[Development plan for palliative care and end-of-life support 2021-2024]. / Plan de développement des soins palliatifs et accompagnement de la fin de vie 2021-2024.

DEVELOPMENT PLAN FOR PALLIATIVE CARE AND END-OF-LIFE SUPPORT 2021-2024. The 5th national Plan on palliative and end-of-life care aims to ensure universal access to palliative care in France. It is based on three axes: communication on palliative care and appropriation of end-of-life rights by each citizen and by each health professional; training professionals and supporting research; deployment of local care, strengthening of coordination, early integration of palliative care.

PLAN DE DÉVELOPPEMENT DES SOINS PALLIATIFS ET ACCOMPAGNEMENT DE LA FIN DE VIE 2021-2024. Le 5e Plan national sur les soins palliatifs et la fin de vie a pour objectif d'assurer un accès universel aux soins palliatifs en France. Il se décline autour de trois axes : la communication sur les soins palliatifs et l'appropriation des droits de la fin de vie par chaque citoyen et par chaque professionnel de santé ; la formation des professionnels et le soutien de la recherche ; le déploiement des prises en charge de proximité, le renforcement des coordinations, l'intégration précoce des soins palliatifs.

Taxonomic study of Hymenochaetaceae species (Agaricomycetes, Basidiomycota) in the municipalities of Tomé-Açu and Bujaru, Pará, Brazil.

The family Hymenochaetaceae includes a diversity of 893 species described around the world. Its representatives are known by their usually rusty colored basidiomes with a poroid hymenial surface, hydnoid or smooth, woody consistency, and wide morphological variation regarding the arrangement on the substrate. They behave as saprophytic, parasitic, ectomycorrhizal and play a fundamental role in the decomposition of wood in forest ecosystems. In the Brazilian Amazonia region, approximately 40 species of Hymenochaetaceae are currently recorded. The main goal of this study was to increase the knowledge on Hymenochaetaceae from the Brazilian Amazonia. Collections were carried out between October 2021 and April 2022 in the state of Pará, municipalities of Tomé-Açu and Bujaru, to expanding the knowledge of this fungal family to the Brazilian Amazonia. A total of 15 specimens were identified, distributed in seven genera and 12 species. Four species are new records for the state of Pará (Fomitiporia apiahyna, Phellinus neocallimorphus, Phellinus sancti-georgii, and Sclerotus extensus) and two of them are new records for the Brazilian Amazonia (P. neocallimorphus and P. sancti-georgii). Our findings contribute to taxonomic knowledge of this family in the Brazilian Amazonia and reduce the information gaps about the diversity of species.

Incidence and risk factors of prolonged grief in relatives of patients with terminal cancer in French palliative care units: The Fami-Life multicenter cohort study.

OBJECTIVES: Psychological consequences of grief among relatives are insufficiently known. We reported incidence of prolonged grief among relatives of deceased patients with cancer. METHODS: Prospective cohort study of 611 relatives of 531 patients with cancer hospitalized for more than 72 hours and who died in 26 palliative care units was conducted. The primary outcome was prolonged grief in relatives 6 months after patient death, measured with the Inventory Complicated Grief (ICG > 25, range 0-76, a higher score indicates more severe symptoms) score. Secondary outcomes in relatives 6 months after patient death were anxiety and depression symptoms based on Hospital Anxiety and Depression Scale (HADS) score (range 0 [best]-42 [worst]), higher scores indicate more severe symptoms, minimally important difference 2.5. Post-traumatic stress disorder symptoms were defined by an Impact Event Scale-Revised score >22 (range 0-88, a higher score indicates more severe symptoms). RESULTS: Among 611 included relatives, 608 (99.5%) completed the trial. At 6 months, significant ICG scores were reported by 32.7% relatives (199/608, 95% CI, 29.0-36.4). The median (interquartile range ICG score) was 20.0 (11.5-29.0). The incidence of HADS symptoms was 87.5% (95% CI, 84.8-90.2%) at Days 3-5 and 68.7% (95% CI, 65.0-72.4) 6 months after patient's death, with a median (interquartile range) difference of -4 (-10 to 0) between these 2 time points. Improvement in HADS anxiety and depression scores were reported by 62.5% (362/579) relatives. SIGNIFICANCE OF RESULTS: These findings support the importance of screening relatives having risk factors of developing prolonged grief in the palliative unit and 6 months after patient's death.

