Compréhension/acceptation de la radiothérapie : un dilemme éthique résolu par une éthique de la considération et de la sollicitude

PURPOSE

Ethical questions are poorly investigated specifically in radiation oncology. The objective of the study was to identify and understand the main ethical issue in radiation oncology.

MATERIALS AND METHODS

A quantitative analysis was based on the answers to a questionnaire of 200 professionals from 22 radiation oncology departments. The questionnaire mainly aimed to characterize the main ethical issue. A monocentric qualitative analysis was based on semi-structured interviews focused on the main identified ethical issue, carried out with eight technologists, and 20 patients undergoing radiotherapy.

RESULTS

The main ethical issue was the understanding and/or acceptance of the treatment by the patients (71 %), which frequently arises (more than once a month) (52 %), and corresponds to an ethical tension between the principles of respect for autonomy and beneficence (the good as viewed by the patient) as defined by Beauchamp and Childress. The technologists, wish the patient to be fully involved in his treatment, with the even possibility of refusing it. However, excluding paternalism and autonomic relentlessness, the technologists have the feeling of acting for the good of the patients by treating them with radiation, even if the patients are not always aware of it, because they are within a situation of vulnerability. If the hierarchy of principles is a compromise alternative, this problem is finally well resolved by the effective implementation of an ethic of consideration and solicitude, restoring the patient capabilities, i.e. the maximum development of his potentialities in his situation of vulnerability. Beyond the legal dimension, patient information is crucial and must consider the specific temporality of the patient.

CONCLUSION

The main ethical issue in radiation oncology is the understanding and/or acceptance of the treatment involving the development of an ethic of consideration and solicitude.

Costal cartilage graft for an unstable post-traumatic trapeziometacarpal intra-articular malunion in a pediatric patient: A case report

Trapeziometacarpal dislocation is a rare traumatic lesion, especially in the pediatric population. Various treatments have been described for acute cases. We report the case of a 15-year-old boy who was admitted in the emergency department with chronic post-traumatic trapeziometacarpal dislocation due to an untreated first metacarpal base fracture (Bennett), with complete articular destruction. The patient was treated by open reduction, interposition of a costal cartilage graft, and intermetacarpal K-wire fixation. Follow-up at 2 years after the surgery showed excellent clinical and radiological results. This surgical technique had not been described previously in the pediatric population.

Impact de l’épidémie à coronavirus 2019 sur l’organisation d’un service de radiothérapie : expérience du télétravail pour les manipulateurs

Introduction et but de l’étude

Matériel et méthodes

Résultats et analyse statistique

Conclusion

[The concept of narrative insight in schizophrenia: A systematic review]

AIM

The aim of this systematic revue of literature is to examine articles dealing with the narrative insight (patient's explanatory models of his difficulties) in patients suffering from schizophrenia. In addition to the theoretical interest of this work, it would make it possible to better adjust the clinical practices concerning the stories of patients about their disorders.

METHOD

A study was conducted using the databases ScienceDirect, Medline, PsychInfo and PubPsych using the key words "narrative insight", "cultural insight", "subjective insight", "narrative awareness", "mental illness", and "psychiatric disorder". This search by keywords led to eighty-six results; abstracts of all the articles were consulted. Then the authors selected and studied all articles corresponding to inclusion criteria and compared their results and reached agreement by consensus in case of difference. The theme of the study was to focus on the concept of narrative insight or any other close concept mentioning an explanatory model of mental and/or psychiatric disorders, moving away from the biomedical model. Nine articles were selected based on the inclusion criteria (articles published in peer reviewed journals, where the both the resume and article are accessible; articles dealing with narrative insight of people suffering from schizophrenia).

RESULTS

The authors of these articles agree that awareness of mental illness, insight, is a narrative act in which people give a personal meaning to their disorder. The most popular biomedical model used has many limitations and is the subject of many controversies. Results of the conducted study suggest considering narrative insight as adaptive strategies to mental illnesses. Indeed the process of narrative insight essentially consists in the patient adapting his life story to his conceptions and his values. To tell the story of one's own troubles with one's own values and beliefs gives meaning that helps protect identity and give back hope. This concept is considered to be dynamic and multidimensional. In addition, studies highlight its positive effects including the simultaneous presence of several models, which would have a greater favorable impact on the prognosis than the medical explanation alone.

