Télémédecine : quis,quid, ubi,quibus auxiliis,cur, quomodo,quando ?

Telemedicine can be defined as the practice of medicine or surgery via telecommunication interposition using technologies which permit the exchange of medical information and the application of medical care at a distance. Geographic separation, logistical problems which impede the delivery of care, extreme climactic conditions, artificial environments, or a combination of these parameters may all influence the health of patients and the ability of healthcare professionals to do their work effectively. This article reviews the standards of current telemedical and telesurgical systems, defines target groups who may benefit from such care, and details the technologic requirements of telemetry; it uses selected cases and a review the medical literature. The conclusion focuses on future developments and the potential for further improvements through ongoing research.     

Névralgie,sympathalgie, psychalgie

Résumé La douleur n'est qu'un symptôme. Le problème étiologique doit toujours être la principale de nos préoccupations. Mais on peut aussi diviser le symptôme de la douleur selon son substratum anatomique et physiopathologique. On arrivera ainsi à la discrimination de la névralgie, de la sympathalgie et de la psychalgie.Lanévralgie a pour support une hyperexcitabilité sensitive périphérique. Il est facile de reproduire expérimentalement cette douleur en excitant la peau, le nerf, la racine postérieure ou le cordon postérieur. La névralgie est incompatible avec la suppression de la sensibilité cérébrospinale.La suppression de la sensibilité par destruction des neurones périphériques n'empêche pas d'autres douleurs de se reproduire. C'est ainsi qu'il est possible de provoquer expérimentalement dans un territoire anesthesié lasympathalgie en excitant directement les formations vasculo-sympathiques de la région.A la douleur physique on oppose la douleur d'origine psychique oupsychalgie; en réalité, toute douleur comporte une part psychique et la psychalgie pure ne doit être admise qu'avec la plus grande réserve.

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Summary Pain is a symptom. Without considering etiological problems we may differentiate, on anatomical and physiopathological basis, three types of pain: neuralgia, sympathalgia and psychalgia. Neuralgia is caused by a peripheral sensory irritation at the level of the skin, peripheral nerves, posterior roots and/or its ganglia. Neuralgia is incompatible with loss of cerebrospinal sensibility. Sympathalgia may experimentally be represented by the pain arising in an anesthetic region after stimulation of the sympathetic structures of the vessels. It may exist with abolished cerebrospinal sensibility. Psychalgia or psychogenic pain differs principally from neuralgia and sympathalgia in having no demonstrable anatomical substratum. But we must be very careful in the diagnosis of pure psychogenic pain since all pain has a psychological factor involved.

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Zusammenfassung Schmerz ist immer ein Symptom. Die übliche diagnostische Abklärung wird nach seiner Ätiologie fahnden. Wir können die Schmerzzustände aber auch nach dem zugrunde liegenden anatomischen und physiopathologischen Substrat unterteilen und so die drei großen Gruppen der Neuralgien, der Sympathalgien und der Psychalgien unterscheiden.DieNeuralgie beruht auf einer peripheren sensiblen Übererregbarkeit. Der neuralgische Schmerz läßt sich von der Haut, vom peripheren Nerven und von der hinteren Wurzel auslösen. Die Neuralgie ist an die mehr oder weniger vollständige Intaktheit der cerebro-spinalen Sensibilität gebunden.DieSympathalgie läßt sich experimentell durch die Reizung vasculär-sympathischer Formationen in einem anästhetischen Bezirk erzeugen. Die Sympathalgie besteht trotz aufgehobener cerebro-spinaler Sensibilität weiter.DiePsychalgie steht diesen zwei Arten physischen Schmerzes als rein seelischer Schmerz gegenüber. Man muß jedoch mit der Annahme einer Psychalgie sehr vorsichtig sein, da jede Schmerzempfindung mit einer seelischen Komponente gekoppelt ist. Die Psychalgie kann durch die Aufhebung der cerebro-spinalen Sensibilität hervorgerufen werden.

