Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology.

BACKGROUND: In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception. METHODS: Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter. RESULTS: 63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life. CONCLUSION: Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.

Recognition and management of delirium among doctors, nurses, physiotherapists, and psychologists: an Italian survey.

BACKGROUND: There are no studies that have identified the ability to recognize and manage delirium among Italian health providers caring for patients at risk. Therefore, the Italian Association of Psychogeriatrics (AIP) conducted a multicenter survey among doctors, nurses, psychologists and physiotherapists to assess their competence regarding the theme of delirium and its management in the everyday clinical practice. METHODS: The survey period was 1st June 2013 to 30th November 2013. The invitation to participate was sent via email, with publication on the AIP website. The survey included 14 questions and two case vignettes. RESULTS: A total of 648/1,500 responses were collected. Most responders were doctors (n = 322/800), followed by nurses (n = 225/500), psychologists (n = 51/100), and physiotherapists (n = 30/100). Generally, doctors and psychologists correctly defined delirium, while nurses and physiotherapists did not. The most frequently used diagnostic tools were the Confusion Assessment Method (CAM) and the Diagnostic and Statistical Manual of Mental Disorders-IV. Delirium intensity was rarely assessed. Hypoactive delirium was generally managed with non-pharmacological approaches, while hyperactive delirium with a combination of non-pharmacological and pharmacological approaches. However, possible causes of delirium were under-assessed by half of doctors and by the majority of other professionals. Nurses, psychologists and physiotherapists did not answer the case vignettes, while doctors identified the correct answer in most cases. CONCLUSIONS: This is the first Italian survey among health providers caring for patients at risk of delirium. This is also the first survey including doctors, nurses, psychologists and physiotherapists. The results emphasize the importance of training to improve knowledge of this relevant unmet medical need.

Lemon (Citrus limon, Burm.f.) essential oil enhances the trans-epidermal release of lipid-(A, E) and water-(B6, C) soluble vitamins from topical emulsions in reconstructed human epidermis.

Topical bioavailability of lipid- and water-soluble vitamins is a critical issue for protecting or anti-ageing formulations. Using 17-day-old SkinEthic(®) reconstructed human epidermis, we investigated (at 34°C) the role of lemon EO in enhancing the penetration of α-tocopherol (E) and retinyl acetate (A), pyridoxine (B(6)) and ascorbic acid (C), released from O/W or W/O emulsions. D-limonene, α-pinene and p-cymene (65.9, 2.2 and 0.5%w/w of the oil) had skin permeability coefficients Ps (10(-3) cm h(-1)) of 0.56 ± 0.03 (or 0.73 ± 0.02), 0.72 ± 0.05 (or 0.98 ± 0.05) and 0.84 ± 0.04 (or 1.14 ± 0.04), respectively, when incorporated in a W/O (or O/W) emulsion. Vitamins B6, C and A had Ps values of (3.0 ± 0.4) × 10(-3), (7.9 ± 0.6) × 10(-3) and (0.37 ± 0.02) × 10(-5) cm h(-1), respectively, and their flux through the skin was enhanced by a factor of 4.1, 3.4 and 5.8, respectively, in the presence of lemon EO. The penetration of vitamin E was nine-fold enhanced. Lemon EO produced only reversible modification of TEWL, and it is a safe and effective penetration enhancer for topical administration of lipid- and water-soluble vitamins.

In vitro evaluation of the permeation through reconstructed human epidermis of essentials oils from cosmetic formulations.

The permeation of essential oils through SkinEthic reconstructed human epidermis, (RHE), was studied in vitro to establish a convenient tool to monitor the kinetics of release of active principles from cosmetic formulations. Twelve days old human epidermis held on polycarbonate disks was revitalized by addition of growth medium and incubated at 37 degrees C in 5% CO(2) atmosphere for five days prior to investigation. A system of six custom designed glass Franz-type diffusion cells were used for the permeation studies at 34 degrees C. The diffusion kinetic for 8 selected terpenes (camphor, carvone, 1,8-cineole, linalool, menthol, alpha-thujone, menthone, t-anethole), chosen as analytical markers of a mixture of plant essential oils contained in a cosmetic formulation, was probed by HS/SPME-GC-MS analysis and elaborated according to Fick's first law to obtain skin permeability coefficients (P(S) = 1.51, 1.47, 1.36, 0.80, 0.62, 0.40 and 0.14x10(-3) cm/h, respectively). The method proved to be sensitive, simple and reproducible, and RHE represents a convenient model for safety/quality assessment of cosmetic formulations.

