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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.

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.

International audience; Introduction: The durability of telehealth projects is too often questioned by the lack of prior development of sustainable business models allowing the finding of the equilibrium of the funding for the deployment and for the operational phases. The existing medico-economic and multidisciplinary methods do not address this problem; hence a new one is needed.Materials and Methods: The complex system design tools used in the field of Industrial Engineering are used as a base for this new method. The holistic approach adopted represents an opportunity to develop sustainable business models taking into account needs and viewpoints of each stakeholder of a telehealth project.Results: The proposed method aims at creating various scenarios of business models and offering a clear vision on how the proposed changes will impact each of the stakeholders involved as well as the overall system. An example of how this can be applied is detailed.Discussion and Conclusions: The presented method allows the design of economic value sharing scenarios between all the stakeholders of a telehealth project. Its application to a particular one can act as a basis for discussions during negotiations between stakeholders. It can also support the assessment of the overall project’s sustainability.; Introduction : La pérennité des projets de télémédecine est trop souvent remise en cause par l'absence de développement préalable de modèles économiques durables qui permettraient d'élaborer de nouvelles organisations à même d'équilibrer le financement de leur déploiement et de leur fonctionnement. Les méthodes d'évaluation médico-économiques et les méthodes multicritères existantes ne permettant pas de répondre à cette problématique, une nouvelle méthode est donc nécessaire. Matériels et Méthodes : Les outils d’analyse des systèmes complexes utilisés dans le domaine du Génie Industriel sont mobilisés pour créer cette méthode. La perspective holiste adoptée est l’occasion d’élaborer des modèles économiques plus durables pour chacun des acteurs d’un projet de télémédecine.Résultats : La méthode proposée permet de créer des scenarii variés de modèles économiques et offre une vision précise de ce que l’évolution projetée aura comme impact sur chacun des acteurs impliqués et sur le système. Un exemple d’application est détaillé.Discussion et Conclusions : La méthode présentée permet de concevoir des scenarii de partage de la valeur économique entre les acteurs d'un projet de télémédecine. Son application à un projet particulier permet de servir de support de discussion lors des négociations

National audience; À partir d'une perspective combinant analyses sociologique et éthique et évaluation médicale, les auteurs rendent compte des usages de la télémédecine en gériatrie, observables dans le cadre de téléconsultations médicales, pour comprendre la place qui est faite aux patients âgés. Ils montrent que celle-ci dépend principalement de l'organisation pratique de la consultation et des modalités d'usage concrètes des dispositifs techniques, qui ne sont, en euxmêmes, ni déshumanisants ni humanisants. Les auteurs mettent ainsi en évidence l'importance des évaluations socio-organisationnelles in situ de ces nouvelles formes d'exercice médical.

■ Desteleconsultations experimentales ont ete mises en place entre un centre hospitalier universitaire (CHU) et un hopital de geriatrie de l'Assistance publique-Hopitaux de Paris (AP-HP) afin de faciliter l'acces des patients âges aux consultations de specialite ■ Les soignants ontdu accepter de profonds bouleversements pour adapter leurs pratiques professionnelles (delegation des tâches, mutualisation des savoirs, etc.) ■ Ce nouveau dispositif de telemedecine represente un immense progres dans la prise en charge des patients.

Consultable en ligne : www.cairn.info/revue-francaise-des-affaires-sociales-2011-2-page-63.htm; National audience; La télémédecine est encouragée en France pour répondre aux enjeux actuels en matière de santé : démographie médicale, vieillissement de la population, égalité d'accès aux soins. Au-delà des problèmes techniques, déontologiques et financiers qu'elle peut poser, la télémédecine n'est pas sans conséquences sur l'organisation des soins et la pratique médicale. L'observation de téléconsultations menées entre un hôpital de gériatrie et un centre hospitalier universitaire, grâce à un dispositif de téléprésence, a permis d'étudier les impacts de son usage sur les pratiques professionnelles et les relations entre professionnels de santé. Elle révèle, notamment, que la mise en place d'un tel dispositif, son développement et son utilisation pérenne nécessitent de recourir à de nouvelles compétences, qui pourraient être celles d'un médecin coordonnateur en télémédecine.

Background: Travel-related illnesses have been studied in visitors to developing countries, but no studies have examined the incidence of health problems in visitors to developed countries. Methods: 4,093 foreign tourists visiting Paris in August and attending to emergency medical care for acute health problems were included in an epidemiological survey conducted over 5 consecutive years. The objective was to determine what types of acute health problems occur in a foreign tourist population and to estimate the incidence of the main health hazards. Results: Gastroenteritis represented the main cause of medical care in that population (from 14.5–21.9%) followed by traumatology, ENT problem, viral syndrome and dermatology which represented altogether 60–64% of all medical problems. Two factors were related to the distribution of diseases observed: age and nationality. The monthly incidence of gastroenteritis was estimated to be between 1.33 to 2.92 per 10,000 visitors, and the overall incidence of health problems between 8 to 10 per 10,000. Conclusions: Even if the incidence rate of gastroenteritis is low compared with developing countries, further studies are needed to support the hypothesis that gastroenteritis could be attributed to sanitary conditions in some restaurants of the French capital.

