Aspects médico-légaux des gestes interventionnels en radiologie ostéo-articulaire

The daily practice of radiologists has evolved and radiologists are increasingly being directly involved with patient care and treatment. Consequently, radiologists have become a part of the therapeutic team available to patients. This active role, in hospital based or out-patient practices, does not only have an impact on the radiologist's professional activities. New liabilities related to interventional procedures or treatments are now added to already existing professional liability from diagnostic activities. Therefore, musculoskeletal radiologists performing interventional procedures must be aware and familiar with their obligations towards patients, including the requirement to provide adequate information to patients and documenting that informed consent was obtained.

End-of-life patients, intensive care and consent: difficulties facing French intensivists

BACKGROUND

The French legislature passed a law in 2005 that assigns a new role to the physician and redefines his liability in end-of-life decisions.

METHOD

This law is presented and discussed in context with current French legal practice.

RESULTS

This law emphasizes patient autonomy, advocating that the patient be fully informed before treatment, and creates specific procedures to be followed according to whether the patient is conscious or unconscious. In the latter situation, the law reinforces the role of both the patient's surrogate and the patient's advance directives in establishing consent. In these extreme situations, doctors have the option to request a second medical opinion. This joint decision-making procedure is laid down by law and becomes obligatory in the interests of transparency.

CONCLUSION

Respect for patients' consent implies the possibility that they may refuse medical care, creating an ethical and legal dilemma of providing medical care or respecting the patients' wishes. The key issue concerning end-of-life patients rests in the decisions taken concerning the continuation or withdrawal of life support and the administration of palliative care.

Application a la thanatologie de l’imagerie en coupe: revue iconographique

The development of new imaging modalities such as computed tomography and magnetic resonance imaging is a new phenomenon in thanatology. The growing accessibility to these technologies allows, under some conditions, the acquisition of cross-sectional images on cadavers. The authors present a practical pictorial review of post-mortem changes and deadly injuries, illustrating the contributions of modern cross-sectional imaging techniques in thanatology.

Homicide-Suicide by Stabbing Study Over 10 Years in the Toulouse Region

The authors conducted a retrospective study of 70 cases of homicide and suicide in the Toulouse region to identify the variables that enable us to determine whether a death is a homicide or a suicide. This work showed that the following characteristics-a female victim, numerous wounds, and the presence of 1 or more vertical chest wounds-suggest homicide. It also highlights the importance of inspecting clothing, in particular the position of clothing and the presence or absence of slashes.

Coracoclavicular joints. Reflections upon incidence, pathophysiology and etiology of the different forms

Since the first description of the coracoclavicular joint in 1861, many papers have been published reporting its occurrence, anatomical description, and geographical distribution. However, there are as yet no published articles with a convincing explanation for the rather variable forms of this variant. In this study, we investigated the occurrence of the coracoclavicular joint in the current and medieval population of Toulouse city and propose, through biometric measures, an explanation for the different forms of this anatomical variant. A total of 2192 chest X-rays taken for various conditions at a receiving hospital and 392 specimens (784 scapulae and an equal number of clavicles) of the L'Isle-Jourdain Series were examined with this aim. When present in the osteologic collection, the sizes of the articular conoid process as well as the height of the corresponding coracoid and acromial processes were noted. A coracoclavicular joint was noted in 0.82% and in 1.78% of the individuals examined in the radiological and osteologic series, respectively. The conoid process varied in size and correlated with the disposition of each correspondent coracoacromial arch. Osteoarthritis was noted in some of these joints when there was discordance between the conoid process size and the architecture of the correspondent coracoacromial arch, suggesting impingement. Our findings support a genetic origin for this variant, and suggest that its occurrence is also probably influenced by environmental factors. Osteoarthritis of this joint may be responsible for shoulder pain.

[Medical responsibility and nosocomial infections]

Modifications of the civil and administrative jurisprudence regarding nosocomial infections reflect the will to pay the patient for compensation for injury. The June 29, 1999 decree of the French Court of Cessation shows the transition from presumption of malpractice to obligation of safety. The authors describe those modifications, including the physician's and hospital liabilities, and assess their consequences, as proof of an external cause is now mandatory while proof of absence of malpractice is no longer sufficient.

