Executive summary on the use of telemedicine in the hospital setting: Recommendations from the International Forum on Internal Medicine.

The implementation of telemedicine as another tool for patient care in the hospital setting is a challenge for any healthcare system. Given the difficulties and limitations, the International Forum on Internal Medicine (FIMI, for its initials in Spanish) has sponsored this consensus document with 20 scientific societies from 17 countries in Europe and the Americas. The aim was to propose a general framework that allows for the development and implementation of telemedicine in hospital clinical care that would be useful to FIMI member countries. The document we present includes recommendations from the FIMI in its executive summary that intend to guarantee effective, safe, efficient, sustainable, and proportional healthcare interventions based on the best scientific evidence available. The authors believe that this document must be updated within a maximum period of two years.

Protein-loosing enteropathy in sclerosing mesenteritis.

Sclerosing mesenteritis (SM) is a rare, idiopathic disorder of unknown aetiology that involves the adipose tissue of the mesentery, being characterized by chronic and non-specific fibrous inflammation. Patients usually present with non-specific clinical manifestations, such as abdominal pain and diarrhoea. The diagnosis of SM is difficult and it can be definitely established only by means of surgical or imaging-guided biopsy. Different therapeutic strategies have been used in case series with different rate of success. The disease is generally self-limiting, and the long-term prognosis is good, even if some cases of severe SM are reported in literature. Here, we report a fatal case of sclerosing mesenteritis associated to protein-losing enteropathy.

Impact of long-acting octreotide in patients with early-stage MEN1-related duodeno-pancreatic neuroendocrine tumours.

BACKGROUND: Somatostatin analogues (SSA) represent one of the main therapeutic option in patients affected with functioning well-differentiated neuroendocrine tumours (NETs). There are no studies specifically focusing on NETs associated with Multiple Endocrine Neoplasia type 1 (MEN1). AIM: To evaluate the efficacy of the long-acting SSA octreotide in MEN1 patients with early-stage duodeno-pancreatic NETs. PATIENTS AND METHODS: Forty patients with MEN1 were retrospectively evaluated. Twenty patients with evidence of one or more MEN1-related duodeno-pancreatic NETs < 20 mm in size (age range 26-61 years) were treated with octreotide long-acting octreotide (LAR) as first-line therapy. Treatment duration ranged 12-75 months. At the baseline radiological evaluation, multiple duodeno-pancreatic NETs (range 1-8, size 3-18 mm) were detected. RESULTS: An objective tumour response was observed in 10%, stable disease in 80% and progression of disease in 10% of cases. In six patients with abnormally increased CgA, gastrin and/or insulin serum concentrations, a significant clinical and hormonal response occurred in 100% of cases and was stable along the time. CONCLUSIONS: Therapy with SSA is highly safe and effective in patients with early-stage MEN1 duodeno-pancreatic NETs, resulting in long-time suppression of tumour and hormonal activity and 10% objective response. This suggests to early start therapy with SSA in patients with MEN1-related NETs.

Shortened interval of long-acting octreotide administration is effective in patients with well-differentiated neuroendocrine carcinomas in progression on standard doses.

BACKGROUND: In patients with well-differentiated (WD) neuroendocrine tumors (NET), long-acting octreotide (LAR), conventionally administered at a dose of 30 mg every 28 days, has well-documented anti-secretive but limited antiproliferative effects. AIM: The objective of this study was to evaluate a different schedule of LAR treatment consistent with a shorter interval between administrations (21 days) in WDNET patients with progressive disease at standard-dose interval. SUBJECTS AND METHODS: Twenty-eight patients followed for diagnosis and therapy of WDNET who had tumor progression during therapy with LAR 30 mg every 28 days were enrolled. Clinical, biological, and objective tumor response was evaluated after LAR 30 mg every 21 days. Time to progression was also evaluated after LAR 30 mg every 21 days and compared to LAR 30 mg every 28 days. RESULTS: The treatment with LAR 30 mg every 21 days resulted in complete and partial control of clinical symptoms in 40% and 60% of cases, respectively. Circulating neuroendocrine markers were significantly decreased in 30% of cases. A stabilization of disease was obtained in 93% and objective response in 7%. The median time to progression was significantly longer by using the shortened interval of LAR administration as compared to the standard one (30 vs 9 months, p<0.0001). The treatment was safe and well tolerated. CONCLUSIONS: The shortened schedule of LAR administration was able to re-institute control of clinical symptoms, to decrease level of circulating neuroendocrine markers and to increase time to progression in patients previously escaping from a standard schedule treatment.

