[From medical complication to compensation for the prejudice]. / De la complication médicale à l'indemnisation du préjudice.

Claims in anesthesia and intensive care remains high, despite the reduction of morbidity and mortality associated with this activity. The absence of a national register makes it difficult to quantify. The Medical Committee of MACSF-Sou Medical Group, professional liability insurer of more than half of French physicians, provided us support. The amount of compensation paid is growing and the scope of compensated damage is expanded by the Dintilhac mission. The Act of March 4, 2002 has fully confirmed the principle of medical liability for misconduct. Generally, compensation for bodily injury is based on the demonstration of a causal link between a wrongful event and injury. The proof of fault lies with the applicant. Information accountable to patients and nosocomial infection are a particular setting. The Act of March 4, 2002 has also defined the concept of therapeutic risk. With the establishment of the Regional Commissions of Conciliation and Compensation (RCCI) and the National Office for Compensation of Medical Accident (Oniam), it is now possible for a patient to be compensated for an injury resulting from an accident Medical non-offending, while acknowledging the lack of accountability of the practitioner. The expertise conducted by an RCCI is adversarial. For the practitioner called to the cause, it is important to prepare for both substance and form, with the assistance of the medical board's insurance company.

Joint infection after knee arthroscopy: medicolegal aspects.

INTRODUCTION: Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients' functional prognosis and engage surgeon's liability. This study analyzes the context of such infection occurrences, their management as well as their medicolegal consequences. PATIENTS AND METHODS: Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medical liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrolysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy. RESULTS: Clinical signs of septic arthritis appeared after a median interval of 8 days (0-37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1-9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0-20), a total temporary work incapacity of 120 days (40-790), a suffering burden averaging 3 out of 7 (0-4.5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation. DISCUSSION: Some risk factors of articular infection are known and well-identified. They can be linked to the patient's condition (addiction to smoking, surgical history, professional activity) or to medical management (intra-articular corticoid injections, interventions under oral anticoagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid's inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic management of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner. LEVEL OF EVIDENCE: Level IV; economic and decision analysis, retrospective study.

A comparison of image characteristics and convenience in panoramic radiography using charge-coupled device, storage phosphor, and film receptors.

This study compared the image layer characteristics, dose requirements, and convenience in use of panoramic radiography using each of four different image receptors including traditional indirect exposure x-ray film, a storage phosphor system, and two solid-state sensors. The OP 100 D (Instrumentarium Imaging, Tuusula, Finland) charge-coupled device (CCD) sensor provided an instant image with a wide focal trough, making patient positioning error unlikely, but at the same time required a patient dose higher than that used with film. While the DigiPan (Trex/Trophy, Marne-la-Vallée, France) CCD significantly reduced the patient dose to radiation and also provided an instant image, the focal trough was narrower making patient positioning error more likely. The storage phosphor system provided high resolution and a reasonable focal trough width, but the procedure took longer than traditional film radiography and did not provide a dose saving.

The role of the dentist in detection of carotid atherosclerosis.

Cerebrovascular accidents (CVA), or stroke, afflict 731,000 Americans each year, with 165,000 of these individuals dying. Stroke is a major cause of death and disability throughout the world, including southern Africa. Atherosclerosis-related formation of thrombi and emboli at the bifurcation of the common carotid artery and proximal internal carotid artery represents a common cause of stroke. The detection of carotid atherosclerosis by dentists using panoramic radiographs recently has been presented to the public through television news stories and the press, but many dentists still do not know how to interpret panoramic radiographs for detection of this condition. This communication illustrates examples in which carotid atherosclerosis was detected using panoramic radiography. Differential diagnoses are presented. Since not every carotid plaque calcifies, panoramic radiography should never be used alone to exclude the possibility of carotid atherosclerosis. It should also be remembered that the mere presence of calcified carotid plaque is not necessarily a reflection on the degree of carotid stenosis. Definitive diagnosis and treatment requires referral of patients deemed to be at risk to an appropriate physician. A variety of advanced diagnostic methods, including gadolinium-enhanced MRI, Duplex Doppler sonography and angiography are used to confirm carotid stenosis.

