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OBJECTIVE—To evaluate the impact of a continuous quality improvement effort implemented by a network of diabetes outpatient clinics in Sicily, Italy. RESEARCH DESIGN AND METHODS—Twenty-two clinics adopted the same electronic medical record system. Process and intermediate outcomes indicators were identified and software was developed, enabling the extraction of the information needed for the profiling of quality of care. Data were centrally analyzed anonymously every year, and results were discussed in meetings with the participants. The performances of the different centers were ranked against the “best performers,” and the reasons for variation were discussed. RESULTS—From 2001 to 2005, a total of 26,782 patients aged ≥18 years have been seen in the participating clinics. Rates of monitoring of A1C, blood pressure, lipid profile, and microalbuminuria constantly increased over the years. The percentage of individuals with A1C values ≤7.0% increased by 16.6%, while the proportion of patients with blood pressure ≤130/85 mmHg increased by 10.7%. The percentage of individuals with LDL cholesterol levels CONCLUSIONS—We found a strong consistency between increasing rates of monitoring, increasing drug prescription, and better levels of intermediate outcomes. Despite the satisfactory achievements, a substantial room for improvement in the care of diabetes still persists.

The treatment for hepatocellular carcinoma (HCC) relies on liver resection, which is, however, burdened by a high rate of recurrence after surgery, up to 60% at 5 years. No pre-operative tools are currently available to assess the recurrence risk tailored to every single patient. Recently liquid biopsy has shown interesting results in diagnosis, prognosis and treatment allocation strategies in other types of cancers, since its ability to identify circulating tumor cells (CTCs) derived from the primary tumor. Those cells were advocated to be responsible for the majority of cases of recurrence and cancer-related deaths for HCC. In fact, after being modified by the epithelial-mesenchymal transition, CTCs circulate as "seeds " in peripheral blood, then reach the target organ as dormant cells which could be subsequently "awakened " and activated, and then initiate metastasis. Their presence may justify the disagreement registered in terms of efficacy of anatomic vs non-anatomic resections, particularly in the case of microvascular invasion, which has been recently pointed as a histological sign of the spread of those cells. Thus, their presence, also in the early stages, may justify the recurrence event also in the contest of liver transplant. Understanding the mechanism behind the tumor progression may allow improving the treatment selection according to the biological patient-based characteristics. Moreover, it may drive the development of novel biological tailored tests which could address a specific patient to neoadjuvant or adjuvant strategies, and in perspective, it could also become a new method to allocate organs for transplantation, according to the risk of relapse after liver transplant. The present paper will describe the most recent evidence on the role of CTCs in determining the relapse of HCC, highlighting their potential clinical implication as novel tumor behavior biomarkers able to influence the surgical choice.