CONCLUSION

It seems necessary to take into account the concept of narrative insight in order to evaluate insight of patients suffering from mental illness. This implies that the evaluation methods of insight as well as the clinical practice must evolve to adapt to the culture and subculture of the patient. This could have beneficial effects on the well-being of patients, therapeutic relations, access to treatment as well as psychiatric research, as well as limit controversies around this topic. It would be interesting to confirm this new conception of insight and the therapeutic relations by carrying out new studies as well as by starting to take it into account in patient care.

[Organization and risk management in stereotaxic body radiotherapy at the treatment station]

The development of stereotaxic body radiotherapy in the last decade has forced the radiotherapy departments to redouble their efforts in the fields of quality and risk management. For this purpose, increasingly complex and rigorous controls of high performance machines as well as a solid team training must be put in place. Extreme hypofractionation requires both increased vigilance at the treatment desk and well-defined and known procedures. The in place organizations contribute to the control of the risks related to the stereotaxic body radiotherapy machines. The medical presence at the beginning of the treatment fractions has been specified as mandatory in a regulatory way since January 2017. This not only ensures security, but also transmits information to the radiation therapy technicians. At the Eugène-Marquis center, the skills of the technicians for stereotaxic body radiotherapy on two dedicated machines (Cyberknife^® and Versa HD^® Novalis^® type) have been upgraded. An accreditation is formalized after a training period and re-evaluated annually. The communication inside and outside the radiotherapy field plays also an important role in maintaining a high level of exchange and sharing of essential information. The means implemented at the Eugène-Marquis center increase the risk control of SBRT, by paying attention to the management of skills at the treatment station.

Aneurysms of the hand: Imaging and surgical technique

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

[Interest of positioning control in onboard imaging and its delegation to the therapists]

The delegation of the on board imaging position control, from the radiation oncologist to the therapist, is justified by the generalization of the image-guided radiotherapy techniques which are particularly time consuming. This delegation is however partial. Indeed, the validation of the position by the therapist can be clearly performed when the registration is based on bony landmark or fiducial. The radiation oncologist needs however to make the validation in case of large target displacement, in more complex soft tissue-based registration, and in case of stereotactic body radiation therapy. Moreover, this delegation implies at least three conditions which are first the training of the staff, then the formalization of the procedures, responsibilities and delegations and finally, the evaluation of the practices of IGRT.

[Dimensions of personality, attachment style and early maladaptive schemas in alcohol-dependent patients: Are there gender-specific differences?]

AIM

Literature reports particularities in certain psychological dimensions, such as personality traits, early maladaptive schemas and attachment styles among patients dependent on alcohol. Several international studies have also emphasized significant gender differences in psychological profiles. However, in France, only a few studies have dealt with this subject. Our aim was on the one hand to study the characteristics of alcohol-dependent patients in these variables, and on the other hand to search for gender differences.

METHOD

The personality dimensions were assessed with the French Big Five Inventory (Fr-BFI), the attachment style with Bartholomew's Relationship Scales Questionnaire (RSQ), and early maladaptive schemas with the short version of Young's questionnaire (YSQ-S1). Seventy-three subjects were included: 39 alcohol-dependent patients (19 men and 20 women) and 34 healthy control subjects (17 men and 17 women). The scores of alcohol-dependent patients were compared with those of a healthy control group (n=34, 17 men, 17 women) and available standards. We also compared the scores of men and women with alcohol dependence between them, and we compared the scores of men and women to those of the control group and those of the reference sample of the same sex.

RESULTS

This is an ongoing study and we publish here the first results. Compared with control subjects, and the reference sample, alcohol-dependent patients showed significantly higher levels of neuroticism and lower levels of extraversion. Furthermore, differences in attachment styles were observed compared to the control group: alcohol-dependent patients presented a less secure attachment, seemed more fearful and detached, but the results remained within the normal standards. Compared to the control subjects, alcohol-dependent patients showed a significant increase in scores regarding many schemas: emotional deprivation, abandonment, abuse/mistrust, isolation, imperfection, dependence, symbiotic relationship, subjugation, and emotional inhibition. Men and women with alcohol dependence did not show a significant difference between them concerning the dimensions of personality, the schemas, and attachment styles. In addition, the comparison of each sub-group (male/female) with the control group of the same sex and standards available showed specific features: for dimensions of personality, alcohol-dependent men presented a high level of neuroticism and a low level of extraversion, while the women showed no specific features. Concerning attachment, both men and women differed from the control group. Their attachment was more fearful and men showed a less secure and more detached attachment. As for patterns, three are higher among men and women with alcohol dependence compared to controls of the same sex: emotional deprivation, abuse/mistrust, and imperfection. In addition, these schemas seem to be more specific according to gender: alcoholic women differed from controls of the same sex at the subjugation schema, which was not the case for men, while only men differed from men of the control group by higher scores in insufficient self-control, dependency and symbiotic relationship.