Comparison of observer performance in determining the position of endodontic files with physical measures in the evaluation of dental X-ray imaging systems.

OBJECTIVE: To examine the feasibility of substituting observers determining the accuracy of endodontic measurements for measurements of physical qualities in comparison of digital imaging systems. METHODS: Sensors from six digital imaging systems were compared for signal-to-noise ratio (SNR), modulation transfer function (MTF) and detective quantum efficiency (DQE). A total of 45 canals in teeth from human cadavers were instrumented to their apical foramina. Endodontic files, ranging in size from size 8 to size 20, were glued in place at random distances from the apical foramina spanning a range of +/- 3 mm. The teeth were imaged with the six digital systems and dental X-ray film. Fifteen dentists independently measured the distance from the end of the file to the apical foramen. Results were expressed as the measurement error. Measurement error was compared to SNR, MTF and DQE for each digital system. RESULTS: CDR (Schick, New York, NY, USA), Digora (Sordex, Helsinki, Finland) and Dexis (Provision Dental Systems, Palo Alto, CA, USA) produced the highest SNR values followed closely by RVG-4 (Trophy, Croissy-Beavborg, France). Sens-A-Ray (Dent-X/Regam Medical Systems, Sundsvall, Sweden), Dexis and the RVG-4 produced the best MTF results. Dexis had the greatest DQE. The mean measurement errors (in mm) were: Film 0.65, Dexis 0.69, CDR 0.71, RVG-4 0.74, Digora 0.89, Sens-A-Ray 0.97, and Visualix-2 (Gendex, Monza, Italy) 0.98. CONCLUSIONS: Digital systems closely approximate film in their accuracy when used for endodontic measurement providing that the assessment instruments have similar resolving power. DQE was the best physical predictor of system accuracy when compared with endodontic length measurements. MTF and SNR alone did not accurately predict observer precision.

Extraoral and panoramic systems.

Digital solutions for extraoral and panoramic radiology have been available for more than 15 years. The costs, however, have been too high for adoption in private dental practice. The past 2 years have seen tremendous growth in the number of relatively cost-effective digital options available to the dentist and dental specialist. Furthermore, computer speed and data storage capacities have progressed. This article presents an overview of systems available at present, and their enabling technologies and enhancement capabilities.

Evaluation of a new F speed dental X-ray film. The effect of processing solutions and a comparison with D and E speed films.

OBJECTIVE: To compare the properties of a new speed group F intra-oral X-ray film with those of three well established types both from groups D and E, and evaluate the impact of six commercially available processing solutions. METHODS: Four types of dental X-ray film, Flow (Flow X-ray, West Hempstead, NY, USA), speed group F, Ektaspeed Plus (Eastman Kodak, Rochester NY, USA) and M2 Comfort (AgfaGevaert, Morstel, Belgium), both speed group E, and Ultra-speed (Eastman Kodak), speed group D, were exposed under standardised conditions and processed in six different processing solutions. Base plus fog density, characteristic curves, film density, speed, average gradient, contrast and latitude and spatial resolution were calculated. RESULTS: The choice of processing chemistry affected radiographic characteristics including speed grouping. The new F film was consistently the fastest. M2 Comfort could achieve F speed and Ultra-speed achieved E speed using Automat XR chemicals. The speed of Ektaspeed Plus was independent of the automatic processing solution used. Ultra-Speed film had the lowest base plus fog density and the widest latitude. Film contrast was similar irrespective of the film and solution combination. CONCLUSIONS: The choice of processing chemistry can affect radiographic characteristics. The new F film reduces patient exposure by one-half compared with E speed film with no detriment to image quality.

Temporomandibular joint pantomography using charge-coupled device, photostimulable phosphor, and film receptors: a comparison.