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Resumen El dolor es un síntoma. Dejando de lado los problemas etiológicos es posible distinguir, sobre bases anatómicas y flsiopatológicas, tres tipos de dolor: neuralgia, simpatalgia y psicalgia.Laneuralgia es provocada por una irritación sensitiva periférica a nivel de la piel, nervios periféricos, raíces posteriores y/o sus ganglios. Es incompatible con la pérdida de la sensibilidad cerebro-espinal.Lasimpatalgia puede ser representada experimentalmente por el dolor que se origina en una zona anestésica después de la estimulación de las estructuras simpâticas vasculares. Puede coexistir con abolición de la sensibilidad cerebro-espinal.Lapsicalgia, o dolor psicogénico, difiere esencialmente de las neuralgias y simpatalgias en la ausencia de sustrato anatómico. Pero debemos ser prudentes en el diagnóstico de dolor psicogénico puro, desde que en todo dolor existe un factor psicológico de tonalidad individual.

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Riassunto Il dolore è soltanto un sintomo. Il problema eziologico deve essere sempre la nostra principale preoccupazione. Possono peró essere considerate varie forme di dolore a seconda del substrato anatomico e fisiopatologico che lo sostiene. Si giunge in tal modo alla definizione di tre gruppi principali di dolore: nevralgia, simpatalgia e psicalgia.Lanevralgia ha per base una ipereccitabilità sensitiva periferica. Questo tipo di dolore puó essere provocato sperimentalmente eccitando la pelle, il nervo, la radie posteriore o il cordone posteriore. La possibilité della sua provocazione è pertanto strettamente collegata all'integrita delle vie sensitive cerebrospinali.Lasimpatalgia puó essere invece provocata anche in caso di interruzione delle vie sensitive cerebrospinali. Essa è dovuta alla stimolazione delle formazioni vasculosimpatiche della regione interessata e puó quindi riscontrarsi anche in zone anestetiche.A questi due tipi di dolore fisico si oppone il dolore di origine psichica opsicalgia. Questa deve essere peraltro ammessa con la più grande riserva poichè in realtà qualunque tipo di dolore ha in sé una componente psichica da cui non puó essere disgiunto. La psicalgia puo verificarsi anche in caso di abolizione della sensibilitá cerebrospinale. Per essa è infatti importante non ció che il paziente sente, ma piuttosto ció che il pazientecrede di sentire.

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Communication du Congrès Européen de Zurich, Juillet 1959.     

Articulation sterno-costo-claviculaire normale,dégénérative et inflammatoire

Many physicians are unfamiliar with the characteristics of the sternocostoclavicular joint (SCCJ). Disorders of the SCCJ, although common, frequently escape recognition. Computed tomography (CT) with thin slices and no gap is at present the best means of investigating the SCCJ. CT features in normal subjects have been described in detail; some are misleading. The most common SCCJ disorder is degenerative disease manifesting as osteoarthritis or as periarticular lesions causing antero-medial dislocation of the clavicle. Septic arthritis is the most severe disorder and can lead to mediastinitis. All inflammatory joint diseases, including spondyloarthropathies, can affect the SCCJ. SCCJ involvement is a typical component of the osteoarticular manifestations seen in patients with palmoplantar pustulosis.     

Effet d'un inhibiteur calcique,le vérapamil,sur le développement des ossifications hétérotopiques

Résumé La section du tendon d'Achille entraîne chez le rat le développement d'ossifications hétérotopiques dans les moignons musculaires et musculo-tendineux. Vingt six rats mâles, Sprague-Dawley, de 270 à 300 g ont subi cette ténotomie. Treize d'entre eux ont été traités par le Vérapamil (36 mg/kg) six jours par semaine. Les treize autres n'ont reçu aucun traitement. Le développement des ossifications hétérotopiques a été apprécié par des radiographies mensuelles des segments jambiers ténotomisés. Tous les animaux ont été sacrifiés cinq mois aprés la ténotomie. Les segments jambiers ont été prélevés en vue des examens microscopiques. L'analyse des radiographies successives a montré que le développement des ossifications hétérotopiques était moins important chez les animaux traités. Cette constatation a été confirmée par les mesures sur les coupes microscopiques des prélèvements post-mortem. L'étude microscopique de ces coupes en lumière polarisée a montré que la proportion d'os fibreux et d'os lamellaire était sensiblement la même chez les animaux traités et chez les témoins. Le Vérapamil a donc réduit la formation des ossifications hétérotopiques, mais n'a pas affecté le processus normal de substitution de l'os fibreux initialement formé par de l'os lamellaire. Il s'est produit, chez les animaux traités une réduction équilibrée de l'ostéoformation et de la résorption osseuse. D'autres posologies et l'effet d'autres inhibiteurs calciques devraient être étudiés.

