Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients.

BACKGROUND: e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies. OBJECTIVES: The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients. METHODS: A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed. RESULTS: a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral. CONCLUSIONS: MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

Treatment of osteoid osteoma with CT-guided percutaneous radiofrequency thermoablation.

Osteoid osteoma is a benign bone tumor with a male predominance occurring mainly in children and young adults. The most common symptom is intermittent pain that worsens at night and is at least partially relieved by nonsteroidal anti-inflammatory drugs. The purpose of this study was to assess the long-term effectiveness of computed tomography-guided percutaneous radiofrequency thermoablation in patients with a minimum follow-up of 2 years. Twenty patients with osteoid osteoma (15 men and 5 women) with a mean age of 20.7 years (range, 4-61 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency thermoablation. Lesion sites were the femur (n=9), tibia (n=7), pelvis (n=1), talus (n=1), cuneiform bone (n=1), and humerus (n=1). Mean follow-up was 44 months (range, 3-106 months). Pain relief was significant in 95% of patients; it disappeared within 24 hours in 14 patients, within 3 days in 4, and within 7 days in 1. The patient with persistent symptoms underwent another percutaneous radiofrequency thermoablation procedure that was successful. The difference between pre- and postoperative pain was significant (P ≤ .01). No recurrences occurred. Computed tomography-guided percutaneous radiofrequency thermoablation is a safe, minimally invasive, and economical procedure with high technical and clinical success rates, and it effectively and durably enhances quality of life.

Trans-arterial chemo-embolization (TACE), with either lipiodol (traditional TACE) or drug-eluting microspheres (precision TACE, pTACE) in the treatment of hepatocellular carcinoma: efficacy and safety results from a large mono-institutional analysis.

More data about TACE and pTACE seem necessary to better define the global treatment strategy for HCC. Aim of our analysis was to evaluate the role of TACE, either with lipiodol (traditional) or drug-eluting microspheres in terms of response rate (RR), time to progression (TTP), overall survival (OS) and toxicity in HCC.Patients with HCC undergoing traditional TACE or pTACE (either alone or in combination with other treatment options) were eligibleOne hundred and fifty patients were analyzed. In the global patient population median OS was 46 months for lipiodol TACE and 19 months for pTACE (p < 0.0001), TTP was 30 months versus 16 months for patients receiving TACE or pTACE respectively (p = 0.003). These results were confirmed also among the group of patients who received exclusive TACE or pTACE. Neither RR nor toxicity was different between TACE or pTACE.At multivariate analysis, age, the Okuda stage, type of TACE and number of TACE proved to be independent prognostic factors influencing overall survival.In our experience, lipiodol TACE showed a better OS and TTP over pTACE, without difference in toxicity profile and RR. Among the staging systems analyzed only the Okuda stage seemed able to reliably predict patients outcome.

Long-term outcome of cirrhotic patients with early hepatocellular carcinoma treated with ultrasound-guided percutaneous laser ablation: a retrospective analysis.

PURPOSE: Percutaneous laser ablation (PLA) has been proposed as an active treatment in patients with hepatocellular carcinoma (HCC). However, large multicenter studies using this technique have not been reported. PATIENTS AND METHODS: We retrospectively analyzed treatment and survival parameters of 432 cirrhotic patients with nonsurgical early HCC (single nodule < or = 4 cm or three nodules < or = 3 cm each) who had received PLA in nine Italian centers. RESULTS: Single tumors were seen in 344 (80%) of 432 patients, and two to three nodules were seen in 88 patients (20%), for a total of 548 tumors. An initial complete response after PLA was observed in 338 patients (78%). Median overall survival time was 47 months (95% CI, 41 to 53 months). The 3- and 5-year cumulative survival rates were 61% and 34%, respectively. In multivariate analysis, independent predictors of survival were serum albumin levels more than 3.5 g/dL (P = .002; risk ratio [RR] = 0.580; 95% CI, 0.409 to 0.821), the achievement of a complete tumor ablation (P = .001; RR = 0.517; 95% CI, 0.346 to 0.771), and age less than 73 years (P < .001; RR = 0.466; 95% CI, 0.320 to 0.681). Child-Turcotte-Pugh class A patients had a 5-year cumulative survival rate of 41%; this figure increased up to 60% with a median survival time of 63 months (95% CI, 48 to 78 months) in patients with tumors < or = 2.0 cm. CONCLUSION: This analysis confirms that a complete tumor ablation results in improved survival in patients with nonsurgical HCC. Ideal candidates for PLA are younger patients with normal serum albumin levels and tumor size < or = 2 cm.

Complications of laser ablation for hepatocellular carcinoma: a multicenter study.

PURPOSE: To retrospectively and prospectively determine the rate and type of complications and their association with clinical or technical factors after percutaneous laser ablation (LA) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The institutional research board of each center approved the study and all patients provided informed consent. By using an Internet liver tumor database of nine Italian centers, 520 patients were included with HCC nodules of any size (small, 0-3 cm; intermediate, >3-5 cm; large, >5 cm). Postprocedural complications were related to clinical or percutaneous LA factors by using the Student t and chi(2) tests. Follow-up was carried out with computed tomography (CT) at 1, 3, 6, 9, and 12 months, and primary effectiveness rate was defined as the percentage of HCCs completely ablated after percutaneous LA. RESULTS: A total of 353 men and 147 women (age range, 24-86 years; Child-Pugh score A = 63.4%, B = 30.8%, C = 5.9%) with 647 nodules (mean diameter, 3.2 cm +/- 1.7) were treated by 1004 percutaneous LA sessions. There were four (0.8%) deaths in 520 patients; 15 (1.5%) of 1004 sessions presented major complications without any seeding. Major complications were associated with excess energy (10 520 J +/- 7073 vs 7474 J +/- 3803; P = .001) and high-risk location (P = .05). Sixty-two (6.2%) sessions resulted in minor complications associated with excess energy (P = .001), high bilirubin level (1.74 mg/dL +/- 1.10), and low prothrombin time (P = .01). Primary effectiveness rates were 60% in all HCCs and 81% in HCCs smaller than 3 cm. CONCLUSION: Percutaneous LA may be considered a safe treatment for small HCCs.

[Diagnostic efficiency on digital snapshots of the standard radiology imaging]. / Validità della diagnosi su fotogrammi digitali ottenuti da radiografie convenzionali.

The authors had experienced the telediagnosis on digital snapshots of standard radiology imaging (chest, abdomen, and bones), sent by e-mailing, to support the medical doctors working in remote areas of developing countries. In order to validate the overall procedure, the authors have set up a simulating model and estimated some parameters of accuracy of the diagnosis on digital snapshots against the golden standard of the diagnosis by direct look. The study concerned the standard X-ray tests of one hundred randomly-selected patients out of a hospital archive. Four years later the diagnosis by direct look, the team of radiologists carried out the blind cross check on the digital snapshots of the radiograms and stated their second diagnosis. Sensibility, specificity, predictive value of positives, predictive value of negatives and efficiency of the whole series have been 83.0, 95.1, 96.1, 79.6 and 88.0%. By breaking up the series by apparatus, the skeleton test shows similar data of the whole series. The chest test shows a specificity and predictive value of positives of 100.0%. Although the number of cases is low, the abdomen test apparently shows a sensibility and predictive value of negatives as high as 100%, but a lower specificity and predictive value of negatives (85.7 and 87.5%). Though this data is supportive to the validation of the procedure, even better results are supposedly achieved by increasing the quality of the snapshots and by improving the skills of using the software.