[Risk of accidents for a Parisian pedestrian]. / Le risque accidentel du piéton dans agglomération parisienne.

The risk of accident for a parisian pedestrian is of reduced frequency and of moderate severity (terrorism and natural disasters not included) according to the statistics of 1999. This is due to security measures and the excellent organisation of assistance to wounded persons. The improvement in protection of pedestrians, even the disabled and elderly persons will soon make Paris the best protected megalopolis of our continent. Pedestrians are involved in 28% of accidents on public streets with a mortality of 1.2%, with serious injuries in 12.6% of the cases. Injuries without collision occur in 57% of the cases. 18% of the wounded older than 75 years with 1.8% of deaths and 66% of severe injury. Accidents related to public transportation represent a very slight risk of 0.00044%. By modification of the concept of transportation and its materials over a five year period there is a decrease in the number of the victims (-3.75%), in spite of the increase of accidents (3.5%). For lone pedestrian being victims of aggression in public places, after a decrease of 10% in 1999, there is in 2001 an increase which raises the question of police proximity again. Over a five year period the RATP (subway authority) has noticed a 14.77% decrease of thefts and a 54.78% decrease in attacks... This makes the Parisian railnet (subway mostly) seven times less dangerous than the streets.

[From risk to damage: the limit between chance and fault in medical responsibility]. / Du risque au dommage: les frontières aléa/faute en responsabilité médicale.

Rare, but serious, the possible accidents of medical or surgical procedures without fault compromise the doctor patient relationship. A pro-compensation philosophy leads to a drift in the classical concept of prejudicial act. This type of confusion adds a random/aleatory legal risk to the random/aleatory medical risk. Determining the limit between random/aleatory risk and malpractice is one of the difficulties in medical evaluation of responsibility. In order to evaluate the random/aleatory risk without malpractice, in relationship to the medical team, we propose a notation grid for the facts of the case, based on simple, precise, identifiable criteria present in all medical records and accepted by both the practising physicians and medico legal experts. This medico-legal research was done in a double blind study of 45 cases which intially brought up a random/aleatory risk related problem for three medical procedures: coronary arteriography, colonoscopy and laparascopy. In 66.6% of the cases the random/aleatory risk was ruled unrelated to any malpractice, but in 33.4% of the cases observed, the initial random/aleatory risk was transformed into actionable malpractice, essentially due to faulty surveillance or tardy treatment of the complication. This notation system, carried out in identical and well defined terms, should allow a reasonable comparison of cases for medico-legal research or computerised databases. It is reserved exclusively for use by medical experts or consultants so they can give a reasoned technical opinion in order to assist the judge in his legal decision. The objective of the proposed grid is to homogenise the concepts used by experts in all national courts. After a multicenter validation, this grid could have an European future as to the boundary between random/aleatory risks and medical malpractice and responsibility.

[Home enteral nutrition: functional partnership experience in the network of care of the Centre Médical de Forcilles, 1990-1999]. / Nutrition entérale à domicile: expérience de partenariat fonctionnel en réseau de soins du Centre Médical de Forcilles de 1990 à 1999.

Since 1990, the home enteral nutrition (HEN) has been experienced by the Centre Médical de Forcilles (CMDF), according to the 1988 and 1993 instructions. This service has a regional vocation and forms an integral part of a partnership system in care including: the prescribing hospital, the usual physician and various specialists. We have a triple objective: 1) To define the structure and the action of this medical service, the only one in France. 2) To appreciate the 9 years experience with 4297 patients: Medical interest, with the nutritional care of patients suffering of heavy diseases, more particularly ORL cancers and neurological troubles disturbing deglutition. The use of regulating flow pumps, care avoid "Mendelson syndrome". Repercussion on patients quality of life, who stays in a family environment. This seems to be beneficial for 58.9% cases. More over, 95.8% patients prefer this solution instead an hospitalization. The permanent communication between the members of this plural disciplinary team guarantees safety, comfort and relief. Economical benefit with a computerized management, recovering of the products and reduction in purchase (large quantities). This allows a very reasonable "price per day" (120.38 F in 1999), to wit a thrift of 95% in comparison with a classical hospitalization. 3) To propose, according to the CMDF example, a quality charter for a HEN centers regional organisation, and the valuation of their activity. According to the fact that the HEN has to be legally realized all over the national territory, the CMDF exemplary fitted to local needs, should allow an appropriate solution, with a control of the costs, thanks to a real partnership in network of care, for this public health problem.

[Unpredictable risk and damage compensation in civil process]. / Le risque aléatoire en chirurgie et l'indemnisation de son préjudice en procédure civile.

