RESUMEN
BACKGROUND AND STUDY AIMS: The aim of this study was to investigate whether telemedicine can help to ensure high-quality endoscopic retrograde cholangiopancreatography (ERCP) in patients living in rural areas. The study was conducted by investigators from two centers: the Karolinska University Hospital, a high-volume center which provided the teleguided support, and the Visby District Hospital, a low-volume center. PATIENTS AND METHODS: From September 2010 to August 2011, 26 ERCP procedures performed at a district hospital were teleguided by an experienced endoscopist at the Karolinska University Hospital. To ensure patient data protection, all communication went through a network (Sjunet) that was separate from the Internet and open only to accredited users. The indications for ERCP were common bile duct stones (n = 12), malignant strictures (n = 12), and benign biliary strictures (n = 2). In 15 cases, this was the patient's first ERCP procedure. RESULTS: The common bile duct was successfully cannulated in all 26 teleguided procedures. The local endoscopist scored the teleguided support as crucial for the successful outcome in 8 /26 cases, as an important factor in 8, and as being of less importance in the remaining 10. In the eight cases where the teleguided support was judged to be crucial, six subsequent percutaneous transhepatic cholangiography procedures and two repeat ERCPs were avoided. The overall cannulation rate at the district hospital improved from 85 % to 99 % after teleguided support was introduced. No procedure-related complications occurred. CONCLUSION: Distant guidance of advanced ERCP procedures in a low-volume center, through teleguided support from a high-volume center, has the potential to improve the quality of care, as reflected in high cannulation rates and the ability to complete the scheduled interventions.
Asunto(s)
Enfermedades de las Vías Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica/normas , Neoplasias del Sistema Digestivo/complicaciones , Hospitales de Bajo Volumen/normas , Servicios de Salud Rural/normas , Telemedicina , Adulto , Anciano , Anciano de 80 o más Años , Ampolla Hepatopancreática , Actitud del Personal de Salud , Enfermedades de las Vías Biliares/diagnóstico por imagen , Enfermedades de las Vías Biliares/etiología , Cateterismo , Colestasis/diagnóstico por imagen , Colestasis/etiología , Colestasis/cirugía , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/etiología , Constricción Patológica/cirugía , Femenino , Cálculos Biliares/diagnóstico por imagen , Cálculos Biliares/cirugía , Humanos , Masculino , Persona de Mediana Edad , Tempo OperativoRESUMEN
OBJECTIVES: Modern guidelines for evaluation of leg ischemia in patients with diabetes and foot ulcer recommend toe blood pressure (TBP) measurements rather than the often unreliable ankle blood pressure (ABP). A drawback with TBP is the complicated measurement procedure, unsuitable the outpatient clinic. The aim of this study was to evaluate the validity of a new automatic TBP device (PresTo, Moor Instruments Ltd) developed for use outside vascular laboratories. DESIGN: Cross-sectional comparative study. METHODS: Twenty-three legs in 16 consecutively included diabetic patients with PAD were examined. TBP was measured three times with 2 min in-between. Three examiners read the obtained graphs (n=69), which were analyzed for variability over time and between examiners. These results were compared with those obtained from an automated TBP device. RESULTS: The mean TBP was 50.9 mm Hg (SD 10.9) when read by examiners compared to 56.4 mm Hg (SD 12.6) when automatically assessed. The 2-min variability was 4.9 mm Hg (SD) for visual readings and 8.1 mm Hg for automatic measurements. The short, long term and examiner dependent variability of visually read TBP ranged from 3.9 to 9.6% of the values. In patients with TBP <45 mm Hg the difference between automatic and visual assessments was small. CONCLUSION: The automatic TBP device is reliable for measuring low pressures and thus for exclusion of critical limb ischemia in patients with diabetes. After algorithm adjustment the device's reliability appears to be acceptable in the entire spectrum of TBP values. TBP appears to have less inter and intraobserver variability than what is reported for ABP.
Asunto(s)
Determinación de la Presión Sanguínea/métodos , Presión Sanguínea , Complicaciones de la Diabetes/diagnóstico , Isquemia/diagnóstico , Flujometría por Láser-Doppler , Pierna/irrigación sanguínea , Dedos del Pie/irrigación sanguínea , Anciano , Algoritmos , Automatización , Velocidad del Flujo Sanguíneo , Determinación de la Presión Sanguínea/instrumentación , Monitores de Presión Sanguínea , Estudios Transversales , Complicaciones de la Diabetes/fisiopatología , Diseño de Equipo , Femenino , Humanos , Isquemia/fisiopatología , Flujometría por Láser-Doppler/instrumentación , Masculino , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Flujo Sanguíneo Regional , Reproducibilidad de los Resultados , Suecia , Factores de TiempoRESUMEN
BACKGROUND: Toe blood pressure is a valuable and often used parameter when lower limb ischaemia is evaluated in patients with diabetes, but little has been done to standardise the method. The aim of this study was to evaluate if the cuff size influences the toe blood pressure values obtained in patients with diabetes. PATIENTS AND METHODS: Eleven patients with diabetes without a history of peripheral vascular disease, and six age matched healthy subjects were investigated. Their blood pressures were measured in the upper arm and at the ankle level repetitively. For measurement of toe blood pressure two different cuff widths were used. RESULTS: All blood pressures were similar in patients and control subjects, as well as over time. The toe blood pressure values were 18 mmHg higher (p < 0.01) if measured with a 2.0-cm compared to a 2.5-cm wide cuff. There was a relationship (r = 0.63, p < 0.05 for patients) between toe circumference and the toe blood pressure value, where smaller hallluxes gave lower values. CONCLUSIONS: The cuff width influences the obtained toe blood pressure value and needs to be considered when evaluating limb ischemia in patients with diabetes.
Asunto(s)
Determinación de la Presión Sanguínea/métodos , Pie Diabético/diagnóstico , Pie Diabético/fisiopatología , Dedos del Pie/irrigación sanguínea , Dedos del Pie/fisiopatología , Presión Sanguínea , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: to evaluate if the pole test at the toe level can be used for assessment of arterial insufficiency in diabetic patients. METHODS: twenty-five legs in 23 diabetic patients suffering from leg ischaemia were examined prospectively. A laser Doppler probe was attached to the pulp of the first toe to monitor perfusion continuously before and after occluding the arterial inflow with a cuff and during elevation of the leg until perfusion disappeared (the pole test). At ankle level the examinations were made similarly but with an ankle cuff and a hand-held Doppler. RESULTS: in the 44% (11/25) of the legs where it was possible to compare cuff blood pressure at ankle level with the pole test, the cuff measurements were significantly higher (p <0.01). In 13 of the remaining 14, maximal elevation did not result in disappearance of the Doppler signal. At toe level where 76% (19/25) of the legs could be compared, there was no significant difference between the two methods. CONCLUSION: the pole test can be used at the toe level to evaluate arterial insufficiency in diabetes. When used in the toe, the pole test can assess pressures below 55-70 mmHg, while only pressures below 45 mmHg can be determined at the ankle level. Falsely elevated blood pressure in diabetics is probably of less importance in digital arteries than in ankle arteries, which makes cuff pressure at toe level a more acceptable approximation.