Differentiation of malignant from benign solitary pulmonary lesions using chest radiography, spiral CT and HRCT.

OBJECTIVE: The aim of this prospective study was to summarize all of the qualitative and quantitative imaging criteria for the differentiation of solitary pulmonary lesions (SPLs) as malignant (MSPLs) or benign (BSPLs) described in the literature and to critically analyze the different characteristics in order to evaluate their clinical importance and usefulness as criteria for a discrimination during the primary diagnostic assessment of SPLs using chest radiography, spiral computed tomography (SCT) and high-resolution computed tomography (HRCT). MATERIALS AND METHODS: SPLs were examined, evaluated and then completely removed by surgery in 104 consecutive patients (MSPLs n=81, BSPLs n=23). No SPL was excluded by size. Chest radiography was performed with frontal and lateral views, SCT was carried out with a slice thickness of 8 mm and HRCT with a slice thickness of 1 mm and a 12-cm field of view. RESULTS: All the characteristics which enabled a reliable differentiation of MSPLs from BSPLs were characteristics which were observed significantly more frequently in MSPLs than BSPLs. Useful characteristics for the differentiation of MSPLs from BSPLs (1) using chest radiography were the indistinct edge (P<0.0001) and a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0. 05); (2) using SCT the presence of spicules (P<0.0005), the vessel sign (P<0.0005), necrotic areas (P<0.001), spicules extending to the visceral pleura (P<0.005), circumscribed pleural thickening (P<0. 005), inhomogeneity (P<0.01), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05), pleural retraction (P<0.05) and the bronchus sign (P<0.05); and (3) using HRCT the presence of spicules (P<0.00005), spicules extending to the visceral pleura (P<0.0005), the vessel sign (P<0.0005), pleural retraction (P<0.001), circumscribed pleural thickening (P<0. 001), the bronchus sign (P<0.005), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05) and the length of spicules (P<0.05). Using any one of the characteristics with a significance level of P<0.01, the identification of MSPLs (1) using chest radiography showed a sensitivity of 64.2% and a specificity of 82.6% (accuracy of 68.3%); (2) using SCT a sensitivity of 88.9% and a specificity of 60.9% (accuracy of 82.7%); and (3) using HRCT a sensitivity of 91.4% and a specificity of 56.5% (accuracy of 83.7%). CONCLUSIONS: Using chest radiography, SCT and HRCT, a precise morphological assessment of the periphery of the pulmonary lesion and the adjacent visceral pleura is necessary to distinguish MSPLs from BSPLs. In this respect SCT and HRCT are useful in differentiation of MSPLs from BSPLs. However, metastases strongly resembled benign lesions in terms of size and edge type and chronic inflammatory pseudotumors as a group mimic MSPLs.

Retroperitoneal laparoscopic nephropexy.

Laparoscopic nephropexy is a suitable and clinically established procedure for the treatment of symptomatic nephroptosis. The availability of a minimally invasive therapy can facilitate decisions regarding the indication after careful selection of patients.

Immunochemiluminometric assay with two monoclonal antibodies against the N-terminal sequence of human parathyroid hormone.

We have developed an immunochemiluminometric assay (ICMA) with two monoclonal antibodies for the N-terminal sequence of human parathyroid hormone (hPTH). One monoclonal antibody (A1-70) was physically adsorbed onto polystyrene beads, the other (B1-70) was labelled with acridinium ester and synthetic hPTH (1-38) was used as standard. This assay has cross-reactions with synthetic hPTH (1-34) and hPTH (1-84) but no cross-reactions with hPTH (4-16), (28-48), (39-84), (44-68), (53-84) and hPTH-rP (1-86). The assay detection limit is 0.4 pmol/l. The normal range is 1.3-12 pmol/l based on 72 normal volunteers. About 91% of study patients (n = 58) with surgically proven primary hyperparathyroidism (1 degree HPT) had PTH values above normal and one of them showed a low normal intact PTH value but elevated PTH values with use of this assay. After immunoabsorption of plasma samples from patients with secondary hyperparathyroidism (2 degrees HPT) on hemodialysis with polystyrene beads containing antibodies against hPTH (39-84), some patients still showed significant amounts of PTH in this new ICMA but not intact PTH. The data reveal that significant amounts of amino-terminal immunoreactive PTH fragments rarely exist in 1 degree HPT but are present in some patients with 2 degrees HPT. The major advantage of this assay is to measure both amino-terminal PTH fragments and intact PTH with no interference from carboxy-terminal PTH fragments because two anti-N-terminal hormone sequence monoclonal antibodies are used.

