The role of perinatal palliative care following prenatal diagnosis of major, incurable fetal anomalies: a multicentre prospective cohort study.

OBJECTIVE: To describe prenatal decision-making processes and birth plans in pregnancies amenable to planning perinatal palliative care. DESIGN: Multicentre prospective observational study. SETTING: Nine Multidisciplinary Centres for Prenatal Diagnosis of the Paris-Ile-de-France region. POPULATION: All cases of major and incurable fetal anomaly eligible for TOP where limitation of life-sustaining treatments for the neonate was discussed in the prenatal period between 2015 and 2016. METHODS: Cases of congenital defects amenable to perinatal palliative care were prospectively included in each centre. Prenatal diagnosis, decision-making process, type of birth plan, birth characteristics, pregnancy and neonatal outcome were collected prospectively and anonymously. MAIN OUTCOME MEASURE: Final decision reached following discussions in the antenatal period. RESULTS: We identified 736 continuing pregnancies with a diagnosis of a severe fetal condition eligible for TOP. Perinatal palliative care was considered in 102/736 (13.9%) pregnancies (106 infants); discussions were multidisciplinary in 99/106 (93.4%) cases. Prenatal birth plans involved life-sustaining treatment limitation and comfort care in 73/736 (9.9%) of the pregnancies. The main reason for planning palliative care at birth was short-term inevitable death in 39 cases (53.4%). In all, 76/106 (71.7%) infants were born alive, and 18/106 (17%) infants were alive at last follow-up, including four with a perinatal palliative care birth plan. CONCLUSIONS: Only a small proportion of severe and incurable fetal disorders were potentially amenable to limitation of life-sustaining interventions. Perinatal palliative care may not be considered a universal alternative to termination of pregnancy. TWEETABLE ABSTRACT: Perinatal palliative care is planned in 10% of continuing pregnancies with a major and incurable fetal condition eligible for TOP.

Dental pulp inflammatory/immune response to a chitosan-enriched fibrin hydrogel in the pulpotomised rat incisor.

Current pulpotomy is limited in its ability to induce regeneration of the dental-pulp (DP) complex. Hydrogels are reported to be well-suited for tissue engineering and are unlikely to induce an inflammatory response that might damage the remaining tissue. The present study investigated the molecular and cellular actors in the early inflammatory/immune response and deciphered M1/M2 macrophage polarisation to a chitosan-enriched fibrin hydrogel in pulpotomised rat incisors. Both fibrin and fibrin-chitosan hydrogels induced a strong increase in interleukin-6 (IL-6) transcript in the DP when compared to the DP of untreated teeth. Gene expression of other inflammatory mediators was not significantly modified after 3 h. In the viable DP cell population, the percentage of leukocytes assessed by flow cytometry was similar to fibrin and fibrin-chitosan hydrogels after 1 d. In this leukocyte population, the proportion of granulocytes increased beneath both hydrogels whereas the antigen-presenting cell, myeloid dendritic cells, T cells and B cells decreased. The natural killer (NK) cell population was significantly decreased only in DPs from teeth treated with fibrin-chitosan hydrogel. Immunolabeling analysis of the DP/hydrogel interface showed accumulation of neutrophil granulocytes in contact with both hydrogels 1 d after treatment. The DP close to this granulocyte area contained M2 but no M1 macrophages. These data collectively demonstrated that fibrin-chitosan hydrogels induced an inflammatory/immune response similar to that of the fibrin hydrogel. The results confirmed the potential clinical use of fibrin-chitosan hydrogel as a new scaffold for vital-pulp therapies.

Intraoperative cerebral hypoperfusion and electroencephalogram suppression resulting in neurological complications after cardiac surgery : the need for an in depth investigation.

Reports on the demographic profile of older populations estimate that, in 2050, 19 countries will have at least 10% of their population aged 80 years or more. Many high risk elderly patients undergo cardiac surgery. In addition, advanced age has been shown to be a strong predictor of adverse neurological outcome. Despite sig- nificant improvements achieved in the perioperative care of cardiac surgical patients, neurological complications remain a global health issue. Recent findings have pointed out that cerebral hypoperfusion and too deep levels of anesthesia are major sources of adverse neurological outcomes. Cerebral near-in-frared spectroscopy provides information about cerebral perfusion non-invasively, and is increasingly used. Depth of anesthesia is evaluated using monitors that are based on processed electroencephalogram. This non-systematic review focuses on the results of studies performed with each monitor separately, and the need for a combined evaluation of their utility and eventual impact on neurological outcomes. The use of a combined cerebral monitoring strategy based on the two aforementioned monitors is proposed in order to optimize cerebral outcomes.