Our objective was to compare the accuracy and practicality in use of three available imaging receptors for temporomandibular joint (TMJ) imaging; namely, two computer-assisted and one traditional analog x-ray film system. A standardized tissue-equivalent encased human skull specimen was imaged using lateral and posteroanterior (PA) pantomographic projections with the Orthopantomograph OP 100 (Instrumentarium Imaging, Tuusula, Finland) and three different receptor modalities: (1) Ektavision film with Ektavision screens (Eastman Kodak, Rochester, NY); (2) DenOptix photostimulable phosphor screens (Dentsply/Gendex, Chicago, IL); and (3) the charge-coupled device (CCD) receptor, DigiPan (TREX/Trophy Radiology, Marne-la-Vallée, France). The effective focal trough was found for each receptor using lead resolution grids placed at fractional millimeter distances along empirically determined beam projection angulations. The time to acquire and process images was also established. We found that the CCD system permitted real-time display, whereas the use of traditional film took 2 minutes to load the cassette in a darkroom and perform the exposure, and then a further 2 minutes to unload and process. The storage phosphor took 3 minutes to unload the cassette and process the image and a further 20 seconds to clear the plate following laser scanning. Film produced the greatest maximum resolution followed by the storage phosphor and the CCD. In conclusion, CCD-based TMJ pantomography provided an instant image. The photostimulable phosphor system used was the least satisfactory in terms of the time expended to obtain an image, but provided better spatial resolution than the CCD. Ektavision film/screens provided the best spatial resolution in this investigation.

RVG-ui: a sensor to rival direct-exposure intra-oral x-ray film.

The RVG-ui is a solid-state system for dental x-ray imaging combining a charge-coupled device (CCD) of small pixel size (19.5 microns) with a caesium iodide (CsI) scintillator. It features two sizes of sensor with receptive areas that approach the size of No. 1 and No. 2 periapical x-ray films. The spatial resolution of the RVG-ui exceeds 20 lp/mm, rivaling direct-exposure intra-oral x-ray film when the latter is optimally exposed and processed. The recording latitude of the RVG-ui for clinically acceptable images is 25:1, making exposure error unlikely. In features such as speed of image acquisition, reduction in radiation dose, retrieval of data, and organization and storage of images, the RVG-ui system surpasses traditional x-ray film. Furthermore, it is possible to make accurate length measurements very quickly, and to apply an artificial intelligence program to determine the probability of proximal dental caries in enamel and dentin.

Panoramic dental radiography using a charge-coupled device receptor.

Panoramic radiography using a slit beam and film/screen receptor is standard for the emergency room evaluation of mandibular fractures and also in dentistry. This study compared the spatial resolution, area distortion factors, and the dosage considerations for a panoramic system where standard film/screen and a charge-coupled device were alternatively employed as the image receptor. Resolution and image contours were determined using a lead resolution grid positioned at selected beam projection angulations. Exposure measurements were carried out using a RANDO average man phantom and a 3 cc beryllium-windowed ionization chamber. The maximum spatial resolution with film approached 5 lp mm-1 whereas with the CCD the maximum resolution was just above 4 lp mm-1. Consequently, the image layer was reduced slightly in width when using the CCD receptor. The use of the CCD resulted in skin exposure reduction exceeding 70%.

Clinical trial of panoramic dental radiography using a CCD receptor.

The objective of this study was to evaluate the perceived clinical efficacy of a charge-coupled device (CCD) detector for panoramic radiography by comparing the images produced to conventional film/screen radiographs using the same machine and patient population. For clinical evaluation, 18 criteria were selected. These included overall assessment of the area of coverage, clarity of dental structures, clarity of bony outlines, specific anatomic details such as the maxillary sinus floor, mandibular canal and mandibular condyle, and region-by-region assessment of the dentition. Observers acted independently using identical optimal viewing conditions. Film and digital radiographs were evaluated separately. A five interval Likert rating scale was used. Digital images were rated superior to the conventional film radiographs for 14 criteria. Film radiographs marginally outperformed digital images for three criteria. For one criterion (periodontal bone status) the two modalities showed no difference in terms of the means ratings. It was concluded that digital images are clinically equivalent to conventional film/screen images for panoramic dental radiography.