Laser endopyelotomy: minimally invasive therapy of ureteropelvic junction stenosis.

Endoscopic pyelotomy is a minimally invasive procedure that is increasingly used for the management of ureteropelvic junction (UPJ) obstruction. We report the results and advantages in the management of UPJ obstruction using a ureteroscopic retrograde laser-assisted approach (laser endopyelotomy; LEP). Thirty-four patients were treated between December 1994 and June 1997 by this new technique. Twenty-seven obstructions were primary. The mean time of follow-up is 18 months. An indwelling ureteral catheter was placed 3 weeks prior to treatment. Intraoperatively, after the removal of the stent, a guidewire was passed across the stenosis, and the ureter was entered with a semirigid ureteroscope. The LEP was then performed under visual control using a contact laser fiber until all obstructive fibers had been cut. Follow-up examinations included sonography, intravenous urography, and, in unclear cases, a radionuclide renal scan with furosemide application after 3 months. The success rate was 85%. The most important factor influencing the outcome was the grade of hydronephrosis. Postoperative side effects have been minimal, and minor complications occurred in only 5 patients (15%). Laser endopyelotomy is a minimally invasive procedure with less morbidity for the treatment of UPJ obstruction. Only patients with a severe extrinsic cause of obstruction should be excluded from this technique. These cases can be approached laparoscopically.

Laparoscopy-assisted penile revascularization: a new method.

Analysis of more than 100 penile revascularizations using the Mannheim modification showed a success rate as high as 82% in properly selected patients. However, the dissection of the epigastric artery requires a relatively large incision, with the risk of postoperative bleeding, pain, and hernia formation. Therefore, we designed a laparoscopic approach for dissection of the epigastric vessels. From January 1995 to October 1996, we performed laparoscopy-assisted penile revascularization in 15 pharmacotesting nonresponders with erectile dysfunction. The first step is dissection of the penile vessels to minimize the occlusion time of the epigastric arteries. Thereafter, the extraperitoneal cavity is exposed using a balloon-trocar system inserted via a 15-mm suprapubic incision. A pneumoextraperitoneum is established, and two further cannulas are inserted (10 mm subumbilical, 5 mm in the lower abdomen contralateral to the desired epigastric artery). The dissection of the epigastric vessels starts caudally at the origin from the external iliac vessels and continues to the periumbilical area. All branches are dissected between clips, keeping the artery and vein together. For extraction of the artery, we insert another 5-mm port through the incision at the penile base. After desufflation of the extraperitoneal space and closure of the trocar wounds, microsurgical penile revascularization is performed using the previously described modification of the Hauri procedure. The mean operating time for laparoscopic dissection of epigastric artery was 120 minutes. No intraoperative complication occurred. One patient suffered from an inguinal hematoma. After a median follow-up of 12 month, 53% of patients showed spontaneous erections, and another 27% achieved a full erection with the aid of additional pharmacotherapy. Laparoscopic dissection of the epigastric arteries proved to be feasible, resulting in a considerable reduction of overall morbidity of penile revascularization without reducing the efficacy of the procedure.

Organ retrieval systems for endoscopic nephrectomy: a comparative study.

Laparoscopic or retroperitoneoscopic interventions such as nephrectomy or tumor nephrectomy call for the removal of large quantities of tissue, which can no longer be extracted via the relatively confined lumen of a cannula. For this purpose, a variety of organ retrieval systems have been designed and are commercially available with the aim of safe tissue retrieval. This paper summarizes the results of an experimental and clinical comparison of the most important organ entrapment systems suitable for endoscopic nephrectomy. The LapSacs was the first organ bag especially designed for laparoscopic nephrectomy. Despite various new modifications of this entrapment system, it still represents one of the best alternatives and has been used worldwide with success. However, because of its simplicity, it requires a certain laparoscopic expertise and involves a learning curve. Newly developed retrieval systems (i.e., LapBag, Extraction Bag, Endo-Catch) offer some advantages regarding the handling of the bag, which may be particularly useful during retroperitoneoscopic nephrectomy with a restricted working space. Retrieval systems (i.e., Endobag, Endopouch) with low resistance to tearing forces or permeability to tumor cells or bacteria (i.e., Espiner Bag) cannot be recommended for endoscopic nephrectomy.