Thermal ablation techniques: a curative treatment of bone metastases in selected patients?

INTRODUCTION: Thermal ablation techniques (radiofrequency-ablation/cryotherapy) can be indicated with a curative intent. The success rate and prognostic factors for complete treatment were analysed. MATERIAL/METHODS: The medical records of all patients who had undergone curatively intended thermal ablation of bone metastases between September 2001 and February 2012 were retrospectively analysed. The goal was to achieve complete treatment of all bone metastases in patients with oligometastatic disease (group 1) or only of bone metastases that could potentially lead to skeletal-related events in patients with a long life expectancy (group 2). We report the rate of complete treatment according to patient characteristics, primary tumour site, bone metastasis characteristics, radiofrequency ablation/cryotherapy and the treatment group (group 1/group 2). RESULTS: Eighty-nine consecutive patients had undergone curatively intended thermal ablation of 122 bone metastases. The median follow-up was 22.8 months [IQR = 12.2-44.4]. In the intent-to-treat analysis, the 1-year complete treatment rate was 67% (95%CI: 50%-76%). In the multivariate analysis the favourable prognostic factors for complete local treatment were oligometastatic status (p = 0.02), metachronous (p = 0.004) and small-sized (p = 0.001) bone metastases, without cortical bone erosion (p = 0.01) or neurological structures in the vicinity (p = 0.002). CONCLUSION: Thermal ablation should be included in the therapeutic arsenal for the cure of bone metastases. KEY POINTS: • Thermal ablation techniques are currently performed to palliate pain caused by bone metastases. • In selected patients, thermal ablation can also be indicated with a curative intent. • Oligometastatic and/or metachronous diseases are good prognostic factors for local success. • Small-size (<2 cm) bone metastases and no cortical erosion are good prognostic factors.

Clinical benefit of anti-PD-(L)1 immunotherapies in advanced cancer in France: a population-based estimate from 2014 to 2021.

BACKGROUND: In France, the potential benefit of new treatments is initially evaluated by the Haute Autorité de Santé to determine reimbursement and pricing, but rarely afterwards. Although immunotherapies (ITs) have considerably improved the survival of patients, few data are available on their long-term benefit at a population-treated level. The present retrospective study aimed to assess the clinical benefit of ITs compared to the previous standards of care (SoCs) in France from 2014 to 2021. MATERIALS AND METHODS: To do this, we analyzed all ITs from the anti-programmed cell death protein 1/programmed death-ligand 1 [anti-PD-(L)1] class used in monotherapy or in association with another treatment available in early access or reimbursed in France between 2014 and 2021, regardless of indication. The number of patients initiating an IT was retrieved by year, drug and indication. Using extrapolated Kaplan-Meier curves, utility scores and the population treated, the clinical benefit was expressed as the number of deaths prevented (DP), life-years (LYs) and quality-adjusted life years (QALYs) gained compared to previous SoC. RESULTS: Across the period, five ITs were marketed in 21 indications related to eight primary tumor sites. Between 2014 and 2021, 132 924 patients initiated an IT. By December 2021, 16 173 (13 804-17 141) deaths were delayed compared to previous SoC, mainly in lung cancer. Compared to their SoC, ITs provided a gain of 37 316 (33 581-41 048) additional LYs and 27 709 (23 784-30 450) additional QALYs. Lung cancer was the driver indication with 70.6% of LYs and 68.4% of QALYs gained followed by melanoma with 18.7% and 20.4% of the gain, respectively. CONCLUSIONS: Significant gains in DP, LYs and QALYs have been observed in France following the introduction of ITs.

A delivery system of linezolid to enhance the MRSA osteomyelitis prognosis: in vivo experimental assessment.