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The effect of the calcium antagonist, Verapamil, in the prevention of heterotopic bone formation in rats

Summary After division of the tendo achilles in rats heterotopic bone forms in the muscle and in the tendon stumps. Tenotomy was performed in 26 male rats. Thirteen received Verapamil (36 mm/Kg) for six days per week for five months, and the remainder were not given this drug. The onset of heterotopic ossification was monitored by monthly x-rays. After five months the animals were killed and the sectioned tendons examined microscopically. The radiographs had shown that the amount of ossification was less in rats treated with Verapamil. This was confirmed at microscopy, but examination of the sections under polarised light showed that the ratio of lamellar to woven bone was the same in the two groups. Verapamil appeared to reduce the amount of heterotopic bone formation but did not influence the substitution of woven by lamellar bone.

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Offprint requests to: J. Duriez     

Lésions liées à l’intubation oro- et nasotrachéale et aux techniques alternatives : lèvres,cavités buccale et nasales,pharynx, larynx,trachée, œsophage

Dysphagia of greater than 48h duration is an indication for indirect laryngoscopy and when odynophagia and otalgia occur simultaneously, the possibility of subluxation of the arytenoids demands an urgent ENT assessment. The potential seriousness of laryngeal lesions following intubation obliges us to use the smallest compatible endotracheal tube. The occurrence of pain cervical surgical emphysema and fever suggests a pharyngeal lesion necessitating the suspension of oral feeding and the initiation of antibiotic therapy with anaerobic activity, while awaiting possible surgical intervention. There is no argument to use a tooth-guard for each intubation, but tooth fragility must be researched. The incidence of nasal fossa trauma is reduced with the use of nasal packs impregnated with local anaesthetic containing a vasoconstrictor. This allows the introduction of a small flexible lubricated tube. Laryngeal mask-induced sore throat is more common than the more serious injuries. The classical technique of introducing a laryngeal mask of appropriate size (4 for women, 5 for men) in which the cuff is inflated to a leak pressure of 20 cm H₂O reduces this frequency. The facial mask may cause injuries especially with prolonged use. The incidence of pulmonary aspiration, linked to the action of drugs, raised intra-abdominal pressure; an emergent situation or difficult intubation is decreased with the performance of the Sellick maneuver at intubation, rapid induction and the neutralization of gastric acidity. A meticulous technique of insertion of the, individualized anaesthesia, particular vigilance at the time of decurarisation and position changes and a calm awakening assure its optimal use, unless the Proseal laryngeal mask modifies this point of view.     

Le TRAPS : définition,sémiologie,pronostic, pathogénie,traitement, place par rapport à d’autres rhumatismes intermittents

Tumor Necrosis Factor-Receptor-Associated Periodic Syndrome (TRAPS) is an autosomal dominant inherited condition of periodic fever and pain. Most patients are of northern European descent. The attacks manifest as fever and pain in the joints, abdomen, muscles, skin, or eyes, with variations across patients. An acute-phase response occurs during the attacks. Patients with TRAPS are at risk for AA amyloidosis, the most common targets being the kidneys and liver. Soluble TNFRSF1A is usually low between the attacks and may be normal during the attacks, when TNF levels are high. TNFRSF1A is found in abnormally high numbers on leukocyte cell membranes. TRAPS is the first condition for which naturally occurring mutations in a TNF receptor were found; the mutations affect the soluble TNFRSF1A gene in the 12p13 region. In some patients, the pathogenesis involves defective TNFRSF1A shedding from cell membranes in response to a given stimulus. Thus, TRAPS is a model for a novel pathogenic concept characterized by failure to shed a cytokine receptor. This review compares TRAPS to other inherited periodic febrile conditions, namely, familial Mediterranean fever, Muckle-Wells syndrome, cold urticaria, and hyper-IgD syndrome. The place of TRAPS relative to other intermittent systemic joint diseases is discussed. Colchicine neither relieves nor prevents the attacks, whereas oral glucocorticoid therapy is effective when used in dosages greater than 20 mg per day. The pathogenic hypothesis involving defective TNFRSF1A shedding suggests that medications targeting TNF may be effective in TRAPS.     

