[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]. / Les directives anticipées en psychiatrie : revue de la littérature qualitative, état des lieux et perspectives.

BACKGROUND: Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations. OBJECTIVE: This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context. METHOD: We used the keywords psychiatric advance directives, crisis card, Ulysse directives, joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders. RESULTS: We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs. DISCUSSION: PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.

[Can concepts of neurodevelopment and neuroplasticity explain post-traumatic psychoses?]. / Les concepts de neurodéveloppement et neuroplasticité pourraient-ils expliquer les troubles psychotiques post-traumatiques ?

Cases of psychoses emerging after a brain injury, included in the diagnostic category "Pychotic disorder due to traumatic brain injury," are not rare in psychiatry. The authors suggest hypotheses aimed at furthering the understanding of the pathogenic mechanisms relating traumatic brain injuries to psychotic disorders. These hypotheses find their starting point in two concepts: neuronal plasticity and the neurodevelopmental theory of schizophrenia. Neuroplasticity is the ability of nerve cells to alter after internal or external changes. The neurodevelopmental theory of schizophrenia is based on the idea that early impairments in cerebral development could later lead to a schizophrenic disorder; this theory has been integrated into the concept of vulnerability to schizophrenia. The authors hypothesize that traumatic brain injuries lead to neuronal reshaping and that this reshaping could cause impairments in subjects vulnerable to schizophrenia.

[Prevalence of trauma-related disorders in the French WHO study: Santé mentale en population générale (SMPG)]. / Prévalence des troubles psychotraumatiques en France métropolitaine.

INTRODUCTION: Trauma-related disorders are disabling affections of which epidemiological data change according to the country, population and measuring instruments. The prevalence of posttraumatic stress disorder (PTSD) appears to have increased over the past 15 years, but one cannot tell whether it has indeed increased or whether the standardized procedure has improved. Moreover, very few epidemiologic studies among the general population have been conducted in Europe, notably in France. DESIGN OF THE STUDY: The "Santé mentale en population générale" (SMPG) survey, that took place in France between 1999 and 2003 among more than 36 000 individuals, gives an estimation of the prevalence of psychotraumatic disorders in the general population. Multi-varied analyses were performed on PTSD-related variables and comorbid disorders. The instantaneous prevalence (past month) of PTSD was of 0.7% among the whole SMPG sample, with almost the same proportion of men (45%) and women (55%). There was a high rate of comorbidity among PTSD individuals, notably with mood disorders, anxiety disorders and addictive behaviour. There was an obvious relationship with suicidal behaviour, with 15-fold more suicide attempts during the past month among the PTSD population. RESULTS: This survey analysed the consequences of a psychic traumatism over and above complete PTSD according to DSM-IV criteria, observing for instance the consequences for people exposed both to a trauma and suffering from at least one psychopathological symptom since the trauma. Those who suffered from a psychotraumatic syndrome, according to our enlarged definition, represented 5.3% of the population, half suffered from daily discomfort and a third of them used medication. Then, we compared those psychotraumatic syndromes to complete PTSD from a sociodemographic, functional and type of care point of view. There was little difference in prevalence of PTSD between men and women in the SMPG survey (45% vs 55%), which is clearly distinct from the other epidemiologic surveys named above. Regarding age, as in the ESEMeD survey, anxiety disorders appeared to be more frequent among younger people. The originality of the SMPG survey is obviously in the fact that it studied the functional impact of the psychic disorder, the type of care and the satisfaction level after care. Only 50% of the PTSD population feels sick which is, however, twice as high as for the psychotraumatized population. This doesn't fit either with the fact that 100% of the PTSD population say they feel uncomfortable with other people. The type of care is in the same vein: 50% of psychotherapies and 75% of medication, but also 25% of mild medicines and 25% of traditional medicines. Moreover, among the drugs, antidepressants (that are still the first choice treatment in all international recommendations) represent only 30%, whereas anxiolytics, hypnotics and phytotherapy represent the remaining 70%. DISCUSSION: Regarding the type of care, the differences between the psychotraumatized population and the PTSD population are obvious. They are obvious in that which concerns the type of care, since the medication is similar. From a very global point of view, patients suffering from a subsyndromal PTSD rarely choose medical care (religion, mild or traditional medicine), while full PTSD patients definitely choose classical medical care (drugs, psychotherapy, and 30% of hospitalization). The prevalence of those who ask for care is very close to that observed in the ESEMeD survey, which was four individuals out of 10 suffering from PTSD. CONCLUSION: The SMPG data show that its necessary to maintain the distinction between subsyndromal PTSD and full PTSD since the populations differ, but both need care.

