[Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]. / Modalités de décision de limitation thérapeutique chez les traumatisés crâniens sévères : enquête auprès des neurochirurgiens en France.

BACKGROUND/INTRODUCTION: In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. AIM OF THE STUDY: The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. METHODS: A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. RESULTS: Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. CONCLUSIONS: Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.

Three-dimensional imaging, an important factor of decision in breast augmentation.

INTRODUCTION: Since the beginning of the 21st century, three-dimensional imaging systems have been used more often in plastic surgery, especially during preoperative planning for breast surgery and to simulate the postoperative appearance of the implant in the patient's body. The main objective of this study is to assess the patients' attitudes regarding 3D simulation for breast augmentation. METHOD: A study was conducted, which included women who were operated on for primary breast augmentation. During the consultation, a three-dimensional simulation with Crisalix was done and different sized implants were fitted in the bra. RESULTS: Thirty-eight women were included. The median age was 29.4, and the median prosthesis volume was 310mL. The median rank given regarding the final result was 9 (IQR: 8-9). Ninety percent of patients agreed (66% absolutely agreed, and 24% partially agreed) that the final product after breast augmentations was similar to the Crisalix simulation. Ninety-three percent of the patients believed that the three-dimensional simulation helped them choose their prosthesis (61% a lot and 32% a little). After envisaging a breast enlargement, patients estimated that the Crisalix system was absolutely necessary (21%), very useful (32%), useful (45%), or unnecessary (3%). Regarding prosthesis choice, an equal number of women preferred the 3D simulation (19 patients) as preferred using different sizes of implants in the bra (19 patients). CONCLUSION: The present study demonstrated that 3D simulation is actually useful for patients in order to envisage a breast augmentation. But it should be used as a complement to the classic method of trying different sized breast implants in the bra.

[Tobacco and plastic surgery: An absolute contraindication?] / Tabac et interventions de chirurgie plastique : vers une contre-indication formelle ?

INTRODUCTION: Smoking increases perioperative risk regarding wound healing, infection rate and failure of microsurgical procedures. There is no present consensus about plastic and aesthetic surgical indications concerning smoking patients. The aim of our study is to analyze French plastic surgeons practices concerning smokers. METHOD: A questionnaire was send by e-mail to French plastic surgeons in order to evaluate their own operative indications: patient information about smoking dangers, pre- and postoperative delay of smoking cessation, type of intervention carried out, smoking cessation supports, use of screening test and smoking limit associated to surgery refusing were studied. Statistical tests were used to compare results according to practitioner activity (liberal or public), own smoking habits and time of installation. RESULTS: In 148 questionnaires, only one surgeon did not explain smoking risk. Of the surgeons, 49.3% proposed smoking-cessation supports, more frequently with public practice (P=0.019). In total, 85.4% of surgeons did not use screening tests. Years of installation affected operative indication with smoking patients (P=0.02). Pre- and postoperative smoking cessation delay were on average respectively 4 and 3 weeks in accordance with literature. CONCLUSION: Potential improvements could be proposed to smoking patients' care: smoking cessation assistance, screening tests, absolute contraindication of some procedures or level of consumption to determine.

Oral information in orthopaedics: how should the patient's understanding be assessed?

INTRODUCTION: Patient information is governed by recommendations of best practices required from any healthcare professional. The aim of this study was to design a tool to measure patient comprehension of the information provided during a surgical consultation before a scheduled surgery. MATERIAL AND METHODS: This was a single-center prospective study of 21 patients using a rating scale-type visual analog scale. Each patient was interviewed and asked to score his or her understanding of the information provided. The investigator checked the external validity of the tool using questions to assess patient's understanding level. RESULTS: The results show that there is a tendency to overvalue some information (reasons for the intervention and alternatives to surgery) and that certain information is not understood (risks and complications) or not provided (postoperative follow-up). CONCLUSION: This study confirms that a rating scale can measure the understanding of information and there is a variation between perceived and actual understanding.

[Photography in plastic surgery: practices, uses and legislation]. / Photographies en chirurgie plastique: pratiques, usages et législation.