Charge-coupled device panoramic radiography: effect of beam energy on radiation exposure.

OBJECTIVE: To determine the consequences for entrance exposure of varying the beam energy and operating current for panoramic radiography using a charge-coupled device receptor. MATERIAL AND METHODS: Images were made of a RANDO average man phantom (Alderson Research Laboratories, Stamford, CT) at kVcp settings of 60, 66, 70 and 80 and an mA of 2.0, 3.2, 6.4 and 10.0. The exposure cycle was set as recommended by the manufacturer at 17.6 s. Diagnostic image quality was rated by a panel of two oral and maxillofacial radiologists and one oral and maxillofacial pathologist. Entrance exposures were assessed using a 3 cc ionization chamber placed at the beam entry points while imaging the molar, premolar, and anterior teeth both using the DigiPan (Trophy Radiologie, Vincennes, France) CCD receptor and conventional T-Mat G film/Lanex Regular screens (Eastman Kodak, Rochester, NY, USA). RESULTS: Acceptable image quality was attained with combinations of 60 kVcp and 3.2, 6.4 or 10 mA, 70 kVcp and 2.0, 3.2 or 6.4 mA; at 80 kVcp irrespective of the mA it was unacceptable. The maximum reduction in entrance dose was 77%, averaged over the three sites, at 70 kVcp and 2 mA. CONCLUSION: The DigiPan receptor produces satisfactory images with saving in entry exposure saving of approximately 70% when compared with a conventional film/rare earth screen combination.

In vivo comparison of Visualix-2 and Ektaspeed Plus in the assessment of periradicular lesion dimensions.

UNLABELLED: Accurate assessment of intraosseous lesion dimensions is useful in determining strategies for treatment of periradicular pathoses of dental causation. OBJECTIVES: To compare the efficacy of digital versus analog imaging for the measurement of mesiodistal and vertical dimensions of periapical lesions in patients that require apical surgery. METHODS: Fourteen examiners assessed the dimensions of 28 lesions with a millimeter ruler and Ektaspeed Plus radiographs (Eastman Kodak, Rochester, N.Y.), and with the Visualix-2 (Gendex/Dentsply, Milan, Italy) in unenhanced, contrast-stretched and equalized modes with proprietary software mouse-driven measurement algorithm. Impregum F (Premier Dental Products) impressions at surgery were used as the "gold standard." Ten randomly chosen images were reread 2 weeks later to assess intra-operator reliability. As the Mauchly sphericity test was significant for all tests, a multivariate analysis of variance was used to assess accuracy. To explain the exact difference between means, the Bonferroni test was applied. Intra-observer reliability was assessed with Friedman's two-way analysis of variance; inter-observer effects were determined with Cronbach's alpha. RESULTS: For accuracy in measurement, the closest to the "gold standard" were achieved with the Visualix-2 with image equalization. The contrast-stretched Visualix-2 and unenhanced Visualix-2 measurements were less accurate; conventional film was consistently the least accurate (p < 0.002). On the other hand, subjective preference placed film radiographs above the unenhanced Visualix-2 images; contrast-stretched Visualix-2 images were preferred over all other modalities. CONCLUSIONS: Charge-coupled device-based images with the Visualix-2 are preferable to film-based radiographs for measuring periapical lesion dimensions.

The OP 100 Digipan: evaluation of the image layer, magnification factors, and dosimetry.