DISCUSSION

This study shows not only particularities in patients with alcohol dependence concerning personality dimensions, styles of attachment and early maladaptive schemas, but also gender differences when comparing each subgroup (men and women) with controls of the same sex. Even if these results need to be confirmed by using a larger sample, the particularities deserve consideration, especially gender differences in view of appropriate psychotherapeutic strategies.

[The Clubhouse model for people with severe mental illnesses: Literature review and French experiment]

AIM

The aim of this article is 1) to present the Clubhouse (CH) Model and the first French CH, and 2) study the empirical background on the efficiency of the CH concerning employment, quality of life and hospitalization for people with mental illness.

HISTORICAL, THEORETICAL AND INSTITUTIONAL BACKGROUND

The first Clubhouse was created sixty years ago in the U.S. The Clubhouse model of psychosocial rehabilitation is a program that offers to people with mental illness support and opportunities to find a job and return to a normal social life. The Clubhouse model has been built over the years thanks to the experiences of members and staff. It is based on "36 standards" (rules which each Clubhouse follows in order to attain its goals). Supported by associations and families of people with mental illness, health professionals, and the international federation of Clubhouses (Clubhouse International), the first Clubhouse in France has opened in November 2011. This non-medicalized association and its co-management by both members and staff are innovative in France. The aims of the Clubhouse are founded on the concept of empowerment and "peer-help", and on the fight against isolation and stigmatization. Clubhouses offer day-programs which allow people with mental illness to have a sense of community and a useful purpose within the association. Indeed, the salaried management team is voluntarily understaffed so that the participation of members is necessary and so that they can benefit from the opportunities for useful activity within the Clubhouse, developing a real opportunity of empowerment.

METHOD

In order to study the efficiency of CH, we conducted a systematic review of publications on CH, first in the database of Club House International (500 publications) and second, in the scientific data base (Psycinfo, Psycarticles, Academic Search Premier, Medline et Science Direct) (205 publications included in the 500). We identified 64 scientific studies. We have selected 28 of them that focused on the variable: employment, quality of life and hospitalisation.

RESULTS

Clubhouses have shown their effectiveness regarding employment, quality of life and hospitalization. Indeed, several studies compare Clubhouses with other programs of psychosocial rehabilitation. The results have demonstrated that Clubhouses' members: find more salaried work, find jobs of higher quality, have a better quality of life and face fewer hospitalizations, than people in other psychosocial rehabilitation programs.

DISCUSSION

We discuss the interest of the CH in France using the experiment of the CH in Paris. This experiment in providing an innovative place of support, mutual aid, and autonomy is currently successful in France. Over 18 months, a team of 65 members and 3 staff members has come together. This enthusiasm is probably due to the fact that the Clubhouse in Paris is a place which helps people with mental illness establish a daily rhythm, social usefulness and affective links, all essential for recovery, in a context different from the usual medically supervised care in other settings: people are treated as individuals rather than as "sick persons" or "patients". This article discusses the benefits of this new model of psychosocial rehabilitation in France, by presenting the originality and complimentarity of this concept, in comparison with other health structures.

Is there any benefit in pre-operative urinary analysis before elective total joint replacement?

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.

We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Cite this article: Bone Joint J 2014;96-B:390–4.

No need to search for the source of haematogenous arthroplasty infections

QUESTIONS UNDER STUDY/PRINCIPLES

Prosthetic joint infections (PJI) may be a potential sentinel event for an unknown neoplastic or infectious source in elderly patients. However, the value and cost-effectiveness of investigations to determine the origin of these infections is unknown.

METHODS

Retrospective study at Geneva University Hospitals, evaluating associated medical examinations performed in search of the origin of all presumed surgical site and haematogenous arthroplasty infections.