Sensitivity to the slope of the amplitude spectrum is dependent on the spectral slopes of recently viewed environments: A visual adaptation study in modified reality.

Scenes contain many statistical regularities that could benefit visual processing if accounted for by the visual system. One such statistic is the orientation-averaged slope (α) of the amplitude spectrum of natural scenes. Human observers show different discrimination sensitivity to α: sensitivity is highest for α values between 1.0 and 1.2 and decreases as α is steepened or shallowed. The range of α for peak discrimination sensitivity is concordant with the average α of natural scenes, which may indicate that visual mechanisms are optimized to process information at α values commonly encountered in the environment. Here we explore the association between peak discrimination sensitivity and the most viewed αs in natural environments. Specifically, we verified whether discrimination sensitivity depends on the recently viewed environments. Observers were immersed, using a Head-Mounted Display, in an environment that was either unaltered or had its average α steepened or shallowed by 0.4. Discrimination thresholds were affected by the average shift in α, but this effect was most prominent following adaptation to a shallowed environment. We modeled these data with a Bayesian observer and explored whether a change in the prior or a change in the likelihood best explained the psychophysical effects. Change in discrimination thresholds following adaptation could be explained by a shift in the central tendency of the prior concordant with the shift of the environment, in addition to a change in the likelihood. Our findings suggest that expectations on the occurrence of α that result from a lifetime of exposure remain plastic and able to accommodate for the statistical structure of recently viewed environments.

Neural markers of suppression in impaired binocular vision.

Even after conventional patching treatment, individuals with a history of amblyopia typically lack good stereo vision. This is often attributed to atypical suppression between the eyes, yet the specific mechanism is still unclear. Guided by computational models of binocular vision, we tested explicit predictions about how neural responses to contrast might differ in individuals with impaired binocular vision. Participants with a history of amblyopia (N = 25), and control participants with typical visual development (N = 19) took part in the study. Neural responses to different combinations of contrast in the left and right eyes, were measured using both electroencephalography (EEG) and functional magnetic resonance imaging (fMRI). Stimuli were sinusoidal gratings with a spatial frequency of 3c/deg, flickering at 4 Hz. In the fMRI experiment, we also ran population receptive field and retinotopic mapping sequences, and a phase-encoded localiser stimulus, to identify voxels in primary visual cortex (V1) sensitive to the main stimulus. Neural responses in both modalities increased monotonically with stimulus contrast. When measured with EEG, responses were attenuated in the weaker eye, consistent with a fixed tonic suppression of that eye. When measured with fMRI, a low contrast stimulus in the weaker eye substantially reduced the response to a high contrast stimulus in the stronger eye. This effect was stronger than when the stimulus-eye pairings were reversed, consistent with unbalanced dynamic suppression between the eyes. Measuring neural responses using different methods leads to different conclusions about visual differences in individuals with impaired binocular vision. Both of the atypical suppression effects may relate to binocular perceptual deficits, e.g. in stereopsis, and we anticipate that these measures could be informative for monitoring the progress of treatments aimed at recovering binocular vision.

Measurement of Energy States of the Trypanosomatid Mitochondrion.

The evaluation of mitochondrial functionality is critical to interpret most biological data at the (eukaryotic) cellular level. For example, metabolism, cell cycle, epigenetic regulation, cell death mechanisms, autophagy, differentiation, and response redox imbalance are dependent on the mitochondrial state. In case of parasitic organisms, such as trypanosomatids, it is very often important to have information on mitochondrial functionality in order to assess the mechanisms of actions of drugs being proposed for therapy. In this chapter we present a set of methods that together allow to evaluate with some precision the mitochondrial functionality in Trypanosoma cruzi and Trypanosoma brucei. We discuss how to determine O2 consumption, mitochondrial inner membrane potential, ATP production, and the endogenous production of reactive oxygen species.

The Fami-life study: protocol of a prospective observational multicenter mixed study of psychological consequences of grieving relatives in French palliative care units on behalf of the family research in palliative care (F.R.I.P.C research network).

