Telemedicine: What Framework, What Levels of Proof, Implementation Rules

The concept of telemedicine was formalised in France in the 2009 “Hospital, patients, health territories” (loi hôpital, patients, santé, territoire) law and the 2010 decree through which it was applied. Many experiments have been carried out and the regulatory institutions (Ministry, Regional Health Agency [Agence régionale de santé, ARS], French National Health Authority [Haute autorité de santé, HAS], etc.) have issued various guidance statements and recommendations on its organisation and on the expectations of its evaluation. With this background, the round table wanted to produce recommendations on different areas of medical telemonitoring (the role of telemonitoring, the regulatory system, the principles for assessment, methods of use and conditions for sustained and seamless deployment). Whilst many studies carried out on new medical telemonitoring approaches have led to the postulate that it offers benefit, both clinically and in terms of patient quality of life, more information is needed to demonstrate its impact on the organisation of healthcare and the associated medico-economic benefit (criteria, methods, resources). Similarly, contractual frameworks for deployment of telemonitoring do exist, although they are complicated and involve many different stakeholders (Director General fo the Care Offering [Direction générale de l’offre de soins, DGOS], ARS, HAS, Agency for Shared Health Information Systems [Agence des systèmes d’information partagés de santé, ASIP], French National Data Protection Commission [Commission nationale informatique et libertés, CNIL], French National Medical Council [Conseil national de l’Ordre des médecins, CNOM], etc.) that would benefit from a shared approach and seamless exchange between the partners involved. The current challenge is also to define the conditions required to validate a stable economic model in order to promote organisational change. One topical issue is placing the emphasis on its evaluation and operation. Access to patient data, particularly data from the health insurance funds and the use of these data, may enable the process to be more effective. In addition, the budgetary non-fungibility of the various financial envelopes for the different areas of work, restricts the consolidation of financial impact. Funding methods will need to be adapted to this new distribution of roles, both at the centre of the healthcare system and in the industrial ecosystem. All of these changes will help the leaders of our healthcare system to bring this new ambition closer to all of the people working in the health economy

Télémédecine : quel cadre, quels niveaux de preuves, quelles modalités de déploiement

Le concept de télémédecine a été officialisé en France avec la loi hôpital patients santé territoires (HPST) de 2009 et le décret d’application de 2010. De nombreuses expérimentations ont été mises en œuvre et les institutions de régulation (Ministère, Agence régionale de santé [ARS], Haute autorité de santé [HAS]…) ont émis diverses orientations et recommandations tant sur le volet organisationnel que sur les attentes d’évaluation. C’est dans ce contexte que la table ronde a souhaité émettre des recommandations sur différents axes de la télésurveillance médicale (la place de la télésurveillance médicale, le parcours réglementaire, les principes d’évaluation, les modalités de prises en charge et les conditions pour un déploiement pérenne et fluide). Si les nouvelles approches utilisant la télésurveillance médicale, font l’objet de nombreuses études conduisant au postulat qu’il existe un bénéfice à la fois sur un plan clinique et pour la qualité de vie du patient, la démonstration de l’impact sur l’organisation des soins et du bénéfice médico-économique restent à mieux préciser (critères, méthodes, moyens). De même, les cadres contractuels du déploiement de la télésurveillance existent mais sont complexes ; ils font appels à de nombreux interlocuteurs (Direction générale de l’offre de soins [DGOS], ARS, HAS, Agence des systèmes d’information partagés de santé [ASIP], Commission nationale informatique et libertés [CNIL], Conseil national de l’ordre des médecins [CNOM]…) qui bénéficieraient du partage d’une même approche et de fluidifier les partenariats. À ce stade, l’enjeu est aussi de définir les conditions permettant la validation d’un modèle économique stable pour engager des changements organisationnels. La problématique est ici de mener de front son évaluation et sa mise en œuvre. L’accès aux données patients, en particulier à celles des caisses d’Assurance maladie et leur exploitation, pourrait permettre une plus grande efficacité de la démarche. De plus, la non-fongibilité budgétaire des différentes enveloppes budgétaires des différents secteurs d’activités limite la consolidation des impacts économiques. Les modalités de financement devront donc être adaptées à cette nouvelle répartition des rôles, à la fois au cœur du système de santé et de l’écosystème industriel. Toutes ces évolutions contribueront à ce que les responsables de notre système de santé puissent porter cette nouvelle ambition en étroite relation avec tous les acteurs de cette économie

De la sangsue à l'hirudine : une thérapeutique qui n'en démord pas. Utilisation à Paris du XVIIIe au XXe siècle