A qualitative analysis of the mini mental state examination on Alzheimer's disease patients treated with cholinesterase inhibitors.

The improvement in cognitive performances due to cholinesterase inhibitors (ChEls) is not homogeneous among Alzheimer's disease (AD) subjects. Aim of this study is to evaluate whether a specific pattern of change in mini mental state examination (MMSE) could be observed in AD subjects after 9-month treatment with ChEls. From September 2000 to September 2002, 99 subjects enrolled in the CRONOS project. They have never been previously treated with ChEls. All of them completed both the 3- and the 9-month follow-up. The multidimensional assessment included MMSE, activity of daily living (ADL), instrumental activity of daily living (IADL), somatic health status, according to design of the CRONOSproject. The MMSE was analyzed both as a total score and disaggregated in 11 items. All subjects were divided in 2 groups according to the degree of change in MMSE total score from baseline to the 9th month. Subjects with a change 0 as responders (R). At start, no statistically significant differences were found between the 2 groups. MMSE score was significantly higher in the R group both at 3 (p < 0.0001) and 9 months (p < 0.0001), while functional status (ADL and IADL) was significantly lower in NR group at 9 months (p = 0.025; p =0.018, respectively). In MMSE qualitative analysis of 3-month, NR significantly worsened in temporal (p

Mood, behavior and memory.

The complexity has been viewed as an obstacle to medical research which, by necessity, depends on reduction. As a consequence, medical science often uses logical reductions in the attempt to understand the various facets of different clinical syndromes.However, such a reduction is not always possible in psychogeriatric syndromes where the clinical and biological complexity is the rule rather than the exception, and to identify correlation of signs and symptoms to a specific disease is often a difficult task. The present paper describes the complex relationships and interactions between the mood, behavior and memory. It is also suggested that the comprehension of psychogeriatric syndromes should not be based only on a separate analysis of these 3 elements (i.e., mood, behavior and memory), but on a multidimensional assessment of their reciprocal and dynamic interactions which may concur in the determination of the outcomes.

Determination of antioxidant efficacy of cosmetic formulations by non-invasive measurements.

BACKGROUND/AIMS: Antioxidants have been proposed, over the last decade, as functional ingredients for anti aging preparations and to prevent and modulate oxidative skin damages. Up to date, beside the photo-induced oxidative skin damages model, none in vivo protocols have shown sufficient reproducibility for the validation of the antioxidant claim for a cosmetic finished product. To this aim, we have recently anticipated a new in vivo protocol based on a microinflammatory model, driven by reactive oxygen species. In the present study our model was validated by comparison with four different instrumental methods. METHODS: The effects of a pre-treatment of two different formulations based on antioxidant functional ingredients, were investigated on forearm skin of 15 healthy volunteers, and compared to a cosmetic base and control area. The instruments considered in the study were Chromameter (CR-300 Minolta), Tewameter TM 210 (Courage-khazaka, Cologne, Germany), Laser Doppler Perfusion Imager (PIM1.0 Lisca Development AB, Sweden), in comparison to DermAnalyzer(R), an easy to use software program developed by us, using the CIE L*a*b* color space parameters. RESULTS: The comparative measurements showed that the antioxidant formulations tested were all able to reduce, in different but statistically significant extent, the intensity of skin redness, and of cutaneous blood flow, when compared to control area (P < 0.0001). CONCLUSIONS: The methyl nicotinate (MN) based microinflammatory model, in conjunction with objective measure- ments, resulted an effective tool for in vivo assessment of oxidative skin injuries. In view of the high level of repeatability, short time of answer and simplicity, the procedure by us developed, is proposed as a possible protocol for the evaluation of in vivo efficacy of antioxidant functional ingredients in cosmetic formulations.

Preclinical development of camptothecin derivatives and clinical trials in pediatric oncology.