Contemporary management of stage I testicular seminoma: a survey of Canadian radiation oncologists.

Recently published studies clearly indicate that there are now several acceptable options for managing stage i testicular seminoma patients after orchiectomy. We therefore decided to survey Canadian radiation oncologists to determine how they currently manage such patients and to compare the results with previous surveys. Our results demonstrate that adjuvant single-agent chemotherapy is being considered as an option by an increasing proportion of radiation oncologists (although it is not considered the preferred option), the routine use of radiotherapy is declining, and surveillance is becoming increasingly popular and is recommended most often.

The preferred treatment for stage I seminoma: a survey of Canadian radiation oncologists.

AIMS: To evaluate the preferences of radiation oncologists for managing stage I seminoma. MATERIALS AND METHODS: An electronic survey evaluating the management of stage I seminoma patients was sent to Canadian radiation oncologists to determine their treatment recommendations and preferences. RESULTS: The survey completion rate was 74% among eligible respondents (78/105). Most (56%) felt that surveillance was the preferred treatment for patients, whereas 31% thought that adjuvant radiotherapy was best, 1% chose adjuvant chemotherapy as being the preferred option and 12% were unsure. Most would choose the same treatment for themselves if they were diagnosed with stage I seminoma. A previously published survey found that most respondents considered radiotherapy as the best option. CONCLUSIONS: Most Canadian radiation oncologists now favour surveillance for most stage I seminoma patients.

Multisequential transformation of a pig cell line (PFT): correlations between tumorigenicity and chromosome and ultrastructural markers.

Cells from representative subcultures of a continuous cell line of pig uterine tube (PFT) and carrying none, one, or two chromosome markers were inoculated in athymic nude mice (RCN) to determine the occurrence of the malignant transformation in this line. No tumors developed in mice after implantation of cells from either the 16th and 65th subcultures (no chromosome markers) or the 106th subculture (one chromosome marker, anchorage-dependent). Three adenomas (11.1%) were found in 27 mice that had been inoculated with anchorage-independent cells having one chromosome marker. Of 27 mice inoculated with cells showing two chromosome markers and gap junctions, 23 mice (85.1%) developed undifferentiated carcinomas. Ultrastructural traits and karyotypes of tumors were generally similar to those of the PFT cell inocula. However, annulate lamellae were found in 8 of 13 tumors examined by electron microscopy but were not seen in PFT cell inocula. The occurrence of a multisequential transformation was indicated by serial examination of the first 400 subcultures of the line and by comparison of the markers observed in three successive populations of cells differing in their genetic constitution.

Intraarterial cisplatin and concurrent radiation for locally advanced bladder cancer.

Between 1983 and 1987 25 patients with invasive bladder cancer (16 stage tumor 3 (T3) and nine stage T4) were treated with intraarterial cisplatin and concurrent radical radiation (20/25) or intraarterial cisplatin, concurrent preoperative radiation, and cystectomy (5/25). One patient died from treatment-related toxicity. Other toxicities have been what one would expect from the individual treatment modalities except for a sensory sacral root neuropathy in 11 of 24 (46%) patients. Twenty-three of 24 (96%) patients achieved a complete response (CR) and the projected actuarial 2-year survival is 90%. Only one of the 23 complete responders has had an invasive local recurrence. The excellent complete local response and survival rates achieved warrant further study of the combination of intraarterial cisplatin and radiation as a bladder-preserving strategy.

