Milan Group Research Articles

Psicoterapia, psicoanalisi e psichiatria nei primi anni 1960. Appunti per una storia

Pier Francesco Galli descrive alcuni sviluppi della psicoterapia, della psicoanalisi e della psichiatria in Italia nei primi anni 1960, in particolare riguardo al progetto culturale del Gruppo Milanese per lo Sviluppo della Psicoterapia da lui fondato (che nel 1978 prenderŕ il nome di Psicoterapia e Scienze Umane). Vengono discussi, tra gli altri, i seguenti temi: l'inserimento di nuove tecnologie e discipline (come la psicologia e la sociologia) nella cultura italiana del dopoguerra, il ruolo degli intellettuali, la formazione alle professioni di aiuto e la diffusione della psicoanalisi, il lavoro di équipe nei servizi psichiatrici, il ruolo delle case editrici, i corsi di aggiornamento organizzati a partire dal 1962, la cultura della psichiatria descrittiva importata nei primi anni 1980 dagli Stati Uniti col DSM-III, la aziendalizzazione della Sanitŕ, e cosě via.

Positioning Oneself Within an Epistemology: Refining Our Thinking About Integrative Approaches

Integrative approaches seem to be paramount in the current climate of family therapy and other psychotherapies. However, integration between and among theories and practices can only occur within a specific epistemology. This article makes a distinction between three different epistemologies: individualizing, systems, and poststructural. It then makes the argument that one can integrate theories within epistemologies and one can adopt practices and some theoretical concepts across theories and across epistemologies, but that it is impossible to integrate theories across epistemologies. It further states that although social constructionism has influenced much of contemporary psychological thinking, because of the divergence between a structural and a poststructural approach, constructionism looks different depending upon one's epistemological stance. Examples of integration within epistemologies and of what looks like integration across epistemologies (but is not) further illustrate these important distinctions. The conclusions reached here are crucial to our philosophical considerations, our pedagogical assumptions, and implications for both research and a reflexive clinical practice.

Karl Tomm: His Changing Views on Family Therapy Over 35 Years

Karl Tomm has been the director of the Family Therapy Program in Calgary for more than 35 years. He has developed an international reputation not only as a family therapist, major innovator, theoretician, and trainer of family therapists but also as a leader in facilitating dialogues among many of the world's family therapists. He started his career applying the problem solving approach to family therapy, developed by Nathan Epstein (Part I). In the 1980s, Karl championed the work of the Milan Group (Part II). More recently, Karl has promoted the work of Michael White and David Epston in narrative therapy (Part III). Don Collins recently had the opportunity and pleasure to interview Karl about the evolution of his thinking and practice over the span of his career.

Tracce: La psicoanalisi e l'istituzione psicoanalitica in Italia. Carlo Viganň intervista Pier Francesco Galli

- Carlo Viganň interviews Pier Francesco Galli on the history of psychotherapy and psychoanalysis in Italy in the 1950s and 1960s. Pier Francesco Galli mentions the quarterly journal Psicoterapia e Scienze Umane ("Psychotherapy, Humanities, and Social Sciences") founded by him in 1967 within the Milan Group for the Advancement of Psychotherapy, and the relationship with the Italian Psychoanalytic Association (SPI). One of the aims of this group was the fostering of psychoanalytic education in Italy, also because at the time the Universities were not equipped for this task. Among other things, since the early 1960s Pier Francesco Galli organized continuing education courses in Milan held by colleagues from the United States and Europe, and founded the book series of Feltrinelli publisher of Milan (87 volumes), and of Bollati Boringhieri publisher of Turin (about 350 volumes). [KEY WORDS: Psicoterapia e Scienze Umane, history of psychotherapy in Italy, psychoanalytic institutions, history of psychoanalysis in Italy, psychoanalytic education]

The Chicken and the Egg

In this issue, Grassi et al1 describe an elegant study in which they measured sympathetic nerve traffic by microneurography in 17 untreated hypertensive subjects with left ventricular (LV) diastolic dysfunction but without LV hypertrophy. The control groups were 20 age-matched normotensive subjects and 20 subjects with hypertension but without LV diastolic dysfunction. Microneurography is a technique in which a microelectrode is inserted into the peroneal nerve posterior to the head of the fibula and is a method of quantifying sympathetic nerve activity, which the Milan group has used to produce some outstanding research in the past. The main finding in this study was that muscle sympathetic nerve traffic was greater in the 2 hypertensive groups than in the normotensive group. In addition, if they compared hypertensive subjects with the same degree of BP elevation, there was a greater increase in sympathetic nerve traffic in those with than in those without LV diastolic dysfunction. They conclude that, “The results of the present study document for the first time that, in essential hypertensive patients, the presence of left ventricular diastolic dysfunction enhances the already elevated …