Although the prognosis of childhood cancers has dramatically improved over the last three decades, new active drugs are needed. Camptothecins represent a very attractive new class of anticancer drugs to develop in paediatric oncology. The preclinical and clinical development of two of these DNA-topoisomerase I inhibitors, i.e. topotecan and irinotecan, is ongoing in paediatric malignancies. Here we review the currently available results of this evaluation. Topotecan proved to be active against several paediatric tumour xenografts. In paediatric phase I studies exploring several administration schedules, myelosuppression was dose-limiting. The preliminary results of topotecan evaluation in phase II study showed antitumour activity in neuroblastoma (response rate: 15% at relapse and 37% in newly diagnosed patients with disseminated disease) and in metastatic rhabdomyosarcoma (40% in untreated patients). Topotecan-containing drug combinations are currently investigated. Irinotecan displayed a broad spectrum of activity in paediatric solid tumour xenografts, including rhabdo-myosarcoma, neuroblastoma, peripheral primitive neuroectodermal tumour, medulloblastoma, ependymoma, malignant glioma and juvenile colon cancer. For several of these histology types, tumour-free survivors have been observed among animals bearing an advanced-stage tumour at time of treatment. The clinical evaluation of irinotecan in children is ongoing. Irinotecan undergoes a complex in vivo biotransformation involving several enzyme systems, such as carboxylesterase, UDPGT and cytochrome P450, in children as well as in adults. Preclinical studies of both drugs have shown that their activity was schedule-dependent. The optimal schedule of administration is an issue that needs to be addressed in children. In conclusion, the preliminary results of the paediatric evaluation of camptothecin derivatives show very encouraging results in childhood malignancies. The potential place of camptothecins in the treatment of paediatric malignant tumours is discussed.

[Epithelial ovarian cancers (advanced stage)]. / Les tumeurs épithéliales malignes de lóvaire (stade avancé).

Ovarian carcinomas are known to have a poor prognosis, not only because their diagnosis is often made in late time, but the risk of recurrence after initial treatment is high. This overview was made to explain the different approaches while dealing with a patient with an ovarian carcinoma. A particular interest went to the familial history of ovarian cancer, concerning a very short population, as shown in the recent data. Prognostic factors, the way of diagnosis, and the histologic classification were also explained in detail. Ovarian cancer is more often found out at an advanced stage of the disease, that's the reason why the treatment of epithelial ovarian cancer was extensively studied, with the recent approaches of the new drugs; for instance, the use of combinations with taxoides in the first part of treatment, or a numerous of other agents, particularly at the time of the recurrence, like the camptothecines, the gemcitabine, or the new derivatives of platinum. The management of the patient after initial treatment (follow up, maintenance therapy) were also included in this overview. As for the "borderline" tumors, a peculiar chapter was devoted to them.

Bimonthly high dose leucovorin and 5-fluorouracil 48-hour infusion with interferon-alpha-2a in patients with advanced colorectal carcinoma. Groupe d'Etude et de Recherche sur les Cancers de l'Ovaire et Digestifs (GERCOD).

UNLABELLED: BACKGROUND; The rationale for the modulation of 5-fluorouracil (5-FU) with interferon-alpha (IFN) is inhibition of 5-FU catabolism and 5-FU resistance. Clinical trials have shown debatable results when IFN is given in high doses with 5-FU used as a bolus alone or in combination with leucovorin (LV). A first-line Phase II study was performed in 50 patients with metastatic colorectal carcinoma who were given a bimonthly combination of high dose LV, a high dose 48-hour infusion of 5-FU, and a low dose of IFN. METHODS: The regimen was comprised of a 2-hour infusion of LV, 500 mg/m2, on each of 2 consecutive days, and a 48-hour infusion of 5-FU, 1.5 to 2 g/m2/24 hours, starting after Day 1 of LV treatment every 2 weeks until there was evidence of disease progression. IFN was administered subcutaneously three times weekly at a dose of 3 MU (body surface area [BSA] < 1.75 m2) or 4.5 MU (BSA > OR = 1.75 m2). RESULTS: World Health Organization toxicity Grade 3-4 occurred in 21 patients (42%): diarrhea in 6%, mucositis in 12%, neutropenia in 30%, and alopecia in 8%. The overall response rate was 44%; 1 patient had a complete response (2%), 21 had partial responses (42%), 23 had stable disease (46%), and 5 had disease progression (10%). The median progression free survival was 9 months, and median survival was 25 months. CONCLUSIONS: Bimonthly high dose LV, a high dose 48-hour infusion of 5-FU, and a low dose of IFN had good activity in patients with advanced colorectal carcinoma. However, as in other schedules of LV and 5-FU, IFN induces high grade toxicity.