Does parasternal irradiation reduce thoracic vertebral metastases in breast cancer?

A review of 197 patients with bone metastases from breast carcinoma was undertaken to assess the effect of adjuvant parasternal irradiation on the distribution of those metastases. A total of 128 patients (Group I) received radiation. The control group consisted of 69 patients (Group II) who did not receive adjuvant radiation. The dose absorbed by the mid-thoracic vertebrae (T3 to T8) varied from 10 Gy in 3 weeks to 20 Gy in 4 weeks. The distribution of bone metastases was analyzed at the initial development in the 197 patients. Repeat assessments (X ray/scans) were available for analysis in 132 patients. Patients in Group I had less metastases from T3 to T8: 37/128 (29%), vs 30/69 (43.5%) for patients in Group II: (chi 2 = 3.62; p less than 0.10). For the 132 patients with serial assessments, the difference at last evaluation was more significant: 45/86 (52%) in Group I, vs 36/46 (78%) in Group II: (chi 2 = 7.44; p less than 0.01). The data shows that patients receiving low-dose exit beam irradiation from the parasternal field have fewer mid-thoracic bone metastases. Potential implications are discussed.

A randomized trial of granulocyte colony-stimulating factor (Neupogen) starting day 1 vs day 7 post-autologous stem cell transplantation.

The purpose of the study was to evaluate the effect of delayed granulocyte colony-stimulating factor (G-CSF) use on hematopoietic recovery post-autologous peripheral blood progenitor cell (PBPC) transplantation. Patients were randomized to begin G-CSF on day +1 or day +7 post transplantation. Thirty-seven patients with lymphoma or myeloma undergoing high-dose therapy and autologous PBPC rescue were randomized to daily subcutaneous G-CSF beginning on day +1 or day +7 post-transplant. Patients < or =70 kg received 300 microg/day and >70 kg 480 microg/day. All patients were reinfused with PBPCs with a CD34+ cell count >2.0 x 10(6)/kg. Baseline characteristics of age, sex and CD34+ cell count were similar between the two arms, the median CD34+ cell count being 5.87 x 10(6)/kg in the day +1 group and 7.70 x 10(6)/kg in the day +7 group (P=0.7). The median time to reach a neutrophil count of >0.5 x 10(9)/l was 9 days in the day +1 arm and 10 days in the day +7 arm, a difference which was not statistically significant (P=0.68). Similarly, there was no difference in median days to platelet recovery >20000 x 10(9)/l, which was 10 days in the day +1 arm and 11 days in the day +7 arm (P=0.83). There was also no significant difference in the median duration of febrile neutropenia (4 vs 6 days; P=0.7), intravenous antibiotic use (7 vs 8 days; P=0.54) or median number of red blood cell transfusions (4 vs 7 units; P=0.82) between the two arms. Median length of hospital stay was 11 days post-PBPC reinfusion in both groups. The median number of G-CSF injections used was 8 in the day +1 group and 3 in the day +7 group (P < 0.0001). There is no significant difference in time to neutrophil or platelet recovery when G-CSF is initiated on day +7 compared to day +1 post-autologous PBPC transplantation. There is also no difference in number of febrile neutropenic or antibiotic days, number of red blood cell transfusions or length of hospital stay. The number of doses of G-CSF used per transplant is significantly reduced with delayed initiation, resulting in a significant reduction in drug costs. For patients with an adequately mobilized PBPC graft, the initiation of G-CSF can be delayed until day +7 post-PBPC reinfusion.

Outpatient total body irradiation as a component of a comprehensive outpatient transplant program.