[Stomatologic and maxillofacial pathology in a medieval population (10th-12th centuries) of southwestern France]

We present an assessment of the dental and maxillofacial pathology in a medieval population in southwestern France. One hundred and ninety eight mandibles and 29 craniofacial complexes were analysed. Dental and periodontal infectious pathology predominated. Third molar agenesia was quite frequent, concerning 25% of the mandibles. Third molar eruption was almost constant and in a normal position. Condylar process degeneration concerned 6% of the population. Three cases of traumatic pathology were observed, one case of long mandible was noted, and two cases of hypertrophic inferior alveolar process. Dento-mandibular maladjustment was uncommon. No unwedging of the maxillo-mandibular bone basis was observed.

Soft tissue tumors following traumatic injury: two observations of interest for the medicolegal causality

Two cases of tumors of the soft tissues developing at the site of a previous traumatic injury occurring a few years earlier are reported. One was finally diagnosed as aggressive fibromatosis and the other as low-grade fibrosarcoma. Among the pathogenic mechanisms and the etiologic factors involved in such tumors, the posttraumatic causality is discussed, and in addition to the initial trauma, the role of iterative surgery in the first case and mineral muscular inclusions in the second case are examined. The different therapeutic approaches of such lesions are also reviewed.

[Severe cutaneous necrosis after ultrasound lipolysis. Medicolegal aspects and review]

The authors report the case of a young patient who developed extensive skin necrosis after ultrasound liposuction of the medial surface of the thigh. These lesions required excision, split-skin graft and installation of an expansion prosthesis. The medicolegal aspects of this case are discussed, in particular the responsibility of the doctor who performed this damaging procedure, from three points of view: damage, fault, causality. In this case, the damage corresponded to necrosis which can be due to a chemical, infectious or thermal mechanism. It is responsible for serious damages due to the number of operations, the length of hospital stay, immobilization, rehabilitation and the time off work. The aesthetic damage, the pretium doloris, and the inconvenience are certainly considerable, but was there fault in this case? Fault by clumsiness if the equipment was used abnormally; fault by negligence or imprudence when the equipment was not approved or when the operator was not a qualified physician, submitting his patient to undue risks. The causality is envisaged in the case of chemonecrosis and burns. It would be strongly presumed in a civil procedure in case of non-approved equipment. The authors are in favour of a hypothesis of a burn and review the current state of ultrasound liposuction, which was the subject of an intense media campaign several years ago.

[Large eventrations: deep extensive cleavage of the abdominal wall and prosthetic repair]

The objective for surgical repair of major defects of the abdominal wall is an anatomical reconstruction and reinforcement with a support prosthesis. Wall reconstruction should be obtained without tension. This requires deep extensive cleavage so the deep musculo-aponevrosis can be advanced approximately 10 cm. This manoeuvre is anatomic and preserves vascularization and innervation. A prosthesis covers the orificies and reinforces the anatomic construction. In peripheral defects, cleavage is necessary for closure. The prosthesis is anchored on deep solid structures (ribs, iliac crests) guaranteeing solidity. In a series of 252 operated patients, abdominal wall solidity was achieved in 91% of the cases with a mean follow-up of 2 to 13 years. Mortality was 1.2% and morbidity 8%, emphasizing the importance of rigorous indications. Intensive preparation including the Goni Moreno pneumoperitoneum is required for surgery in all major abdominal wall defects.

[An unusual complication of cervicofacial lift: paralysis of the external branch of the accessory spinal nerve]

Paralysis of the lateral branch of the accessory nerve is an extremely rare lesion during cervico-facial facelift. Based on 3 detailed and published personal cases observed over a period of 15 years, the authors review the literature, revealing a total of 9 cases over a period of 30 years, but other cases have probably not been published. Their review reveals the following points. This is an exceptional lesion. However, the nerve can be damaged as it emerges from the posterior border of the sternocleidomastoid muscle during slightly deep dissection and the electrical scalpel must be used cautiously. Even, partial paralysis of the trapezius muscle induces pain and considerable functional impairment with partial permanent disability. The natural history of this paralysis is very long and may be followed by regression after several years. Although there is an obvious cause-and-effect relationship between the operation and accessory nerve paralysis, it is always difficult to attribute this lesion to a possible surgical error, as the exact mechanism of the nerve lesion remain hypothetical and once again raises the problem of therapeutic risk.