BACKGROUND: Grieving relatives can suffer from numerous consequences like anxiety, depression, post-traumatic stress disorder (PTSD) symptoms, and prolonged grief. This study aims to assess the psychological consequences of grieving relatives after patients' death in French palliative care units and their needs for support. METHODS: This is a prospective observational multicenter mixed study. Relatives of adult patients with a neoplasia expected to be hospitalized more than 72 h in a palliative care unit for end-of-life issues will be included within 48 h after patient admission. End-of-life issues are defined by the physician at patient admission. Relatives who are not able to have a phone call at 6-months are excluded. The primary outcome is the incidence of prolonged grief reaction defined by an ICG (Inventory Complicate Grief) > 25 (0 best-76 worst) at 6 months after patient' death. Prespecified secondary outcomes are the risk factors of prolonged grief, anxiety and depression symptoms between day 3 and day 5 and at 6 months after patients' death based on an Hospital Anxiety and Depression score (range 0-42) > 8 for each subscale (minimal clinically important difference: 2.5), post-traumatic stress disorder symptoms 6 months after patient' death based on the Impact of Events Scale questionnaire (0 best-88 worst) score > 22, experience of relatives during palliative care based on the Fami-Life questionnaire, specifically built for the study. Between 6 and 12 months after the patient's death, a phone interview with relatives with prolonged grief reactions will be planned by a psychologist to understand the complex system of grief. It will be analyzed with the Interpretative Phenomenological Analysis. We planned to enroll 500 patients and their close relatives assuming a 25% prolonged grief rate and a 6-month follow-up available in 60% of relatives. DISCUSSION: This study will be the first to report the psychological consequences of French relatives after a loss of a loved one in palliative care units. Evaluating relatives' experiences can provide instrumental insights for means of improving support for relatives and evaluation of bereavement programs. TRIAL REGISTRATION: NCT03748225 registered on 11/19/2018. Recruiting patients.

Dynamic properties of internal noise probed by modulating binocular rivalry.

Neural systems are inherently noisy, and this noise can affect our perception from moment to moment. This is particularly apparent in binocular rivalry, where perception of competing stimuli shown to the left and right eyes alternates over time. We modulated rivalling stimuli using dynamic sequences of external noise of various rates and amplitudes. We repeated each external noise sequence twice, and assessed the consistency of percepts across repetitions. External noise modulations of sufficiently high contrast increased consistency scores above baseline, and were most effective at 1/8Hz. A computational model of rivalry in which internal noise has a 1/f (pink) temporal amplitude spectrum, and a standard deviation of 16% contrast, provided the best account of our data. Our novel technique provides detailed estimates of the dynamic properties of internal noise during binocular rivalry, and by extension the stochastic processes that drive our perception and other types of spontaneous brain activity.

Spatial summation of broadband contrast.

Spatial summation of luminance contrast signals has historically been psychophysically measured with stimuli isolated in spatial frequency (i.e., narrowband). Here, we revisit the study of spatial summation with noise patterns that contain the naturalistic 1/fα distribution of contrast across spatial frequency. We measured amplitude spectrum slope (α) discrimination thresholds and verified if sensitivity to α improved according to stimulus size. Discrimination thresholds did decrease with an increase in stimulus size. These data were modeled with a summation model originally designed for narrowband stimuli (i.e., single detecting channel; Baker & Meese, 2011; Meese & Baker, 2011) that we modified to include summation across multiple-differently tuned-spatial frequency channels. To fit our data, contrast gain control weights had to be inversely related to spatial frequency (1/f); thus low spatial frequencies received significantly more divisive inhibition than higher spatial frequencies, which is a similar finding to previous models of broadband contrast perception (Haun & Essock, 2010; Haun & Peli, 2013). We found summation across spatial frequency channels to occur prior to summation across space, channel summation was near linear and summation across space was nonlinear. Our analysis demonstrates that classical psychophysical models can be adapted to computationally define visual mechanisms under broadband visual input, with the adapted models offering novel insight on the integration of signals across channels and space.

Binocular vision adaptively suppresses delayed monocular signals.