INTRODUCTION: Photography in plastic surgery is omnipresent. Through its various uses, it may present both ethical and forensic risks. The objective of this study is to analyze the use of medical photography by the plastic surgeon, the perception of this use by the patient, and consequence of such use. METHOD: A questionnaire about the use of medical photography was assessed to 629 plastic surgeons. A questionnaire was given to patients, about their perception of the use of photography by their surgeon. RESULTS: One hundred and seventy-six surgeon's questionnaires and 93 patient's questionnaires were analyzed. For 97.7% of the responding surgeons, the proportion of patients refusing to be photographed was less then 1/20. The objective of the photography was especially medicolegal for 62.5% of the surgeons, especially for following the patient progress (87.5%), partially for the formation (72.1%), partially for scientific publications (57.8%) and not at all for the personal publicity (73.1%). Surgeons often share his photographs with others surgeons (71.1%), sometimes with others medical personnel (48.8%). The security and the access to photographs were determined to be correct for 67.6% of the surgeons and perfect for 23.3%. In total, 17.2% of the surgeons obtained a written consent, 41.4% obtained an oral consent, and 38.5% did not request patient consent. It was found that 48.3% of the surgeons and 40.2% of the patients think that the right to the photographic images belong to the patient. CONCLUSION: Medical photographs expose the plastic surgeon to medico-legal risks. He must know and follow the law in order to prevent eventual legal proceedings.

[Perioperative conflicts between anaesthesiologists and surgeons: ethics and professionalism]. / Conflits en période périopératoire: un enjeu collectif, éthique et professionnel.

In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others' constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.

[Trusted person and living will: information and implementation defect]. / Personne de confiance et directives anticipées: défaut d'information et de mise en œuvre.

PURPOSE: The French law allows the persons of age to appoint a trusted person and to draft advance directives in case they are one day in a condition that prevents them from expressing their will regarding their health care. Our study objective was to assess patients' and relatives' knowledge and collecting their opinion regarding these means of expression of their will. METHODS: An anonymous survey by self-administered questionnaire was conducted in the admission offices of the University Hospital of Nancy in April 2011. The questions focused on trusted person and anticipated directives. RESULTS: We collected 367 answers, 61.8% of which were females. Average age of respondents was 48.7 years old (standard deviation: 15.6). Three fourths of respondents were informed of their possibility to appoint a trusted person and were able to establish the difference between a trusted person and a contact person. Respondents mainly chose their spouse (52%). They thought that the trusted person's opinion takes precedence over the family's or relatives' one (64.7%), given that this opinion is based on indications previously provided by the patient (74.8%). The majority of people surveyed were ignorant of the possibility to draft advance directives but were glad of it (57.5%). They would include herein their refusal of unreasonable obstinacy (75.8%), their wishes to withhold/withdraw of some treatments, to stop active treatments in case of high odds of chronic coma or vegetative state (52.8%) or their will to donate organ after death (50.6%). More than three fourths of the patients wished to include these informations on their health care card chip. CONCLUSION: Legal means of expression of the patient's wishes and are not systematically known by the population. The possibility to appoint a trusted person is much more known than that to draft advance directives. After the release in December 2012 of the Sicard report regarding the end of life in France, an important information campaign of the general public remains to be undertaken.

[Morbidity and mortality conferences in anaesthesia and intensive care: experience feedback from Nancy university hospital]. / Revues de morbi-mortalité (RMM) en anesthésie-réanimation : retour d'expérience au CHU de Nancy.

OBJECTIVES: Assessment of the morbidity mortality conferences (MMC) durableness in the Anaesthesiology and Surgical Intensive Care Department of the Urban Hospitals of Nancy University Hospital; evaluation of the proportion of medical education in the corrective actions implemented, and research for improvement ways. PATIENTS: All the cases of death and near-death in the operating room and all the cases deemed to be instructive or useful for security improvement. METHOD: Retrospective analysis of MMC activity since its initiation in 2005. RESULTS: Durability of MMC and good attendance rate have been sustained over time. As in the USA, MMCs result firstly in resident's education and continued medical education actions. Medical education actions represent 75% of all corrective measures, followed by changes in practices (62%), in procedures (48%) and in organisation (5%). DISCUSSION: The development process of a culture of the safety has been initiated and perpetuated. Some ways of improvement have been proposed: MMC must certainly be widened as well regarding to the categories of addressees, as the topics (any event deemed to be noteworthy for the safety of care) or the time scale of the analysis. Others propositions: preparation of the presentations with a colleague experienced in MMC; participation of external MMC experts; monitoring of local markers of security of care and of corrective measures efficiency; inclusion of MMC cases presentation in the trainees pedagogic objectives.