Staphylococcus aureus, a major responsible microorganism of osteomyelitis, represents a challenge to treat because of the poor penetration of antibiotics in bone and increasing minimum inhibitory concentrations (MICs) to glycopeptides. The calcium-deficient apatites (CDA), closer to the biological components found in bone and other calcified tissues, have osteoconductive properties. So, to process severe osseous infections, CDA can be used to deliver in the infectious site antibiotics like linezolid. The acute experimental osteomyelitis due to methicillin-resistant Staphylococcus aureus (MRSA) was induced in rabbit's femurs and surgery mimicking human procedures was performed at day three after inoculation. Animals were randomly assigned to treatment groups: L((IV)) [4-day linezolid IV infusion, human-equivalent dose of 10 mg/kg/12 h], L((CDA50%)) (100 mg CDA with linezolid 500 µg/mg) and L((CDA50%)) + L((IV)). Surviving bacteria were counted in bone marrow (BM) and bone (Bo) at day 3 (before treatment), day 7 (4-day treatment) or day 17 (14-day treatment). L(iv) was effective after a 4-day treatment with a log(10)CFU/g decrease of -2.63 ± 1.92 and -2.17 ± 1.58 in bone marrow and bone, respectively. CDA loaded with linezolid enhance the efficacy of the IV linezolid regimen by more than one log(10)CFU/g.

Validation of the adherence evaluation of osteoporosis treatment (ADEOS) questionnaire for osteoporotic post-menopausal women.

SUMMARY: We developed and validated a specific 12-item questionnaire to evaluate adherence to oral antiresorptive medication by post-menopausal osteoporotic women in everyday practice. Over the following 9 months, an index of ≤16 was associated with an increase in the risk of treatment discontinuation of 1.69 and of 2.10 for new patients who had started treatment within the previous year. INTRODUCTION: Adherence to medication in osteoporosis is poor. The goal of this study was to develop and validate a disease-specific questionnaire to evaluate adherence to treatment of women with post-menopausal osteoporosis taking oral antiresorptive medication. METHODS: A prototype adherence questionnaire with 45 items developed from patient interview, literature review, and physician opinion was evaluated in a sample of 350 post-menopausal women with osteoporosis treated in primary care. Item responses were matched against scores on the Morisky Medication Adherence Scale (MMAS). The most discriminant items were retained in the final questionnaire. Concurrent and predictive validity were assessed. RESULTS: Twelve items were associated with MMAS score at a probability level of 0.05. These were retained in the final questionnaire which provided an adherence index ranging from 0 to 22. An index of ≥20 was associated with a high probability of persistence and an index ≤ 16 with a high probability of treatment discontinuation in the following 9 months. CONCLUSIONS: The ADEOS-12 is a simple patient-reported measure to determine adherence to osteoporosis treatments with good concurrent and discriminant validity. This is the first disease-specific adherence measure to have been developed for osteoporosis.

Time to next treatment or death as a candidate surrogate endpoint for overall survival in advanced melanoma patients treated with immune checkpoint inhibitors: an insight from the phase III CheckMate 067 trial.

BACKGROUND: Time to next treatment or death (TNT-D) may be a patient-relevant endpoint in patients treated with immune checkpoint inhibitors. This study investigated TNT-D as a surrogate endpoint (SE) for overall survival (OS) in previously untreated advanced melanoma patients. METHODS: Patient-level data from the 60-month results of the CheckMate 067 randomised, controlled trial were used. Analyses were carried out for nivolumab monotherapy or nivolumab with ipilimumab versus ipilimumab monotherapy. The SE 1-step validation method based on a joint frailty-copula model was used where the country of enrolment was applied to define clusters. Kendall's τ and the coefficient of determination (R2trial) were estimated for respective measurements of association at the individual and cluster levels. The surrogate threshold effect, the maximum threshold hazard ratio for TNT-D that would translate into OS benefit, was estimated. A leave-one-out cross-validation analysis was carried out to evaluate model robustness. RESULTS: Fifteen clusters of data were generated from 945 patients. For both nivolumab-containing arms, the association between TNT-D and OS was deemed acceptable at the individual level (Kendall's τ > 0.60) and strong at the cluster level, with R2trial fairly close to 1, with narrow confidence intervals. The estimated surrogate threshold effects were 0.61 for nivolumab versus ipilimumab and 0.49 for nivolimub + ipilimumab versus ipilimumab. Cross-validation results showed minimum variation of the correlation measures and satisfactory predictive accuracy for the model. CONCLUSION: Results suggest that TNT-D may be a valuable SE in previously untreated advanced melanoma patients treated with immune checkpoint inhibitors. Surrogacy analyses considering multiple randomised controlled trials are warranted for confirming these findings.

A new experimental model of acute osteomyelitis due to methicillin-resistant Staphylococcus aureus in rabbit.

