[Intervention of psychological and ethical professionals of human science in obstetrical morbidity and mortality conferences]

OBJECTIVE

To identify the defence mechanisms manifested by medical staff which could disturb the decision making, revealed by professionals of human science (PHS) in morbidity and mortality conferences (MMC).

MATERIALS AND METHODS

Application of two methods of psychological intervention in MMC, conducted between March 1st, 2009 and November 30, 2010, in 20 randomized maternity among five perinatal networks: the method of inter-active problem solving targeted at the functioning of the teams and the method for developing professional practice centred on individual. The data collection was realized during analyse of case in MMC, with note-taking by two pair PHS. The oral expressions of RMM' participant were secondarily re-written, analyzed and classed by theme.

RESULTS

Fifty-four MMC were performed. The mechanisms of defence have been identified by PHS intervention in MMC: denial of situation, pact of denegation, rift and overprotection. They were be identified by two PHS intervention methods, this consolidates these results. This intervention began staff medical to transformation at different level, in particular to improve the capacity of cooperation.

CONCLUSION

The identification of the mechanisms of defence in MMC enables staff medical to improve communication and quality relationship between healthcare professionals. This could constitute an actual factor of practices improvement. However, complementary studies must be performed to confirm this hypothesis.

The distribution of tritium in the terrestrial and aquatic environments of the Creys-Malville nuclear power plant (2002-2005)

The Creys-Malville nuclear plant, located on the left bank of the Rhône, was shut down in 1998. The facilities are currently in their initial stage of dismantling. In order to establish a baseline for tritium in the vicinity of the site prior to the main dismantling phase, we carried out a monitoring program between 2002 and 2005 in the main terrestrial and aquatic compartments of the local environment. Tritium levels in the groundwaters and in the Rhône waters correspond to the regional tritium concentration in precipitation. The data obtained for the terrestrial environment are also in good agreement with the regional background and do not show any specific signature linked to the nuclear plant. The various aquatic compartments of the Rhône (fish, plant, sediment) are significantly enriched in tritium both upstream and downstream of the power plant: although Tissue-Free Water Tritium concentrations are in equilibrium with the river water, the non-exchangeable fraction of organic bound tritium in plants and fishes shows values which outpace the river water background by one to two orders of magnitude, and up to four to five orders of magnitude in the sediments. This tritium anomaly is not related to the nuclear plant, as it is already present at the Swiss border 100km upstream of the site. Although fine particles of tritiated polystyrene entering the composition of the luminous paints used by the clock industry have been suspected on several occasions, the exact nature and the origin of this tritium source remain unknown and require further investigations.

Choroidal readaptation to gravity in rats after spaceflight and head-down tilt

To determine when choroidal structures were restored after readaptation to Earth gravity or orthostatic position, fine structure and protein distribution were studied in rat choroid plexus dissected either 6 h [Space Life Sciences-2 (SLS-2) experiments] or 2 days [National Institutes of Health-Rodent 1 (NIH-R1) experiments] after a spaceflight, or 6 h after head-down tilt (HDT) experiments. Apical alterations were noted in choroidal cells from SLS-2 and HDT animals, confirming that weightlessness impaired choroidal structures and functions. However, the presence of small apical microvilli and kinocilia and the absence of vesicle accumulations showed that the apical organization began to be restored rapidly after landing. Very enlarged apical microvilli appeared after 2 days on Earth, suggesting increased choroidal activity. However, as distributions of ezrin and carbonic anhydrase II remained altered in both flight and suspended animals after readaptation to Earth gravity, it was concluded that choroidal structures and functions were not completely restored, even after 2 days in Earth's gravity.

Changes in apical organization of choroidal cells in rats adapted to spaceflight or head-down tilt

Structural changes observed in choroid plexuses from rats dissected aboard a space shuttle, on day 13 of an orbital flight (NASA STS-58 mission, SLS-2 Experiments) demonstrated that choroidal epithelial cells display a modified organization in a microgravitational environment. Results were compared with ultrastructural observations of choroid plexus from rats maintained under anti-orthostatic restraint (head-down tilt) for 14 days. In both experiment types, the main alterations observed by transmission electron microscopy, at the level of choroidal epithelial cells from the third and fourth ventricles, concerned the formation and the organization of apical microvilli, whereas pseudopod-like structures appeared. Immunocytochemical distribution of ezrin, a cytoskeletal protein involved in apical cell differentiation in choroid plexus, confirmed the structural alteration of microvilli in head-down tilted rats, Kinocilia tended to disappear from the apical surface, suggesting a partial loss of cell polarization. In addition, large amounts of clear vesicles were gathered in the apical cytoplasm of choroidal epithelial cells. Disorganization of apical microvilli accumulations of apical vesicles and partial loss of cell polarity showed that long-stays in weightlessness induced alterations in the fine structure of choroid plexus, consistent with a marked reduction of cerebrospinal fluid production.