[Research in clinical epidemiology: which rules should be applied?]. / Recherche en épidémiologie clinique: quelles règles appliquer?

The adaptation of the European directive 2001/20/CE on clinical drug trials was the opportunity for a profound reform of the legislative framework on biomedical research in France. Within the main innovations, the distinction between the three broad research categories was retained: biomedical research, research on standard care, and non-interventional research. These changes have rendered the legislative arsenal of research more complex, and therefore these changes should be reviewed. This article presents how the 2007 French healthcare research regulations can be applied. Briefly, four questions should be asked before research is undertaken: (1) does the study require a specific procedure on a person (intervention or investigation)? (2) Does it use material from the human body that will be preserved or discarded? (3) Does it require processing personal patient data? (4) Does it include genetic data? Researchers are expecting a simplification of procedures with the new regulations. This objective has been partially met, but a certain number of questions remain unanswered, particularly in the field of epidemiology.

[Therapeutic education for heart failure: a necessity in 2007]. / Education thérapeutique pour l'insuffisance cardiaque: une nécessité en 2007.

Heart failure is a severe illness, marked with a still too high morbidity and mortality. Therapeutic education, fundamental for any chronic pathology, is taking a more and more important place in heart failure. Its value has been proved, and its importance in the multidisciplinary management of heart failure patients has been confirmed in terms of improving the prescription of medical treatment and allowing a better quality of life. France was late to recognise this technique, but the successful development of the I-CARE programme should contribute to improving both the quality of care for patients and the understanding of this pathology.

[Market licensing authorisation: medico-legal impact]. / Recommandations et autorisation de mise sur le marché: quel impact médico-légal?

Respecting market licensing authorisation recommendations is a prudent and preventive policy in respect of professional liability, but is not sufficient to avoid all of the doctor's responsibility. Conversely, not respecting the recommendations or off-indication prescribing does not necessarily make the practitioner liable. Although neither the recommendations, nor the market licensing authorisation are legally binding for the cardiologist, they can be invoked during a lawsuit. For this reason it seemed appropriate for us to study the medico-legal impact.

[Medical ethics and human rights training in Europe]. / Enseignement de l'éthique et des Droits de l'Homme en Europe.

In 1999 the World Medical Association (WMA) issued a declaration recommending that there be the teaching of medical ethics and human rights included in the basic medical school curricula across Europe. The study aims to investigate the level of medical ethics and human rights training provided and to take an inventory of the existing programmes in the European Union's medical schools. The study was carried out using a self-administered questionnaire which was disseminated in the year 2002 to 219 schools of medicine in 14 of the 15 European Union member states (Luxembourg did not yet have a school of medicine). One-fourth of the medical schools solicited sent back a reply. Medical ethics are taught in 93% of medical schools; its teaching is of a multi-disciplinary and cross-cutting nature in 80% of the schools. Courses on ethics are compulsory in 75% of the cases. Human rights are taught in 63% of the European medical schools, and it is most often the case that the teaching of human rights is incorporated into the ethics courses. Even if the WMA's recommendation is not always fully implemented according to the guidelines of their declaration, this study demonstrates and reveals nonetheless the increasing of awareness and realization by European medical schools of the significance of including such a track in their programme.

[Requests for access to medical files at the Nancy University Hospital Center]. / Evaluation des demandes d'accès au dossier medical au CHU de Nancy.

OBJECTIVE: Law 2002-303 of March 04, 2002, authorizes patients to have direct access to their medical record, without requiring a physician to serve as interme-diary. The aim of this study was to characterize these requests for a 23-month period. METHOD: A database was created to record information about these requests. The descriptive and quantitative analysis here covers 23 months. RESULTS: There were 942 requests in all, 64.5% by patients themselves and 18.5% by their heirs or assignees. The mean age of the patients seeking access to their medical file was 53 years, with a slight majority of men. Heirs and assignees av-eraged 49 years of age and were generally women. Thirty percent of them reported wanting some additional information, while 51% requested a copy of the entire file. Only 5.8% asked for a physician to help them understand the file, although that was systematically offered. CONCLUSION: Patients' new legal rights to direct access to their medical files imply that physicians will modify the way they maintain these files.