Telemedicine Has a Social Impact: An Italian National Study for the Evaluation of the Cost-Opportunity for Patients and Caregivers and the Measurement of Carbon Emission Savings.

Background: Owing to COVID-19, all stakeholders have recognized the advantages of telehealth and they were available for its permanent implementation, both from the normative and economic point of view. It is, therefore, necessary to understand what were the real benefits created in society through telehealth. Objective: Develop a method to identify a social impact of telemedicine in Italy, considering the reduction on the patient moves with a consequent travel cost, time (opportunity costs), and carbon emission savings. Methods: Since March 2020, we have conducted a quality improvement study in 17 centers, collecting sociodemographic variables. To assess the social impact, we transform the data into outcome measures. The protocol used "Telemedicina Subito" allows the rapid implementation of telemedicine, using operating manual, structured according Health Technology Assessment approach. Results: We collected data related to 2,091 televisits, analyzing three different perspectives. First, one patient with a televisit had a saving equal to the median of EUR 97.16 (interquartile range [IQR]: 64.29-159.69), USD 113.88; considering that the median cost for the visit in presence was EUR 105.91 (p-value <0.05) and after the use of telehealth had a median of EUR 0 (mean: EUR 14.70; p-value <0.05). Second, informal caregivers have a median savings of EUR 65.06 (IQR: 55.52-89.21), USD 76.26. Finally, for one single telemedicine visits we can contribute with a median carbon emission savings of ∼13 kg (IQR: 6-24). Conclusions: The evaluation of the social impact on telemedicine facilitated the creation of an important framework for decision-makers.

The COVID-19 Pandemic as an Opportunity to Improve Health Care Through a Nurse-Coordinated Multidisciplinary Model in a Headache Specialist Center: The Implementation of a Telemedicine Protocol.

Background: Due to coronavirus disease-19 (COVID-19) pandemic, Italian outpatient clinics were suspended in March-April 2020 and subsequently slowed down. Telemedicine was shown to be useful in headache clinics, despite absence of a detailed protocol for its development. Objective: To describe the implementation of a structured telemedicine protocol during COVID-19 pandemic. Materials and Methods: Since May 2020, we performed a quality improvement study in a Headache Specialist Center in central Italy. We involved patients who had in-person follow-up visits scheduled during suspension and initial reopening of clinics. Patients had two appointments with a nurse specialized in headache care and a headache physician, respectively, using Microsoft Teams®. The service is still active. We collected sociodemographic and clinical characteristics of patients, technical details of telemedicine visits, patient feedback, medical judgment about complexity of clinical decisions, and need for in-person re-evaluation. We also performed a Strengths-Weaknesses-Opportunities-Threats analysis to provide a realistic picture of the service. Results: We performed 207 telemedicine visits involving 100 patients with a median age of 44 (interquartile range [IQR]: 35-56) years; 76.0% were women and lived at a median of 68 (IQR: 24-109) km from the Center. Thirty-nine (39.0%) were visited for migraine without aura. Patients mostly used a computer (68.1% visits) with high audio-video quality in 93.2% of visits. First and second appointments lasted in median 20 (IQR: 14-25) minutes and 9 (IQR: 7-13) minutes, respectively. Interacting with patients was very easy in 66.7% of visits. Patients reported no difficulty in sharing documents and high satisfaction in 78.6% and 93.5% of visits, respectively. Perceived complexity of clinical decisions was generally low (86.5%), whereas 8.2% of cases required in-person re-evaluation. Conclusions: Telemedicine facilitated follow-ups, ensuring multidisciplinary care and high patient satisfaction, justifying its wider adoption in headache care.

Redeployment of specialist surgeons in the COVID-19 pandemic in a general hospital: critical issues and suggestions.

