[Stigmatisation of patients with mental disorders by medical interns specialising in general practice: A national survey]. / Stigmatisation des patients atteints d'un trouble mental par les internes de médecine générale : une enquête nationale.

OBJECTIVES: The objective was to assess the level of stigmatisation of psychiatric patients by medical interns specialising in general practice (GP), and to assess the influencing factors of stigmatisation. METHODS: A national survey was carried out among interns in general practice (GP) contacted through their local associations from December 10, 2019 to March 9, 2020. An online questionnaire was diffused. The validated French version of the Mental Illness Clinicians' Attitudes (MICA) was used to measure stigmatising attitudes towards psychiatry and persons with psychiatric disorder by the interns. This 16-item scale is designed to measure attitudes of health care professionals towards people with mental illness with scores ranging from 16 to 96 (the most stigmatizing). Several covariates were collected: socio-demographics, personal experiences with mental health, and mental health trainings during medical studies. All questionnaires were strictly anonymized. Comparative analyses of the MICA score by group were performed using Student's tests. RESULTS: A total of 389 interns responded. The majority of respondents were female (n=277; 71%) and the mean age was 27years [standard deviation (SD)±2.39]. The mean MICA rate was 40.64 (SD±8.09) for a neutral score of 56, reflecting low overall stigmatizing attitudes. MICA scores were significantly lower among female interns (40.11 vs. 41.95; P=0.042), those who had benefited from personal psychological or psychiatric support (38.70 vs. 41.61; P=0.001), and those who had completed a psychiatric externship (39.47 vs. 42.16; P=0.001). CONCLUSIONS: GP interns had an attitude that is generally not very stigmatizing even if its improvement should still be sought. This is particularly verified among those who have completed a psychiatric internship during their externship. This suggested association should be supported by other studies. The stakes are high for the future management of patients since stigmatisation by a physician is strongly implied in the worse healthcare management of patients with psychiatric disorders, leading them to a shorter lifespan.

Drug Prescription Including Interactions with Anticancer Treatments in the Elderly: A Global Approach.

BACKGROUND: Consequences of inappropriate prescriptions and polymedication in patients suffering from cancer are beginning to be well documented. However, the methods used to evaluate these consequences are often discussed. Few studies evaluate the risk of interaction with anticancer drugs in elderly patients suffering from cancer. OBJECTIVES: To describe the prevalence (i) of polypharmacy, (ii) of potentially inappropriate drug prescriptions and (iii) of drug interactions involving anticancer treatments, using a multiple reference tools. DESIGN: A retrospective, cross-sectional, multicenter study performed from January to December 2012. PARTICIPANTS: Patients aged 65 years or older suffering from cancer presented at the oncogeriatric multidisciplinary meeting. MEASUREMENTS: Polymedication (>6 drugs), potentially inappropriate prescriptions and drug interactions involving anticancer treatment were analyzed in combination with explicit and implicit criteria within a global approach. RESULTS: Among the 106 patients included in this study, polypharmacy was present in 60.4% of cases, potentially inappropriate drug prescription in 63.1% and drug interactions in 16% of case, of which 47% involved anti-cancer treatments. Twenty-seven major drug interactions were identified and eight interactions involved chemotherapy. CONCLUSION: Polymedication, inappropriate prescribing and drug interactions involving anti-cancer drugs are common and largely underestimated in elderly cancer patients.

Methodology of phase II clinical trials in metastatic elderly breast cancer: a literature review.

PURPOSE: As the incidence of invasive breast cancer will increase with age, the number of elderly patients with a diagnosis metastatic breast cancer will also rise. But the use of cytotoxic drugs in elderly metastatic breast cancer patients is not systematic and is dreaded by medical oncologists. The need for prospective oncologic data from this population seems increasingly obvious. The main objective of this review is to investigate design and characteristics of phase II trials that assess activity and feasibility of chemotherapies in elderly advanced/metastatic breast cancer patients. METHODS: An electronic search in PUBMED allowed us to retrieve articles published in English language on phase II trials in elderly metastatic breast cancer between January 2002 and May 2016. Sixteen publications were finally included in this review. RESULTS: The primary endpoint was a simple, a composite, and a co-primary endpoints in 11, three, and two studies, respectively. Efficacy was the primary objective in 15 studies: simple (n = 10), composite (n = 3), co-primary endpoints (n = 2). Composite or co-primary endpoints combined efficacy and toxicity. Thirteen studies used multistage designs. CONCLUSIONS: Only five studies evaluated the feasibility, i.e., to jointly assess efficacy and tolerance to treatment (toxicity, quality of life, etc) as primary endpoint. Development of elderly specific phase III clinical trials might be challenging, it therefore seems essential to conduct phase II clinical trials evaluating jointly efficacy and toxicity in a well-defined geriatric population. Use of multistage designs that take into account heterogeneity would allow to identify a subpopulation at interim analysis and to reduce the number of patients exposed to an inefficient or a toxic treatment regimen. It is crucial to evaluate new therapies (targeted therapies, immunotherapies) using adequate methodologies (Study design, endpoint).

