Emergency department diagnosis and management of skin diseases with real-time teledermatologic expertise.

IMPORTANCE: Skin conditions are a common reason for patients to consult emergency department (ED) physicians. OBJECTIVE: To evaluate real-time teledermatologic expertise with the use of mobile telephones for the diagnosis and management of skin conditions in patients seen in the ED. DESIGN, SETTING, AND PARTICIPANTS: This observational study of adults who consecutively consulted in the ED for a dermatologic condition was conducted under routine conditions in the ED from May 1, 2008, through June 30, 2010. MAIN OUTCOMES AND MEASURES: Diagnosis agreement and management concordance. RESULTS: One hundred eleven patients were enrolled in the study. Eighty-three patients (74.8%) were evaluated using videoconferencing. Dermatologic remote expertise invalidated, enlarged, or clarified ED physicians' diagnosis and management in 75 of 110 cases (68.2%). Videoconferencing improved the diagnostic performance in 57 of 83 cases (68.7%) (P < 10(-4)). Management concordance was moderate between ED physicians and dermatologists for specialist consultation within 24 hours (κ, 0.49; 95% CI, 0.14-0.84) and immediate hospitalization (κ, 0.49; 95% CI, 0.41-0.57). Patients were significantly more often discharged by dermatologists (46.8% vs 39.1%) (P < 10(-4)). CONCLUSIONS AND RELEVANCE: Compared with standard hardware, new-generation mobile devices reduce the cost of videoconferencing, increase the versatility of teledermatology, and decrease general practitioner investment time.

Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. METHODS: In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471. FINDINGS: 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk [RR] 0·83, 95% CI 0·68-1·01, p=0·06). The incidence of death (enoxaparin, 17 [4%] vs heparin, 29 [6%] patients; p=0·08), complication of myocardial infarction (20 [4%] vs 29 [6%]; p=0·21), procedure failure (100 [26%] vs 109 [28%]; p=0·61), and major bleeding (20 [5%] vs 22 [5%]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7%] vs 52 [11%] patients; RR 0·59, 95% CI 0·38-0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10%] vs 69 [15%] patients; p=0·03), death or complication of myocardial infarction (35 [8%] vs 57 [12%]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5%] vs 39 [8%]; p=0·04) were all reduced with enoxaparin. INTERPRETATION: Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. FUNDING: Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.

[High blood pressure in the emergency department: epidemiology and evaluation of a dedicated consultation]. / Pression artérielle élevée aux urgences : épidémiologie et évaluation d'un réseau de soins hospitalier.

OBJECTIVES: The Arterial High blood pressure represents a consultation on 5 in general medicine. The main objective of our study was to estimate patients' proportion appearing at emergency department (ED) with a high Blood pressure and to demonstrate that it is possible to detect the patients at risk of essential and secondary hypertension as well as their cardiovascular risk there. METHODS: Non-interventional forward-looking Study led over 6 weeks. After measure of the vital parameters in the reception of ED, the patients were included if the Systolic Blood Pressure (SBP) was ≥ 140 mmHg and\or Diastolic Blood Pressure (DBP) ≥ 90 mmHg. A control of Blood Pressure (BP) was made at least 40 minutes after the inclusion. If the Arterial High blood pressure persisted (BP ≥ 140/90 mmHg and age < 30 years or BP ≥ 180/110 mmHg after 30 years), the patients had to see again a cardiologist of the hospital in 7 days because they were considered as at high cardiovascular risk. RESULTS: A high initial BP was discovered to 582 (8,7 %) 6685 patients having consulted in ED during the period of the study. 64 % of them (n = 372) had a persistent Arterial High Blood pressure after 40 minutes. 27 patients, defined at high cardiovascular risk had a proposition of consultation of cardiology, appeared 11 to it. 4 secondary hypertension was discovered. CONCLUSION: During the period of study, 582 patients presented a High BP. To 64 % of those who had a control of BP this imbalance was confirmed. The patients (n=27) presenting a high cardiovascular risk had a proposition of fast consultation. This one allowed discovering 4 secondary hypertension. There is thus a utility to estimate the BP in a systematic way at Emergency Department.