Conflit d'intérêt économique entre avocats et clients : la questions des honoraires

In the line of the agency question, the lawyer/client relationship cannot escape the risk of conflict of interests. This text broadly redefines the nature of this conflict, and links it to an important source of tension, i.e. fees. We study three types of billing : contingency fees, hourly, and alternative billing. Besides billing structures, we examine their influence on this latent conflict, and propose a few ways of managing and preventing tensions.Agency question; Principal/agent tension; Lawyer; Conflict of interests; Tension management; Billing structure; Contingency fees; Hourly billing; Alternative billing

Role of Imaging in Left Atrial Appendage Occlusion

Percutaneous left atrial appendage (LAA) occlusion is now a valid alternative to long-term oral anticoagulation in patients with non-valvular atrial fibrillation at high thrombo-embolism risk, especially for patients who are considered ineligible for anticoagulation. The most frequently used occluders worldwide include the WATCHAMN (Boston Scientific, Natick, MA, USA) and the Amplatzer Cardiac Plug or Amulet (St. Jude Medical/Abbott, St Paul, MN, USA) devices. Multimodality imaging is key in the understanding of 3D aspects of the LAA and surrounding structures anatomy. Imaging is essential for procedural planning, during each step of the procedure and for device surveillance after implantation. Multimodality imaging, including 2D/3D echocardiography, fluoroscopy, and cardiac computed tomography can increase the safety and efficacy of the procedure

Facing COVID-19 : myocarditis following vaccination with mRNA SARS-CoV-2.

editorial reviewedMyocarditis is a relatively uncommon and underdiagnosed heart disease. Its clinical presentation is variable, from pauci-symptomatic to a symptomatology of sudden chest pain. The latter mimics cardiological emergencies and must therefore be quickly discerned to guide the rest of the treatment. The treatment is mainly supportive and rarely directly etiological. This is a pathology that resurfaced with the onset of the COVID-19 pandemic but also with vaccination. We present here the case of a mRNA SARS-CoV-2 vaccine-induced myocarditis whose clinical manifestations impose a rapid decision concerning the differential diagnosis with an acute coronary syndrome.La myocardite est une pathologie cardiaque relativement peu fréquente et sous-diagnostiquée. Sa présentation clinique est variable, de paucisymptomatique à une symptomatologie de douleur thoracique brutale. Cette dernière mime les urgences cardiologiques et doit donc être rapidement diagnostiquée pour orienter la suite de la prise en charge. Le traitement est principalement supportif et peu étiologique. Il s’agit d’une pathologie qui a refait surface avec l’arrivée de la pandémie COVID-19, mais aussi avec la vaccination. Nous présentons ici le cas d’une myocardite induite par un vaccin SARS-CoV-2 à ARNm dont les manifestations cliniques imposent une décision rapide concernant le diagnostic différentiel avec le syndrome coronarien aigu

Validation d'un Nouveau Modèle Statistique de Scapula Augmenté de Marqueurs Anatomiques

International audienceCe papier décrit la validation d'un modèle statistique de scapula (SSM) augmenté d'un ensemble de marqueurs anatomiques ayant un intérêt clinique. Le SSM utilisé est issu de nos récents travaux ayant abouti à la publication d'un des premiers modèles statistiques de l'os scapulaire chez l'humain adulte. En effet, la scapula est une forme 3D difficile à modéliser statistiquement du fait de sa forme complexe et de sa grande variabilité. Ce SSM avait été validé par les critères classiques de robustesse de construction du SSM à savoir, compacité, généralité et spécificité. Cependant, la robustesse de la représentation statistique n'est pas garante de sa validité anatomique pourtant primordiale pour des applications cliniques. Dans cette étude, nous présentons une nouvelle méthode pour l'ajout d'informations anatomiques dans le SSM développé et nous l'évaluons par un processus de sélection des marqueurs anatomiques utilisant un groupe mixte d'observateurs. Nous obtenons d'excellents résultats issus des analyses de variance intra et inter-observateurs. Ces résultats nous permettent d'envisager l'utilisation de ce SSM augmenté pour des applications de segmentation automatique d'IRM et des études biomécaniques du complexe de l'épaule

Coronary chronic total occlusion intervention: utility or futility.

peer reviewedINTRODUCTION: Despite an incidence of about 18-52% of the patients undergoing coronary angiography, chronic total occlusions (CTO) are rarely revascularised by percutaneous angioplasty (PCI). Nevertheless, current evidence suggests that successful CTO angioplasty improves symptoms, quality of life and long-term survival. During the last decade, the improvement of specific tools and techniques for these complex procedures, and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO angioplasty. Areas covered: This review focuses on the clinical benefits of CTO revascularization and on appropriate patient selection. Expert commentary: Current evidence suggests that successful CTO-PCI improves symptoms, quality of life and long-term survival. During the last years, the improvement of specific techniques for these complex procedures and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO lesion angioplasty

Tricuspid regurgitation: transcatheter treatment by TriClip®.