Visual Impairment Screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle.

OBJECTIVES: To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital. DESIGN: Retrospective, observational cross-sectional, single-centre study. SETTING: Institutional practice. PARTICIPANTS: Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648). MEASUREMENTS: Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups. RESULTS: The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score. CONCLUSION: The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

Body Composition and Anti-Neoplastic Treatment in Adult and Older Subjects - A Systematic Review.

BACKGROUND: The estimation of the risk of poor tolerance and overdose of antineoplastic agents protocols represents a major challenge in oncology, particularly in older patients. We hypothesize that age-related modifications of body composition (i.e. increased fat mass and decreased lean mass) may significantly affect tolerance to chemotherapy. METHOD: We conducted a systematic review for the last 25 years (between 1990 and 2015), using US National library of Medicine Medline electronic bibliographic database and Embase database of cohorts or clinical trials exploring (i) the interactions of body composition (assessed by Dual X-ray Absorptiometry, Bioelectrical Impedance Analyses, or Computerized Tomography) with pharmacokinetics parameters, (ii) the tolerance to chemotherapy, and (iii) the consequences of chemotherapies or targeted therapies on body composition. RESULTS: Our search identified 1504 articles. After a selection (using pre-established criteria) on titles and abstract, 24 original articles were selected with 3 domains of interest: impact of body composition on pharmacokinetics (7 articles), relationship between body composition and chemotoxicity (14 articles), and effect of anti-cancer chemotherapy on body composition (11 articles). The selected studies suggested that pharmacokinetic was influenced by lean mass, that lower lean mass could be correlated with toxicity, and that sarcopenic patients experienced more toxicities that non-sarcopenic patients. Regarding fat mass, results were less conclusive. No studies specifically explored the topic of body composition in older cancer patients. CONCLUSIONS: Plausible pathophysiological pathways linking body composition, toxicity, and pharmacokinetics are sustained by the actual review. However, despite the growing number of older cancer patients, our review highlighted the lack of specific studies in the field of anti-neoplastic agents toxicity regarding body composition conducted in elderly.

[Locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma: French national guidelines]. / Traitements locorégionaux de métastase(s) cérébrale(s) chez des patients atteints d'un mélanome cutané métastatique : recommandations nationales françaises.

INTRODUCTION: The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals. OBJECTIVE: The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations. METHODS: The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS: This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.

[Management of patients with metastatic cutaneous melanoma: French national guidelines. French National Cancer Institute]. / Prise en charge thérapeutique des patients atteints d'un mélanome cutané métastatique : recommandations nationales françaises. L'Institut national du cancer.

BACKGROUND: Recent years have seen the emergence of new molecules for the treatment of patients with metastatic cutaneous melanoma, with significant benefits in terms of survival and the opening of new therapeutic perspectives. In addition, many techniques are currently being developed for locoregional treatment of metastatic sites. Management of metastatic melanoma is thus fast-changing and is marked by innovative therapeutic approaches. However, the availability of these new treatments has prompted debate among healthcare professionals concerning their use and their place in therapeutic strategy. AIMS: Since 2008, the French National Cancer Institute (INCa) has been leading a project to define and diffuse national clinical practice guidelines. It has performed a review of these treatment methods, which it aims to circulate, and it is seeking to develop recommendations in order to allow nationwide implementation of innovative approaches while promoting good use thereof. METHODS: The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts within a multidisciplinary working group, with feedback from specialists in cancer care delivery. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS: This article presents the national recommendations for first- and second-line systemic treatment and for locoregional treatment of metastatic sites in patients presenting metastatic cutaneous melanoma.

Impact of an oncogeriatric consulting team on therapeutic decision-making.

Increased life expectancy and cancer incidence imply the need to develop a specialized care policy for elderly patients with cancer. We created an oncogeriatric consulting team (OGCT) in Toulouse University Hospital to carry out comprehensive gerontological assessment at the bedside of hospitalized patients. We analyze the impact on the final cancer treatment decision of this mobile geriatric assessment. We carried out a descriptive, retrospective real-life analysis of a patient cohort over a two-year period. The OGCT assessed 124 patients, of whom the majority were women (54.8%), median age 81 years, living at home (95.2%) and with family caregivers (86.5%). Nearly all were frail (96.7% according to the classification of Balducci and colleagues) and 3.2% were vulnerable. The team's decisions were analyzed for patients who had not yet been treated (n=107). After analysis, the team's proposal was in line with the initial cancer treatment plan in 68.2% of cases (n=73). In cases where there was a disagreement, the final decision was in line with the mobile team's proposal in 17.75% of 107 patients (n=19). The decision of the team was followed more often when their assessment proposed strictly palliative treatment. The decision to give elderly patients specific cancer treatment seems in our experience rather to be a matter for the oncologists, and is not very susceptible to modification by geriatric opinion. On the other hand, the geriatrician appears to be more credible and his/her opinion more likely to be followed when the patient is considered too frail and less aggressive, or even exclusively palliative, treatment is proposed.