Liver Transplantation for Hepatocellular Carcinoma: Results of Down-Staging in Patients Initially Outside the Milan Selection Criteria

Conventional criteria for liver transplantation for patients with hepatocellular carcinoma are single HCC <or= 5 cm or less than or equal to three HCCs <or= 3 cm. We prospectively evaluated the possibility of slightly extending these criteria in a down-staging protocol, which included patients initially outside conventional criteria: single HCC 5-6 cm or two HCCs <or= 5 cm or less than six HCCs <or= 4 cm and sum diameter <or= 12 cm, but within Milan criteria in the active tumors after the down-staging procedures. The outcome of patients down-staged was compared to that of Milan criteria after liver transplantation and since the first evaluation according to an intention-to-treat principle. From 2003 to 2006, 177 patients with HCC were considered for transplantation: the transplantation rate was comparable between the Milan and down-staging groups: 88/129 cases (68%) versus 32/48 cases (67%), respectively. At a median follow-up of 2.5 years after transplantation, the 1 and 3 years' disease-free survival rates were comparable: 80% and 71% in the Milan group versus 78% and 71% in the down-staging. The actuarial intention-to-treat survival was 27/48 patients (56.3%) in the down-staging and 81/129 cases (62.8%) in the Milan group, p = n.s. The proposed down-staging criteria provide a comparable outcome to the conventional criteria.

A Cephalometric Intercenter Comparison of Patients with Unilateral Cleft Lip and Palate: Analysis at 5 and 10 Years of Age and Long Term

To compare the short- and long-term craniofacial growth of patients operated with the Milan protocol to those operated with the Oslo protocol. The Milan sample included 88 patients with unilateral cleft lip and palate (UCLP) at 5 years, 26 at 10 years, and 23 at the end of growth. The Oslo samples included 48 UCLP patients at 5 years, 29 at 10, and 23 at growth completion. Lateral cephalograms were used for comparison. An unpaired t test was run for the 5- and 10-year-old samples. The samples long term were matched for age and sex, and a paired t test was run. There was no significant cephalometric difference in the maxillary prominence at 5 years, a mild but significant difference at 10 years, and again no difference at the end of growth. Nevertheless, at an older age, the need for orthognathic surgery was larger in the Milan sample (26%) than in the Oslo sample (13%). Although no statistically significant differences in the cephalometric measurements were found long term, the need for orthognathic surgery was clinically judged to be larger in the Milan sample. On the other hand, although the Milan protocol seemed to require more final jaw surgery, only the cases that needed an additional orthognathic procedure in the Milan group will undertake a third surgical step, while the Oslo protocol included three surgical steps for all the patients.

A cephalometric intercentre comparison of patients with unilateral cleft lip and palate at 5 and 10 years of age

The aim of this study was to evaluate any differences between the craniofacial growth of unilateral cleft lip and palate (UCLP) patients who underwent surgery in the Milan CLP centre with those from the Oslo CLP centre at 5 and 10 years of age. The Milan sample comprised 88 UCLP patients (60 males, 28 females) at 5 years of age and 26 patients (17 males, 9 females) at 10 years of age all operated on by the same surgeon. The Oslo sample consisted of 48 UCLP patients (26 males, 22 females) aged 5 years and 29 patients (20 males, 9 females) aged 10 years treated by four different surgeons. Lateral cephalometric radiographs obtained for both samples were analysed and angular measurements and ratios were calculated both for the hard and soft tissues. Statistical analysis was undertaken with an unpaired t-test. At 5 years of age, there were neither sagittal nor vertical hard tissue differences between the two groups. With regard to the soft tissues, only the naso-labial angle showed a statistically significant difference (Milan greater than Oslo by 5 degrees, P < 0.01). At 10 years of age, both SNA and ANB differences were larger in the Oslo group than in the Milan group, >2.6 degrees, P < 0.01 and >2.9 degrees, P < 0.001, respectively. At 5 years of age, the Milan UCLP sample had the same maxillary protrusion as the Oslo group, while at 10 years of age, the Milan sample were slightly less protruded than the Oslo group.