Choroidal responses in microgravity. (SLS-1, SLS-2 and hindlimb-suspension experiments)

Fluid and electrolyte shifts occurring during human spaceflight have been reported and investigated at the level of blood, cardiovascular and renal responses. Very few data were available concerning the cerebral fluid and electrolyte adaptation to microgravity, even in animal models. It is the reason why we developed several studies focused on the effects of spaceflight (SLS-1 and SLS-2 programs, carried on NASA STS 40 and 56 missions, which were 9- and 14-day flights, respectively), on structural and functional features of choroid plexuses, organs which secrete 70-90% of cerebrospinal fluid (CSF) and which are involved in brain homeostasis. Rats flown aboard space shuttles were sacrificed either in space (SLS-2 experiment, on flight day 13) or 4-8 hours after landing (SLS-1 and SLS-2 experiments). Quantitative autoradiography performed by microdensitometry and image analysis, showed that lateral and third ventricle choroid plexuses from rats flown for SLS-1 experiment demonstrated an increased number (about x 2) of binding sites to natriuretic peptides (which are known to be involved in mechanisms regulating CSF production). Using electron microscopy and immunocytochemistry, we studied the cellular response of choroid plexuses, which produce cerebrospinal fluid (CSF) in brain lateral, third and fourth ventricles. We demonstrated that spaceflight (SLS-2 experiment, inflight samples) induces changes in the choroidal cell structure (apical microvilli, kinocilia organization, vesicle accumulation) and protein distribution or expression (carbonic anhydrase II, water channels,...). These observations suggested a loss of choroidal cell polarity and a decrease in CSF secretion. Hindlimb-suspended rats displayed similar choroidal changes. All together, these results support the hypothesis of a modified CSF production in rats during long-term (9, 13 or 14 days) adaptations to microgravity.

[Metastatic malignant thymoma]

Three cases of metastatic malignant thymoma are reported. In all three cases the tumour was invasive and excision was only partial or impossible. Histologically, these tumours were of epithelial origin with a variable lymphocytic component. Metastases were initially present in one case and in the other two developed within the first year. Partial remission was obtained with different drug combinations in only one case, and it was of short duration. The authors emphasize the increased frequency and poor prognosis of these tumours and the need for multiple chemotherapy and loco-regional treatment in the management of invasive thymomas.

[Treatment of hypercalcemia in osteolytic metastases with oral amino-hydroxypropylidene-diphosphonate]

Twelve patients with malignant hypercalcemia were treated with amino-hydroxypropylidene-diphosphonate (APD), a potent inhibitor of osteoclast-mediated bone resorption. The mean serum calcium levels fell from 3,48 +/- 0,27 mmol/l before treatment to 2,66 +/- 0,31 after 10 days of oral APD (10 to 15 mg/kg/d) as the sole agent (p less than 0,001). The molar calcium/creatine ratio in the 24-h urine was significantly reduced from 2,11 +/- 0,73 to 0,70 +/- 0,52 after ten days of treatment (p less than 0,001). Serum phosphorus and urine hydroxyproline did not change significantly. Tolerance was good except for two patients with hiatal hernia who developed oesophagitis. Ours results confirm that oral APD is an effective and simple treatment of malignant hypercalcemia.

Cancer treatment by methotrexate: rational use following pharmacokinetic study

We used the test-dose method to calculate the dose of methotrexate to administer to the patients to reach the therapeutic but non-toxic blood concentration of 10(-5) mol/L. Methotrexate was tested with a radioimmunoassay technique and in 19 out of 20 patients we obtained the desired plateau during 24-h infusion.

[Place of hormone receptor determination in the therapeutic strategy of breast cancer]

Up to the discovery of hormonal receptors it was somewhat uncertain to prescribe hormonotherapy for the treatment of a breast cancer. The presence of estrogen receptors (ER) and progesterone receptors (PR) allows the estimation of the probability of hormone-dependence. The response to endocrine therapy will be expected with a rate of: 80% of the tumors PR +; 30% of the tumors ER+ but PR-; 10% of the tumors ER - and PR -. The response to chemotherapy is no accurately correlated with the concentration of receptors. The planning of therapy will be founded on the following principles. ER -: less favourable prognosis and unlikely response to endocrine therapy, therefore chemotherapy if the other prognostic factors are bad. ER +: endocrine therapy is required, especially if PR +. The role of chemotherapy ought to be discussed with respect to the other prognostic factors. All these factors are reviewed and a decision-tree of the treatment of advanced breast cancers is put forward. In short, it is obvious that the receptors assays have to be carried out as for as possible.

