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DevicesAccess at: www. CFRjournal.com Telehealth is a multiform term embracing the applications of telematics to medicine, in order to enable diagnosis and/or treatment remotely through a set of communication tools, including phones, smartphones and mobile wireless devices, with or without a video connection.1 Until a few years ago, digital applications in medicine were restricted to the use of data obtained from electronic health records (EHR), but, in more recent times, the technological context has notably expanded: the number of existing internet-connected mobile devices has roughly doubled every five years. This phenomenon will probably lead to the simultaneous operability of around 50 billion devices by 2020. 2 SensorsSensors are tools that are capable of detecting, recording and responding to specific inputs coming from a physical setting (e.g. a patient's vital signs) and are increasingly embedded in smartphones and other mobile devices. Recording and quantifying biological variables by means of sensors is generating large digital datasets that are suitable for transmission in real-time to healthcare and non-healthcare professionals. Computer applications arising from these phenomena are potentially numberless and will probably drive changes in both doctor-patient relationships and healthcare economic scenarios. Several insurance companies have already introduced better money premiums for customers who demonstrate regular use of smartphone applications aimed at illness prevention. 1 Some issues that will need to be addressed in the near future concern patient privacy and data safety. 3 As the practice of selling personal data to third parties for commercial purposes has come to light, increased attention has focused on data security of digital platforms and mobile devices. 4,5 Several reports published recently have revealed a concerning lack of details regarding the way that personal data is managed by telehealth application developers. 5 TheGlobal Privacy Enforcement Network has disclosed that around 60 % of the applications they evaluated exhibited criticisms regarding privacy issues, as they did not properly inform users how their personal data would be used and the number of personal questions asked was considered inappropriate. 6 Heart Failure EpidemiologyHeart failure (HF) is a common clinical syndrome associated with high morbidity and mortality. It is a major public health problem, with a prevalence of over 5.8 million people affected in the US, and over 26 million people worldwide. 7 In the US and in Europe, HF prevalence ranges from 1.1 % to 2.2 % in the general population. Most of the HF burden is situated in people aged over 65 years, who account for more than 80 % of deaths and prevalent cases in the US and in Europe. 8,9The lifetime probability of developing HF is believed to be one in five.Notwithstanding the historical equation that attributes HF genesis to a reduced left ventricular ejection fraction (LVEF), it has been shown that, in real medical practice, HF with preserved LVEF is ...

This paper considers the use of Machine Learning (ML) in medicine by focusing on the main problem that this computational approach has been aimed at solving or at least minimizing: uncertainty. To this aim, we point out how uncertainty is so ingrained in medicine that it biases also the representation of clinical phenomena, that is the very input of ML models, thus undermining the clinical significance of their output. Recognizing this can motivate both medical doctors, in taking more responsibility in the development and use of these decision aids, and the researchers, in pursuing different ways to assess the value of these systems. In so doing, both designers and users could take this intrinsic characteristic of medicine more seriously and consider alternative approaches that do not "sweep uncertainty under the rug" within an objectivist fiction, which everyone can come up by believing as true.

This article focuses on the production side of clinical data work, or data recording work, and in particular, on its multiplicity in terms of data variability. We report the findings from two case studies aimed at assessing the multiplicity that can be observed when the same medical phenomenon is recorded by multiple competent experts, yet the recorded data enable the knowledgeable management of illness trajectories. Often framed in terms of the latent unreliability of medical data, and then treated as a problem to solve, we argue that practitioners in the health informatics field must gain a greater awareness of the natural variability of data inscribing work, assess it, and design solutions that allow actors on both sides of clinical data work, that is, the production and care, as well as the primary and secondary uses of data to aptly inform each other’s practices.

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr McKee reported that she has received funding from the National Football League (NFL) and World Wrestling Entertainment, is a member of the Mackey-White Committee of the NFL Players' Association, and has received honoraria for speaking engagements. No other disclosures were reported.

Case presentationDr. Del Pace: A 72-year-old man with history of coronary and peripheral artery disease was admitted to this hospital with fever, fatigue and loss of weight. He had hypertension, type 2 diabetes mellitus and hyperlipidemia. He suffered from an ischemic cardiomyopathy with a low ejection fraction (33%). Fifty years prior he had undergone subtotal gastroresection for peptic ulcer. Seventeen years prior to this current admission (PTA), he had an aortobifemoral bypass grafting for symptomatic peripheral artery disease, and 8 years prior he had a myocardial infarction. Three vessel coronary disease was detected and coronary-artery bypass grafting had been carried out.One year PTA, he experienced an episode of sustained ventricular tachycardia, treated with stenting of the anterior descending coronary artery, followed by an internal cardiac defibrillator (ICD) implantation. Ten months PTA, he had a massive enteric bleeding complicated by hemorrhagic shock. A colonoscopy revealed ulcerated cecal angiodysplasia that was treated with an application of metallic clips.During the following months, he was admitted several times for sideropenic anemia without evidence of acute gastrointestinal bleeding, and iron therapy was administrated. Two colonoscopies were performed but no source of active bleeding was detected.Two months PTA, he developed a low-grade fever resistent to a 2-week course of antibiotic therapy with levofloxacin.Laboratory tests showed a normocytic anemia (8.1 g/dL) with normal levels of B12 and folic acid, with low levels of sideremia (13 lg/dL), and a normal haptoglobin.An esophagogastroduodenoscopy was normal. Neoplastic markers (NSE, CA 125, CEA, were all in the normal range. Antinuclear antibody, ANCA, rheumatoid factor were negative as well as immunofixation in serum and urine.A computed tomography (CT scan) of the abdomen with contrast material confirmed ceacum angiodysplasia, but did not reveal active enteral bleeding. Transesophageal echocardiography was performed, and a vegetation on the ICD catheter was found. One blood culture was positive for Streptococcus intermedius. Treatment with amoxicillin was started, and during the hospital stay, the fever disappeared. Removal of the pacemaker was suggested, but the patient refused it. After discharge, he completed a 4-week cycle of antibiotic therapy, but after 1 week of withdrawal, fever developed again with malaise, fatigue and weight loss. He was readmitted to this hospital.On examination, the patient appeared in mild distress. He had low-grade fever (37.5°C). The Blood pressure was 100/50 mmHg, pulse rate 70 beats/min and oxygen saturation 98% while he was breathing ambient air. A grade 2/6