Cost Analysis of Tumor Downsizing for Hepatocellular Carcinoma Liver Transplant Candidates

We report the results of a prospective, intent-to-treat (ITT) trial on the costs of selective tumor downsizing (DS) before liver transplantation (LT) for patients affected with hepatocellular carcinoma (HCC). The trial started in January 1997 including adult patients with nodular-type HCC within and beyond the Milan criteria. Patients were downsized with transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI) and/or radiofrequency ablation (RFA) according to clinical predictors. TACE and RFA were performed as inpatient procedures, while PEI was performed on an outpatient basis. Costs of DS were obtained according to the Tuscany Health Reimbursement Fee Catalog adjusted to yearly inflation rates from 1997 through 2005. Data analysis was performed at 1 year after the last enrollment of 198 patients, including 161 (81.3%) who were transplanted: 34 (17.2%) dropped out and 3 (1.5%) were still on the waiting list. One hundred and fifty-two patients (76.7%) underwent DS for a total of 201 procedures: 159 TACE, 39 PEI, and 3 RFA. Overall costs in Euros (€) of waitlisting were 861,801.24€: 548,460€ (63.7%) for pretransplantation evaluation; 197,994.84€ (22.9%) for control visits and hospitalizations; and 115.346.4€ (13.4%) for DS. Mean costs of DS were 758.58€ ± 270€ per downstaged patient (747.53€ ± 257.1€ Milan; 774.01€ ± 287.71€ non-Milan); 582.85€ ± 398.87€ per waitlisted patient (520.28€ ± 406.23€ Milan; 520.28 ± 364.48€ non-Milan); and 716.4€ per transplanted patient (580.67€ Milan; 1026.76€ non-Milan; +76.8%). A selective policy of tumor DS increased the costs of LT waitlisting by 13.4%, but due to higher dropout rates among non-Milan patients, the cost utility of DS was 76.8% higher in the Milan group.

Reflecting Teams and Microcounseling in Beginning Counselor Training: Practice in Collaboration

This study examined the integration of the Reflecting Team Method (T. Andersen, 1991) and the Microcounseling Model (A. E. Ivey &amp; M. B. Ivey, 2003) as a collaborative counselor training option. Reflecting team reflections, client–counselor role plays, and feedback from master's‐level students were transcribed and analyzed for themes; 10 themes were identified.

Gadolinium dosimetry, a problematic issue in the neutron capture therapy. Comparison between experiments and computational simulations.

In GdNCT the interested isotope is 157Gd that captures neutrons with (n, ) reaction and also emits internal conversion and Auger electrons. These electrons have an important effect on DNA strands, mainly due to the property of gadolinium to link to DNA. The emitted gamma rays partially interacts with tumours but mainly diffuse in the body damaging healthy tissues. Therefore in the study of Gd therapeutical effect both dosimetric and microdosimetric analyses must be performed. At Pisa University, in the last years some works were performed by NCT group. At the present these researches are continued on these topics carrying out also a PhD thesis. In this frame some simulations, using MC code, were performed in order to evaluate the dose distribution due to Gd reactions. It is however necessary to calibrate the calculations on experimental results, though they are scarce in GdNCT. Some experiments with 157Gd were performed by Milan group using gel dosimetry [1, 2, 3]. Therefore some computational comparisons were done. In these article the results of this comparisons are shown and discussed.

An early peak of relapse after surgery for breast cancer

There is great interest among oncologists concerning what we might learn by examining the pattern of relapse after breast cancer surgery. What you see depends upon how hard you look. Up to now, investigators have examined the hazard ratio for relapse every 6–12 months. In a research paper, published in this issue of Breast Cancer Research, the Milan group have looked at the hazard ratio every three months and have found, for the first time, a distinct, very early peak of relapse in a group of premenopausal, node-positive patients not given chemotherapy or hormone therapy. What is now needed is for other groups to repeat this observation and, if found, to examine the characteristics of the tumours producing this phenomenon in order to develop hypotheses about its cause and possible treatments.

Neoadjuvant Chemotherapy of Breast Cancer

The use of neoadjuvant chemotherapy in the treatment of breast cancer has been evolving during the past two decades. Fisher's group accomplished the scientific rationale in mouse models in the 1970s. The Milan group was the first to use neoadjuvant therapy in locally advanced breast cancer and also determined that adjuvant sequential doxorubicin with cyclophosphamide/methotrexate/fluorouracil (CMF) offered improved survival when compared to alternating CMF with doxorubicin. Other groups (M. D. Anderson and NSABP) have evaluated similar doxorubicin-based neoadjuvant therapies in locally advanced breast cancer (LABC) and in early disease. These studies have shown an increase in breast-conserving therapy (BCT) and an increase in pathologic complete response (pCR) when neoadjuvant therapy was used. Due to anthracycline resistance, taxanes were added to the doxorubicin-based neoadjuvant chemotherapy regimen with an increase in BCT and pCR than when an anthracycline regimen was used alone. Overall survival has yet to be determined when comparing an anthracycline-based regimen to the same regimen with the addition of a sequential taxane. Therefore, a combined treatment of an anthracycline/cyclophosphamide/taxane regimen is the recommended neoadjuvant chemotherapy for patients with breast cancer.