[Cardiac risks of adriamycin. Early detection of high-risk patients by isotopic cardiac function study]

Adriamycin is known to be effective in the treatment of breast cancer. Serial radionuclide determinations of the left ejection fraction can provide advanced warning of adriamycin cardiotoxicity, prior to clinical signs of the left ventricular dysfunction. Patients at high risk of congestive heart failure can be detected. Depending on the results of the second course of chemotherapy, guidelines and criteria can be laid down to predict the appropriate time for drug discontinuation.

[Proposal for a surgical evaluation index card for ovarian cancers]

The authors propose a computer card for registering the main information required in the management of ovarian cancers. The data include a detailed description of the lesions noted at operation, the surgical procedure, and postoperative lesions. They concern both the initial laparotomy and any second-look operations.

[Complications of antitumor and antileukemia chemotherapy. 3 (conclusion)]

Among the neurological side-effects, peripheral neuropathy is a result of therapy with vindesine and above all vincristine. Although in most cases it is responsible only for paresthesias, it may cause extensive paralysis and requires that the drug be discontinued. These drugs may also affect the neurovegetative system. Ototoxicity may be seen with cis-platinum and vigilance disturbances with L-asparaginase. Genetic consequences are mainly due to alkylating agents. These agents almost constantly impair male and female fertility but recovery is possible. Libido is also affected with the attendant psychological consequences. The offspring of patients previously treated by chemotherapeutic agents are normal. Development of secondary carcinoma or leukemia is currently a major concern. Secondary malignant disease may develop after the treatment of any cancer, especially if radiotherapy was associated with alkylating agents. Leukemias are of the acute myeloid type and usually follow a preleukemic phase. A table summarizes the main toxicities of the most usual drugs.

[Adverse effects of antitumor and antileukemic chemotherapy. 2]

Aplastic anemia is the most severe hematologic side-effect. All chemotherapeutic agents, with the exception of bleomycin and L-asparaginase, may induce aplasia, but the degree of hematotoxicity varies according to the drug. With the exception of acute leukemia in which drug-induced aplasia is part of the treatment, aplasia must be prevented through perfect knowledge of the posology and injection schedules for each drug, as well as by adjusting doses to the patient's hematological status. If aplasia develops, intensive hematological care is requisite. The most common cardiac side-effect is toxic cardiomyopathy caused by anthracyclines, which must be diagnosed early by EKG recordings before each injection and repeated ultrasonography or dynamic cardiac scintigraphy. The risk of toxic cardiomyopathy makes it requisite not to exceed the maximal doses set for each drug. Pulmonary side-effects include acute hypersensitivity pneumopathy and chronic diffuse interstitial fibrosis, the latter being more common and mainly caused by bleomycin. The risk of chronic fibrosis demands that patients be closely monitored and that the total dose be kept under 300 mg. Renal toxicity usually results in acute transient renal failure, as with cisplatinum, and requires a thorough biological study before each injection. Vesical hemorrhage, which is threatening in some instances, may occur with cyclophosphamide. VM26 and VP16 may induce anaphylactic shock. Allergic symptoms are possible with L-asparaginase and bleomycin.

[Complications of antitumor and antileukemic chemotherapy. 1]

The recent development of chemotherapy in the treatment of cancer and leukemia requires that all practitioners involved have a thorough knowledge of the sometimes life-threatening side-effects of chemotherapeutic agents. All these agents, whether used alone or in a combination, carry a risk because of their lack of specificity which make active on normal cells, especially those with a rapid turn-over such as the hematopoietic cells or the cells of the digestive tract. Prior to the prescription of a chemotherapeutic regimen, the acceptable risk must always be clearly defined, according to the seriousness of the disease and to the patient's age, physical condition and psychological status. During the course continuous monitoring adjusted to the specific toxicity of the agents used is requisite. More or less prominent asthenia and weight loss are common, as the result of various physiopathological mechanisms. Digestive disorders may consist only of nausea and emesis or include mucosal lesions with diarrhea as the main feature. Vincristine and vindesine are responsible for constipation. Hepatic toxicity, which is less common, is usually due to L-asparaginase. Transient hair loss is the most frequent cutaneous side-effect. Hyperpigmentation, photosensitivity, nail lesions, cellulitis and ulcerations may occur, as well as specific lesions with bleomycin. High fever during injection often occurs with this last agent.

[Management of advanced breast cancer in post-menopausal women. A comparative trial of hormonal therapy, chemotherapy, and a combination of both]

A randomized trial was done in 98 post-menopausal women with breast cancer. Hormonal receptors had not been assayed in any patient. Patients were given hormonal therapy with tamoxifen and drostanolone propionate (n = 34), or chemotherapy with the CMF protocol (n = 30), or a combination of both (n = 34). The results are in favour of hormonal therapy alone, which gave the best immediate objective responses, the least adverse side-effects, and possibly improved survival rates.

