System-level and patient-level explanations for non-attendance at diabetic retinopathy screening in Sutton and Merton (London, UK): a qualitative analysis of a service evaluation.

OBJECTIVES: Non-attendance at diabetic retinopathy screening has financial implications for screening programmes and potential clinical costs to patients. We sought to identify explanations for why patients had never attended a screening appointment (never attendance) in one programme. DESIGN: Qualitative analysis of a service evaluation. SETTING: One South London (UK) diabetic eye screening programme. PARTICIPANTS AND PROCEDURE: Patients who had been registered with one screening programme for at least 18 months and who had never attended screening within the programme were contacted by telephone to ascertain why this was the case. Patients' general practices were also contacted for information about why each patient may not have attended. Framework analysis was used to interpret responses. RESULTS: Of the 296 patients, 38 were not eligible for screening and of the 258 eligible patients, 159 were not contactable (31 of these had phone numbers that were not in use). We obtained reasons from patients/general practices/clinical notes for non-attendance for 146 (57%) patients. A number of patient-level and system-level factors were given to explain non-attendance. Patient-level factors included having other commitments, being anxious about screening, not engaging with any diabetes care and being misinformed about screening. System-level factors included miscommunication about where the patient lives, their clinical situation and practical problems that could have been overcome had their existence been shared between programmes. CONCLUSIONS: This service evaluation provides unique insight into the patient-level and system-level reasons for never attendance at diabetic retinopathy screening. Improved sharing of relevant information between providers has the potential to facilitate increased uptake of screening. Greater awareness of patient-level barriers may help providers offer a more accessible service.

[Early management of infants born to mothers with meconium-stained amniotic fluid: a survey in French delivery rooms]. / Prise en charge précoce des enfants nés avec un liquide méconial: enquête dans les maternités françaises.

UNLABELLED: The meconium aspiration syndrome is the first cause of respiratory distress in full term newborns. At birth, management includes systematical oropharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction. During last 10 years, many trials were published which discuss again the value of this strategy. AIM: To assess practices of the current management of births with a meconial amniotic liquid in the French maternities. METHODS: Observational survey by written questionnaires sent to the 617 French maternities. RESULTS: The rate of answers was of 54.3%. The incidence of the births presenting a meconial amniotic fluid was of 8.2%, complicated of meconium aspiration syndrome in 4.7%. In case of birth with presence of a meconial amniotic liquid, half of the maternities resorted systematically to oropharyngeal suctioning before shoulders delivery. A glottis exposition under laryngoscopy was practiced of principle for half of the newborn. Tracheal suctioning was achieved systematically in a quarter of the establishments. These techniques, with the exception of suctioning before clearing of the shoulders, were especially been achieved in a systematic way in the maternities of I and II A levels. CONCLUSION: This survey shows the necessity of harmonization of the practices in France for the management of the births with a meconial amniotic liquid.

[Fetal toxicity of angiotensin-II receptor antagonists]. / Toxicité foetale du candesartan.

We report a case of a newborn with an oligohydramnios, acute renal failure and ossification abnormalities. The role of maternal treatment of essential hypertension by angiotensin-II receptor antagonists is discussed in regard to the literature and pathophysiological data.

[The French preliminary experience of the use of a seed-projector for exclusive iodine 125 prostate brachytherapy: feasibility and acute toxicity]. / L'expérience française de l'utilisation d'un projecteur de source pour la curiethérapie prostatique exclusive par implants permanents d'iode radioactif: faisabilité et données de toxicité aiguë.

PURPOSE: To analyse a new technique for prostate brachytherapy with permanent Iodine implants characterized by the use of a seed projector after a 3D dosimetric peroperative treatment planning (FIRST technique). PATIENTS AND METHOD: 395 patients have been treated in France with this technique in six radiotherapy centres between November 2002 and December 2005 for a localized prostate cancer. RESULTS: Thirteen patients (3.3%) developped a urinary retention, and respectively 7.8 and 26.5% an acute RTOG grade 3 and 2 toxicity. The 6-weeks IPSS score was equal or lower to 15 in 73% with a 11 median IPSS value. A failure of the loading with the seed-projector, leading to a manual loading of the seeds, occurred in 9 patients (2.3%) in two centres, directly related to the loading procedure with the seed-projector in 5 cases. The median duration of the procedure was reduced by 30 minutes for the patients treated in 2005. CONCLUSIONS: This multicenter study establishes the feasibility of the routine use of a seed projector for permanent iodine 125 prostate implants with an initial tolerance similar to the best results published for other implants techniques.