Hybrid rendering of the chest and virtual bronchoscopy [corrected].

Thin-section spiral computed tomography was used to acquire the volume data sets of the thorax. The tracheobronchial system and pathological changes of the chest were visualized using a color-coded surface rendering method. The structures of interest were then superimposed on a volume rendering of the other thoracic structures, thus producing a hybrid rendering. The hybrid rendering technique exploit the advantages of both rendering methods and enable virtual bronchoscopic examinations using different representation models. Virtual bronchoscopic examinations with a transparent color-coded shaded-surface model enables the simultaneous visualization of both the airways and the adjacent structures behind of the tracheobronchial wall and therefore, offers a practical alternative to fiberoptic bronchoscopy. Hybrid rendering and virtual endoscopy obviate the need for time consuming detailed analysis and presentation of axial source images.

Diagnostic value of chest radiography, computed tomography and tumour markers in the differentiation of malignant from benign solitary pulmonary lesions.

BACKGROUND: The aim of this prospective study was to assess the diagnostic value of the imaging modalities (chest radiography, spiral computed tomography (SCT) and high-resolution computed tomography (HRCT)) and the tumour markers (carcinoembryonic antigen (CEA), cytokeratin marker (CYFRA 21-1) and neuron-specific enolase (NSE)) in the differentiation of malignant (MSPLs) from benign solitary pulmonary lesions (BSPLs). PATIENTS AND METHODS: Solitary pulmonary lesions (SPLs) were examined, evaluated and then completely removed by surgery in 104 consecutive patients (MSPLs n = 81, BSPLs n = 23). Chest radiography was performed with frontal and lateral views, SCT was carried out with a slice thickness of 8 mm and HRCT with a slice thickness of 1 mm and a 12-cm field of view. For the tumour marker analysis, serum concentrations were determined 1-3 days prior to surgery by ELISA for CEA and CYFRA 21-1 and by IRMA for NSE using commercially available assay kits. The cut-off values were set at 3 ng/ml (for non-smokers) and 5 ng/ml (for smokers) for CEA, at 3.3 ng/ml for CYFRA 21-1 and at 12.5 ng/ml for NSE. RESULTS: Using any one of the characteristics with a significance level of P <0.01, the identification of MSPLs using chest radiography showed a sensitivity of 64.2% and a specificity of 82.6%, using SCT a sensitivity of 88.9% and a specificity of 60.9% and using HRCT a sensitivity of 91.4% and a specificity of 56.5%. For the identification of MSPLs using CEA a sensitivity of 27.2% and a specificity of 87.0% (accuracy of 40.4%) was observed. Using CYFRA 21-1 a sensitivity of 19.8% and a specificity of 100.0% (accuracy of 37.5%) and using NSE a sensitivity of 13.6% and a specificity of 100. 0% (accuracy of 32.7%) was found. CONCLUSIONS: Using chest radiography, SCT and HRCT, a precise morphological assessment of the periphery of the pulmonary lesion and the adjacent visceral pleura is necessary to distinguish MSPLs from BSPLs. Tumour markers used alone or in combination with the imaging methods brought no additional benefits, in terms of sensitivity and accuracy, over the diagnostic imaging methods alone. However, the tumour markers exhibited a far superior specificity (100% for CYFRA 21-1 and NSE) compared with the imaging methods.

Psybertherapy on the Internet and its implications for psychiatry, psychotherapy, and psychosomatics.

First of all, an introduction to worldwide communication networks is given. Some relevant basic features are explained. Actual and future aspects of the Internet for psychiatry, psychotherapy, and psychosomatic medicine are highlighted. There is a variety of possible advantages in World Wide Web telemedicine for patients, clients, consultants, clinicians and scientists. Useful tools and established opportunities are discussed and listed as Web-sites. The systematic review gives access to the most important fields of mental health on the Internet. Finally, some of the risks of this kind of communication for therapy and society are visible.