Outpatient total body irradiation (TBI) as part of a comprehensive outpatient transplant program was delivered to 142 of 167 (85%) consecutive patients receiving TBI-based conditioning therapy. Outpatients received either a single fraction of 500 cGy (110 patients) or 1200 cGy in six fractions over 3 days (32 patients). Patients were assessed daily and were administered oral ondansetron and dexamethasone for prophylaxis of nausea and vomiting as well as i.v. hydration. Accommodation during outpatient TBI-based conditioning was either the patient's home if within 30 min of the hospital, a hotel on the hospital grounds or on a closed hospital ward. None of the 142 patients required admission to the inpatient program during their TBI. There was no difference in 100-day mortality between those receiving TBI as an outpatient (9%) vs as an inpatient (16%). Of four deaths occurring within the first 14 days post transplant, none could be attributed to receiving TBI as an outpatient. Two hundred and six inpatient days were saved through the delivery of outpatient TBI. A comprehensive outpatient program, appropriate patient selection, daily hydration, the use of prophylactic 5HT3 antagonist anti-emetic therapy all contribute to the safe delivery of outpatient TBI.

A translating-bed technique for total-body irradiation.

Total-body irradiation (TBI) is a therapy modality that is being used with increasing frequency, in conjunction with chemotherapy, for patients undergoing bone-marrow transplantation. At the Ottawa Regional Cancer Centre a technique has been developed for the delivery of TBI to patients prior to bone-marrow transplantation. In this technique patients are treated on a mobile couch at approximately 195 cm SSD with a field size of 66.5 cm wide by 57 cm long. A computer-controlled stepping motor drives the patient couch at a user-selectable speed. The total dose delivered to the patient is a function of couch velocity, field size and patient separation. Treatment times are of the order of 10 min for each of the anterior and posterior fields for a 400 cGy fraction. It has been found that the conventional central axis tissue maximum ratio (TMR) and percentage depth dose (PDD) functions are not appropriate for describing dose delivered during dynamic treatment. To this end we have developed dynamic TMR and PDD functions. Extensive measurements have been performed in an anthropomorphic water phantom to determine the dose distributions in three dimensions and the efficacy of polymethyl methacrylate (PMMA) beam spoilers as a replacement for anterior and lateral bolus. It has been found that 2.4 cm PMMA spoilers do provide full skin dose and negate the requirement for lateral bolus. This TBI procedure is simple, rapid and appears to be well tolerated by the patients. 55 patients have been treated since the introduction of this technique in 1991.

Prognostic factors in early carcinoma of the endometrium.

Two hundred forty-one patients with clinical-pathological Stage I and 58 patients with clinical-pathological Stage II carcinoma of the endometrium treated between January 1959 and December 1983 at the Ottawa General Hospital were analyzed. The adjusted survival rate at 5 years was 92% in patients with Stage I and 66% in patients with Stage II. In patients with Stage I, the most important prognostic factors were the histological grade of the tumor and the depth of myometrial invasion. In patients with Stage II, the single most important prognostic factor was the clinical extent of the disease. Grade and depth of myometrial invasion were also significant prognostic factors, particularly in patients with pathological Stage II. Combined surgery and radiation therapy was clearly superior to surgery alone in patients with Stage II but not in patients with Stage I, although, with long-term follow-up, our results may suggest improved survival in these patients as well.

A consensus development approach to define national research priorities in bone metastases: proceedings from NCIC CTG workshop.

AIMS: A 1-day workshop was conducted to gather interested Canadian radiation oncologists to identify priority research questions that could be answered through clinical trials under the auspices of the National Cancer Institute of Canada--Clinical Trials Group (NCIC-CTG) Symptom Control committee. MATERIALS AND METHODS: In preparation for the workshop, a survey of Canadian radiation oncologists resulted in four research areas in symptom control, including radiation-induced mucosal reactions, fatigue, radiotherapy for brain metastases and radiotherapy for bone metastases. The first half of the workshop consisted of plenary sessions where the research setting and perspective was defined for each area. This was followed by deliberations by a subgroup of researchers with special interest in the topic area. The bone-metastases subgroup deliberated the clinical context, the scientific merits and the required methodology of research questions related to the role of radiotherapy in early treatment of bone metastases, the role of re-irradiation, the role of systemic radiotherapy and patient selection for different fractionation schedules. A list of prioritised clinical studies was proposed. RESULTS: The question of single vs multi-fraction re-irradiation for symptomatic bone metastases was identified as most pertinent to the Canadian radiation oncologists present. A multi-centre, international intergroup study is undergoing protocol development. Other study concepts, such as an alternative dose-schedule of 17 Gy/2 fractions/1 week for intermediate-prognosis patients, and early referral for radiation oncologist assessment of early or mildly symptomatic bone metastases for good-prognosis patients, require further methodological development before a clinical trial can be proposed. CONCLUSION: An NCIC-CTG workshop provided an update on current evidence-based knowledge in palliative radiotherapy for bone metastases. New trial concepts were discussed among practitioners and clinical investigators to promote dialogue and collaboration. The proposal of an international intergroup randomised trial of single vs multiple fraction re-irradiation for painful bone metastases received the most support among participants.