OBJECTIVES: The purpose of this study was to describe the Orthopantomograph OP 100 Digipan modification and to determine the image-layer and dosimetric characteristics of this system. RESEARCH DESIGN: Image-layer contours for the Digipan were determined at resolution limits of 4.0, 3.0, and 1.5 line pairs (Ip) mm(-1) using a resolution grid positioned at intervals along the beam projection paths. A hexagonal test device was placed above the grid to determine the magnification factors at the selected resolution limits. For dosimetry, a 30 mm2 ionization chamber was placed at the beam entry points while imaging the molar, premolar, and anterior teeth using both the Digipan and conventional film receptors. RESULTS: The maximum resolution exceeded 4.0 Ip mm(-1)in the center of the image layer. Using a 1.5 Ip mm(-1) resolution limit, the focal trough width was 14 mm at 0-degree horizontal angulation, 20 mm at 37 degrees, and 36 mm at 83 degrees. At 1.5 Ip mm(-1), the horizontal magnification was -21% facial and +42% lingual to the center of the image layer in the incisor region; -25% facial and +19% lingual to the center of the image layer at a horizontal angulation of 83 degrees. At 4.0 Ip mm(-1), horizontal magnifications in the incisor region were -2.0% facially and +0.5% lingually; at 83 degrees they were -3.9% facially and +1.1% lingually. The neck entrance dose for imaging the anterior and premolar regions averaged 89.5 (+/-5.6) microGy. The cheek entrance doses for imaging the molar region averaged 220.6 (+/-8.0)microGy with the Digipan. With film the average entrance doses were 297.9 (+/-8.6) microGy (anterior and premolar regions) and 682.1 (+/-16.9) microGy (molar region). CONCLUSIONS: The Digipan image layer is similar, but slightly narrower than that previously reported for the Orthopantomograph OP 100 using standard film-screen combinations. The resolution at the center of the image layer exceeded 4.0 Ip mm(-1). The Digipan produced images with an entry dose savings of approximately 70% when compared with photo-timed exposures using conventional film with the Orthopantomograph OP 100.

[Forensic medical implications in the course of sclerotherapy of varicose veins]. / Implications médico-légales au cours du traitement sclérosant des varices.

Complications are exceptional compared to the number of sclerosis treatments performed. We report 58 case-files with medico-legal implications. Intraarterial injections are by far the most severe complications: we observed 40 such cases with the following consequences: 7 major amputations including 2 above the knee and 5 below the knee, 6 minor peripheral amputations of one or more toes, 27 severe sequelae, mainly due to retraction of the triceps sural muscle. This type of accident occurs more readily after attempted sclerosis of the lesser saphenous vein "crosse", although other localizations can be involved: inguinal area by sclerosis of the greater saphenous vein "crosse", the lower third of the leg with direct injection into the anterior or posterior tibial artery or its branches. Subcutaneous injections of the sclerosis agent produce either simple inflammatory reactions or skin necrosis. Neurological disorders can be observed by direct damage to the nerve. Sensorial complications may occur by lesion of a cutaneous branch of the popliteal sciatic nerve. Other cases involve motor disorders. Pulmonary thromboembolic events (4 cases) appear to be exception when modern criteria for the diagnosis of phlebitis are used. General allergic and anaphylactic reactions are very rare and often related to overdose. The same is true for toxic reactions. One case of septicemia occurred after incision of post-sclerosis clots. From a medicolegal point of view, the responsibility of the practician is usually confirmed for severe accidents (intraarterial injections) leading to trophic disorders. For necrosis or limited eschars, the question is debated.

Optical densities of dental resin composites: a comparison of CCD, storage phosphor, and Ektaspeed plus radiographic film.

Density versus exposure was determined for digital and film radiographic images of various thicknesses of six dental resin composites. The curves were relatively parallel; saturation at the black end of the contrast scale occurred at lower exposures with Computed Dental Radiography (CDR, Schick Industries, Long Island City, NY) than with the Sens-A-Ray (Regam AB, Sundsvall, Sweden). Ektaspeed Plus film (Kodak Dental Products, Rochester, NY) was the least sensitive modality tested. The DIGORA storage phosphor system (Soredex-Orion, Helsinki) had a wide exposure latitude with significantly less steep characteristic slopes than for images from the charge-coupled devices (CCDs). Slopes generated for the Sens-A-Ray and the CDR were not significantly different. Slopes generated for each resin composite were not significantly different for each of the modalities. Relative radiopacities of the resin materials with respect to each other were constant across all modalities; hence, in these systems, sensor type is unlikely to affect differentiation between resin composites and dental enamel or recurrent caries.