period were compared with original pathologic diagnoses. When there was a discrepant diagnosis with the second interpretation, the case was reviewed by at least two pathologists. Discrepancies were coded as no diagnostic disagreement, no diagnostic disagreement but pertinent information not included, diagnostic disagreement without clinical consequences, diagnostic disagreement with minor clinical significance, or diagnostic disagreement with major clinical significance. Proportions and confidence intervals were calculated. Pathology reports from 295 referred patients were reviewed. Two hundred forty-five (83.1%) showed no discrepancy. Discrepancies were found in 50 cases (16.9%). There was significant information missing in four cases (1.4%), diagnostic disagreement with no clinical significance in 22 cases (7.5%), and diagnostic disagreement with minor clinical significance in 10 cases (3.4%). In 14 cases (4.7%, 95% confidence interval 2.28, 7.12) the changes in diagnoses had major therapeutic or prognostic implications that included changes from malignant or low malignant potential to benign (seven cases), malignant to low malignant potential (three cases), change in tumor type (two cases), and assessment of invasion (two cases). The cost of reviewing 295 specimens was approximately $39,235. The cost of identifying each major discrepancy was about $2802. Routine pathology review of gynecologic-oncologic cases before definite treatment revealed notable discrepancies in diagnoses. In 4.7% of cases, the change in diagnosis had a major effect on proper treatment planning or a significant prognostic implication.