Supportive care organisation in France: an in depth study by the French speaking association for supportive care in cancer (AFSOS).

BACKGROUND: Supportive care in cancer (SCC) was further enhanced in the Second National Cancer Act decreed in December 2009. The aim of our study was to assess current SCC efficacy. PATIENTS AND METHODS: The French speaking association for supportive care in cancer (AFSOS) conducted an observational study to evaluate practices, organisations and information given to patients. A specific 32 point questionnaire was sent to 1621 French physicians (MDs) caring for cancer patients. RESULTS: Three different organisations were evaluated: the individual MDs, the transversal team and its particular structure specialised in global patient care specifically developed at comprehensive cancer centres - CCC. During their disease, 68% of patients received SCC, which was more available during the palliative period (90%) than at the diagnosis (44%). Our results found that 71% of cancer departments had a specific interdisciplinary cross-team to provide SCC, particularly in CCC (62%; p=0.01) while 37% had specific inpatient units. A specific organisation dedicated to home care was greater in CCC than in public or private centres (69%, 45%, 20% respectively; p=0.01). Adverse event information was performed more by an oncologist than other specialists (p=0.01). CONCLUSION: Our results suggest that the specific SCC organisation could be a useful management tool to improve supportive care for cancer patients.

End-of-life care for persons with advanced Alzheimer disease: design and baseline data from the ALFINE study.

CONTEXT: Alzheimer disease (AD) is the most common cause of dementia. Most affected individuals survive to an advanced stage of dementia, which is under-recognized as a terminal illness. OBJECTIVES: Our objectives were to better understand the clinical trajectory of advanced AD and to identify the palliative care needs of these patients. METHODS: This was an observational prospective study of AD patients in severe stage of disease included after a hospitalization in geriatric wards. They were followed up every three months during 2 years. At each visit, interviews provided data regarding: pain (Elderly Pain Caring Assessment scale), pressure ulcers, eating patterns, daily medications and use of health services. This paper describes the design of the ALFINE study and the characteristics of the recruited cohort. RESULTS: 112 patients were recruited (mean age: 84.03 + 6.96) years; 76.79% were women. Mean time since diagnosis of AD was 5.28 years. Pressure ulcers were observed in 42 patients. Pain assessment with the EPCA showed a mean score of 8.58. One third of patients with an EPCA score of more than 7 (median) had no analgesics. More than half of patients had been treated with antibiotics during the three months before inclusion in the study and 33 patients were still receiving antibiotics at inclusion. Two third of patients had been hospitalized in the month before inclusion. CONCLUSION: End-of-life care for individuals with end-stage AD is increasingly important because of the rising number of patients with this disease. Health care systems and clinicians should make efforts to ameliorate the suffering of patients and their caregivers.

Alzheimer's disease therapeutic trials: EU/US Task Force report on recruitment, retention, and methodology.

While we may not be able to find a cure for Alzheimer's disease (AD) in the near future, several drugs presently in trials have shown promise as possible modifiers of disease progression. However, we may not be able to demonstrate efficacy due to issues of recruitment, retention, site-to-site variability, and other methodological issues. It is thus incumbent on the scientific community to find solutions to these problems, particularly as the field moves toward preventing illness or treating the disease in its prodromal stages, where these methodological issues will become even more critical. We need to better understand why participants agree or refuse to enter drug trials, and why both primary care physicians and Alzheimer's specialists agree or refuse to involve their patients. We also need to quantify the impact of requiring imaging studies, extensive questionnaires, cognitive testing, and lumbar punctures on recruitment and retention. With these concerns in mind, an international task force meeting of experts from academia and industry in the United States, European Union, and Japan in San Diego, California on November 2, 2011 to focus on recruitment, retention and other methodological issues related to clinical trials for AD. Based on the recommendations of this Task force meeting, this Perspectives article critically reflects on the most critical and timely methodological issues related to recruitment and retention in prevention and therapeutic trials in AD, which are paralleled by a paradigm shift in the diagnostic conceptualization of this disease, as reflected by recently new proposed diagnostic criteria involving preclinical stages of the disease.