Treatment of Infantile Hemangioma in Regional Hospitals With eHealth Support: Evaluation of Feasibility and Acceptance by Parents and Doctors

Specialists accessing specialty advice: Evaluating utilization, benefits, and impact of care of an e-consultation service

INTRODUCTION

The usual referral pathway is from a primary care provider (PCP) to a specialist; however, specialists also refer to and consult with other specialists. Electronic consultation (eConsult) allows clinicians to submit questions on behalf of patients to specialists to receive timely advice. Most eConsult studies in the past have examined questions asked from PCPs to specialists. This study investigates the utilization of specialists submitting clinical questions to other specialists through the Ontario eConsult Service and identifies use-case scenarios where specialist-to-specialist eConsult may be beneficial.

METHODS

A retrospective, descriptive, cross-sectional analysis of eConsults submitted by specialists through the Ontario eConsult Service for 24 months (March 2019 to February 2021). Utilization data is collected automatically by the service, including specialty referred to, time billed, region, and results from a closeout survey which includes the referral outcome of the eConsult and the utility to the submitting clinician.

RESULTS

4% (n = 3285) of all eConsults sent within the study period were specialist-to-specialist, with the others being sent by a PCP. The number of specialist-to-specialist eConsults grew 120% following the onset of the COVID-19 pandemic. The top three specialties that submitted eConsults were pediatrics, internal medicine, and endocrinology. The top three specialties that specialists submitted to were dermatology, neurology, and hematology. A face-to-face referral was avoided in 69% of referrals.

CONCLUSION

Evaluating the utilization patterns of specialist-to-specialist eConsults allows us to better understand and expand the scope of eConsult services, which have traditionally been thought of as a workflow between a PCP and a specialist.

[Cost and potential savings generated by a paediatrics e-Health web site for parents]

INTRODUCTION

There are few studies on e-Health interventions directed at parents that analyse their costs and any potential savings that may occur. The aims of this study consisted of calculating the costs of the development and maintenance of paediatric web site for parents, including the costs per visit and per visitor, and the potentially savings made as regards medical visits avoided as a result of its use.

METHODS

The technology costs as well as the work of the professionals were considered as costs of the web site. The calculation of the cost of the professionals and the potential savings were based on the official fees and public prices of the Andalusian Public Health Service.

RESULTS

During 5years and 6months of the study, the total cost of the web site was €45,201.56. The cost per visit received was €0.0155€, and €0.0186 for each single visitor. Among the 516 users that took part in the study, face-to-face visits to Primary Care paediatric clinics were avoided, as well as those to Paediatric Emergency Department, at a savings of €22,263.89.

CONCLUSIONS

The costs of developing a paediatric e-Health website for parents written in Spanish, using existing and free technologies, are low compared to other forms of e-Health development. Furthermore, the costs are considerably low if they are divided by the total number of visits or the number of visitors. There is also a considerable potential financial saving on contributing to avoid face-to-face visits.

Teledermatology in paediatrics: Health-care impact on the early treatment of infantile haemangiomas

INTRODUCTION

Teledermatology can solve diagnostic and therapeutic problems in paediatrics, for example in infantile haemangiomas (IHs) requiring early treatment with propranolol. This study aims to assess the impact of teledermatology following its implementation in a health area of Spain, specifically analysing its effectiveness in reducing the age of first propranolol treatment for IH.

METHODS

This was a descriptive study of paediatric teledermatology from 2015 to 2018, studying age, sex, diagnosis, time and mode of resolution. All IHs referred via teledermatology were analysed, and age at propranolol initiation was compared to the period prior to implementation (2008-2014). We also analysed IHs according to referral pathways (teledermatology vs. conventional pathways).

RESULTS

We included 432 consultations (47.7% boys). The main diagnoses were IH, erythematous-desquamative diseases and infections. Concordance in diagnosis between paediatricians and dermatologists was good, and 48.12% of cases consulted via teledermatology were resolved remotely. Response time was 2.81 days on average. Children younger than two months of age showed the highest proportion of in-person visits. In 2015-2018, children with IHs began treatment with propranolol at a mean age of 4.5 months (1.9 months in those referred via teledermatology vs. 5.6 months in those using conventional referral pathways). In 2008-2014, the mean age at referral was 7.1 months. These differences were significant.

DISCUSSION

Teledermatology is a fast and effective tool to resolve paediatric cases, enabling a significant decrease in the age of treatment in infants with IH.