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer.

PURPOSE: This study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer. MATERIALS AND METHODS: A retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher's exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen. RESULTS: MR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts. CONCLUSIONS: In patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.

A simplified approach to virtual colonoscopy using different intestinal preparations: preliminary experience with regard to quality, accuracy and patient acceptability.

PURPOSE: The authors assessed the quality, diagnostic accuracy and patient acceptability of computed tomography (CT) colonography performed using a simplified bowel preparation and software for post-processing digital elimination of stool and fluid data from images compared with the examination obtained with conventional preparation. MATERIALS AND METHODS: Two groups of 40 consecutive asymptomatic patients aged between 48 and 72 years underwent CT colonography. In group A, the CT scan was performed with conventional bowel preparation (a full cathartic dose and oral contrast medium to tag any residue in the 3 days preceding the study). In the second group, CT colonography was performed after a reduced bowel preparation, with the oral contrast medium for residue tagging being administered only on the day of the investigation. Examination quality, diagnostic performance and patient acceptability (rated with a self-completed questionnaire) in the two groups of patients were compared by using the McNemar test. RESULTS: No significant difference was obtained with regard to examination quality (180 vs. 165 segments free from stools and fluid, p>0.05) and overall diagnostic accuracy (16/17 colonic polyps detected in group A and 12/13 in group B, p>0.05). The questionnaires revealed a greater acceptability of the reduced bowel preparation compared with the standard procedure (p=0.01). CONCLUSIONS: In asymptomatic patients, the use of software for post-processing digital elimination of residue from images in conjunction with reduced bowel preparation does not reduce examination quality or diagnostic performance when compared with the conventional CT colonography technique and is more acceptable to and better tolerated by the patient.

Screening of pancreaticoduodenal endocrine tumours in patients with MEN 1: multidetector-row computed tomography vs. endoscopic ultrasound.

PURPOSE: The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identification of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1). MATERIALS AND METHODS: Fourteen consecutive patients (eight men and six women, aged 26-54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5-20 MHz) within 7-28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation. RESULTS: MDCT detected a total of 25 PETs (3-18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22, 81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2-18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1). CONCLUSIONS: Our preliminary data indicate that MDCT is complementary to EUS in the identification of PETs in MEN-1 patients.

Inflammatory breast carcinoma and locally advanced breast carcinoma: characterisation with MR imaging.

PURPOSE: This study was done to identify the typical magnetic resonance (MR) imaging findings of inflammatory breast carcinoma (IBC) in comparison with noninflammatory locally advanced breast carcinoma (LABC). MATERIALS AND METHODS: MR images of 30 patients with IBC (T4d) were compared with those of a cohort of 30 patients with LABC (T3/T4a-c). The age distribution was approximately equal in the two groups. MR images were assessed for the following features: skin thickening (>4 mm), skin oedema, architectural distortion, enhancement pattern (mass-like/non-mass-like), time-signal intensity curve (continuous-persistent type/wash-out type), skin enhancement. Fisher's exact text was used to compare MR imaging appearances of IBC and LABC (significant p value <0.05). RESULTS: Skin involvement and enhancement pattern differed between groups: skin thickening was present in 16/30 IBC (53%) vs 8/30 LABC cases (27%, p=0.06), skin oedema was present in 26/30 IBC (87%) vs 8/30 LABC (27%, p < 0.0001), and skin enhancement in 10/30 IBC (33%) vs 2/30 LABC (7%, p=0.02); non-mass-like enhancement was present in 22/30 IBC (73%) vs 12/30 LABC (40%, p=0.02). CONCLUSIONS: IBC is a distinct clinical and pathological entity resulting in typical MR imaging features. Skin changes (thickening, oedema, enhancement) related to neoplastic involvement of the dermal lymphatics are suggestive of IBC and should prompt a skin biopsy to confirm or rule out the diagnosis.