AIMS: To assess the impact of antibiotic therapy on severe osseous infections, animal models of chronic bacterial infections have been developed; however, these models suffer from many experimental limitations. The aim of this work was to develop a new model system in which high levels of bacteria are obtained within femoral bone marrow and bone tissue, and such infections are maintained for at least 14 days. METHODS AND RESULTS: Experimental osteomyelitis was induced in 25 New Zealand white rabbits. A 10(9) CFU ml(-1) suspension of methicillin-resistant Staphylococcus aureus was injected into the knee after bone trepanation. On day 3, surgical debridement was performed to mimic a surgical procedure. Animals were euthanized 1, 2, 3, 9 and 14 days post-inoculation to determine the bacterial counts in marrow and bone, and to evaluate the stability of the infection. Inoculated lesions also were assessed for changes in histological parameters on days 3 and 7 post-inoculation. At days 1, 2, 3, 9 and 14 post-inoculation, we observed 6·50 ± 0·64, 7·30 ± 0·49, 7·82 ± 0·19, 8·00 ± 1·48 and 8·99 ± 0·20 log10 CFU g(-1) in bone marrow and 8·40 ± 0·68, 7·65 ± 0·27, 7·58 ± 0·30, 8·88 ± 0·52 and 8·28 ± 0·39 log10 CFU g(-1) in bone tissue, respectively. No statistical differences in bacterial count were found between bone marrow and bone tissue at any time point. CONCLUSION: This new model of acute osteomyelitis was validated by histological and microbiological changes in the absence of sclerosing agents, and these changes remained stable for 14 days. SIGNIFICANCE AND IMPACT OF THE STUDY: These results describe a new experimental model of acute osteomyelitis and demonstrate its usefulness in assessing the activity of antibacterial agents in vivo soon after bone infection.

Crop diversity management: Sereer smallholders' response to climatic variability in Senegal.

Beyond the observation of climatic variations and their impact on livelihoods, farmers' knowledge about climate change? can help understand how rural populations respond to environmental changes and what factors should policies consider when planning rural adaptation. This study documents Sereer farmers' observations of local environmental changes in the Fatick region of Senegal and explores how the farmers use crop diversity to adapt to those changes. Their observations of environmental changes were documented through focus group discussions and semi-structured interviews. Variations in crop diversity as well as farmers' explanations for these variations were assessed through surveys in two villages (n=126 households). Sereer farmers identify four distinct periods of similar climate trends and reported how they managed crop diversity in response to the climate variations between periods. Three management responses stand out: abandonment of long-cycle varieties during drought periods, adoption of short-cycle varieties during periods with shorter rainy seasons, and reinstating of long-cycle varieties with the return of rains. Sereer farmers consider that climate variations are important reasons to modify their crop varieties, although variety selection is also affected by other socio-economic and cultural reasons. This study illustrates the contributions that local knowledge can bring to understanding the local impact of climate change on smallholder farmers. Understanding how they use crop diversity to adapt to climate variations can be the bases of climate change adaptation policies that address local needs and constraints.

Management of lung cancer patients' quality of life in clinical practice: a Delphi study.

BACKGROUND: The assessment of health-related quality of life (HRQoL) has seen exponential growth in oncology clinical trials. However, the measurement of HRQoL has yet to be optimised in routine clinical practice. This study aimed at exploring the operationalisation of HRQoL in clinical practice with the goal of reaching a consensus from a panel of physicians. MATERIALS AND METHODS: Physicians involved in the management of lung cancer patients in France were recruited to participate in a Delphi study. The study involved three rounds of iterated queries to gain consensus on management aspects of HRQoL, including timing of discussion on HRQoL, which specific domains of HRQoL should be discussed, and what was the most appropriate method of assessment. The threshold adopted for consensus was at least 70% agreement among physicians. A scientific committee reviewed results following each round of the Delphi study. RESULTS: A representative panel of 60 physicians participated in this study. Consensus was obtained for HRQoL management at all time points in the patient care pathway. Panellists agreed that HRQoL discussions should occur during routine visits and hospitalisation. The involvement of patients' relatives was also recognised as important, except when discussing side-effects and involvement of a multidisciplinary team. There was a lack of consensus on a systematic assessment for all patients at each visit and no consensus on how HRQoL should be measured in clinical practice. CONCLUSIONS: HRQoL discussions are considered an integral part in the management of lung cancer patients, and are deemed key to success in patient-physician interaction. Further research is required to harmonise how best to implement HRQoL assessment.

Adherence to monthly and weekly oral bisphosphonates in women with osteoporosis.