Maugendre Philippe, Poinsotte Valérie, Brassier Nicolas, Chast François. De la sangsue à l'hirudine : une thérapeutique qui n'en démord pas. Utilisation à Paris du XVIIIe au XXe siècle. In: Revue d'histoire de la pharmacie, 84ᵉ année, n°312, 1996. Actes du XXXIe Congrès International d'Histoire de la Pharmacie (Paris, 25-29 septembre 1995) pp. 385-388

Syndrome de détresse respiratoire aiguë sur hémorragie intra-alvéolaire révélant une vascularite. [Acute respiratory distress syndrome related to intra-alveolar hemorrhage revealing a vasculitis].

International audienceIntra-alveolar hemorrhage (IAH) could be revealed by acute respiratory failure. The classic association of hemoptysis - anemia - radiological infiltrates is suggestive and has to be confirmed by broncho-alveolar lavage with Golde score. Etiologies included immune and non-immune diseases, with specific treatment for each. We report a case of IAH revealed by acute respiratory distress syndrome and anemia (3 g/dL), related to pulmonary and cerebral vasculitis without renal involvement. The patient was efficiently treated with corticosteroids and cyclophosphamide. This case highlights the critical role of BAL cytological analysis with Golde score, and the need for a rapid and accurate diagnosis in order to guide specific treatment. If histology is needed, renal biopsy even without renal involvement, or surgical lung biopsy is possible

Regulation of MMP/TIMP balance as therapeutic target in pulmonary diseases

International audienceMatrix metalloproteinases (MMPs) are a family of zinc endopeptidases, regulated by endogenous tissue inhibitors (TIMPs) and inducer (EMMPRIN). The demonstration of a functional role of MMPs in pulmonary diseases raises the possibility of therapeutic intervention targeting MMP/TIMP balance to prevent pathological processes

Increased extracellular matrix metalloproteinase inducer (EMMPRIN) expression in pulmonary fibrosis.

International audienceExtracellular matrix metalloproteinase inducer (EMMPRIN) was examined on bronchoalveolar lavage fluids (BALFs) and lung tissue from patients with fibrosis (usual interstitial pneumonia-idiopathic pulmonary fibrosis [UIP-IPF], n = 15; diffuse parenchymal lung diseases without IPF characteristics on computerized tomography scan, n = 8) and without fibrosis (n = 6). In UIP-IPF, EMMPRIN staining was increased in areas of fibrosis, mainly in macrophages and in epithelial cells. EMMPRIN was also found in the extracellular medium with significant levels in patients with lung fibrosis compared to subjects without fibrosis. Moreover, macrophages from patients with lung fibrosis spontaneously produce EMMPRIN. These findings show that EMMPRIN is increased in lung fibrosis

¹³¹I-labeled lipiodol-induced interstitial pneumonia: a series of 15 cases.

International audienceBACKGROUND: The drug (131)I-labeled lipiodol is used as internal radiotherapy for unresectable hepatocellular carcinoma. Although the drug was considered safe during preapproval studies, we observed several cases of interstitial pneumonia following its administration. METHODS: Cases were retrospectively identified through the drug safety unit database of Rennes University Hospital. RESULTS: From 1994 to 2009, interstitial pneumonia developed in 15 patients following (131)I-labeled lipiodol administration, with an estimated prevalence of 15.5 cases (95% CI, 7.7-23.2) per 1,000 treated patients. Mean age of the patients was 60 ± 8 years, and the male to female ratio was 6.5:1. All patients had cirrhosis, mainly related to long-term alcohol intoxication (n = 12). Most (n = 10) cases occurred after the second (131)I-labeled lipiodol injection. The median delay between last (131)I-labeled lipiodol administration and first respiratory symptoms was 30 days (interquartile range, 16.5-45 days). All patients presented with shortness of breath. Physical examination mostly revealed fever (n = 11) and bilateral crackles (n = 12). Chest CT scan showed bilateral ground-glass opacities (n = 8) with septal thickening, retraction, or both (n = 8). BAL (n = 7) was remarkable for increased neutrophils (n = 4) or CD8(+) T cell count (n = 3). Despite corticosteroids, 12 (80%) patients died, mostly of untractable respiratory failure (n = 9). Median delay between last (131)I-labeled lipiodol injection and death was 63 days (interquartile range, 34-129 days). CONCLUSIONS: Interstitial pneumonia may be a serious and not uncommon complication of (131)I-labeled lipiodol administration