Proof of patient information: Analysis of 201 judicial decisions

INTRODUCTION: The ruling by the French Court of Cassation dated February 25, 1997 obliged doctors to provide proof of the information given to patients, reversing more than half a century of case law. In October 1997, it was specified that such evidence could be provided by "all means", including presumption. No hierarchy in respect of means of proof has been defined by case law or legislation. The present study analyzed judicial decisions with a view to determining the means of proof liable to carry the most weight in a suit for failure to provide due patient information. MATERIAL AND METHOD: A retrospective qualitative study was conducted for the period from January 2010 to December 2015, by a search on the LexisNexis JurisClasseur website. Two hundred and one judicial decisions relating to failure to provide due patient information were selected and analyzed to study the characteristics of the practitioners involved, the content of the information at issue and the means of proof provided. The resulting cohort of practitioners was compared with the medical demographic atlas of the French Order of Medicine, considered as exhaustive. RESULTS: Two hundred and one practitioners were investigated for failure to provide information: 45 medical practitioners (22±3%), and 156 surgeons (78±3%) including 45 orthopedic surgeons (29±3.6% of surgeons). Hundred and ninety-three were private sector (96±1.3%) and 8 public sector (4±1.3%). Hundred and one surgeons (65±3.8% of surgeons), and 26 medical practitioners (58±7.4%) were convicted. Twenty-five of the 45 orthopedic surgeons were convicted (55±7.5%). There was no significant difference in conviction rates between surgeons and medical practitioners: odds ratio, 1.339916; 95% CI [0.6393982; 2.7753764] (Chi test: p=0.49). Ninety-two practitioners based their defense on a single means of proof, and 74 of these were convicted (80±4.2%). Forty practitioners based their defense on several means of proof, and 16 of these were convicted (40±7.8%). There was a significant difference in conviction rate according to reliance on single or multiple evidence of delivery of information: odds ratio, 0.165; 95% CI [0.07; 0.4] (Chi test: p=1.1×10). DISCUSSION: This study shows that surgeons, and orthopedic surgeons in particular, are more at risk of being investigated for failure to provide due patient information (D=-0.65 [-0.7; -0.6]). They are not, however, more at risk of conviction (p=0.49). Being in private practice also appeared to be a risk factor for conviction of failure to provide due information. Offering several rather than a single means of proof of delivery of information significantly reduces the risk of conviction (p=1.1×10). LEVEL OF EVIDENCE: Level IV: Retrospective study

Qu’en est-il de la personne de confiance sept ans après sa mise en place ? Enquête sur deux établissements hospitaliers du Maine et Loire

The survey carried out among 41 nursing assistants spread over two hospital establishments in the Maine et Loire region, France, set about describing the perception of the trustworthy person seven years after its creation. Data relating to ways in which information is given to patients and the methods used to ascertain the identity of the trustworthy person highlight the practical difficulties in applying the texts, which are sometimes inaccurate, by nursing assistants. Although some concepts are well integrated by teams, this mission of assigning a trustworthy person by the patient each time hospitalisation takes place is seen as an additional administrative burden, whose usefulness is seldom appreciated

Individual mapping of innate immune cell activation is a candidate marker of patient-specific trajectories of disability worsening in Multiple Sclerosis