Phosphore,tubule rénal et appareil ostéoarticulaire

A component of ATP, phosphate is at the hub of the energy-related mechanisms operative in muscle cells. Together with calcium, phosphate is involved in bone tissue mineralization: thus, a chronic alteration in the metabolism of phosphate can induce bone and joint disorders. Diagnosis of chronic hypophosphatemia. Serum phosphate, calcium, and creatinine should be assayed simultaneously. Serum calcium is increased in hypophosphatemia caused by hyperparathyroidism and decreased in osteomalacia. Urinary phosphate excretion should be measured in patients with a normal serum calcium level and a serum phosphate level lower than 0.80 mmol/L. A decrease in urinary phosphate excretion to less than 10 mmol/24 hours strongly suggests a gastrointestinal disorder, such as malabsorption, antacid use, or chronic alcohol abuse. In patients with a urinary phosphate excretion greater than 20 mmol/24h, the maximal rate of tubular reabsorption of phosphate (TmPO₄) and the ratio of TmPO₄ over glomerular filtration rate (GFR) should be determined to look for phosphate diabetes. Manifestations and causes of phosphate diabetes in adults. Moderately severe phosphate diabetes in adults manifests as chronic fatigue, depression, spinal pain, and polyarthralgia, with osteoporosis ascribable to increased bone resorption. Although many cases are idiopathic, investigations should be done to look for X-linked vitamin D-resistant rickets missed during childhood, a mesenchymatous tumor, or Fanconi syndrome with renal wasting of phosphate, glucose, and amino acids. Management of phosphate diabetes. Phosphate supplementation and, in patients with normal urinary calcium excretion, calcitriol produce some improvement in the symptoms and increase the bone mineral density. Whether dipyramidole is clinically effective remains unclear.     

Retentissements de la douleur postopératoire,bénéfices attendus des traitements

Physiological responses to postoperative acute pain may impede organ functions (cardiovascular, pulmonary, coagulation, endocrine, gastrointestinal, central nervous system, etc). Pain alleviation improves patient's comfort, but also may minimise perioperative stress response, physiological responses and postoperative organ dysfunction, assist postoperative nursing and physiotherapy, enhance clinical outcome, and potentially shorten the hospital stay. Potent postoperative analgesia, especially by epidural route, may be associated with reduction in incidence and severity of many perioperative dysfunctions. Peridural analgesia using local anaesthetics is the best technique for decreasing postoperative stress after lower abdominal or lower limb surgery. Analgesia using either epidural or high doses of morphine may improve some cardiac variables such as tachycardia and ischaemia, but does not change the incidence of severe cardiac complications. For patients undergoing vascular or orthopaedic surgery, epidural analgesia can improve clinical outcome by preventing the development of arterial or venous thromboembolic complications. However, in comparative studies, the control groups did not receive adequate prophylactic treatment for thromboembolic complications. Epidural analgesia can hasten the return of gastrointestinal motility and shorten the hospital stay. Postoperative mental dysfunction is decreased using intravenous PCA morphine in the elderly. Epidural analgesia with local anaesthetics improves postoperative respiratory function but, for unknown reasons, these benefits are not associated with a decrease in respiratory complications. On balance, the mode of acute pain relief decreases adverse physiological responses and many intermediate outcome variables; however, there is inconclusive evidence that it affects clinical outcome. Major advances in postoperative recovery can be achieved by early aggressive perioperative care, including potent analgesia, early mobilisation and oral nutrition. As a result, the hospital stay may be shortened.