Extensively drug-resistant bacteria: Which ethical issues?

OBJECTIVE: The increased bacterial resistance to antibiotics has now become a public health concern. How can we preserve the well-being of patients presenting with infections caused by extensively drug-resistant bacteria (EDRBs) and that of their contacts without inducing any loss of chance of survival, all the while living together and controlling the spread of these EDRBs? METHOD: Terre d'éthique, a French territorial ethics committee, was asked to reflect on this topic by the infection control unit of a French University Hospital as it raises many ethical issues. RESULTS: Patients are at the core of any ethical approach, and respecting their autonomy is fundamental. Patients should be adequately informed to be able to give consent. Indeed, the creation and dissemination of a register (list of names of contacts or infected patients) entails responsibility of the infected person and that of the community. This responsibility leads to an ethical dilemma as protecting the group (the whole population) necessarily means limiting individual freedom. The principle of autonomy should thus be compared with that of solidarity. Is medical confidentiality an obstacle to the sharing of information or lists of names? CONCLUSION: We did not aim to answer our problematic but merely wanted to show the complexity of EDRB spread in a broader societal and economic context, all the while respecting the rights of patients.

Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study.

Essentials Bleeding incidence as hemorrhagic risk factors are unknown in palliative care inpatients. We conducted a multicenter observational study (22 Palliative Care Units, 1199 patients). At three months, the cumulative incidence of clinically relevant bleeding was 9.8%. Cancer, recent bleeding, thromboprophylaxis and antiplatelet therapy were independent risk factors. SUMMARY: Background The value of primary thromboprophylaxis in patients admitted to palliative care units is debatable. Moreover, the risk of bleeding in these patients is unknown. Objectives Our primary aim was to assess the bleeding risk of patients in a real-world practice setting of hospital palliative care. Our secondary aim was to determine the incidence of symptomatic deep vein thrombosis and to identify risk factors for bleeding. Patients/Methods In this prospective, observational study in 22 French palliative care units, 1199 patients (median age, 71 years; male, 45.5%), admitted for the first time to a palliative care unit for advanced cancer or pulmonary, cardiac or neurologic disease were included. The primary outcome was adjudicated clinically relevant bleeding (i.e. a composite of major and clinically relevant non-major bleeding) at 3 months. The secondary outcome was symptomatic deep vein thrombosis. Results The most common reason for palliative care was cancer (90.7%). By 3 months, 1087 patients (91.3%) had died and 116 patients had presented at least one episode of clinically relevant bleeding (fatal in 23 patients). Taking into account the competing risk of death, the cumulative incidence of clinically relevant bleeding was 9.8% (95% confidence interval [CI], 8.3-11.6). Deep vein thrombosis occurred in six patients (cumulative incidence, 0.5%; 95% CI, 0.2-1.1). Cancer, recent bleeding, antithrombotic prophylaxis and antiplatelet therapy were independently associated with clinically relevant bleeding at 3 months. Conclusions Decisions regarding the use of thromboprophylaxis in palliative care patients should take into account the high risk of bleeding in these patients.

Return home at the end of life: Patients' vulnerability and risk factors.

Although most of the people in good health questioned about the subject said they would like to die at home, in the western world between 60 and 80% of deaths occur in hospital. Most authors consider that the indispensable conditions for a return home are the patient's desire and presence of the family and caregivers with the appropriate skills. The assessment of other factors predictive of a return home is inadequate. The aim of this study is to clarify how the return home is influenced by the vulnerability of the patient at the end of life, and by that of the family and caregivers. We carried out a multicentric, observational, prospective, exhaustive and longitudinal epidemiological study (three months follow-up), including 146 patients hospitalized at the end of their life and desiring to return home. For these patients the caregivers respected their freedom to choose to die at home in over half the cases (56%). Their overall vulnerability (personal, family context and caregivers) had a significant influence on the return home. This overall vulnerability was in fact identified as applying in 40% of the clinical situations, and made the possibility of a return home 50% less likely.

Patient set-up using portal images: 2D/2D image registration using mutual information.

OBJECTIVE: Conformal radiation therapy requires accurate patient set-up for each fraction delivery. Electronic portal imaging devices allow the acquisition of portal images just before and even during dose delivery. However, the quantitative interpretation of these images in determining and correcting the patient's position remains uncertain, and automated methods are therefore being developed. Such methods must be usable for the different radiation therapy techniques. They must be robust and as automated as possible for use in clinical routines. This work was undertaken to establish the feasibility of 2D/2D registration for portal/portal and portal/simulator images in radiotherapy. MATERIALS AND METHODS: This paper describes an automated method based on the combination of calibration algorithms and pixel-based registration algorithms. We present experiments with the different imaging techniques, some of which use a phantom with and without a gold standard. Preliminary results obtained using patient data are also presented and discussed. RESULTS: The results obtained with a phantom demonstrated that this automated method for 2D/2D registration is fast, accurate, and robust, even in the case of blurred images for small treatment fields. CONCLUSIONS: Mutual information is a feasible method for 2D/2D portal/portal and portal/simulator image registration in radiotherapy.