BACKGROUND AND AIM: to gain experience and highlight any margins for improvement, we outlined the role played by specialist surgeons (with particular reference to orthopedic surgeons), redeployed in treating COVID-19 patients in the Emergency Department of a general hospital, with severe overcrowding due to the massive and continuous arrival of patients Methods: "on the field" experience of the Authors is reported, followed by a narrative review of the literature, mainly on the topic of health-personnel redeployment during an emergency Results: a brief chronological discussion of the progressive reorganization of the hospital, in relation to the progress of the epidemic in the area, is reported, with specific reference to the experience of orthopedic and other branches specialist surgeons, that was characterized by a high degree of uncertainty about what to do, worsened by organizational difficulties due to the incessant arrival of patients and subsequent overcrowding. Observations relating to the critical aspects that have emerged and the various solutions proposed or implemented, if they have been identified, as well as the problems still open, are then made and compared to current literature. CONCLUSIONS: The most significant aspect that we have tried to outline is the organizational difficulty, due to the rapid and unpredictable change in the situation: greater efficiency and flexibility, seen as the ability to overcome bureaucratic, logistical, regulatory or budgetary obstacles that prevent the rapid changes made necessary by the epidemic, could perhaps help to face better any subsequent pandemic wave, like the fierce one ongoing at the present moment.

Residual interfragmentary gap after intramedullary nailing of fragility fractures of the humeral diaphysis: short and midterm term results.

The purpose of this retrospective study was to evaluate the short and midterm radiological outcome with regards to bone healing, correlated with humeral shaft fractures treated with anterograde intramedullary nailing, when interfragmentary gap was significant. Here, we critically review our experience of short and midterm term results in over 65 year-old patients. Inclusion criteria in the study were: (1) patients over 65 years old (2) patients with displaced humeral mid shaft fractures (AO/OTA 12 A B C type fractures); (3) patients treated with closed reduction and internal fixation with intramedullary nail (Trigen Humeral Nail® Smith and Nephew) with at least two screws for proximal locking and one screw for distal locking; (4) residual interfragmentary gap, being considered significant any gap >6 mm (being 7 mm the minimum nail diameter available in our facility). Various factors were considered in our analysis: the size of the interfragmentary gap in both projections (also the mean of the measured gaps was calculated), the relationship between the greater and the mean interfragmentary gap and the second diameter measurement of the nail in the half distal part, the number of the screws in distal locking procedure, the use of a reaming procedure or not, the AO classification, the actual age at the time of surgery, the operating time, the nail second diameter as described before and its ratio with the measured residual gap. At 3 months follow-up, 4 patients showed radiographic healing (26,67%), 9 patients showed a visible callus (60%), with a total of 13 patients (86,67%) showing signs of normal recovery, the remaining 2 patient had insufficient callus formation (13,3%). At 6 months follow-up, 1 patient was missing (6,67%), although radiographic healing was already evident during the previous follow-up check, another one showed incomplete callus formation, the remaining 13 patients showed radiographic healing (86,67%), with a total of 14 patient considered healed at 6 months follow-up (93,33%). In conclusion, osteosynthesis with anterograde nail in geriatric patients appears to be a quite safe approach despite a great interfragmentary gap. After 6 months of treatment, callus formation and the overall clinical outcome were proven to be above satisfaction. (www.actabiomedica.it).

Preliminary report of the characteristics of the upper thigh spur area of the femoral neck in Garden I and II subcapital fractures.

The "heart" of the calcar is the internal cortical septum called "femoral thigh spur". Nevertheless, the integrity of the femoral thigh spur and its extensions in Garden I and II  femoral neck fractures has not been examined in depth, in CT scan-based studies. The aim of this retrospective study is to analyze characteristics as integrity of upper thigh spur area of the intra-capsular femoral neck using precise CT scans, as well as features of the medial cortical bone interruption of orthopedic calcar, in femoral fractures that are radiographically defined as Garden type I-II.A total number of 23 patients was finally included in our study. We called it the "upper thigh spur area" the area around a 360 degree perimeter of the upper thigh spur. The above-mentioned area is a cylindrical intracapsular structure oriented parallel to the intertrocanteric line of the proximal femur . We analyzed the modification of the cortical bone in this specific intra-capsular area of the femoral neck. In all the cases the upper thigh spur area (the internal cortical septum) was intact. The medial cortical (the known "orthopedic calcar") was evaluated by CT scans in coronal views; it was found to be interrupted in 14 patients and intact in 9; among patients of the first group, 50% were classified as Garden I and 50% as Garden II. The cortical integrity on 360° of the upper thigh spur area was evaluated by CT scans in axial views through different cuts, and it was found to be intact in all cases. More extended studies including CT scans of Garden I-II-III and IV fractures are needed so as to obtain more complete results. In conclusion, it seems that the integrity of the upper thigh spur zone is associated with stable fractures.

Early-stage radiological critical analysis of unsuccessful cases following a four-part fracture osteosynthesis of the proximal humerus: focus on the "P" sign.

