Telemedicine: first steps in a north-eastern Italian region during first year of pandemic

Background

Covid-19 pandemic imposed searching for innovative solutions to ensure safety access to outpatient services. In March 2020 first cases were reported in Friuli Venezia Giulia (FVG) region, in Italy; in April 2020 FVG included teleconsultation in the healthcare offer. This study evaluated in-presence medical consultations (IPCs) delivered in FVG before and after first cases reported in region and correlation between IPCs, teleconsultations and new admissions to Covid-19 wards during pandemic.

Methods

IPCs were analysed dividing in pre (February 1st, 2019-February 29th, 2020) and post (March 1st, 2020-March 31st, 2021) Covid-19 emergency period and comparing mean months values with t-test. IPCs and teleconsultations delivered during emergency (March 1st, 2020-March 31st, 2021) were divided in months and correlated with new admissions to Covid-19 wards in the same period with Pearson test.

Results

IPCs delivered in pre-Covid-19 period compared with post were 1,105,823 vs 973,350 (-12%), peaking in October (98,980 vs 86,821; -12.3%) and minimum in April (82,061 vs 61,523; -25.1%). Pre-Covid-19 mean IPCs were significantly different compared to post (85,063 vs 74,873; p=.003). Focusing on emergency period, IPCs were negatively related to teleconsultations (973,350 vs 2140; r=-.43; p=.13). The negative correlation found between new admissions to Covid-19 wards (9154) and IPCs was weak and not significant (r=-.12; p=.69), while a positive and significant correlation was found between teleconsultations and new admissions to Covid-19 wards (r=.59; p=.03).

Conclusions

Results showed a significant reduction of post-Covid-19 IPCs compared to pre and a significant correlation between teleconsultations and new admissions to Covid-19 wards in FVG during first year of Covid-19 emergency. Contagion containment measures and fear probably influenced access to outpatient services while teleconsultation should be considered as an alternative to face-to-face during pandemic period.

Key messages

A reduction of in-presence medical consultations was found in a north-eastern Italian region during first year of pandemic.

Teleconsultation could be a valid solution in case of increasing Covid-19 hospitalizations.

Value of bone marrow biopsy in Hodgkin lymphoma patients staged by FDG PET: results from the German Hodgkin Study Group trials HD16, HD17, and HD18

Background

Bone marrow (BM) involvement defines advanced-stage Hodgkin lymphoma and thus has impact on the assignment to treatment. Our aim was to evaluate whether the established BM biopsy may be omitted in patients if 18F-fluorodeoxyglucose positron emission tomography (PET) scanning is carried out during staging.

Patients and methods

Our analysis set consisted of 832 Hodgkin lymphoma patients from the German Hodgkin Study Group trials HD16, HD17, and HD18 who underwent both PET scanning and BM biopsy before treatment. All PET studies were centrally reviewed and BM was categorized as showing focal involvement or not.

Results

Taking BM biopsy as reference standard, baseline PET showed a negative predictive value of 99.9% [95% confidence interval (CI) 99.2% to 100%] with true-negative results in 702 of 703 cases. The sensitivity of PET for detecting BM involvement was 95.0% (95% CI 75.1% to 99.9%) as it could identify 19 out of 20 patients with positive BM biopsy. Moreover, PET found 110 additional subjects with focal BM lesions who would have been considered negative by biopsy.

Conclusions

When compared with BM biopsy, PET was able to detect focal BM lesions in a large number of additional patients. This indicates that conventional BM biopsy may substantially underestimate the actual incidence of BM involvement. Given the high negative predictive value, baseline PET scanning can safely be used to exclude BM involvement in Hodgkin lymphoma. BM biopsy should be considered only in such patients in whom PET-detected lesions lead to a change of treatment protocol.

Registered trials

The trials included in this analysis were registered at ClinicalTrials.gov: HD16-NCT00736320, HD17-NCT01356680, and HD18-NCT00515554.

Outcome of patients with primary refractory diffuse large B cell lymphoma after R-CHOP treatment

Primary refractory diffuse large B cell lymphoma (DLBCL) following R-CHOP chemotherapy is a major concern. We identified 1126 patients with DLBCL treated with R-CHOP from 2000 to 2009, of whom 166 (15 %) had primary refractory disease. Of the 75/166 (45 %) who were age <70 years and had been planned for stage-directed curative therapy, 43 (57 %) were primary nonresponders and 32 (43 %) relapsed within 3 months of completing R-CHOP. Thirty of 75 (40 %) patients had serious comorbidity and organ dysfunction precluding intensive treatment and had palliative treatment only. Twelve of 45 (27 %) patients responded to second-line treatment and underwent ASCT. The median overall survival for the 75 patients was 10 months with only seven patients alive without evidence of disease at follow-up ranging from 14 to 106 months. Primary refractory DLBCL after R-CHOP has a very poor outcome with only anecdotal survivors independent of the intended treatment approach.

Observational case-control study of non-invasive ventilation in patients with ARDS

BACKGROUND

The application of non-invasive pressure support ventilation (NIPSV) in patients with acute lung injury or ARDS remains controversial despite recent promising results. Data in rather homogeneous ARDS groups is lacking.

OBJECTIVE

To compare the outcome of NIPSV-treated patients satisfying the diagnostic criteria for primary (pulmonary) ARDS (ARDSp) and presenting without distant organ failures at admission, with those of a matched control group treated in the same ICU with endotracheal mechanical ventilation (ETMV).

METHODS

We applied NIPSV in 12 immunocompetent and collaborative patients who met the above cited criteria. NIPSV failure rate, short-term oxygenation, length of stay, mortality rate and complications were analyzed and compared with a control group of 12 intubated ARDSp-patients matched for age, SAPS II, PaO2/FiO2 and pH at admission.

RESULTS

NIPSV failed in 4 patients developing distant organ failures. Compared to the ETMV control group, NIPSV success patients had reduced cumulative time on ventilation (p = 0.001) and length of ICU stay (p = 0.004). After the first 60' of ventilation, oxygenation improved more in the NIPSV than in the ETMV group (146 +/- 52 mmHg vs 109 +/- 34 mmHg; p = 0.05). The overall ICU mortality rate did not differ significantly between the groups but tended to be higher in the NIPSV group.

CONCLUSIONS

In ARDSp patients without distant organ failures at admission and during the disease course, NIPSV might be a suitable alternative to invasive ventilation; however, the real effects on outcome of NIPSV applied to stable homogeneous subgroups of ARDS patients merit further investigations in randomised studies.

Primary cardiac rhabdomyosarcoma in a cat

A seven-year-old domestic shorthair (DSH) cat was presented with anorexia and dyspnea. Pleural-pericardial effusion was detected with thoracic radiographs and echocardiography. Echocardiography demonstrated a large, soft-tissue mass in the right ventricular wall, protruding both into the pericardial space and into the right ventricle. Postmortem examination findings included a large mass in the right ventricular wall and multiple smaller masses on the external surface of the left ventricle and on the internal surface of the pericardium. Results of the histopathological and immunohistochemical examinations of the masses were consistent with rhabdomyosarcoma. This is the first reported case of primary cardiac rhabdomyosarcoma in the cat.

[Considerations on the establishment of a computer center for use at hyperbaric medicine centers]

The advantages and prospects deriving from the establishment of a special computer centre to serve hyperbaric medicine centres are described. Improved management of hyperbaric chambers, the availability of a data bank, the assistance to medical biological and bio-engineering research are only some of the fundamental benefits to be derived from such a centre.