Coronary stent thrombosis (CST) is a major concern of interventional cardiology. Several risk factors for CST have been identified, but as a whole they do not explain the pathophysiology of CST. This study was designed to investigate whether acute infection-inflammation could facilitate the occurrence of CST. Forty-one patients, aged 66.6 +/- 11 years, consecutively admitted to our catheterization laboratory for acute, subacute or late CST, were retrospectively analysed. Transient acute infection-inflammation on admission for CST was diagnosed by predefined criteria. Prevalence of known risk factors for CST was also investigated. Twenty-one patients (51%) met predefined criteria for the occurrence of acute infection-inflammation. On admission, in these patients, levels of systemic humoral and cellular inflammatory markers were significantly higher than those of patients without recent or ongoing acute infection-inflammation (p < 0.05 for all). 62% of patients with acute infection-inflammation had less than two known risk factors for CST whereas only 37% patients without infection-inflammation showed less than two risk factors (p = 0.03) and showed more frequent interruption of antiplatelet treatment (17 vs. 2.4%, p = 0.02), mean longer stent length (20.5 +/- 4.8 vs. 16.5 +/- 5.1 mm, p = 0.02) and lower left ventricular ejection fraction before CST (42.9 +/- 14 vs. 47.3 +/- 11%, p = 0.02). In conclusion, acute infection-inflammation could play a role in facilitating the occurrence of CST in a subgroup with low risk profile for known risk factors. Our findings, if confirmed, could suggest new opportunities for prevention and treatment of CST.

Case presentationDr. Micheli: A 48-year-old woman was admitted to our hospital after a 2-month history of dyspnoea on exertion. She did not report fever, sweats, chills, chest pain or recent weight loss.Twenty years before she had undergone mitral commissurotomy for rheumatic mitral stenosis.One week before current admission, the patient was seen in the emergency department (ED) because of paroxysmal atrial fibrillation. Synchronized electrical cardioversion was performed with recover of sinus rhythm. Echocardiography showed mitral stenosis with a valve area 1 cm 2 and mild pulmonary hypertension. Results of routine laboratory tests were normal except for anemia and thrombocytopenia (platelet count 35,000/mm 3 , hemoglobin 11.1 g/dl). Seven months before admission, these values were in the normal range. After discharge, the patient continued to experience dyspnoea while walking for a short distance and orthopnea.Eleven years before she had undergone excision of a right breast carcinoma, and had received a 6-month cycle of adjuvant chemotherapy. No local or systemic relapse had subsequently been documented.She worked as a pianist. There was no history of allergies. She did not report diabetes mellitus, illicit drug use, smoke history, alcohol use, hypertension, dyslipidemia or family history of heart disease or cancer. She did not consume medications except propafenone that had been prescribed in the ED a few days before.On physical examination, the patient was not in acute distress. Blood pressure was 115/70 mmHg, pulse rate 98 beats/min, respiratory rate16 breaths/min, temperature 36°C and SpO 2 98% while she was breathing room air. Lungs fields were clear on auscultation. A low-frequency holodiastolic murmur and mitral valve opening snap were heard over the cardiac apex. There was neither peripheral oedema nor increased jugular venous pressure. Peripheral pulses were normal and symmetrical. Abdomen was soft and non-tender. No masses or enlarged organs were detectable. There were no petechiae, ecchymoses, skin rash or lymphadenopathy. Neurologic examination was unremarkable. An electrocardiogram showed sinus rhythm. A blood gas analysis was normal. Thrombocytopenia (38,000/mm 3 ) was confirmed and pseudo-thrombocytopenia was excluded.On second hospital day, the patient abruptly developed left hemiplegia and dizziness. A CT scan of the head excluded acute intracranial hemorrhage. NIHSS was 12. The hospital Stroke Team was alerted within 30 min after the onset of symptoms but thrombolytic therapy was not performed because of the low platelet count. The patient underwent cerebral angiography that revealed diffuse bilateral microemboli not suitable for mechanical revascularization. Transesophageal echocardiography showed left appendage thrombosis. Intravenous heparin therapy