Radiological evaluation of complex intra-articular fractures of the proximal humerus is still challenging. Here, we describe the post-operative "P" sign as a reproducible radiographical mark of a varus reduction, performed by assembling a head-shaft angulation of less than 130 degrees. Our retrospective study was conducted in a group of subjects who previously suffered from proximal humerus four-part fractures. We evaluated the post-operative evolution of specific radiographical parameters that are of crucial prognostic significance: Cervix-diaphysis angle (HHSA), quality level of the orthopaedic reduction (insufficient, sufficient and good) based on a radiological generalized subjective overview, presence of calcar screws through the Philos plate. The final cohort included a group of 39 patients of 70.76 ± 8.3 years of age and an average follow-up of 7.2 months. The post-operative mean HHSA was 131.5 ± 9.4. Interestingly, a positive correlation was detected between presence of the radiographical "P" sign in the post-operative period and the number of surgical complications coming up in the post-operative period (OR:  3.68 - I.C. 95%: 0.7984255-19.2532430), although not statistically significant. In our study, the high number of complications corresponds to literature database. Presence of the "P" sign could be a useful tool for assessing the quality of reduction during intra and post-operative radiological evaluation. We  underline the importance of the "P" sign as a "quality of reduction" factor and strongly recommend its intra-operative monitoring as an additional tool together with a standard subjective evaluation of the reduction.

A rare combined injury of dorsal fracture-dislocation of four carpometacarpal joints and trapezium, trapezoid and distal radius bone fractures.

Incorrect or delayed diagnosis and treatment of the carpometacarpal fracture-dislocations is often associated with poor prognosis. We present a rare case of unusual pattern of injury, involving dorsal dislocation of four ulnar carpometacarpal joints, associated with fracture of the trapezium, a burst fracture of the trapezoid  bone and an extra-articular fracture of the third distal  of the radius. The first surgical intervention was followed by unsatisfactory results, confirmed by the CT scans. A second surgery followed and an open reduction and pinning with K wires performed. Post-operative follow up lasting for nine months revealed a very good surgical outcome.

Surgical treatment of partial anterior cruciate ligament lesions: medium-term results.

PURPOSE: this study was conducted to evaluate subjective and objective clinical outcomes of partial reconstruction of the anterior cruciate ligament (ACL) in comparison with complete ACL reconstruction. METHODS: three groups, each comprising 20 patients, were evaluated at a minimum follow-up of 12 months. The group 1 patients underwent partial ACL reconstruction, while those in group 2 and group 3 underwent complete ACL reconstruction, performed using either bone-patellar tendon-bone (BPTB) or quadrupled hamstring tendon (HT) grafts, respectively. The subjective outcome was evaluated using the Lysholm knee scale and the subjective International Knee Documentation Committee (IKDC) scoring system. A visual analog scale (VAS) was used for pain assessment and sporting activity was rated using the Tegner activity scale. Objective evaluation was performed using the IKDC objective form, KT-1000 arthrometer and KiRA triaxial accelerometer. RESULTS: at the follow-up evaluation, the mean subjective IKDC score was 86.1±10.3 in group 1, 85.2±11.1 in group 2, and 82.7±7.8 in group 3. The Lysholm score was 91.3±7.3 in group 1, 91.7±9.6 in group 2, and 89.4±6.1 in group 3. KT-1000 tests showed a mean side-to-side difference of 1.1 mm ± 1.5 mm (range, 0-5 mm) in group 1; 0.79 mm ± 0.8 mm (range, 0-2mm) in group 2; and 1.45 mm ± 1 mm (range, 0-3 mm) in group 3. The differences between groups were not statistically significant. CONCLUSIONS: both subjective and objective outcomes of partial ACL reconstruction were comparable to those of complete reconstruction, but partial reconstruction in the presence of a partial lesion of the ACL is considered by the authors to be more respectful of the native vascularization, innervation and anatomy of the ACL, conferring an advantage in terms of recovery of the complete function of the knee. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The integration environment of the hospitals of H:S in Copenhagen.

This paper highlights the scenario implemented by the hospitals of the Copenhagen Hospital Corporation (H:S), for allowing the integration and interoperability of legacy and new systems, based on the establishing of a common and open information asset according to the CEN HISA standard and on top of the DHE middleware.