This study involved 35 patients who claimed to have been drugged before being robbed or raped, despite urine negative toxicologic screening by immunoenzymatic methods. The urines were frozen for further investigations, including enzymatic hydrolysis of urinary conjugates, liquid-solid extraction and, finally, immunoenzymatic screening of concentrated urine extract.Urine benzodiazepines were analyzed by immunoenzymatic assay before and after enzymatic hydrolysis combined with extraction.On direct immunoenzymatic screening, 17 of the 35 urine samples were benzodiazepine positive. Enrichment of preserved specimens improved the detection threshold from 200 ng/mL to 50 ng/mL and 10 of the 18 negative urines became positive.This method allowed us to demonstrate the benzodiazepines in half of previously negative urine samples. Benzodiazepine screening is particularly problematic because of low dosage, rapid elimination, failure to detect conjugated metabolites by immunoenzymatic reagents and high threshold of sensitivity for certain substances.

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.

France, like many other western countries, observes a massive increase of health care costs. This is partly due to the rapidly ageing population and the growth of the number of patients suffering from chronic diseases. Simultaneously, the number of medical staff decreases in many regions. To overcome these developments, telehealth seems to be one of the responses that ensure accessibility for all to quality care. The main idea of telehealth is to provide a remote access of health care services thus closing the distance with appropriate health care professionals. However, the introduction of telehealth involves a major organizational change. The purpose of this paper is to present the research framework and to discuss the development of methods and tools of industrial engineering suitable for developing a new telemedicine system and realize its medico-economic evaluation. Thus, we propose a research framework to explore several scenarios in order to elaborate an optimal organization in terms of economic development considering all values sought by stakeholders. Specific tools such as systems approach and value analysis are proposed to be used to help design the telehealth system. A first application of these methods and tools is discussed regarding the telehealth experience named Telegeria at the Georges-Pompidou European Hospital of Paris., La France, comme nombre d'autres pays occidentaux, assiste à une inflation des coûts de santé dûe en partie au vieillissement rapide de la population et à l'accroissement du nombre de malades atteints de pathologies chroniques. Simultanément nous assistons à une diminution des densités de personnels médicaux dans de multiples régions. Pour pallier ces évolutions, la télémédecine apporte une réponse qui participe à l'accessibilité de tous à des soins de qualité. Elle permet d'accéder à distance à des professionnels de santé. Toutefois, l'introduction de la télémédecine entraîne un changement organisationnel majeur. L'objet du présent article est de présenter le cadre de recherche ainsi que de discuter le développement de méthodes et outils de génie industriel appropriés permettant d'élaborer un nouveau système de télémédecine et de réaliser son évaluation médico-économique. Ainsi nous proposons un cadre de recherche afin d'explorer plusieurs scenarii d'organisation de l'infrastructure du point de vue économique tout en garantissant l'ensemble de valeurs recherchées par toutes les parties prenantes. Les outils conceptuels spécifiques tels que l'approche systémique et l'identification de valeurs seront utilisés afin d'aider à la conception du système de santé en télémédecine. Une première application de ces méthodes et outils sera évoquée concernant les travaux en cours dans le cadre du programme de télémédecine Télégéria de l'Hôpital Européen Georges-Pompidou de Paris.

Current immigration law establishes that conditional residents divorced could remove the conditions on their LPR status but people not divorced but separated could not. What is the public policy behind banning people separated but not divorced from applying for a waiver for bona fide marriage, when divorced people could do so? How is such a public policy justified, considering that the law requires only evidence that the marriage was entered in good faith, and the immigrants, whether separated or divorced, could prove that the marriage was bona fide? This article analyzes the USCIS’s treatment of the I-751 application for removal of conditions for people who are neither happily married nor divorced. Part II provides a background of basic concepts such as conditional residency, its antecedents, how and why it was created, the law regulating conditional residency, how to remove the conditions, and the waivers available. Part III focuses on the waiver for bona fide marriage, its requirements, and the situation of people unable to apply for it because they are neither joint petitioning, nor applying for the bona-fide-marriage waiver. Part IV analyzes a hypothetical case. Finally, Part V analyzes the public policy behind forbidding separated, non-divorced people from using the waiver for removing the conditions on their LPR status.

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.

Qui a vocation a s’occuper des soins et expertises des victimes et gardes a vue, les urgences generales ou specialisees ? Role et mission des urgences medico-judiciaires sont ici detailles. En procedure correctionnelle ou criminelle, la plainte deposee par la victime conduit a une requisition qui precise la mission : constater ses blessures et preciser l’incapacite totale de travail (ITT, periode pendant laquelle la victime est incapable d’effectuer les actes ordinaires de la vie). Si l’ITT est inferieure a huit jours, c’est le tribunal de simple police qui intervient, si elle est superieure, c’est un jugement correctionnel. Pour un garde a vue, la tâche consiste a etablir un bilan de sante precisant la compatibilite avec la garde a vue. Des conferences de consensus definissent les bonnes pratiques cliniques encadrant la prise en charge des patients. Point fondamental du code de deontologie : celui qui soigne n’est pas celui qui expertise.