RESULTS

A total of 182 PJI were found in 182 patients (median age 75 years). Seventy PJI (38%) were classified as probably haematogenous, occurring more than 2 years post-implantation, with 27 (15%) due to Gram-negative pathogens. Overall, the origin of PJI was found solely by admission history in 28 cases (15%). Among the remaining 154 cases, no remote origin could be detected despite 17 echocardiograms, 17 other sonograms, 49 chest x-rays, 23 computed tomograms, 107 urinary cultures, 11 endoscopies, 9 scintigraphies and 31 medical specialist consultations. The average cost of these exams was 675 Swiss francs (845 US$) per PJI. At long-term follow-up six patients were found to have developed a neoplasm, of which only one (hepatocellular carcinoma after PJI due to Streptococcus bovis) could eventually be attributed to prior infection.

CONCLUSIONS

From an epidemiologic point of view, patient history is the best way to predict the origin of PJI. Blind additional radiographic or endoscopic exams are costly, inconclusive and do not contribute to the management of these cases.

[Early dropout patients in psychiatric psychosocial rehabilitation treatment and their bindings with relational skills, object relation and intensity of psychopathology]

INTRODUCTION

Between 30 and 60% of patients drop-out of institutional psychiatric treatment. There are few studies on this issue and these have not provided a clear understanding of this fact. Although it is a different therapeutic setting, there are many studies on patients' dropout in psychotherapy: the influence of many patient sociodemographic variables such as gender, age, diagnostic, were studied without providing strong and regular links with early dropout. Other, more relational variables (such as object relation and interpersonal functioning), gave stronger results although insufficiently confirmed by different studies. A third kind of variable involves the concrete relationship between patient and therapist (therapeutic alliance, patient's expectations) and provided interesting results (but not easy to use in institutional treatment).

AIM

The aim of this study is to provide data to understand patients' institutional dropout in a French psychiatric centre. The latter's aim is psychosocial rehabilitation for schizophrenic and borderline patients. Thirty percent of these dropout during psychosocial treatment. According to the specificities and aims of this psychiatric centre, we hypothesize that there are strong links between relational dimensions (objet relation, interpersonal functioning), subjective evaluation of pathology intensity, and early dropout.

POPULATION

Thirty-one subjects; 65% schizophrenic, 23% borderline, 13% other (according to the ICD10 criteria); 71% females; mean age 34 years (min=23; max=55); mean education level=3.4 (2 years of high school university).

INCLUSION CRITERIA

to have dropped out before 6 months' of the treatment, or continuing the treatment after 6 months (mean of treatment for all patients=15 months).

EXCLUSION CRITERIA

patients present in the service for less than 6 months).

METHODOLOGY

At the beginning of the treatment, each patient (informed consent provided) underwent a psychological assessment with: Échelle d'aptitude psychosociale (EAPS) for assessing interactional functioning; SCL90-R for assessing the intensity of psychopathology; TAT (with Social Cognition and Object Relation Scale [SCORS] scales) and Rorschach (with Mutuality Of Autonomy [MOA] scale) for assessing object relations. After 6 months of treatment, each patient was evaluated with a five-point scale (dropout and continuity scale), which assessed the investment in the treatment (criteria: dropout at 3 or 6 months or continuity; according or not to the centre's professionals; level of assiduity). We have correlated this variable with EAPS, SCORS and MOA. In addition, we have calculated statistical relationships between age, gender, diagnostic, education level and early dropout.

RESULTS

Correlation was found neither between interactional functioning (EAPS) and dropout nor between object relations (SCORS and MOA) and dropout. Correlations were found between the dropout and intensity of the psychopathology (SCL90-R): the more the patient sees himself suffering, the more he invests the centre and the less he drops out (Spearman R=0.37, P<0.05). No differences were found between the dropout (N=10) and continuity group (N=21) regarding age, gender and diagnostic. However, a correlation was found regarding the education level: the more patients are educated, the more they continue the treatment (R=0.45; P<0.05).

CONCLUSION

The dropout (and the continuity of treatment) seems more likely related to concrete variables such as psychological and relational suffering, educational level in this study, than structural psychological variables such as object relation, relational skills, and diagnostic. Other studies are necessary for a better understanding of these drops out. An interesting way should be the study in institution of the therapeutic alliance.

[Effectiveness of a health network in secondary prevention among coronary patients]

OBJECTIVE

To improve the secondary prevention, particularly hypertension management among coronary patients.