editorial reviewedTricuspid regurgitation (TR) is not rare and has been associated with poor clinical outcomes when severe. The etiology of TR is functional in most cases and is usually associated with left-sided valvular heart disease. Severe TR is responsible for right heart failure and may evolve to global heart failure. Current echocardiographic classification includes several grades (trivial, moderate, severe, massive, torrential TR) which influence patients' prognosis in an incremental manner. Management of patients with severe TR is discussed in Heart Team after evaluation of surgical risk. The TRI-SCORE may be used to evaluate the intra-hospital mortality risk in case of isolated tricuspid surgery. Isolated TR surgery is rarely performed as surgical risk outweighs expected clinical benefits. Transcatheter treatment of severe TR may be considered in highly selected cases. Transcatheter edge-to-edge repair (TEER) restores leaflets coaptation. First tricuspid TEER procedures were performed with the MitraClip® (Abbott, Santa Clara, CA, USA) device, but a specific device has been developed: the TriClip® (Abbott). The prospective multicenter TRILUMINATE trial evaluated the TriClip® procedure in patients with symptomatic moderate to severe TR and high surgical risk. The results show a good efficacy with reduction of post-procedural TR grade and increase in NYHA functional class, 6-minute walking test distance, right ventricular function, and quality of life at 1 year. Other devices are currently being evaluated or in development (i.e., transcatheter tricuspid implantation). Non-surgical TR management is likely to evolve and improve significantly soon.L’insuffisance tricuspide (IT) est une valvulopathie assez fréquente dans la population et qui est associée à un mauvais pronostic lorsqu’elle est modérée à sévère. Elle est le plus souvent fonctionnelle et liée à une valvulopathie du cœur gauche. Cliniquement, elle se marque par le développement de signes d’insuffisance cardiaque droite avec évolution vers une décompensation cardiaque globale. La classification échocardiographique actuelle distingue plusieurs stades (IT minime, modérée, sévère, massive et torrentielle) qui influencent le pronostic de façon incrémentielle. La prise en charge est discutée de manière collégiale après stratification du risque opératoire, dont l’évaluation est facilitée par le TRI-SCORE (risque de mortalité intra-hospitalière post-opératoire de chirurgie isolée de la valve tricuspide). La prise en charge chirurgicale d’une IT isolée est rarement pratiquée en raison d’un risque opératoire souvent élevé. Une prise en charge percutanée peut être envisagée dans certains cas, selon les limitations anatomiques. La technique de réparation bord à bord au niveau tricuspidien permet de restaurer une coaptation valvulaire par accolement des feuillets. Initialement réalisée à l’aide du système MitraClip® (Abbott, Santa Clara, CA, USA), il existe maintenant un système dédié spécifiquement à la tricuspide : le TriClip® (Abbott), dont la dernière génération existe en quatre tailles. Le TriClip® a été évalué dans l’étude prospective multicentrique TRILUMINATE chez des patients avec IT modérée à sévère symptomatique à haut risque chirurgical. La procédure a montré une efficacité avec réduction rapide du grade d’IT et amélioration de la classe fonctionnelle NYHA, de la distance de marche à 6 minutes, de la fonction ventriculaire droite et de la qualité de vie à un an. D’autres dispositifs sont en cours d’étude ou en développement (implantation tricuspide percutanée). La prise en charge non chirurgicale de l’IT devrait se développer de manière significative dans le futur

Atherosclerosis, an inflammatory disease.

editorial reviewedChronic inflammation is recognized as a contributing factor to the development, progression and complications of atherosclerosis. The inflammatory nature of atherosclerosis has been proven by the presence of inflammatory cells, cytokines and chemokines at all stages of the disease. There is a widely accepted association between cardiovascular events and serum inflammatory markers, such as CRP, IL-6 and IL-1? produced via the inflammasome pathway. The involvement of inflammatory processes in atherosclerosis and progress in the therapeutic strategy are detailed in the article

Validity and reliability of 3D marker based scapular motion analysis : a systematic review

Methods based on cutaneous markers are the most popular for the recording of three dimensional scapular motion analysis. Numerous methods have been evaluated, each showing different levels of accuracy and reliability. The aim of this review was to report the metrological properties of 3D scapular kinematic measurements using cutaneous markers and to make recommendations based on metrological evidence. A database search was conducted using relevant keywords and inclusion/exclusion criteria in 5 databases. 19 articles were included and assessed using a quality score. Concurrent validity and reliability were analyzed for each method. Six different methods are reported in the literature, each based on different marker locations and post collection computations. The acromion marker cluster (AMC) method coupled with a calibration of the scapula with the arm at rest is the most studied method. Below 90–100° of humeral elevation, this method is accurate to about 5° during arm flexion and 7° during arm abduction compared to palpation (average of the 3 scapular rotation errors). Good to excellent within-session reliability and moderate to excellent between-session reliability have been reported. The AMC method can be improved using different or multiple calibrations. Other methods using different marker locations or more markers on the scapula blade have been described but are less accurate than AMC methods. Based on current metrological evidence we would recommend (1) the use of an AMC located at the junction of the scapular spine and the acromion, (2) the use of a single calibration at rest if the task does not reach 90° of humeral elevation, (3) the use of a second calibration (at 90° or 120° of humeral elevation), or multiple calibrations above 90° of humeral elevation

Muscle activation during gait in children with Duchenne muscular dystrophy

The aim of this prospective study was to investigate changes in muscle activity during gait in children with Duchenne muscular Dystrophy (DMD). Dynamic surface electromyography recordings (EMGs) of 16 children with DMD and pathological gait were compared with those of 15 control children. The activity of the rectus femoris (RF), vastus lateralis (VL), medial hamstrings (HS), tibialis anterior (TA) and gastrocnemius soleus (GAS) muscles was recorded and analysed quantitatively and qualitatively. The overall muscle activity in the children with DMD was significantly different from that of the control group. Percentage activation amplitudes of RF, HS and TA were greater throughout the gait cycle in the children with DMD and the timing of GAS activity differed from the control children. Significantly greater muscle coactivation was found in the children with DMD. There were no significant differences between sides. Since the motor command is normal in DMD, the hyper-activity and co-contractions likely compensate for gait instability and muscle weakness, however may have negative consequences on the muscles and may increase the energy cost of gait. Simple rehabilitative strategies such as targeted physical therapies may improve stability and thus the pattern of muscle activity