Transient heart failure in an adult with Kawasaki disease.

Kawasaki disease is a mucocutaneous lymph node syndrome with important cardiovascular complications that usually afflicts young children. We describe a 31-year-old woman who developed transient heart failure during the acute phase of Kawasaki disease. The diagnosis was supported by the presence of all six criteria of the disease: fever, conjunctivitis, strawberry tongue, cervical lymphadenopathies, truncal exanthem, and periungual membranous desquamation. Related clinical and laboratory findings included heart failure, arthralgias, transverse nail grooves, thrombocytosis, and elevated serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), and bilirubin. Alternative diagnoses were excluded. During her acute febrile illness, the patient developed tachycardia, hypotension, pulmonary rales, S3 gallop, and hepatojugular reflux. The chest roentgenogram showed new Kerley A and B lines. A first-pass isotopic ventriculography showed diffuse hypokinesia and decreased ventricular ejection fractions; spontaneous recovery occurred after a few days. A coronarography performed two months later showed no aneurysmal dilatation. Kawasaki disease is a cause, albeit rare, of myocardial dysfunction in the adult human, and should be sought for actively in a patient with heart failure during the course of an acute febrile illness, associated with mucocutaneous changes.

Interstitial brachytherapy for penile carcinoma: an alternative to amputation.

From 1987 to 1994, 15 patients with penile saquamous cell carcinoma were referred to the Ottawa Regional Cancer Centre. Seven had already been managed surgically. The other eight were treated with interstitial implantation. Mean age was 58 years (range 39-80). Two patients had previous incomplete local excision and six had biopsy only, with tumor from 1.5 to 4 cm in diameter. Six tumors were located on the glans, one on the corona and one at the base. All were clinically node negative. Six patients were implanted using a rigid technique with a fixed array of steel needles in pre-drilled plexiglass templates, and two with flexible nylon tubing. Implants were manually afterloaded with Iridium-192 wire. The prescribed dose of 60-65 Gy was delivered in 2.5-5.5 days. Local tumor control is 100% at a mean follow-up of 37 months (range 6-64). One patient died of metastases at 15 months with the primary controlled. The remaining seven patients are alive without evidence of disease. Six who were sexually active, continue to be so. One patient has a urethral stricture requiring dilatations. Cosmesis is generally good: mild to moderate hypopigmentation, telangiectasia and fibrosis may develop at the implant site. Intersititial brachytherapy for T1 or minimally invasive T2 penile squamous cell cercinoma up to 4 cm in diameter provides excellent local control with preservation of function and is a viable alternative to amputation.

Continuous purification of porcine lipase by rotating annular size-exclusion chromatography.

Crude porcine lipase (triacylglycerol lipase, EC 3.1.1.3) was purified in a single-stage chromatographic process. The purification was accomplished in a batch, as well as in a continuous system. Two types of size-exclusion packing materials (Sephadex and Sephacryl) were used. The average x-fold increase in purity, and the average recovered activity in the batch Sephadex and Sephacryl experiments were 13.6 and 89.7%, and 34.2 and 98.8%, respectively. The average x-fold increase in purity and the average activity recovered in the continuous Sephadex and Sephacryl experiments were 27.1 and 82.5% and 16.2 and 89%, respectively. Flow visualization experiments were carried out by tagging the protein to be separated with a fluorescent dye. The results from these experiments are also reported in this article.