METHODS

In 2004-2005, out of 175 coronary patients having taken part in a cycle of the Educoeur center of the health network Rivarance, 131 (75%) aged between 32-79 years of age (an average of 61 years with 11% women, 52% hypertensive, 24% smokers, 10% diabetics and 72% with unbalanced dyslipidemia (LDL>1g/l)) were re-examined within 12 months and were compared with a French cohort of the EuroAspire II study (365 patients - Lancet 2001). 56% were treated by angioplasty, 24% by coronary bypass and 20% by medical treatment. The 4-week ambulatory educational program consisted of a physical education with 22 meetings of cardiac rehabilitation (ergo cycle, carpet, segmentary muscular work, steps and balneotherapy) and a therapeutic and dietetic education (18 courses and cooking workshops, supermarket visits and self BP measurement). These 131 patients were re-examined 3, 6 and 12 months after by the paramedical team. The GP and nurses were taught recommendations on CV risk factors management. The patients were followed by a computerized medical file. BP (average of 3 measurements by OMRON M4), total cholesterol (CT), weight, physical activity (insufficient if less than 3 walks of 30 min per week), smoking and drugs intake were analyzed on J0 then at one year and were compared with the French results of EuroAspire II. [table: see text]

CONCLUSION

The education and the follow-up of the patient in a network of health improve CV risk factors and particularly hypertension management of these coronary patients but this decreases with time.

[Evaluation of the incidence of serological cross reactions between Legionella and Mycoplasma or Chlamydia]

Because of the possible serological cross reactions frequently described in the literature between L. pneumophila and M. pneumoniae or between L. pneumophila and Chlamydia, we decided to determine their frequency with our sera and our own methods. The anti M. pneumoniae and Chlamydia antibodies were researched in 162 sera samples from 46 cases of legionellosis serologically diagnosed and in 51 sera from 26 hyperimmunised rabbits. Conversely, anti L. pneumophila antibodies were researched in 165 sera from mycoplasmosis (61) or chlamydiosis (25 cases). None of the sera from mycoplasmosis or chlamydiosis tested by IFA and MA had antilegionella antibodies. None of the rabbits' sera hyperimmunised with Legionella had anti M. pneumoniae or Chlamydia antibodies. On the contrary, by complement fixation and IFA, out of the 46 cases of legionellosis under study, 6 showed a seroconversion in M. pneumoniae and 2 in Chlamydia. The Ig class determination did not show IgM titers in 7 of these 8 sera. The mechanisms of these cross reactions are discussed: antigens and methods used, booster effect during legionellosis, concurrent mycoplasmosis or chlamydiosis.

Le diagnostic rapide des infections à virus respiratoire syncytial (RS) par le titrage des IgM sériques (immunofluorescence indirecte)

En janvier 1981, au cours d'une épidémie d'infections respiratoires survenue chez des enfants âgés de 1 à 3 mois, 9 sujets atteints de bronchiolites sévères ont été hospitalisés dans un service de pédiatrie et 11 cas sont survenus dans le service.

Pour le diagnostic rapide direct, les prélèments pharyngés et/ou des aspirations nasales effectués chez 10/11 malades étaient tardifs par rapport à l'apparition des symptômes. Le diagnostic direct n'a été positif que dans 2 cas, et l'isolement d'un virus a toujours été négatif.

Pour le diagnostic sérologique, dans 9 cas/16, le premier sérum a été prélevé après 5 jours d'évolution. La réaction d'immunofluorescence (IF) a permis de faire le diagnostic d'une infection à virus respiratoire syncytial dans 13 cas. La r'eaction de fixation du complément (FC) est restée négative dans tous les cas.

Pendant la période de novembre 1980 à janvier 1981, on a prélevé les sérums de 32 enfants et 13 adultes hospitalisés pour des infections respiratoires aiguës (bronchites et bronchopneumophathies) et les sérums de 35 adultes hospitalisés dans un service de transplantation rénale. La réaction d'IF indirecte n'a pas été plus sensible que la FC, mais elle a permis:o1)

de différencier les infections primaires des réinfections;

2)

de prouver que dans la majorité de ces réinfections (13 cas/17), on pouvait détecter des IgM;

3)

de porter un diagnostic de certitude rapide sur un seul sérum dans environ 60% des cas, alors que la FC était négative (1 cas) ou ne permettait qu'un diagnostic présomptif (10 cas).