UNPREDICTABLE RISK DEFINITION: Any medical or surgical action with diagnostic or therapeutic purpose involves a potential risk of complication, unrelated to the initial pathology or a technical error, but could lead to death or disability. Proof of unpredictable risk without initial fault requires a careful examination of each case by a judicial expert in order to eliminate the complications related to an unskilled surgeon or to poor postoperative care. UNPREDICTABLE RISK COMPENSATION: Conclusions of the Academy: In current French common law, damage compensation can only be obtained in cases where all possible medical means are not implemented and professional fault can be proven. It is illogical to extend the civil responsibility of the practitioner to an obligation of procedural result. In the absence of fault, damage compensation does not come under the civil responsibility of the surgeon. A special insurance system for unpredictable risk has to be created using the principles of mutual insurance.

Differential transferrin receptor density in human colorectal cancer: A potential probe for diagnosis and therapy.

Transferrin receptor density was investigated in human colorectal surgical specimens. Crude membranes were prepared from 23 cancer tumors (adenocarcinoma or malignant villous tumor) and 3 non-cancer tumors (polyadenoma or villous tumor) and 26 adjacent control mucosa. Contrary to non-cancer tumors, Scatchard analysis of 125I-transferrin binding data evidenced higher maximal transferrin binding capacity and lower dissociation constant in cancer tissues (Bmax cancer 1.828+/-0.320 nmol/g, Kd 24.1+/-4.7 nM), as compared to paired control colonic mucosa (Bmax contol 0.851+/-0.182 nmol/g, Kd 30.7+/-7.3 nM), paired t-tests: Bmax p<0.001, Kd p<0.05). As the cancer/control Bmax ratio was 2.6+/-0.4,transferrin carrier constructs should be proposed for cancer imaging or therapy.

[Esophageal and cardial risk of treating gastroesophageal reflux by laparoscopic surgery]. / Le risque oesocardiotubérositaire de la cure de reflux gastro-oesophagien par chirurgie coelioscopique.

A qualitative study of risk was performed on 4 forensic files and on accidents published in the literature (1,609 cases). The surgeon may be charged with the responsibility of specific complications involving the oeso-cardial-tuberosity junction including perforation of the esophagus (13 cases), perforation of the stomach (8 cases) and necrosis of the Nissen valve by ischemia after section of the short vessels of the lesser curvature (2 cases). Sudden migration into the mediastinum or the left pleural space may occur after laparoscopic surgery (23 cases). As for all surgery, it is the surgeon's responsibility to provide adequate means for the indicated procedure and to perform the operation and follow-up. Since this is a new technique, the severity of judgements increases with the notion of special risk and aggravated risk.

[Benign anal granular cell tumor. Apropos of a case]. / Tumeur anale bénigne à cellules granuleuses. A propos d'un cas.

A case of benign granular cell tumor of the perianal region is presented. The patient was treated by local excision of the tumor. This is an unusual site. Superficial biopsy specimens may indicate an incorrect diagnosis of squamous cell carcinoma.

[The surgeon, the expert, the judge]. / Le chirurgien, l'expert, le juge.

A study of 125 medico-legal opinions and evaluation of the literature allows for: an appreciation of the evolution in the concept in the jurisprudence pertaining to the responsibility of the surgeon in France in present practice conditions, a definition of the role of the legal expert, an explanation of the development of paths outside the procedural setting. In the present state of our knowledge the responsibility related to a prejudicial error has a frequency of 25-30% all jurisdictions and disciplines considered together. In 66% of cases the error is the absence of a timely treatment decision or a defective postoperative follow up. A mishap without proven error is present 50% of the cases which justifies a decision of coverage outside the civil responsibility of the surgeon. The modern conditions of surgical practice, the implications of the new technologies, the evolution of economic and socio-cultural ideas must lead the political decision makers and health-professionals to rapidly define a clear line of conduct. In the absence of comprehensive statistics from the courts, the qualitative and quantitative information contained in the national database "Remedhos France", now available, will be useful to inform the surgical community on the risk and its prevention, as well as to orient a homogenous doctrine and its applications in view of a common European approach.

[Risk of laparoscopic surgery. 100 records of complications. A qualitative study]. / Le risque en coeliochirurgie. 100 dossiers d'accidents. Etude qualitative.

A total of 100 accidents occurring during laparoscopic surgery between 1969 and 1993 were studied. Fifty-five of the cases concerned gynaecology surgery over a 24 year period. The other 45 concerned digestive surgery over a 5 year period (1989-1993). The surgical risk was not statistically greater compared with open surgery. Overall morbidity was 1%. Overall mortality was 0.5/1000. A more precise statistical analysis was recently reported. The examination of the 100 cases was qualitative rather than quantitative. The study demonstrated an imbalance between age (mean age 38 years) in patients with major pathology initially and the gravity of the induced accidents: 26 deaths for 100 observations. These deaths were related to technology trocar, capnoperitoneum, electrocoagulation. Technical skill, cautiousness, vigilance and humility are qualities the surgeon must have to perform successful operations. The irreversible acceleration of the new surgical technique should not cloud the basic precepts of sound surgical technique.