[Image fusion methods for the repositioning of the patient in radiotherapy]. / Méthodes de recalage d'images pour le repositionnement de patients en radiothérapie.

Conformal radiotherapy requires the accurate and reproducible setup of the patient for each fraction delivery. Megavoltage imaging could enable this. This requires the development of image processing and data fusion algorithms. We describe an automated method based on the use of mutual information for registration. Such a method does not require any preliminary segmentation of the images. This method has been extensively tested on phantom as well as on some patient data. The obtained results demonstrated that this automated method for 2D/2D registration is rapid, accurate and robust even in the case of blurred images for small treatment fields.

The use of a semi-customized phantom for verification of conformal plans.

We have developed a technique for inverse treatment planning of prostate therapy designed to improve the degree of conformation between the dose distribution and the target volume. We compared the inverse plan with a "standard" four-field box technique as well as a four-field technique using oblique fields ("cross technique"). We validated the dosimetry of the inverse plan using Fricke gel solution in phantom specifically designed for this purpose. The phantom is a Plexiglas tank with a cross section, which approximates the dimensions of the pelvis. Anatomical data from computed tomography (CT) images of a patient were used to simulate organs in our phantom. This allows us to calculate dose distributions with the external geometry of the phantom and internal anatomy of the patient. Dose-volume histograms (DVHs) for the three different plans were calculated. The phantom containing the Fricke gel was irradiated according to the inverse plan. Magnetic resonance (MR) images was used to determine the dose distribution delivered to the phantom. We observe, on DVHs, that the inverse plan significantly reduces the dose to the rectum and the bladder but slightly increases the inhomogeneity inside the target volume. Correlation is good between isodoses on MR images and calculated isodoses. We conclude that inverse planning software can greatly improve the conformal degree of treatment to the prostate. This technique could be applied to other complex anatomic sites at which dose to organs at risk is a limiting factor and increased dose to the target volume is indicated. Our phantom and the Fricke gel solution are convenient to carry out validation of conformal treatments.

[Multicenter study on sensitization to Alternaria mold]. / Enquête multicentrique sur la sensibilisation à la moisissure alternaria. CNERAR. Commission Nationale d'Etudes et de Recherches en Allergologie Rurale.

The reality emerged of a non-negligible frequency of positive tests to "Alternaria". This was conducted by the inclusion of this mould in the standard allergy assessment, especially if a summer predominance of symptoms was known. A significant difference emerged between seasonal peaks which had to do with mono or polysensitisation. The highest frequency of positives was found near to humid surroundings or woods.

[3-D conformal radiotherapy procedure and registration of pre- and intra-radiotherapeutic data]. / Procédure de la radiothérapie conformative tridimensionnelle et mise en correspondance des données pré- et per-radiothérapiques.

The authors describe the different steps of 3-D conformal external irradiation. They mention as well two procedures of isocentric repositioning which are mandatory for the matching of anatomical data: the first one is acquired before the simulation and the second one just before the radiotherapy session.

Patient setup optimization for external conformal radiotherapy.

The aim of conformal radiotherapy is to deliver precisely a specific dose of radiation to a planning target volume, concurrently radiating as little healthy tissue and organs as possible. This can be accomplished only with the accurate positioning of the patient with respect to the radiotherapy system. In this paper, we describe a system to achieve a higher overall accuracy in the delivery of a prostatic radiation boost for treatment of carcinoma of the prostate. The system is based on the use of ultrasound images for measuring the actual position of the patient's prostate just before the radiation. Since these images are registered with pretreatment computed tomography or magnetic resonance imaging, the position and orientation of the planning target volume are computed with respect to the radiotherapy system and can be corrected as needed. This system is under clinical evaluation.

Conformal external radiotherapy of prostatic carcinoma: requirements and experimental results.

The aim of conformal radiotherapy is to deliver, with high precision, a specific dose (which may be a high dose) to a planning target volume, concurrently with irradiating as little as possible healthy tissue and organs at risk. Radiation therapy may suffer from a number of problems that result in both over- or under-sizing the irradiation fields, making over-rough simplifications of the irradiation ballistics and delivering an insufficient tumoral dose (to spare critical organs and reduce toxicity). One of these problems lies in the accurate positioning of the planning target volume with respect to the irradiation system, thence in the correct execution of the ballistics. In this paper, we describe a system aiming at achieving a higher overall accuracy in the delivery of prostatic boost for carcinoma of the prostate. The system is based on the use of ultrasonic images for measuring the actual position of the prostate just before irradiation. Since these images are registered with pre-operative (CT or MR) images, the position and orientation of the planning target volume is computed with respect to the irradiation system, and can be corrected accordingly. First experiments have been performed on dummies, and the results are discussed.