Objective: To develop a novel approach to generate individual maps of white matter (WM) innate immune cell activation using 18F-DPA-714 translocator protein (TSPO) positron emission tomography (PET), and to explore the relationship between these maps and individual trajectories of disability worsening in patients with multiple sclerosis (MS). Methods: Patients with MS (n = 37), whose trajectories of disability worsening over the 2 years preceding study entry were calculated, and healthy controls (n = 19) underwent magnetic resonance magnetic and 18F-DPA-714 PET. A threshold of significant activation of 18F-DPA-714 binding was calculated with a voxel-wise randomized permutation-based comparison between patients and controls, and used to classify each WM voxel in patients as characterized by a significant activation of innate immune cells (DPA+) or not. Individual maps of innate immune cell activation in the WM were employed to calculate the extent of activation in WM regions-of-interests and to classify each WM lesion as "DPA-active", "DPA-inactive" or "unclassified". Results: Compared with the WM of healthy controls, patients with MS had a significantly higher percentage of DPA+ voxels in the normal-appearing WM, (NAWM in patients=24.9±9.7%; WM in controls=14.0±7.8%, p<0.001). In patients with MS, the percentage of DPA+ voxels showed a significant increase from NAWM, to perilesional areas, T2 hyperintense lesions and T1 hypointense lesions (38.1±13.5%, 45.0±17.9%, and 51.9±22.9%, respectively, p<0.001). Among the 1379 T2 lesions identified, 512 were defined as DPA-active and 258 as DPA-inactive. A higher number of lesions classified as DPA-active (OR=1.13, P = 0.009), a higher percentage of DPA+ voxels in the NAWM (OR=1.16, P = 0.009) and in T1-spin-echo lesions (OR=1.06, P = 0.036), were significantly associated with a retrospective more severe clinical trajectory in patients with MS. Conclusion: A more severe trajectory of disability worsening in MS is associated with an innate immune cells activation inside and around WM lesions. 18F-DPA-714 PET may provide a promising biomarker to identify patients at risk of severe clinical trajectory

Development of a method to estimate skeletal age at death in adults using the acetabulum and the auricular surface on a Portuguese population

Aging techniques that use the posterior or middle part of the pelvis are of interest because this part of the body is very resistant to decay. In a preliminary study, acetabular criteria correlated with age were isolated. In a second study, three acetabular criteria and four auricular surface criteria were described and it was demonstrated that it is of interest to associate these criteria. The goal of the present study was to test these criteria in a larger sample and to elaborate a standardized procedure for the use of these criteria. The study concerned 462 os coxae (hip bones) of known age and sex. All of the criteria are correlated with age. Establishing a score allows a better correlation with age with lower intra-/inter-observer variability. Seven categories of overall score corresponding to eight age groups were defined and the probabilities of belonging to an age group depending on the overall score were calculated. The first main advantage of this procedure is that it is still applicable when only some parts of the body remain. The other benefit is its ability to discriminate older people

Disruption of the leptomeningeal blood barrier in neuromyelitis optica spectrum disorder

OBJECTIVE: To describe leptomeningeal blood-barrier impairment reflected by MRI gadolinium-enhanced lesions in patients with aquaporin-4 immunoglobulin G (AQP4-IgG)-positive neuromyelitis optica spectrum disorder (NMOSD). METHODS: A retrospective case series of 11 AQP4-IgG-positive NMOSD patients with leptomeningeal enhancement (LME) were collected from 5 centers. External neuroradiologists, blinded to the clinical details, evaluated MRIs. RESULTS: LME was demonstrated on postcontrast T1-weighted and fluid-attenuated inversion recovery images as a sign of leptomeningeal blood-barrier disruption and transient leakage of contrast agent into the subarachnoid space in 11 patients, 6 in the brain and 6 in the spinal cord. The patterns of LME were linear or extensive and were accompanied by periependymal enhancement in 5 cases and intraparenchymal enhancement in all cases. The location of LME in the spinal cord was adjacent to intraparenchymal contrast enhancement with involvement of a median number of 12 (range 5-17) vertebral segments. At the time of LME on MRI, all patients had a clinical attack such as encephalopathy (36%) and/or myelopathy (70%) with median interval between symptom onset and LME of 12 days (range 2-30). LME occurred in association with an initial area postrema attack (44%), signs of systemic infection (33%), or AQP4-IgG in CSF (22%) followed by clinical progression. LME was found at initial clinical presentation in 5 cases and at clinical relapses leading to a diagnosis of NMOSD in 6 cases. CONCLUSION: This study suggests that altered leptomeningeal blood barrier may be accompanied by intraparenchymal blood-brain barrier breakdown in patients with AQP4-IgG-positive NMOSD during relapses