Hybrid rendering and virtual endoscopy of the auditory and vestibular system.

A hybrid rendering method (color-coded 3D shaded-surface and volume display) with the possibility of virtual endoscopy using image data sets from HR-SCT was developed. To show the possible advantages and benefits of the improved rendering algorithm we have specifically highlighted the use in relation to the auditory and vestibular system. Postprocessing image visualization offers improved morphological analysis, and will benefit radiological diagnostics, medical education, surgical planning, surgical training and postoperative assessment.

Gene therapy and medical genetics on Internet.

In this report we consider the development of the Internet, from its origins as a military invention in the times of the cold war to its present day role, together with the World Wide Web, as a means of global communication which plays a key role in medical research and particularly in medical genetics. A few of the major genetics related research projects and gene research centers are introduced and their aims are briefly discussed. Detailed information about chromosome and gene mapping, together with sequence and structure databases, can be easily and rapidly accessed through the Internet. A variety of web-sites are briefly described and then listed at the end of the report, which will serve as a useful starting point from which the interested reader can access an almost endless source of genetics related information on the Internet. Finally, some of the ethical, legal and social implications of the links between gene therapy and the Intemet are considered.

Retroperitoneal laparoscopic lymph node dissection for staging non-seminomatous germ cell tumors before and after chemotherapy.

We describe our experience with laparoscopic retroperitoneal lymph node dissection in 19 patients with non-seminomatous germ cell tumors. Twelve patients had stage I disease with no clinical evidence (CT-scan, ultrasound, tumor markers) of metastases; 7 patients (stage IIb=2, stage IIc=5) had residual tumor after chemotherapy but with negative tumor markers. A laparoscopic dissection was used to asses more fully the pathologic status of the relevant retroperitoneal lymph nodes of both groups. The patient was positioned and trocars introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position, five ports - 3 x 10 mm; 2 x 5 mm). After reflecting the colon anteromedially, the landmarks of the lymph node dissection were isolated-namely the ureter, aorta, inferior vena cava, and both renal veins. The lymph node dissection included the paracaval, interaorto-caval, upper preaortic, and right common iliac zonal nodes for right-sided tumors, and paraaortic, upper preaortic zones for left-sided tumors. Retrieval of the lymph nodal chains was accomplished using a small organ bag. The mean duration of the procedure was 298 (range 150-405) minutes. In only one patient was a lymph node positive for tumor (stage I). Otherwise nodes showed extensive necrosis (after chemotherapy). No intraoperative complications were encountered but three patients developed a delayed complication (ureteral stenosis, pulmonary embolism, and retrograde ejaculation, respectively). Whereas we completed the dissection in each patient with stage I tumors, the laparoscopic procedure was more difficult in patients with stage II tumors after chemotherapy. In two patients with stage IIb disease laparoscopic lymphadenectomy was successful. In four other patients parts of the dissection had to be done after conversion to an open (conventional) operation using a small incision (suprainguinal or pararectal); in one patient the laparoscopic approach was abandoned and converted to an open operation. In the post-chemotherapy group the outcome depended primarily on the tumor bulk prior to drug treatment. In two patients in whom all residual necrotic tissue was removed laparoscopically they had "minor" disease (stage IIb); the others had stage IIc tumors. Our preliminary experience suggests that a modified laparoscopic lymph node dissection is feasible for stage I tumors and in selected patients with marker negative residual tumor after chemotherapy (stage IIb).

[Retroperitoneoscopy--experiences with the first cases]. / Retroperitoneoskopie--Erfahrungen mit den ersten 200 Fällen.