[Radiosurgery of single brain metastasis without combined total cerebral irradiation. Results of a consecutive series of 12 cases]. / Radiochirurgie de métastase cérébrale unique sans irradiation cérébrale totale associée. Résultats d'une série consécutive de 12 cas.

PURPOSE: To evaluate the usefulness of radiosurgery without whole brain irradiation for a solitary brain metastasis. PATIENTS AND METHODS: Between December 1994 and November 1996, 12 patients were treated for a single brain metastasis by radiosurgery alone. Median age was 53, and 10 patients had a Karnofsky performance status above 70. Half the patients had active extracranial disease at the time of radiosurgery. Stereotactic radiosurgery delivered a single dose of 20 Gy (specified at the isocenter with a 70% isodose reference curve). Evaluation of results was performed according to local control, survival, evolution of performance status, as well as evolution of neurologic symptoms. RESULTS: No patient had immediate toxicity. One month later, ten patients showed improvement in their neurologic impairments, and none had progression of the cerebral lesion according to CT scan evaluation (diminution for seven patients, and stabilization for five). Local control rate was 58%, and median time to failure was 4 months. The overall median survival time was 10 months. Three patients were alive, with good performance status, and six died following cerebral progression. CONCLUSION: These poor results in terms of local control are in favor of supplementary whole brain irradiation, except for particular cases.

Magnetic resonance imaging in the treatment planning of radiation therapy in carcinoma of the cervix treated with the four-field pelvic technique.

PURPOSE: To evaluate magnetic resonance imaging (MRI) in the planning of radiation therapy for patients with carcinoma of the cervix treated with a four-field technique. METHODS AND MATERIALS: Between May 1994 and February 1995, 18 patients with carcinoma of the cervix were entered in the study (1 T1 N-; 2 T2a N-; 1 T2b NO; 10 T2b N-; 2 T2b N+; 2 T3b N+). Node status was assessed by a laparoscopic pelvic lymphadenectomy. During the first step, all the patients were simulated with an isocentric four-field pelvic technique. In one group (11 patients) simulation was done based on clinical examination, computed tomography (CT), and standard guidelines. In the second group (seven patients) simulation was based on clinical examination, CT, and with the help of diagnostic MRI, which was available at that time. During the second step, MRI in treatment position with skin markings of the isocenter of the radiation fields was then performed in every patient. During the third step, in each patient, the simulated radiation fields were correlated with the MRI defined target volume by superimposing them on midsagittal and midcoronal MR images. The adequacy of the margins was arbitrarly defined as 1 cm around the MRI defined target volume (tumor of the cervix and its extension, and uterus). RESULTS: In the first group (11 patients), MRI in treatment position led to a change in 7 patients: six inadequate margins in the lateral fields and one in the anterior and lateral field. In almost all the cases, the adjustments were of an increase of 10 mm, equally matched between the anterior and posterior borders of the lateral fields. In the second group (seven patients), MRI in treatment position has led to a change in lateral fields in five patients. The mean adjustment was 10 mm: four increases (two anterior border, one posterior border, one anterior and posterior border), and one decrease of the posterior border. In the two groups, modifications of the anterior border of the lateral fields have allowed adequate margins around the uterine fundus and modifications of the posterior border have allowed adequate coverage of the cervical tumor. CONCLUSION: When treating carcinoma of the cervix with a four-field radiation technique, standard portals do not exist. The design of lateral fields has to be based on individual morbid anatomy, which is given accurately by diagnostic MRI. Magnetic resonance imaging in treatment position assesses the design of simulated lateral fields.

Evaluation of whole abdominal irradiation in ovarian carcinoma with a four orthogonal fields technique.