Screening for lung cancer

With the development of newer forms of technology such as low-dose spiral computed tomography, there has been a resurgent interest in screening for lung cancer. The purpose of this review is to highlight recent advances in screening for lung cancer. Articles published since September 2002 are reviewed here. More frequent screenings (every 4 or 6 months) showed increased mortality from lung cancer, compared with annual screening. A mass screening conducted in 1990 was effective in a case-control study. The results of lung cancer screening by low-dose spiral computed tomography were reported from the Milan group and the Mayo Clinic. Computed tomography depicted peripheral early lung cancer, especially adenocarcinoma. These results are consistent with previous reports from other groups. Screening with imaging becomes more sensitive with automated computerized methods. A high percentage of stage IA lung cancers were detected by screening with low-dose helical computed tomography. The characteristics of the nodules detected by low-dose spiral computed tomography have been clarified. There have been many controversial discussions about cost effectiveness and overdiagnosis. There is still no evidence that screening tests reduce the rate of cancer-specific mortality. Several studies of screening for lung cancer are under way.

High dose sequential (HDS) followed by autologous bone marrow transplantation (ABMT) as salvage treatment in advanced Hodgkin’s disease (HD)

ABMT has been proposed as a salvage treatment of resistant/refractory HD. HDS using Cy 7g/m2 for debulking and PBPC mobilization followed by MTX 8g/m2 and then VP-16 2g/m2 before ABMT, described by Milan group, seems to be effective in these patients. We report the results obtained using this procedure in 31 patients with HD who failed conventional therapy or relapsed within 24 months of conventional chemo +/−radiotherapy. Patients were treated with HDS followed by ABMT receiving BEAM (BCNU, Etoposide, Ara-C and Melphalan) as conditioning regimen. The median age was 25 years (12–61), 20 male (64,5%) and 11 female (35,5%). The histology at diagnosis showed: 19 (61,3%) nodular sclerosis; 9 (29%) mixed cellularity; 2 (6,5%) lymphocyte-depleted and 1 (3,2%) lymphocyte-rich HD. Bulky disease was presented in 15/31 (49%) patients and 6/31 (20%) had bone marrow infiltration. The Overall survival (OS) and disease free survival (DFS) were 49% (n = 31) and 60% (n = 15), respectively, in 1825 days. The OS was 62% for patients with 0–1 prognostic factors at diagnosis and a shorter OS was observed in patients with more than 2 prognostic factors (P = 0.004). Bulky disease, histology type and bone marrow involvement did not correlate with poor outcome. Fifteen patients died, 8/15 due to progressive disease (53%), 5/15 due to toxicity after the HDS (33%) and 2/15 due to toxicity after ABMT (13%). Status presens for alive patients after a median time of 783 days (range 50–1929) from transplant is: CR 11 (35,5%), partial response 2 (6,5%) and 4 in progressive disease (12,9%). We conclude that HDS followed by ABMT is an effective salvage regimen for patients with resistant/refractory Hodgkin’s disease and probably induces a long and stable CR mainly in chemosensitive patients. Patients presenting >2 prognostic factors at diagnosis presented worst outcome.

Sirolimus-based immunosuppression for liver transplantation in the presence of extended criteria for hepatocellular carcinoma.

An increasing number of patients with hepatocellular carcinoma (HCC) are undergoing evaluation for listing for liver transplantation. Criteria for selection require ongoing review for suitability. A consecutive series of 40 patients with HCC within the standard Milan criteria (single tumors n = 19 < 5 cm, or up to 3 tumors < 3 cm) and beyond (Extended Criteria; single tumors n = 21 < 7.5 cm, multiple tumors < 5 cm) underwent liver transplant with a sirolimus-based immunosuppressive protocol designed to minimize exposure to calcineurin inhibitors and steroids. At 44.3 +/- 19.3 months (mean +/- standard deviation) follow-up, 1- and 4-year survivals (Kaplan-Meier) are 94.1 +/- 5.7% and 87.4 +/- 9.3%, in the Milan group, respectively, and 90.5 +/- 6.4% and 82.9 +/- 9.3% in the Extended Criteria group, respectively. Five patients died during follow-up, only 1 from recurrent HCC. Five tumor recurrences have occurred at median 17 (mean 22 +/- 17) months posttransplant, 1 in the Milan group and 4 in the Extended Criteria group. Median survival in the patients with recurrent tumor is 42 months (mean 45 +/- 25), and the median postrecurrence survival is 15.5 months (mean 23 +/- 16). The rate of patients who were alive and free of tumor at 1 and 4 years is 94.1 +/- 5.7% and 81.1 +/- 9.9%, respectively, in the Milan group and is 90.5 +/- 6.4% and 76.8 +/- 10.5%, respectively, in the Extended Criteria group. Five patients had sirolimus discontinued for toxicity, while 24 of 35 surviving patients have sirolimus monotherapy immunosuppression. In conclusion, the Milan criteria for liver transplantation in the presence of HCC can be carefully extended without compromising outcomes. This sirolimus based immunosuppression protocol appears to have beneficial effects on tumor recurrence and survival with an acceptable rate of rejection and toxicity.