Label-free and fluorescence biosensing platform using one dimensional photonic crystal chips

The increasing demand for early detection of diseases drives the efforts to develop more and more sensitive techniques to detect biomarkers in extremely low concentrations. Electromagnetic modes at the surface of one dimensional photonic crystals, usually called Bloch surface waves, were demonstrated to enhance the resolution and constitute an attractive alternative to surface plasmon polariton optical biosensors. We report on the development of Bloch surface wave biochips operating in both label-free and fluorescence modes and demonstrate their use in ovalbumin recognition assays

Thalamic energy dysfunction is associated with thalamo-cortical tract damage in multiple sclerosis: a diffusion spectroscopy study

Background: Diffusion-weighted 1H magnetic resonance spectroscopy (DW-MRS) allows to quantify creatine-phosphocreatine brain diffusivity (ADC(tCr)), whose reduction in multiple sclerosis (MS) has been proposed as a proxy of energy dysfunction. Objective: To investigate whether thalamic ADC(tCr) changes are associated with thalamo-cortical tract damage in MS. Methods: Twenty patients with MS and 13 healthy controls (HC) were enrolled in a DW-MRS and DW imaging (DWI) study. From DW-MRS, ADC(tCr) and total N-acetyl-aspartate diffusivity (ADC(tNAA)) were extracted in the thalami. Three thalamo-cortical tracts and one non-thalamic control tract were reconstructed from DWI. Fractional anisotropy (FA), mean (MD), axial (AD), and radial diffusivity (RD), reflecting microstructural integrity, were extracted for each tract. Associations between thalamic ADC(tCr) and tract metrics were assessed using linear regression models adjusting for age, sex, thalamic volume, thalamic ADC(tNAA), and tract-specific lesion load. Results: Lower thalamic ADC(tCr) was associated with higher MD and RD of thalamo-cortical projections in MS (MD: p = 0.029; RD: p = 0.017), but not in HC (MD: p = 0.625, interaction term between thalamic ADC(tCr) and group = 0.019; RD: p = 0.320, interaction term = 0.05). Thalamic ADC(tCr) was not associated with microstructural changes of the control tract. Conclusion: Reduced thalamic ADC(tCr) correlates with thalamo-cortical tract damage in MS, showing that pathologic changes in thalamic energy metabolism are associated with structural degeneration of connected fibers

A graphical method for performance mapping of machines and milling tools

Optimal design of the machining setup in terms of installed machines, cutting tools and process parameters is of paramount importance for every manufacturing company. In most of the metal cutting companies, all choices related to machine eligibility and cutting parameters selection typically come from heuristic approaches and follow supplier indications or base on the skill of experienced machine operators. More advanced solutions, such as model-based and virtual approaches, are adopted less frequently mainly due to the lack of these techniques in grasping the underlying knowledge successfully. Aim of this work is to introduce a synthetic graphical representation of machining centers and cutting tools capabilities, to provide an accessible way to evaluate the feasibility and close-to-limit conditions of the cutting process. Taking inspiration from previous scientific works from the measurement engineering field, a set of 2D and 3D graphs are presented to map machine, tools and process capabilities, as well as their obtainable manufacturing performances and expectable tool life. This approach synthesizes the nominal data coming from different sources (catalogues, database, tool model geometries etc.) and the real cutting tools parameters used during the production phase. Some examples are provided to show the potential of this graphical evaluation in supporting process planning and decision-making and in formalizing the machining setup knowledge. Further developments are devoted to extend the method to other manufacturing processes, including hybrid processes. At the same time, an in-process data gathering software will be integrated for building a solid database that can be used by an autonomous multi-technological process selector, as well as by a pre-process condition advisor in an Industry 4.0 oriented way