PURPOSE: The purpose of this study is to evaluate the toxicity and the results of abdominopelvic irradiation with a four orthogonal field's technique in patients with ovarian carcinoma. METHODS AND MATERIALS: Between May 1981 and December 1990, 167 patients with ovarian carcinoma have been treated with whole abdominal irradiation: 62 patients with no or minimal residual disease < 2 cm after initial surgery (group 1) and 105 patients with no residual disease or macroscopic residual disease < 2 cm assessed by second-look surgery after incomplete debulking surgery and cisplatin-based polychemotherapy (group 2). Irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam (1.5 Gy/fraction/day, 20 fractions over 30 days). Boosts were performed in 50 cases (median dose of 15 Gy). RESULTS: With a median follow-up of 68 months, the 5-year actuarial survival rate was 50% in the entire group, 67% in group 1, 40% in group 2, and 84% in T1, 61.5% in T2, 38% in T3. Five-year actuarial survival was analyzed according to the residuum: (a) after initial surgery (no residual disease: 70%, residual disease: 36.5%), (b) after second-look surgery: 76% in patients with a negative second look, 66% in patients with microscopic residual disease, 22% in patients with macroscopic residual disease and secondary surgical reduction, and 10% in patients with small unresectable nodules. Nine percent of the patients failed to complete irradiation acute side effects related. Five percent required surgery for bowel obstruction. CONCLUSION: The abdominopelvic irradiation with this four orthogonal field's technique was associated with tolerable acute toxicity and a low risk of serious late complications. Similar late results to have been reported whole abdominal irradiation with chemotherapy in patients with negative or microscopic residual disease after surgery. Randomized trials comparing these two adjuvant treatments are warranted.

[Abdominopelvic radiation therapy in the treatment of ovarian carcinoma. Study of a continuous series of 167 patients]. / L'irradiation abdominopelvienne dans le traitement des cancers ovariens. Analyse d'une série continue de 167 patientes.

From May 1981 through December 1990, 167 patients with ovarian carcinoma were treated with whole abdominal irradiation. All patients of the first group (n = 62) presented with no or minimal (< 2 cm) residual disease at the time of irradiation. They received whole abdominal irradiation after initial surgery. Residual disease was left after initial surgery for patients of the second group (n = 105). They underwent a cisplatin polychemotherapy regimen followed by second-look laparotomy and abdominopelvic irradiation. The irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam. Boosts were performed in 50 cases (mean dose of 15 Gy); 91% have completed irradiation at the prescribed dose level; 5% had severe intestinal toxicity requiring surgery. The median follow-up was 68 months. The 5-year actuarial survival rate was 50%, 67% group 1.40% group 2. Five-year actuarial survival was 84% for T1, 61.5% for T2, 38% for T3. Five-year survival depended on tumor rest after initial surgery (residual disease 36.5%, no residual disease 70%). For patients in group 2, the size of residual disease at second-look laparotomy was a significant prognostic factor: five-year actuarial survival 76% with negative second-look, microscopic residual disease (positive cytology or random biopsies) 60%, microscopic disease after cytoreductive surgery at second-look 22%, macroscopic residual disease (small nodules) 10%. These results indicate that abdominopelvic irradiation is valuable in the treatment of ovarian carcinoma when there is no macroscopic residual disease after initial surgery or second look laparotomy. To assess the place of radiotherapy, randomized trials comparing whole abdominal irradiation with chemotherapy, watch policy for staged patients is warranted.

[Radiotherapy and cerebral stereotaxis. Examples of dosimetry with 3D reconstruction]. / Radiothérapie et stéréotaxie cérébrale. Exemples de dosimétrie avec reconstruction 3-D.

External stereotactic radiotherapy allows to irradiate a small and carefully delimited intracranial volume according to the spatial definition of the target. To determine the distribution of the dose in the volume irradiated, we developed a dosimetric programme adapted to our particular treatment conditions (arc therapy in the frontal and oblique planes converging onto the centre of the target volume with circular beams 8 to 20 mm in diameter using 18 MV X photons). The principle of the programme is a 3D reconstruction based on ten transverse CT slices. This reconstruction, related to the stereotactic coordinates defined during stereotactic localization, visualises the outline of each oblique frontal treatment plane and the outline of the three perpendicular reference planes passing through the centre of the target volume (i.e. transverse, sagittal, coronal). The isodose distribution is then calculated in the planes defined by these reconstructions. Under treatment conditions, we use the parameters measured for each beam with their additional collimation. We present an evaluation of this software performed on a phantom consisting of a skull containing a defined target.