A selective history of the therapy of Hodgkin's disease.

A selective history of the therapy of Hodgkin's disease.

Eighteenth UICC International Cancer Conference June 30–July 5, 2002

The Halstedian concept of total ablation, which held sway for nearly a century, has given way to the Fisherian where the role of surgery is local disease control in a systemic disease. Fisher hypothesises that metastasis occurs early and all patients can be regarded as having metastatic disease at diagnosis, which should then be managed by systemic therapies. Certainly it can be argued that the approach of systemic therapy has been successful as patient survival has definitely improved in the last 20 years. However it is clear that surgery alone can “cure” some patients as long term survivors were seen in the pre-chemotherapy era after treatment by surgery alone. Whereas the surgical emphasis in the past was on maximal removal of tissue, the current philosophy is minimal normal tissue removal with reliance on adujuvant treatment to destroy residual low volume cancer. But can this process go too far? The Milan group showed clearly in an elegant series of controlled trials that getting closer to the tumour carried the penalty of higher local recurrence (in reality continuing growth of cancer left behind), of up to 20% especially if radiotherapy is omitted. These studies and many others in both invasive cancer and DCIS show that careful conservative surgery can produce low levels of local recurrence with reasonable cosmesis. More recently it has emerged that inadequate surgery with consequent high local recurrence rates may have a small but significant effect on survival as demonstrated in the Oxford overview of 2000. If these effects are true for in-breast recurrences they may be even greater for local recurrence in the axilla where there is ready access to systemic dissemination via the lymphatic channels. These concepts suggest that surgeons should be very careful to make sure that the trend for minimal surgery in the axilla in the form of sentinel node biopsy should be carried out to a high standard with due attention to training and learning curves.

History of Family Therapy

In the past few decades various new family therapy theories and their accompanying intervention strategies have been popularized. Their progression into the limelight has been accelerated by the ongoing spread of family therapy to more areas of the universe. Exciting approaches have originated both in and outside of the United States, and much cross pollination has occurred in the recent theoretical entries, just as it did with psychodynamic family therapy in the 1960s and systemic therapy beginning in the 1970s, with much input from the Milan group (see for example: Boscolo, Cecchin, Hoffman & Penn, 1987; Boscolo & Bertrando, 1992; Selvini-Palazzoli, Boscolo, Cecchin & Prata, 1978). Also of great importance has been the narrative therapy approach (White & Epstein, 1990), with much excitement and substance emanating from the Australians. In this article, synopses of the evolution of family therapy in diverse parts of the globe (excluding the U.S.) are presented. These are meant to be illustrative of the larger scene. The intent is to provide a more universal overview of the field than appears in the histories of family therapy in the United States. The field now exhibits a multihued patchwork quilt of many different, though interconnected, philosophic and theoretical schools of thought that undergird clinical practice and research. The various countries are sequenced alphabetically. Since developments emanating from Australia, Israel (Halpern, 2000), and Italy often have been chronicled elsewhere, less familiar histories from other countries are presented here.

Cryogenic Semiconductor Electronics

The Milan group has centred its activity on cryogenic microelectronics on the use of GaAs MESFET technology. This choice was taken after having found extremely low 1/f noise at 4 K in discrete MESFETs fabricated by NEC and SONY about 20 years ago. Those devices have been discontinued and replaced by equivalent units which nevertheless did not give the same cryogenic performance. A commercial MESFET process has been characterized at cryogenic temperatures, after which FETs and monolithic preamplifier circuits, intended for operation in liquid Helium and liquid Argon, have been designed and fabricated. We will report on our FETs and monolithic preamplifiers which could be of interest for STJ applications. We will briefly review characteristics and results obtained with other technologies which promise new opportunities for the realization of deep cryogenic front-end electronics.