Estradiol and progesterone receptors content and response to norethisterone treatment in advanced breast cancer

Twenty-six patients with advanced breast cancer and progressive disease were treated by norethisterone. Estradiol and progesterone receptors were measured before starting treatment, and in three cases after 2 to 4.75 months of therapy. Partial remissions (greater than 50% decrease of all lesions) or objective improvements (decrease of 20-50%) were obtained in 7 patients, with a mean duration of 6.7 months. Stabilization of the lesions (no change or decrease of less than 20% in the size of the target lesion) was observed in 7 patients. No clear-cut correlation was found between clinical response and presence in biopsies of estradiol and progesterone receptors. However, absence of response occurred more frequently if tumors did not contain progesterone receptors.

[Retroperitoneal malignant xanthogranuloma (author's transl)]

A rare retroperitoneal malignant xanthogranuloma is described. The patient developed malignant bone lesions followed by brain localization, and died three years later. At autopsy a very large cystic retroperitoneal tumor with osteolytic lesion of sacrum was found. A review of cases diagnosed as retroperitoneal xanthogranuloma indicates that this lesion seems to be a particular form of the wide group of malignant fibrous histiocytoma with xanthomatous and inflammatory cells. Moreover it could be a primary malignant fibrous histiocytoma of bone. Furthermore, difficulties of differential diagnosis of these tumors are discussed mainly with histiocytosis X.

[Chronic renal failure after CCNU treatment (author's transl)]

Terminal chronic renal failure was discovered in a patient who had received CCNU 1 940 mg/m2 during the previous two years. The renal function was normal before treatment, and there was no evidence of other causes of renal failure. The clinical picture was identical with that observed in patients receiving such treatment and recently published. This case emphasizes the need for limiting the dose of nitrosyl-urea compounds to 1 200 mg/m2 and for monitoring the renal function very closely during and towards the end of the treatment.

Cisplatinumdiamminodichloride (CPDD) in chemotherapy of cancers: a phase II therapeutic trial

We have conducted a phase II trial of cisplatinumdiamminodichloride (CPDD) which not only demonstrated its remarkable activity in embryonic carcinoma of the testes, but also in ovarian carcinoma, in melanoma, and in epidermoid carcinoma, especially of the head and of the uterus cervix. Its toxicity, manifested mainly in the digestive and renal tracts, confines its administration to hospitalized patients only. This compound is now indicated in combination therapy for the above-mentioned tumors.

[Cis-diammino-dichloro-platinum therapy of cancers; phase II therapeutic trial]

We have conducted a phase II trial of cisdiammino-dichloro platinum (CDDP) which demonstrates its remarkable activity in testis embryonic carcinoma, in ovary carcinoma and in epidermoid cancers, especially head and neck and uterus cervix carcinoma. Its toxicity in mainly digestive and renal. This compound is now indicated in combinations in the case of the above mentioned tumors.

[Chemotherapy of soft tissues sarcomas. Summary of a decade and current trends]

The results of palliative chemotherapy applied to 123 patients with disseminated soft tissue sarcomas are reviewed with the recent literature data. With the exception of embryonal rhabdomyosarcomas of children, which are considered separately, the response of these tumors to chemotherapy is poor but not negligible. The association of several active drugs should permit substantial progress, especially in the initial stage of local treatment, when the number of disseminated cells is still reduced. A follow-up of controlled clinical studies must specify the modalities of multidisciplinary treatment in an effort to reduce regional recurrence or metastasis.

[Anticancerous chemotherapy trial with duborimycin. Analysis of 151 cases]

Duborimycin is a new antimitotic agent approaching danorubicin and adriamycin in activity which has been tried on 151 patients suffering from cancer of different types, is an advanced local/regional stage and/or metastatic disease. It was administered intravenously every fortnight in a mean unit dose of 400 mg, and the duration of the treatment ranged from 2 to 52 weeks. Objective improvement was registered in 56 patients of the 135 cases in whcih the results were assessed (around 41.4% of cases). In 4 cases the regression of tumour volume was greater than 50% (one of these cases was in melanoma, the other a sarcoma) and in 2 cases regression was complete (a squamous cell carcinoma and an embryonal testicular tumour). The subjective effects were appreciable in 53 of the 115 cases which could be studied (46%) and above all in the refractory pain of bony secondaries from breast cancer (a favourable response in 78% of cases). Manifestations of intolerance/toxicity were of a minor nature on the haematologic side, that cardiologic ones relatively frequent (18% of treated cases) and occasionally serious (2 cases of asystole). Great care is therefore necessary in supervision of the treatment. However, the first results obtained by this line of approach, notably in chemo-resistant forms of tumour such as melanoma and sarcomas, utilizing the very strict criteria in one analysis encourage further study of duborimycin in cases of this sort (preferably in association and in accordance with protocols of comparative trials) so that its place in cancer chemotherapy may be more precisely defined.