[Deployment of telemedicine, context and challenges]. / Déploiement de la télémédecine, contexte et enjeux.

The last decade has contributed to the emergence of telemedicine. Legislation and regulations, new tools, efficient networks and regional deployments have all played their part in its growth. There are several regional solutions, often experimental. The implementation of telemedicine services nevertheless comes up against obstacles which concern all specialities, including cardiology.

[Remote medical consultations in gerontology]. / Les téléconsultations médicales en gérontologie.

Experimental teleconsultations have been set up between a university hospital and a public geriatric hospital in Paris in order to facilitate elderly patients' access to specialist consultations. Caregivers have had to accept major changes to their professional practices (delegation of tasks, sharing of knowledge, etc.). This new telemedecine scheme represents huge progress in patient care.

Diagnosis of tetanus immunization status: multicenter assessment of a rapid biological test.

Diagnosis of tetanus immunization status by medical interview of patients with wounds is poor. Many protected patients receive unnecessary vaccine or immunoglobulin, and unprotected patients may receive nothing. The aim of this study is to evaluate the feasibility and accuracy of the Tetanos Quick Stick (TQS) rapid finger prick stick test in the emergency department for determining immunization status. We designed a prospective multicenter study for blinded comparison of TQS with an enzyme-linked immunosorbent assay (ELISA). Adults referred for open wounds in 37 French hospital emergency departments had the TQS after receiving standard care (emergency-TQS). TQS was also performed in the hospital laboratory on total blood (blood/lab-TQS) and serum (serum/lab-TQS). ELISA was performed with the same blood sample at a central laboratory. We assessed concordance between emergency-TQS and blood/lab-TQS by the kappa test and the diagnostic accuracy (likelihood ratios) of medical interview, emergency-TQS, and lab-TQS. ELISA was positive in 94.6% of the 988 patients included. Concordance between blood/emergency-TQS and blood/lab-TQS results was moderate (kappa=0.6), with a high proportion of inconclusive blood/emergency-TQS tests (9.8%). Likelihood ratios for immunization were 3.0 (95% confidence interval [CI], 1.8 to 5.1), 36.6 (95% CI, 5.3 to 255.3), 89.1 (95% CI, 5.6 to 1,405.0), and 92.7 (95% CI, 5.9 to 1,462.0) for medical interview, blood/emergency-TQS, blood/lab-TQS, and serum/lab-TQS, respectively. The sensitivity of the blood/emergency-TQS was 76.7%, and the specificity was 98% by reference to the ELISA. TQS use in the emergency room could make tetanus prevention more accurate if its technical feasibility were improved, and our assessment will be supplemented by a cost effectiveness study.

[Drug users attending at hospital emergency rooms. Changes in sociodemographic features, health care, referral attitudes and impact of substitution therapy, between 1993 and 1998]. / L'accueil des toxicomanes dans un service des Urgences hospitalier.

The purpose of this work was to assess changes observed between 1993 and 1998 relative to drug users seen at hospital emergency rooms. We retrospectively reviewed our medical files for two periods, 1993-1995 and 1996-1998, i.e. before and after routine institution of substitution therapy with buprenorphine and methadone. A predefined grid was used to select files. All patients whose file indicated drug use, irrespective of the reason for consultation, were eligible for inclusion. Overall demographic features were: mean age 29 years, men 74%, known address 60%, indication of medical coverage 29%, institutional transportation 70%, heroine abusers 53%, injecting drug users 65%, associated acute alcohol intoxication 27%. There was a significant decline in the incidence of drug abusers during the second period (2.42% versus 3.44%) with no difference for age, sex, or area of residence. Documentation of medical coverage improved. There was no change in the hour of arrival, more than 50% arrived outside regular hospital hours but a higher proportion arrived during the weekend, indicating some access difficulty. Our results are in agreement with the OFDT data on product use: reduction in the use of heroine and significant increase in the use of cocaine, alcohol consumption remaining unchanged. Among the 63 patients seen during the second period, 31.7% stated they were taking substitution therapy, indicating this population has access to treatment. There was no statistical difference for diagnosis, but certain trends were observed: acute intoxication with loss of consciousness leading to emergency squad transfer to the emergency room remained the most common situation, rate of trauma was unchanged at approximately 10%, as was the rate of post-IV abscesses; there was a 3-fold reduction in request for drugs and a 2-fold rise in public intoxication. These data help better define management conditions for drug users attending emergency rooms.