UNLABELLED: This primary care database survey evaluated whether osteoporotic women treated with bisphosphonates were more adherent to monthly than to weekly treatment. Both compliance (medication possession ratio [MPR]) and persistence (time to discontinuation) were superior in the monthly ibandronate treatment group. Better control of fracture risk may thus be achieved using monthly treatment regimens. INTRODUCTION: Treatment adherence in osteoporosis is poor. The objective of this study was to evaluate whether monthly bisphosphonate treatment provided superior adherence than weekly treatment. METHODS: We analysed medical claims from a national prescription database (Thales). All women aged >45 years receiving a first prescription of monthly ibandronate or weekly bisphosphonates in 2007 were included. Treatment adherence was monitored from initial prescription until January 2008. Compliance was measured by the MPR and persistence by the time from treatment initiation to discontinuation. Multivariate analysis was used to identify variables independently associated with adherence. RESULTS: Twelve-month persistence rates were 47.5% for monthly ibandronate and 30.4% for weekly bisphosphonates. Compliance was significantly higher in the monthly cohort (MPR = 84.5%) than in the weekly cohort (MPR = 79.4%). After adjustment for potential confounding variables, women with monthly regimens were 37% less likely to be non-persistent (HR = 0.63 [0.56-0.72]) and presented a 5% higher mean MPR (84.5% versus 79.3%, p < 0.001) than women with weekly regimens. Other major factors associated with improved adherence were previous densitometry and calcium or vitamin D supplementation (p < 0.01). CONCLUSIONS: Adherence to bisphosphonates may be superior for monthly treatment than for weekly treatment and may thus provide improved fracture protection.

Antibiotic prophylaxis of infective endocarditis in patients with predisposing cardiac conditions: French cardiologists' implementation of current guidelines.

BACKGROUND: To prevent infective endocarditis (IE), with the exception of the United Kingdom, antibiotic prophylaxis (AP) is recommended in patients with predisposing cardiac conditions (PCCs) worldwide. To conclude on the relevance of this strategy, how the current guidelines are applied is a crucial point to investigate. The first aim of this study was to assess cardiologists' implementation of the current guidelines. The secondary objective was to identify specific areas where the training and knowledge of French cardiologists could be improved. METHODS: A national online survey was carried out among the 2228 cardiologist members of the French Society of Cardiology. RESULTS: The high risk PCCs for which IE AP is recommended were correctly identified by the vast majority of the respondents so that IE AP is mostly prescribed correctly in such patients. But only 12% identified all the right indications for IE AP according to 13 predefined PCCs (3 at high-risk, 6 at moderate-risk and 4 at low-risk of IE) so that some IE AP misuses are recorded, overprescription in particular. Only 47% prescribed the proper amoxicillin schedule and only 15% prescribed the appropriate clindamycin schedule in cases with penicillin allergy. CONCLUSION: This study evidenced relevant areas where the training of cardiologists could be improved such as knowledge of the risk of IE for certain PCCs and some common invasive dental procedures. Cardiologists' knowledge should be improved before any conclusion can be drawn on the relevance of this AP strategy and its influence on IE incidence.

[Safety and accuracy of surgical procedures: case law evolution]. / L'exactitude du geste chirurgical: évolution de la jurisprudence.

Surgeons, like other doctors, practice their profession within a framework of contractual liability defined by statute in 1936. This established that the doctor was subject to a contractual obligation to provide appropriate and diligent care. Care and technical acts should conform to those which would have been provided by a prudent doctor within the standards of knowledge and practice of his field; care which deviates from this standard would be considered medical error or fault. This standard of care is referred to as "sound professional conduct". However, while not calling this basic principle into question, civil jurisdictions have progressively held surgeons liable whenever injury has occurred following surgical acts, without considering whether care deviates from sound professional conduct. Since 2000, judges have begun to attribute a requirement for absolute safety of results in cases where the surgeon had injured an organ unrelated to the planned operation. However it seems that the rare judgments given on this topic in the last 2-3 years have become less frequent. The creation of a compensation regime for medical accidents, via the law dated March 4, 2002, has contributed to this evolution. It is to be hoped that the flaws described in this system do not encourage jurisdictions to reconsider previous case law decisions.

Lipoxin A4 Attenuates the Inflammatory Response in Stem Cells of the Apical Papilla via ALX/FPR2.