[Merkel cell carcinoma of the skin]

This study reports five cases of Merkel-cell carcinoma of the skin. Then the authors review the present state of the art from the data already available in the literature concerning this malignant primary skin tumor. A part from local excision, no standard procedures are described. The literature provides a lot of discrepancies concerning the additional treatments such as lymph mode excision, radio and chemotherapy. The prognosis of this tumor remains poor because of a high incidence of local recurrence, a frequent spread to regional lymph modes and the development metastases.

[Launois Bensaude disease. Focus apropos of 16 cases]

After a review of the clinical, pathological and aetiological features, the authors describe the various surgical techniques used (conventional surgery or liposuction) to restore a normal social life to these patients, deformed by their disease. They confirm the predominant role of conventional surgery and define the limited indications in which liposuction can be used. Based on a review of 16 cases, the surgeon must make sure that the patient has ceased his or her alcohol abuse before performing this difficult treatment associated with a number of complications.

Proton NMR conformational study of an annexin I fragment: influence of a phospholipidic micellar environment

A 32 residue peptide, Ac-AQWDADELRAAMKGLGTDEDTLIELASRTNK, spanning the first helix-loop-helix motif of the second repeat of human annexin I, was synthesized and studied by standard 2D proton NMR and molecular modeling. The peptide was solubilized either in aqueous solution, in TFE-H2O mixtures or in aqueous phospholipidic micellar solution. In pure aqueous solution, elements of helix secondary structure were observed. Addition of TFE led to a dramatic cooperative effect on the secondary structure with a very low transition midpoint indicative of the strong tendency of the peptide to form alpha helices. Only in the aqueous micellar solution was the full helix-loop-helix motif obtained, showing again the potency of a membrane-like micellar environment to initiate peptide secondary structures and even elements of tertiary structure. There were sufficient NMR data to perform molecular modeling of the structure of the annexin fragment solubilized in the presence of micelles. However, this structure showed a relatively high degree of flexibility, especially around the T17-D18 hinge at the end of the loop.

[Drowsiness and traffic accidents. Importance of diagnosis]

"Tiredness", often cited in civil and penal responsibilities secondary to car accidents, hides neurophysiological phenomena which must now be taken into account. The problems of watchfulness in car-driving, is sleepiness, are indeed linked to a genuine disorder in the sleep-wake rythm and attention should be drawn to them in medico-legal cases. Investigations and clinical examinations concerning 110 experts' reports confirm the role played by sleep' disorders in the occurrence of car accidents. Prevention in actually possible. Early detection can take place at various levels and concerns general practitioners, specialists of industrial medicine and specialists for driving tests. In France, the list of diseases associated with, and retraining of a driving license refer only to concentration disorders induced by drug administration, but do not mention sleep pathologies (sleep apnea syndrome, narcolepsy, etc). What is the responsibility of a driver who ignores or says nothing about a sleep pathology from which he is suffering? Is it really necessary to include these pathologies on such a list? It could be more useful to make a large audience; including children, aware of the physiology and pathology of sleep. It appears, from experts' reports, that the management of the problem requires a "driving hygiene".

[Computed tomographic exploration of eventrations]

With physical examination alone it is difficult or even impossible to evaluate the abdominal wall damage in patients with major evisceration, especially when they are obese. Computerized tomography (CT) is very useful in this respect as it provides a detailed anatomical overview of the lesions. CT was performed in 30 out of 229 patients operated upon. It supplied information on the size, site and extension of eviscerations and showed whether they were single or multiple; it also informed on the quality, thickness and retraction of the abdominal muscles. All this is extremely important to know before surgery as it enables the operative problems to be foreseen and, to some extent, the operative procedure to be determined. In all cases of complex evisceration CT may be regarded as the "key examination".

Island flaps with an exclusively venous pedicle. A report of eleven cases and a preliminary haemodynamic study

Eleven cases are reported of island flaps containing only venous pedicles. All but two survived completely without arterial input and all the successful cases were on the extremities. The possible reasons for this are discussed.

Dermatofibrosarcoma protuberans: a case report and clinicopathologic review

Dermatofibrosarcoma protuberans is a soft tissue, low-grade malignant tumor. Histologically, the tumor is a low-grade sarcoma with a constant storiform growth pattern. The tumor may possibly arise from histiocytes, a thesis supported by recent tissue culture and electron microscopic studies. Treatment consists of the wide local excision. Conservative excision often results in recurrences. Lymph node and other distant metastases, although rare, have been documented. Most often, the clinical course shows this tumor to be slow growing and often painless. Presented herein is a patient in whom this uncommon tumor developed.