UNLABELLED: A retroperitoneal access is most commonly applied for open procedures in urology. With introduction of the balloon dissecting technique, this anatomical route could also be used for laparoscopic surgery. MATERIALS AND METHODS: From 12/1992 to 10/1997, a total of 200 retroperitoneoscopic procedures have been performed in 197 patients (age 4-82 years): 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph-node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Thirty-eight patients (19%) had undergone previous abdominal surgery; 22 (11%) had had kidney and ureter operations. Dissection of the retroperitoneal space was done with a balloon catheter in 14 or a balloon trocar system in 93 cases, and in the last 93 patients digital dissection with the index finger proved to be sufficient. RESULTS: We classified 76 as simple (i.e., renal biopsy, renal cyst resections, ureterocutaneostomy) and 102 as difficult (i.e. adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult operations (i.e., pyeloplasty, heminephrectomy, lymphadenectomy). There has been a significant learning curve during the first 50 cases as reflected by increased operating time and complications and the conversion rate to open surgery. After that, the OR times mainly depended on the difficulty of the procedure, averaging 45-100 min for an easy retroperitoneoscopy, 95-185 min for a difficult and 185-240 min for a very difficult operation. In the last 50 cases, the complications, conversion and reintervention rate have become comparable to open surgery (2, 4 and 2%). CONCLUSIONS: After more than 200 cases of retroperitoneoscopy, the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.

[Techniques for bladder neck suspension with osseous screw fixation]. / Blasenhalssuspensionstechniken mit ossärer Schraubenfixation.

We investigated the technical feasibility and clinical results of bone fixation techniques in combination with needle suspension for correction of female stress urinary incontinence. In our experience the screw-like bone anchor, which is drilled into the public tubercle, represents a minimally invasive but very stable and reliable technique. However, the needle suspension fixed to the bone anchor turned out to be critical. Even though the suspension was fixed in the paraurethral tissue with a deep Z-stitch between the bladder neck and the midurethra, the 1-year recurrence rate was 76%. Our data showed that the suspension sutures pull through the paraurethral tissue because there is no paravesical scar formation as in open procedures. Modifications of the suspension technique (four-point suspension, simultaneous laparoscopic or digital dissection of the paravesical space, combination with sling procedures) revealed significantly improved short-term results. Therefore we conclude that after improvement of the suspension technique the bone anchor will represent a valid option for minimally invasive fixation of a bladder neck suspension.

[Retroperitoneoscopy. Technique and experiences with the first 100 patients]. / Retroperitoneoskopie. Technik und Erfahrungen mit den ersten 100 Patienten.

Retroperitoneoscopic procedures were already being performed in the late 1970s. The clinical breakthrough of retroperitoneoscopy, however, was initiated in 1992 by the balloon-dissecting technique of Gaur, together with the experience gained with transperitoneal laparoscopic procedures in the upper retroperitoneum. We have modified the balloon-dissecting technique into a hydraulic video-optically controlled balloon dissection of the retroperitoneal space, and this procedure was recently further simplified. From December 1992 to December 1995 we performed 100 retroperitoneoscopic procedures in 98 patients (aged 4-82 years). Twenty-two patients had undergone previous abdominal surgery, 16 patients had been operated on for kidney and ureter problems. We performed 28 simple procedures (6 renal biopsies, 17 renal cyst resections, 4 ureterocutaneostomies, 1 foreign body retrieval), 65 difficult operations (47 nephrectomies, 5 nephroureterectomies, 5 nephropexies, 4 ureterolithotomies, 2x ureterolysis). There were also 9 complicated cases (5 heminephrectomies, 2 tumor nephrectomies, 2 dismembered pyeloplasties). Operating time, complications and conversion rate to open surgery mainly depended on the difficulty of the procedure and the personal learning curve, resulting in 50-90 min, 0% and 3.8%, respectively, for an easy retroperitoneoscopy, 90-210 min, 12% and 9.2% respectively for a difficult operation, and 180-390 min, 22% and 11%, respectively, for a very difficult procedure. Excluding the 17 patients with complications or conversion (unclear anatomy, extremely difficult dissection), the mean postoperative need for analgesics was 0.7 vials, and the mean hospital stay was 4.7 days. We have now passed most of our learning curve, and retroperitoneoscopy has become a standardized procedure that is a part of the training program for the experienced urologist.

[Transperitoneal and retroperitoneal laparoscopic nephrectomy in comparison with conventional nephrectomy]. / Transperitoneale und retroperitoneale laparoskopische Nephrektomie im Vergleich zur konventionellen Nephrektomie.