A neutral density filter placed before one eye will produce a dichoptic imbalance in luminance, which attenuates responses to visual stimuli and lags neural signals from retina to cortex in the filtered eye. When stimuli are presented to both the filtered and unfiltered eye (i.e., binocularly), neural responses show little attenuation and no lag compared with their baseline counterpart. This suggests that binocular visual mechanisms must suppress the attenuated and delayed input from the filtered eye; however, the mechanisms involved remain unclear. Here, we used a Steady-State Visual Evoked Potential (SSVEP) technique to measure neural responses to monocularly and binocularly presented stimuli while observers wore an ND filter in front of their dominant eye. These data were well-described by a binocular summation model, which received the sinusoidal contrast modulation of the stimulus as input. We incorporated the influence of the ND filter with an impulse response function, which adjusted the input magnitude and phase in a biophysically plausible manner. The model captured the increase in attenuation and lag of neural signals for stimuli presented to the filtered eye as a function of filter strength, while also generating the filter phase-invariant responses from binocular presentation for EEG and psychophysical data. These results clarify how binocular visual mechanisms-specifically interocular suppression-can suppress the delayed and attenuated signals from the filtered eye and maintain normal neural signals under imbalanced luminance conditions.

The Effects of tDCS Across the Spatial Frequencies and Orientations that Comprise the Contrast Sensitivity Function.

Transcranial Direct Current Stimulation (tDCS) has recently been employed in traditional psychophysical paradigms in an effort to measure direct manipulations on spatial frequency channel operations in the early visual system. However, the effects of tDCS on contrast sensitivity have only been measured at a single spatial frequency and orientation. Since contrast sensitivity is known to depend on spatial frequency and orientation, we ask how the effects of anodal and cathodal tDCS may vary according to these dimensions. We measured contrast sensitivity with sinusoidal gratings at four different spatial frequencies (0.5, 4, 8, and 12 cycles/°), two orientations (45° Oblique and Horizontal), and for two stimulus size conditions [fixed size (3°) and fixed period (1.5 cycles)]. Only contrast sensitivity measured with a 45° oblique grating with a spatial frequency of 8 cycles/° (period = 1.5 cycles) demonstrated clear polarity specific effects of tDCS, whereby cathodal tDCS increased and anodal tDCS decreased contrast sensitivity. Overall, effects of tDCS were largest for oblique stimuli presented at high spatial frequencies (i.e., 8 and 12 cycles/°), and were small or absent at lower spatial frequencies, other orientations and stimulus size. Thus, the impact of tDCS on contrast sensitivity, and therefore on spatial frequency channel operations, is opposite in direction to other behavioral effects of tDCS, and only measurable in stimuli that generally elicit lower contrast sensitivity (e.g., oblique gratings with period of 1.5 cycles at spatial frequencies above the peak of the contrast sensitivity function).

A cortical locus for anisotropic overlay suppression of stimuli presented at fixation.

Human contrast sensitivity for narrowband Gabor targets is suppressed when superimposed on narrowband masks of the same spatial frequency and orientation (referred to as overlay suppression), with suppression being broadly tuned to orientation and spatial frequency. Numerous behavioral and neurophysiological experiments have suggested that overlay suppression originates from the initial lateral geniculate nucleus (LGN) inputs to V1, which is consistent with the broad tuning typically reported for overlay suppression. However, recent reports have shown narrowly tuned anisotropic overlay suppression when narrowband targets are masked by broadband noise. Consequently, researchers have argued for an additional form of overlay suppression that involves cortical contrast gain control processes. The current study sought to further explore this notion behaviorally using narrowband and broadband masks, along with a computational neural simulation of the hypothesized underlying gain control processes in cortex. Additionally, we employed transcranial direct current stimulation (tDCS) in order to test whether cortical processes are involved in driving narrowly tuned anisotropic suppression. The behavioral results yielded anisotropic overlay suppression for both broadband and narrowband masks and could be replicated with our computational neural simulation of anisotropic gain control. Further, the anisotropic form of overlay suppression could be directly modulated by tDCS, which would not be expected if the suppression was primarily subcortical in origin. Altogether, the results of the current study provide further evidence in support of an additional overlay suppression process that originates in cortex and show that this form of suppression is also observable with narrowband masks.

Treatment of myelodysplastic syndromes with excess of blasts by bevacizumab is well tolerated and is associated with a decrease of VEGF plasma level.