Targeted anti-staphylococcal therapy with endolysins in atopic dermatitis and the effect on steroid use, disease severity and the microbiome: study protocol for a randomized controlled trial (MAAS trial)

BACKGROUND

Atopic dermatitis (AD) is associated with reduced skin microbial diversity and overgrowth of Staphylococcus (S.) aureus. However, the importance of S. aureus colonisation in the complex pathogenesis remains unclear and studies on the effect of anti-staphylococcal therapy in non-infected AD show contradictory results. Long-term interventions against S. aureus might be needed to restore the microbial balance, but carry the risk of bacterial resistance induction. Staphefekt, an engineered bacteriophage endolysin, specifically kills S. aureus leaving other skin commensals unharmed. Bacterial resistance towards endolysins has not been reported, nor is it expected, which allows us to study its effect as long-term anti-staphylococcal treatment in non-infected AD.

METHODS

This is a multi-centre, placebo-controlled, double-blinded and randomized superiority trial with a parallel group design. A total of 100 participants, aged 18 years or older, diagnosed with moderate to severe AD and using a topical corticosteroid in the weeks before enrolment are included in the study. The study is executed in the Erasmus MC University Medical Centre Rotterdam in collaboration with the Havenziekenhuis Rotterdam. After a 2-week run-in period to standardize the corticosteroid use with triamcinolone acetonide 0.1% cream, participants will be randomized to either treatment with Staphefekt in a cetomacrogol-based cream or a placebo for 12 weeks, followed by an 8-week follow-up period. The primary objective is to assess the difference in the need for corticosteroid co-therapy between the Staphefekt and the placebo group, measuring the number of days per week of corticosteroid cream (triamcinolone) use. Secondary outcomes include the difference in use of corticosteroid cream measured in grams, differences in clinical efficacy, quality of life (QoL), microbial composition (includi23ng S. aureus) between the Staphefekt and the placebo group, and the safety and tolerability.

DISCUSSION

The results of this trial will provide data about the effect of long-term anti-staphylococcal therapy with Staphefekt on corticosteroid use, clinical symptoms and QoL in patients with moderate to severe AD. Additional data about growth characteristics of the skin microbiome, including S. aureus, will give insight into the role of the microbiome as a factor in the pathophysiology of AD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02840955 . Registered on 11 July 2016.

The Empirical Foundations of Teledermatology: A Review of the Research Evidence

INTRODUCTION

This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area.

MATERIALS AND METHODS

The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration.

RESULTS

Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health.

CONCLUSIONS

Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.

Propranolol induces regression of hemangioma cells via the down-regulation of the PI3K/Akt/eNOS/VEGF pathway

BACKGROUND

Infantile hemangioma (IH) is a benign vascular neoplasm resulting from the abnormal proliferation of endothelial cells and pericytes in infants. Propranolol, a non-selective β-adrenergic blocker, has recently emerged as an effective therapy for IH, causing regression. However, its potential therapeutic mechanism remains largely unknown.

PROCEDURE

An XPTS-1 cell line was established by isolating hemangioma-derived endothelial cells (HemECs) from a specimen of human proliferating IH. Flow cytometer assay was performed to assess the effect of propranolol on cell cycle distribution. Western blot was employed to determine changes of protein expression. Matrigel invasion and tube formation assays were used to measure invasion ability and tube formation ability, respectively. Commercial kits were employed to quantify NO and VEGF levels.

RESULTS

Propranolol blocked norepinephrine-induced HemECs cell cycle progression as well as the expression of cyclin A2 and cyclin D2; whereas p21 and p27 proteins were altered conversely. Propranolol inhibited norepinephrine-induced cell invasion by reducing the expression of MMP-9, VEGF, and p-cofilin. NO and VEGF release induced by norepinephrine was decreased by propranolol pretreatment, coincident with alterations in the phosphorylation of Akt, eNOS, and VEGFR-2. Tube formation ability and subsequent levels of NO and VEGF elevated by norepinephrine were distinctively counteracted in HemECs.

CONCLUSIONS

The current study demonstrated the antiangiogenic properties of propranolol in vitro and that the drug was able to induce the regression of hemangioma cells via the inhibition of cell cycle progression, invasion, and tube formation, concomitantly with decreased NO and VEGF levels through the down-regulation of the PI3K/Akt/eNOS/VEGF pathway.