Similar to the onset phase of inflammation, its resolution is a process that unfolds in a manner that is coordinated and regulated by a panel of mediators. Lipoxin A4 (LXA4) has been implicated as an anti-inflammatory, pro-resolving mediator. We hypothesized that LXA4 attenuates or prevents an inflammatory response via the immunosuppressive activity of Stem Cells of the Apical Papilla (SCAP). Here, we report for the first time in vitro that in a SCAP population, lipoxin receptor ALX/FPR2 was constitutively expressed and upregulated after stimulation with lipopolysaccharide and/or TNF-α. Moreover, LXA4 significantly enhanced proliferation, migration, and wound healing capacity of SCAP through the activation of its receptor, ALX/FPR2. Cytokine, chemokine and growth factor secretion by SCAP was inhibited in a dose dependent manner by LXA4. Finally, LXA4 enhanced immunomodulatory properties of SCAP towards Peripheral Blood Mononuclear Cells. These findings provide the first evidence that the LXA4-ALX/FPR2 axis in SCAP regulates inflammatory mediators and enhances immunomodulatory properties. Such features of SCAP may also support the role of these cells in the resolution phase of inflammation and suggest a novel molecular target for ALX/FPR2 receptor to enhance a stem cell-mediated pro-resolving pathway.

Evaluation of unenhanced post-mortem computed tomography to detect chest injuries in violent death.

PURPOSE: The aim of this study was to assess the performances of unenhanced post-mortem computed tomography (CT) to detect thoracic injuries in violent death. MATERIALS AND METHODS: Retrospectively, we conducted a review of unenhanced CT scans of 67 victims of violent deaths with thoracic injuries and compared CT findings with the results of clinical autopsy. Our gold standard was a comparison of CT scans with autopsy discussed in a monthly forensic radiology multidisciplinary team meeting (MDTM). The data were collected by organ system: heart, pericardium, aorta, lungs, pleura, bone, and diaphragm and performance indices (sensitivity, specificity, accuracy) were calculated. RESULTS: Pleural (59/67) and bone (55/67) injuries detected on CT were also found at autopsy and confirmed by the MDTM (sensitivity and specificity 100%). Seventeen out of 67 diaphragmatic lesions were visible on CT. Eighteen out of 67 were confirmed during MDTM after autopsy, yielding overall sensitivity of 94% and specificity of 98%. Forty out of 67 lung contusions were found on CT with two false positives and one false negative yielding 95% sensitivity for CT with a specificity of 96%, and accuracy of 95%. Fourteen out of 67 aortic injuries were found on CT compared to 19 confirmed during MDTM (sensitivity 74%, specificity 85%, accuracy 82%). In terms of pericardial lesions, 19/67 were found on CT and 20 on autopsy and confirmed during MDTM (sensitivity 80%, specificity 94%, accuracy 85%). Ten out of 10/67 cardiac lesions were visible on CT imaging and 15 found on autopsy and confirmed during MDTM (sensitivity 57%, specificity 94%, accuracy 81%). CONCLUSION: Unenhanced post-mortem CT performs well to detect pleural, pulmonary, bone and diaphragmatic injuries but less well to identify cardiac and aortic injuries, for which the use of indirect signs is essential.

[More on compensation of the handicapped child]. / Loi "anti-Perruche": suite et... suite.

By adopting a heading enTITREd "solidarity towards handicapped people" within the French law dated March 4, 2002 on health reform, the government hoped to put an end to the controversy that ensued after the so-called "Perruche" ruling. Since then, several rulings have been given by administrative jurisdictions and it seems that debate in this area is far from over. The first point developed concerns issues raised about the concept of 'characterized malpractice' introduced under this law, the only type of malpractice that may render a doctor liable. A ruling by the Council of State on February 19, 2003 and two decisions by the Administrative Appeal Courts dated February 19 and April 20, 2004 gave an answer. Recent decisions, namely a ruling by the Council of State dated February 9, 2005, seem to confirm this impression. Characterized malpractice that can render a doctor liable is not gross neglect but rather neglect that is simple, certain and cannot be contested. However, due to its intensity and its proof, this type of neglect is more than just ordinary negligence. The second point discussed is the limitation of parents' compensable hardship attributable to medical malpractice. The law dated March 4, 2002 limited this compensation "solely to parents' hardship" to the exclusion of expenses incurred as a result of the child's handicap. National solidarity, which was intended to absorb this expense, is taking some time to become apparent. The legal decisions given since 2002 have thus brought about a certain level of unease both in public opinion and the legal profession. In June 2003, the Parisian Court of Appeal gave a surprising but apt ruling that may nevertheless bring certain concerns to the surface. To our knowledge, the Council of State has yet to issue an opinion on this subject. Doctors' liability in terms of the birth of child born with a congenital handicap is still a possibility.