We report on our clinical experience with laparoscopic nephrectomy in 35 patients. We have performed a total of 18 transperitoneal laparoscopic nephrectomies (TLN) for benign renal disease. After the introduction of a hydraulic dissecting device, we have since performed 17 retroperitoneal laparoscopic nephrectomies (RLN). These data were compared with those in 19 consecutive open nephrectomies (N). All groups were comparable in terms of indication. The mean operative time for benign disease was 206.5 min for TLN, 211.2 min for RLN and 117 min for N. Analgesic medication requirement per patient was 2 days for TLN, 1 day for RLN and 4 days for N, while the postoperative hospital stay averaged 7 days for TLN, 6 days for RLN and 10 days for N. Our results demonstrate the advantage of a laparoscopic approach over open surgery and also reveal the distinct benefit of a retroperitoneal approach. However, due to the small number of indications this procedure should be restricted to a few urologic centers.

Hydrodynamic assessment of efferent limb valve mechanisms in continent urinary diversion: comparative study on a cadaveric model.

Various valve mechanisms, customarily employed in continent urinary diversion, were constructed from fresh cadaveric porcine bowel for later urodynamic assessment. A total of six different types of valves were formed from ileum or colon in varying lengths and tested by volume pressure trials. The leak point or maximum pressure were recorded at constant perfusion rates of 30 ml/min of the constructed reservoir. Ileal or colonic nipple valves, as well as the embedded or pulled-through ileum, tapered to 12 F at a length of 3 cm, withstood maximum pressures ranging between 75 and 138 cm H2O before leakage or protrusion of the valve occurred. Plicated or tapered terminal ileum in caecal reservoir revealed water leakage at pressures as low as 25 to 40 cm H2O. A newly-developed valve mechanism consisting of a 12 F, plicated colonic-serosal tunnel with a minimum intra-reservoir length of 5 cm resisted maximum pressures of more than 70 cm H2O. Our cadaveric porcine bowel model proved to be reliable for acute volume/pressure trials and correlated with all clinical urodynamic results and animal trials. It is simple, inexpensive and allows scope for individual ideas before commencing with animal trials.

[Depression and suicidal behavior more effectively controlled by a team approach. Pilot project to optimize diagnosis and therapy]. / Depression und Suizidalität vernetzt wirksamer bekämpfen. Pilotprojekt soll Diagnose und Therapie optimieren.

The aim of the competition (Specialist-field Networks in Medicine "MedNet") announced by the Federal Ministry for Education and Research (BMBF) is to stimulate the creation of supraregional networks for specific diseases, in order, in this way, to improve cooperation and the transfer of knowledge between research institutions and various levels of medical care. The MedNet "Depression, Suicidal tendency" is one of the winners of this BMBF competition". In view of the central role played by the family doctor in the care given to patients with depressive disorders, permanent improvement in cooperation between physicians in private practice and the research institutions is a central aspect of the planned MedNet activities.

[Communication on the Internet. Possibilities and risks of the Internet for psychiatry]. / Ubertragung im Internet. Anwendungsmöglichkeiten und Risiken des Internet für die Psychiatrie.

The article is preceded by an introduction to world-wide communication networks. Some important basic features are explained. The major impact is on temporary and future aspects of the Internet for psychiatry. A variety of advantages in World Wide Web telemedicine for patients, clients, psychotherapists, clinicians and scientists are extensively demonstrated. Useful and established possibilities are discussed. Finally, the risks of this kind of communication are shown and listed.

[Psychiatry and psychotherapy on the internet. Current overview]. / Psychiatrie und Psychotherapie im Internet. Eine aktuelle Ubersicht.

The Internet is a fast growing medium, which is about to alter our all day life. Most impact is given to advantages of telemedicine to psychiatrists and psychotherapists as well as patients. After introduction of the essential features of the Internet practical aspects of medicine in Cyberspace for psychotherapists, psychiatrists and their patients are shown. Then, the general prohibition of advertisement for physicians is discussed on the bases of actual laws related to Internet activities. Relevant resources of medical information are shown with regard to the detailed facilities of using search engines. Highlighting opportunities and possible resources of medicine in cyberspace, it is made clear, that the rising interest in telemedicine on Internet is more than justified. Finally, some risks of virtual communication are visible. Important and mentioned Web-sites are listed at the end.