Myelodysplastic syndromes (MDS) are associated with increased bone marrow vascularity and increased levels of various angiogenic factors including Vascular Endothelial Growth Factor (VEGF) which is implicated in the proliferation and survival of leukemic cells. Before the approval of hypomethylating agents in this indication, the GFM conducted a multicenter phase II trial testing the efficacy and tolerance of bevacizumab, a humanized monoclonal antibody against VEGF, in MDS with excess of marrow blasts and its impact on bone marrow angiogenesis. Twenty-one patients were enrolled (16 males and five females) with a median age of 70 years and 19 were evaluable for haematological response after treatment (5 mg/kg IV every 2 weeks for 12 weeks). WHO diagnosis at baseline was RAEB-1 (38%) and RAEB-2 (62%). Treatment was well tolerated and was associated with significant decrease of VEGF plasma level [median (low quartile-high quartile)] from 65.5 pg/ml [LQ (low-quartile)-HQ (high quartile), 35.3-87.3 to 30.4 pg/ml (LQ-HQ, 22.5-34.0 pg/ml)] (p < 0.01) and reduction of bone marrow angiogenesis from a median of 20 vessels/mm(3) (LQ-HQ, 16.5-33 vessels/mm(3)) to 15.5 vessels/mm(3) (LQ-HQ, 10-23.2 vessels/mm(3)) (p = 0.03). On the other hand, only one patient had a significant haematological response with achievement of RBC transfusion independence. Thus, although bevacizumab had a significant impact on VEGF levels and angiogenesis in our patients, very few responses were seen when this drug was used as single agent. Given its good tolerability profile, however, combination of bevacizumab with other drugs, especially hypomethylating agents, could be considered in MDS.

The magnitude of center-surround facilitation in the discrimination of amplitude spectrum is dependent on the amplitude of the surround.

Recent studies explored the sensitivity of human perception to natural images, in particular the sensitivity of the visual system to discriminate changes in the amplitude spectrum slope. Previous slope discrimination experiments were carried out with stimuli presented either in the fovea or the parafovea/periphery and show that both yield poor discrimination at very steep or relatively shallow slopes. We verified if the well-known center-surround spatial interactions that operate early on in the visual processing stream influence the perception of real-world images. The results show that amplitude slope discrimination is greatly reduced (i.e., flat) when the stimulus is viewed in isolation. However, when a 2° target is placed within a surround containing an amplitude spectrum slope of 1 or 1.3, we see significant facilitation in detecting variations in the slope of the amplitude spectrum, particularly when the target contains an amplitude spectrum slope of 1 and 1.3. The results suggest that our visual system is sensitive to contextual interactions for stimuli that have the characteristics of natural images.

18F-Fluorodeoxyglucose positron emission tomography for the diagnosis of adrenocortical tumors: a prospective study in 77 operated patients.

CONTEXT: Most adrenal incidentalomas are nonfunctioning adrenocortical adenomas (ACAs). Adrenocortical carcinomas (ACCs) are rare but should be recognized at an early stage. OBJECTIVE: The objective of the study was to evaluate the usefulness of (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) to predict malignancy in patients without a previous history of cancer. DESIGN: This was a prospective, multicenter study from 2001 to 2006. SETTING: The study was conducted at a network of seven university hospitals in Paris. PATIENTS: Seventy-seven patients were included. All underwent surgery because of hypersecretory and/or growing benign lesions (n = 18), obvious ACCs (n = 21), or radiologically indeterminate lesions (n = 38). MAIN OUTCOME MEASURE: The degree of (18)F-FDG PET uptake [maximum standardized uptake value (maxSUV)] was related to the pathological findings serving as a reference, and its diagnostic value was compared with that of computerized tomography (CT) scan. RESULTS: Pathology eventually diagnosed 43 ACAs, 22 ACCs, and 12 nonadrenocortical lesions. Using a cutoff value above 1.45 for adrenal to liver maxSUV ratio, the sensitivity and specificity to distinguish ACAs from ACCs were, respectively, 1.00 (95% confidence interval 0.85-1.00) and 0.88 (95% confidence interval 0.75-0.96). Among the 38 indeterminate lesions at CT scan, we could analyze a subgroup of 16 adrenocortical tumors with high unenhanced density (>10 HU) and an inappropriate washout: (18)F-FDG PET correctly predicted the benignity in 13 of 15 ACAs. CONCLUSIONS: In a multidisciplinary team approach, (18)F-FDG PET helps to manage suspicious CT scan lesions. An adrenal to liver maxSUV ratio less than 1.45 is highly predictive of a benign lesion.

Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis.

OBJECTIVES: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. DESIGN: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. METHODS: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (2002 Euro) discounted at 3% yearly were estimated from the health care system perspective. RESULTS: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of 2688 Euro/QALY versus BNES and VAPS of 17,250 Euro/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. CONCLUSIONS: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.

18F-fluorodeoxyglucose positron emission tomography as a diagnostic tool for malignancy of adrenocortical tumours? Preliminary results in 13 consecutive patients.

DESIGN: This study is a preliminary report on 18F-fluorodeoxyglucose (18F-FDG) uptake for the characterization of hypersecretory or non-hypersecretory adrenocortical masses in patients without known neoplastic disease, thereby minimizing the presence of adrenal metastases, and without phaeochromocytoma, in comparison with computed tomography (CT) scanning and with iodocholesterol scintigraphy. METHODS: Thirteen consecutive patients with an adrenal mass scheduled to have surgery, underwent hormonal exploration, a CT scan for tumour size measurement and an 18F-FDG positron emission tomography scan. Eleven of these patients also had unenhanced density measurement at CT scan and iodocholesterol scintigraphy. RESULTS: CT-scanned adrenal masses ranged in size from 2.2 to 10 cm; attenuation value was <10 Hounsfield units (HUs) in two cases and >10 HU in nine. All benign lesions demonstrated iodocholesterol uptake. In the case of malignant tumours, results were non-homogeneous: no uptake, uptake and non-informative scintigraphy. All patients with an adrenocortical carcinoma had positive adrenal 18F-FDG uptake (n=3), one had a liver metastasis with positive 18F-FDG uptake, one showed 18F-FDG uptake in an adrenal metastasis from an unknown primary kidney tumour. All patients with a benign adrenocortical lesion had negative 18F-FDG uptake (n=9). Patients' lesions were hypersecretory (n=5), or non-hypersecretory (n=8), regardless of the pathology. CONCLUSION: This short preliminary study indicates that 18F-FDG gave a correct classification of tissue characterization with accurate identification of malignant lesions, as well as the disease stage (metastasis or primary). These promising preliminary results on adrenocortical lesions, seldom studied with 18F-FDG, are to be confirmed in larger series.

[Standards, options and recommendations for the use of medical analgesics for the treatment of pain arising from excess nociception in adults with cancer (update 2002): opioid analgesics with the exception of morphine by mouth and the rotation]. / Standards, Options et Recommandations 2002 pour les traitements antalgiques médicamenteux des douleurs cancéreuses par excès de nociception chez l'adulte, mise à jour : place des opioïdes forts (morphine orale exclue) et rotation des opioïdes.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the federation of French Cancer Centers (FNCLCC), the 20 French cancer centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines for the use of opioid analgesics with the exception of oral morphine and for opioid rotation related to the treatment of nociceptive pain in adults with cancer according to the definitions of the Standards, Options and Recommendations project. METHODS: In 1996, a working group, set up by the FNCLCC published clinical practice guidelines for pain management in adult and paediatric patients with cancer: In the light of the evolution of knowledge, and practice these guidelines need to be updated The section on "médical analgesic treatments" in the document published in 1996 was examined by the working group to identify which questions should be updated. These questions and the relevant key words were used to develop a search strategy which was used to search Medline, and for particular questions, Embase, from January 1994 to March 1999, for relevant references, published in English or French. RESULTS: For this update, only a few randomised clinical trials were identified, and their conclusions were generally weak. Thus much of the information in this document is based on the World Health Organisation (WHO) guidelines and represents the "state of the art" on this subject in France and is supported by expert agreement. Some changes to the original SOR are presented, particularly for the prescription of new opioids and opioid rotation. The full text of this SOR is available on the FNCLCC web site (http ://www.fnclcc.fr).